How to Survive a Serious Burn, by Cynthia J. Koelker, MD

Monday, Jul 22, 2013

How large must a burn be to kill you?  How is a burn fatal anyway?  Is there anything you can do to improve your odds?
Lacking an emergency response system, you’ll be on your own if you cook yourself on a heating pad, or catch your clothes on fire, or spill hot coffee down your pants while driving.  What would now be referred to a burn unit for specialized care may require home treatment when it’s the only option.
Without skin, you die.  The danger of burns is related to the function of the skin.  Normally the skin “keeps the insides in and the outside out.”  Skin protects against invading microorganisms which may cause infection.  It helps regulate the body temperature by preventing heat loss.  Skin acts as a barrier preventing excess water loss from the body.   

Death may occur related to interruption of any of these functions.  Dehydration, hypothermia, and/or infection are all potentially lethal.     

Skin burns are the most common type of thermal injury, and the most common burn for which patients seek treatment.  (Inhalation burns will not be addressed here.)  Most first-degree burns are treated at home, and cause only discomfort and reddening of the skin, but no blisters or significant fluid loss.  Third-degree burns are fortunately uncommon.  It is the second-degree burns which pose the greatest danger.  These burns cause blistering, pain, and fluid loss as the top layers of the skin are disrupted, exposing the tender inner layers to the outside environment.  Deeper, third-degree burns destroy the nerve endings as well, and scorch the skin into an unfeeling, leathery crust.  These deep burns are often surrounded by a zone of painful blistered second-degree burns.

As with all avoidable injures, at TEOTWAWKI , prevention is essential.  Will you allow your children to play in the kitchen while you’re boiling water?  Are you crazy enough to pour gasoline on a fire?  Is it necessary to open a hot radiator while it’s still steaming?  The great majority of the burns that I’ve seen were preventable:
Don’t lean on your curling iron as you apply make-up
Don’t wear shorts riding a motorcycle with a hot exhaust
Don’t set your water heater just below boiling
Don’t fall asleep on a heating pad
Don’t smoke in bed
Don’t let your toddler turn on the hot water
Don’t drink steaming hot coffee while driving
Don’t leave the stove on unattended
Don’t wear loose clothing around an open fire
Prevention is 90% – maybe 99% – of the battle.  Put some thought into how you might live differently if no fire truck is coming – not ever. 
Regarding treatment, the first rule of burn treatment is to protect yourself then STOP THE BURNING.  Cool the burned area with lukewarm water.  Remove clothing from the burned area.  Have the patient lie down if possible, especially if dizzy or light-headed.  Once the burned area is cooled off, heat loss will begin, so warm the patient with blankets or extra clothing.

Now for saving a life
:  if adequate fluids are not given in the first 24 hours, the kidneys may shut down permanently, resulting in death.  You must estimate the extent of the burn and calculate needed fluids accordingly.  The Rule of Nines is used to estimate the total body surface area (TBSA) damaged by second- and third-degree burns.  In an adult, the body is divided as follows:
9% for the head
9% for each arm
18% for each leg
18% for front of trunk (chest plus abdomen)
18% for back of trunk
1% for genitalia
For smaller or scattered areas, the size of the patient’s palm including fingers is considered 1%. 

A burn of 10 to 15% of the body can be life-threatening.  Death occurs early on from fluid loss causing renal failure.  Normally these patients are referred to a burn center.  IF YOU DON’T REPLACE LOST FLUIDS ON DAY ONE THE PATIENT WILL DIE. 

The Parkland Formula estimates the amount of fluids required in the first 24 hours:
4 ml x patient weight in kg x % body surface area burned
(Or approximately 1.8 ml x patient weight in pounds x % body surface area burned)
Half the fluid is given in the first 8 hours immediately after the burn, and the second half given over the next 16 hours.
For example, a 150-pound man who has burned his chest and shoulders after opening a steaming radiator may well have 18% of his body surface area involved with 2nd and 3rd degree burns.  Using the above formula, he will require nearly 5 liters of fluid in the first 24 hours (1.8 ml x 150 pounds x 18% = 4,860 ml).  That’s 5 large bags of IV solution (Ringer’s Lactate is preferred). 
Normally fluids are given intravenously.  The first half of the fluids (2.5 liters, in this case) must be given in the first 8 hours after the burn, not after treatment begins.  If it’s already been 4 hours, then this amount must be given over the next 4 hours, not 8 (divided out per hour and per minute), and the second half given over the next 16 hours.  A nurse, EMT, or physician could accomplish this.  I know this is technical, but it’s only middle-school math.
What if you can’t provide an IV?  If the patient is sufficiently alert, oral fluids are the best option (Gatorade or Oral Rehydration Solution).  However burns are painful and patients often require sedation.  Then what?
If you have the IV fluids, they may be administered rectally (similar to an enema) or via hypodermoclysis (a needle placed under the skin, not in a vein – various protocols are available online). 

What if you don’t have IV fluids on hand?  If the patient cannot take fluids orally, then Oral Rehydration Solution given rectally is probably the best option.  The recipe for this is:
6 level teaspoons of sugar
½ level teaspoon of table salt
1 liter of water (5 cups)
It should be given at approximately the same rate as an IV would be given, but taking into account any fluid which leaks out.   
On subsequent days fluids should be given in the amount needed to balance that which is lost, by measuring urine output as well as by daily weights.  Enough fluid must be given to prevent weight loss and to keep urine output above 20–30 ml/hour.  That’s only a few teaspoons per hour.  Less than this and the kidneys shut down.  In an average adult, this equals at least 1.5 to 2 liters daily, and could well be more in a burn patient.

Again, don’t forget to keep the patient warm
.  Since the patient may not be able to tell you he’s cold, measure their temperature periodically.  Aim to maintain body temperature in the normal range of 98–100o F.  The likelihood of death increases as body temperature drops below approximately 90 degrees F.

The next enemy is infection
.  Thorough cleaning of the injured area is essential.  Any embedded dirt or foreign material such as scorched fabric must be removed.  Clean, soapy water is sufficient in most cases.  Vaseline may be applied gently to remove grease or tar.  A gentle water pik or baby hair brush may help. 
Systemic antibiotics (pills, shots, IVs) are not generally given unless signs of infection occur.  However, topical antibiotics such as Bacitracin and Silvadene can help prevent infection.  Topical honey has also been shown to improve burn healing and prevent infection.
Signs of infection include increasing redness, pus, fever, or overall deterioration of the patient’s condition.  Pus must not be confused with eschar, the white or yellowish-white membrane that forms to cover a burn, much like a soft scab.  In general, this soft eschar is preferable to hard eschar (like a hard scab), which may compromise circulation and impair healing. 

If infection is suspected, nowadays a culture would be taken and the bacteria identified.  Lacking that option, a broad-spectrum antibiotic should be given, such as Augmentin, cephalexin, or possibly erythromycin.  If these are ineffective after a few days of treatment, a resistant organism or gram-negative bacteria may be present, and the patient should be switched to trimethoprim-sulfamethoxazole, doxycycline, ciprofloxacin, or similar drug.  If the infection enters the blood stream, it may cause sepsis, heart valve infection, or other fatal outcome.

Aside from potentially fatal problems, pain is a major concern with serious burns, and often requires narcotics and/or sedation.  Even exposing a burn to air may increase pain, so keeping wounds covered is essential not only for preventing infection, but also for comfort.  Your supply of narcotics and sedatives could easily be consumed with a single burn patient.  Over-the-counter sedating antihistamines (diphenhydramine, doxylamine) may be useful, but alcohol should be avoided unless the situation is hopeless, in which case easing a patient’s discomfort with any means available is reasonable. 

The current treatment of burns using early debridement and skin grafting is probably not a realistic goal without a team of medical providers. 
ReCell (spray-on skin) is a new technology that appears promising even for TEOTWAWKI.  Unfortunately it is not yet available in the US.  Perhaps the concept could be applied to grid-down medicine. 

About the Author: Dr. Cynthia Koelker serves as Medical Editor for SurvivalBlog, and hosts the survival medicine web site www.armageddonmedicine.net. She is the author of the book Armageddon Medicine and is the chief instructor for the Survival Medicine Workshops. Burn injuries are just one of numerous topics covered in her Survival Medicine Workshops. 


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