National Registry Paramedic Exam: Trauma - Burns

Burns are soft-tissue injuries resulting from the sudden and violent release of energy. Burns can occur from a release of heat in the form of fire, energy from chemical reactions, or radiation released from radioactive substances. Damage to the skin in such a profound way also affects body systems other than just the skin; there may be airway burns compromising the respiratory system, fluid shifts can lead to hypovolemia and cardiovascular compromise, and destruction to the skin will open the person up to the risk of a massive infection that overtaxes the immune system.

We will discuss all these issues from all 3 major burn sources.
Temperature is a quantitative measure of how much energy an object possesses. As an object gains or absorbs energy, its temperature will rise a predictable amount. Conversely, if an object releases energy, its temperature will drop a predictable amount. Think about baking cookies for a moment. Ever notice that the cookie sheet itself cools off considerably faster than the cookie itself? This is because of the predictable nature of the 2 different materials. The water in the cookie releases a tremendous amount of energy as it cools; therefore, it takes longer to release that energy than the cookie sheet, even though they were the same temperature when they came out of the oven. It is the process of releasing this energy—by transferring it to another object, in this case human tissues—that is the root cause for all burns.

Thermal Burns
Thermal burns occur when the heat source a body comes in contact with exceeds the body’s ability to dissipate that heat.

Thermal burns are dependent on the following:

- The length of time the body is exposed to the heat source
- The temperature of the heat source
- The amount of energy the heat source releases when it comes in contact with the body

The longer the body is exposed to the heat source, whether it is a flame, a hot stove, or water from a shower, the more significant the burn. This is because the body has more time to absorb the energy being released. The burn will likely involve deeper layers and a broader area, perhaps even beyond the local area of contact. The hotter the source, the more energy it has to release, resulting in a more significant burn.
The amount of energy an object possesses at any given temperature will vary based on the type of material that comprises it. Pull a beach towel off a metal fence on a hot sunny day, no problem; touch the hot fence for a long enough period of time, and a person may get a burn. Water, whether liquid or steam, will release more energy per gram than any other household substance. (For those curious, ammonia will release more energy; however, most people do not have vats of hot ammonia sitting around their houses). Remember, there does not need to be a flame for a person to receive a burn.

Types of Thermal Burns
Thermal burns can be classified as follows:

- Contact Burns. Burns caused by coming in direct contact with a hot object. Reflexes often limit the damage done as a result of contact burns. These can be more severe if a patient is restrained or impaired by alcohol or a medical condition. A contact burn also can be a sign of abuse in the elderly and the very young, especially if there is a pattern to the burn.
- Flame Burns. Caused by open flame, these often are the deepest burn, especially if the patient’s clothes are on fire.
- Flash Burns. These burns are caused by sudden heat from an explosion or being near a lightning strike. These are usually minor in nature, although sometimes they can have a lasting effect on the eyes.
- Scald Burns. This type of burn can be seen in any age patient, but it is most commonly found in children and handicapped, especially as a result of cooking. Scald burns can result from hot liquids being spilled off the stove by children reaching up or even from the shower head if the hot water heater is set too high. Scald burns can cover a broad area, particularly if they soak into clothing because the burn will continue to deepen until the energy of the water is used up or the clothing can be removed. If it gets into the diaper of a child (or an adult), it can be especially destructive to the genitals.
- Steam Burns. When steam comes in contact with any surface, it will condense back into liquid water. This change releases a colossal amount of energy—in fact, more than 6 times the highest defibrillation setting per gram of water. This steam can not only burn the skin of the hands and face but also cause serious burns of the airway if it is inhaled.
- Inhalation Burns. In a fire, inhalation of superheated air can cause airway burns. In an airway burn, the airway lining swells, sometimes to the point that it closes off the airway completely. The superior structures, including the epiglottis, larynx, and pharynx, are often the worst burned because they are the first to dissipate the heat energy. The patient with upper airway burns will require fast, aggressive airway management before it closes off entirely.

Smoke Inhalation
CO is the predominant chemical in smoke and is largely responsible for deaths associated with smoke inhalation. CO poisoning and its treatment were discussed here. However, it is worth mentioning that the pulse oximetry in a person with smoke inhalation may be 100%. Despite this, always provide high-flow O2 either via a non-rebreathing mask or positive pressure ventilation. 
During a fire, the most lethal part of a fire is the smoke, not the flames or the intense heat. The smoke, along with the superheated air surrounding it, is so hot that it contributes to airway damage. This can contribute to swelling of the airways and should be considered whenever a patient has soot around the mouth and nose or singing to the facial hair or nose hairs. Smoke also contains a wide array of toxic chemicals. 

Other chemicals in structure fire smoke include cyanide and hydrochloric acid. Cyanide is a poison that will shut down the electron transport chain in cellular respiration, and hydrochloric acid is a strong acid that can destroy living tissue. These chemicals can cause problems but are usually not in a concentration high enough to be a concern.

Burn Severity

Superficial Burns
Superficial burns, formerly known as first-degree burns, are a typical sunburn. In a superficial burn, only the epidermis is affected. The skin will be red, hot to the touch, and often swollen and painful. When touched, the skin will blanch and return to the red color. The patient is extremely sensitive to touch because of damaged nerve endings.

Partial-Thickness Burns
Partial-thickness burns involve the epidermis and can be subdivided as either moderate or deep partial-thickness burns based on how much of the dermis is involved. Moderate partial-thickness burns typically involve only the superficial dermis, resulting in the hair follicles remaining intact. The skin will be red with fluid-filled blisters. The redness will blanch when touched and return to the color.
Deep partial-thickness burns also will have blisters and damage deeper into the dermis. This depth of burns damages the hair follicles and the sweat and sebaceous glands. Such a burn also may be deep enough to destroy pain receptors in the dermis, and the burn will not be painful in some areas.

Full-Thickness Burns
Full-thickness burns involve the entirety of the epidermis and the dermis, burning all the way down to the basement membrane where the skin anchors to the fascia and new skin cells are generated. The skin will appear either white and waxy and charred or leathery. This is called an eschar (said “ess-car") and is dry, hard, and tighter than regular skin. The eschar can tighten to the point that it acts as a tourniquet on extremities or greatly hampers chest excursion during breathing. The patient has destroyed all nerve endings in the full thickness burn, so he or she will not feel pain, except perhaps on the edges of the burn where partial and superficial burns may exist.


Figure: Burn Severity

Thermal Burn Assessment and Treatment
By now, it should go without saying that scene safety is the first thing to assess on any call. Here, assessing the scene is of paramount importance. Unless trained as a firefighter and equipped with the proper gear, including the self-contained breathing apparatus, never enter a building that is or recently was on fire. Leave it up to the firefighters to bring any patients to the ambulance or triage area. When they do, ask them about the thickness of the smoke, the area in which they found each patient relative to the location of the fire or the drift of the smoke, and how long it took them to get each patient out from the time the alarm was sounded. These questions will provide valuable information about the scene.
Body substance isolation for the burn patient should, whenever possible, include gloves and a gown. Skin can come off in sheets after a burn, so protection may be warranted beyond just gloves. Once the patient arrives, ensure that the burning process has stopped and that the patient is, in fact, no longer on fire; it is possible that the clothes are still smoldering or still hot enough to intensify burns. Wet the patient down and remove all clothing as soon as the patient can be touched. This is essential because polyester will turn to solid plastic when heated, which can just hold more heat against the patient, worsening the burn.
Only now is it possible to begin the primary assessment.

During the airway and breathing portion, note any signs and symptoms that may signal smoke or heated air inhalation:

- Facial burns
- Singed facial and/or nose hair
- Cough
- Black sputum, lips, nasal lining (carbon)
- Hoarseness
- Wheezing (bad)
- Stridor (worse)

If the patient has any of these signs and symptoms, suspend the remainder of the assessment and prepare to aggressively manage the airway. Early recognition will invariably lead to early intervention, which will be life saving in the patient with the above conditions. Begin first with nebulized saline. This will help the patient with the conditions noted above who is currently breathing. It also may help lubricate the airway and accelerate the removal of contaminants in the lungs and airways. If this does not work, or respiratory distress is increasing or stridor or wheezing is present, field intubation may be necessary.
Only the most experienced paramedic should attempt an intubation of this patient because there may only be 1 opportunity for successful intubation. As the upper airways swell, any irritation to them will make them swell faster, quickly eliminating the opportunity for airway maintenance. The intubation attempt also may be performed on a person who is conscious, agitated, anxious, or otherwise uncooperative as a result of the pain from the burn or other trauma sustained. If the patient is able to understand the need for the intubation, it should be thoroughly explained to him or her, with ongoing communication throughout and after the process.

Take the following steps:

- Prepare all equipment necessary for the intubation, including a smaller tube than would otherwise be used. Consider starting with a 6.0 or 5.5 cuffed tube in an adult to enhance chances of success. It is also worth having a couple different sizes prepared at the same time to facilitate switching between sizes quicker.
- Place a stylette in the selected tube and conform the tube to the preferred shape.
- Lubricate the external part of the ETT liberally with water soluble lubricant.
- If available, spray the patient’s mouth with lidocaine spray. It will already be painful from the burn; the laryngoscope will only exacerbate this and make the patient more resistant to the procedure.
- Ideally, the patient should receive rapid sequence intubation (RSI) for this. Sedation with 2 mg Versed, 1.5 mg/kg lidocaine, and 1 mg/kg fentanyl. Administer 20 mg etomidate for induction followed with 1.5 mg/kg succinylcholine chloride for paralysis.
- Introduce the ETT and secure with a commercial tube holder. Evaluate placement with lung sounds and EtCO2.

If these steps do not work or intubation is no longer possible, a tracheotomy may be required.
Once the airway is secure and patent, evaluate circulation. Assess peripheral pulses at any of the usual places, with preference to those that are not under burned areas if possible. Assessing blood pressure may be challenging if the extremities are burned. Here again, if possible, avoid taking a blood pressure over a burned area. Remember that severe burns will result in a fluid shift out of the vasculature and into the interstitial space, resulting in profound and potentially lethal hypovolemia. If the patient has any partial- or full- thickness burns on his or her body, it is safe to presume that the patient will be hypovolemic eventually and begin to treat for such a case. Establish at least 1 peripheral intravenous as soon as possible for fluid resuscitation and pain management.
As long as circulation is intact, evaluate the total body surface area (BSA) burned and the degree to which the patient has been burned to determine the burn severity. The BSA is determined as a percentage of the total body surface. The most common ways to estimate this are the rule of palms or the rule of 9s. The rule of palms states that the percentage of BSA burned can be estimated using the patient’s palm as a reference. The patient’s palm (not including fingers) is approximated as 1% BSA; therefore any area the palm can cover equates to approximately 1%. More likely, the rule of 9s will be used. This method assigns regions of the body percentages in multiples of 9 across the entire body for the adult. This changes slightly in infants about 1 year old who lose 9% from their legs and gain it back in their head. Approximations are all that is needed for this step because the paramedic will not be able to accurately determine the exact amount in the chaos of initial care and the scene.


Figure: (A) Adult. (B) Infant.


Adult Burns

Fluid resuscitation can now be fully planned once the BSA burned has been estimated. The Parkland formula is used to determine the amount of fluid in milliliters the patient will need within the first 24 hours after the incident. Half of this amount is to be administered in the first 8 hours, with the remaining half given over the remaining 16 hours. The Parkland formula is 4 times the BSA times the patient weight in kilograms.

Normal saline is preferred to lactated Ringer solution because it contains potassium. Because of the extent of cellular damage that has already occurred, potassium levels in the blood may already be elevated. Mortality in burn patients increases the longer the patient goes without intravenous fluid resuscitation. The paramedic’s goal should be to establish at least 1 large-bore peripheral intravenous line and begin running fluids. This process should not delay the transport of the patient to the helicopter or the hospital.

Pain Management
For burn patients, pain management is an essential part of the care plan. The pain the burn patient experiences is extraordinary and often requires multiple doses of pain medication to achieve a reduction in pain level because the patient’s metabolism has increased from the burn process and the anxiety. In addition, absorption is altered because of fluid shifts, so intravenous or intraosseous administration is required. Begin with 1 mg/kg fentanyl or 10 mg morphine sulfate and consult medical control for further orders.

Electrical Burns
Electrical burns are a difficult burn to assess because much of the damage is internal. For an electrical burn to happen, the electricity must complete a circuit by entering the body and then flowing into another wire or the ground. When the circuit is completed, the electricity flows into the body from the point of contact with the live electrical source until it exits the body. High-voltage electrical current, such as that from outdoor electrical supply lines will follow the shortest path to the nearest conductor or the ground. Lower voltage sources under 1,000 V, such as household interior wiring, will usually take the path of least resistance to electrical flow, which is usually nerves and blood vessels.
Between the entry and exit wounds, electricity produces immense heat from the natural resistance of human tissue to electricity. The electricity also will cause skeletal muscle tetany, freezing a person in position connected to the electricity source if the current is high enough. Skeletal muscle tetany can be powerful enough to cause fractures during the spasm. As the current increases beyond 20 mA, respiratory muscle paralysis sets in if the current flows through these muscles. Finally, VT may be induced with as little as 50–100 mA if the current flows through the heart. Although skeletal muscle tetany and respiratory muscle paralysis will subside when the electrical current stops, VT will not spontaneously convert to normal rhythm.

There are 3 types of electrical injury:

- True Electrical Burns. This is the most common form and occurs when electricity flows directly into the body from a source and into another conductor or the ground.
- Arc Burns. These most often come from extremely high-voltage wires. Electricity essentially leaps through the air and into the body of a person close enough to the source to become a suitable conductor. Temperatures of the arc, because of the very high resistance of air, can reach well in excess of 5,000°C (>9,000°F). If the arc initially contacts the person through a tool, for example, a screwdriver, the tool is vaporized.
- Flame Burns. Occur when electricity flows through clothing and sets it on fire.

Before assessment can begin, ensure that the scene is safe and that the electricity has been turned off if the patient is still near where he or she contacted the source. Supply lines can spontaneously turn back on if they are programmed to do so to prevent long term black-outs. Once ensured of security from the electricity, proceed with assessment of the ABCs in the usual fashion; however, open the airway with the modified jaw thrust if needed; muscle spasms may have caused a neck injury. Ventilate as needed if not breathing or breathing inadequately; otherwise provide high-flow O2. Initiate CPR if needed and defibrillate VF as soon as possible. Treat other cardiac dysrhythmias as needed.
During the secondary assessment, try to evaluate the likely path of the electricity through the body. Areas that have been affected will tend to be extremely hard as a result of the damage. Essentially, the tissues in this area have been cooked. Because the electricity will cauterize any bleeding it may have caused, external or internal bleeding is highly unlikely. Appropriately splint any fractures or dislocations found and document the presence of distal pulses.

Lightning Burns
Lightning differs from electricity in that the current from lightning is a direct current, which means it travels in only 1 direction, whereas electrical current in wires is typically alternating current. In addition, it lasts for only milliseconds, rather than exposing the patient until the current is turned off. Consequently, it more resembles a blast injury than what may be expected from a high-voltage electrical burn. It also is similar to arc burns, where a large, onetime discharge of electricity travels from a body—the cloud—to another body—a person or persons on the ground.
A person does not need to be struck directly to sustain the damaging effects from lightning. Often, the person receives a splash burn, which results from a lightning striking nearby and electricity traveling through the air from that point to the person. As the electricity spreads in the ground after striking the ground, the person also can sustain injuries from the ground current.
Treatment for the patient who was struck by lightning is very similar to that of the electrocuted patient. Unless there is still lightning activity in the area, and the patient is outside near a tall object, the likelihood that lightning will hit the same spot again is remote, so the scene is typically safe. The patient who is not breathing or is in cardiac arrest is the highest priority when there is more than 1 patient. Because lightning is direct current, it will act as a defibrillator, depolarizing the entire heart at the same time. As often as not, the heart will begin beating immediately after the lightning is done. Other times, it will restart after a defibrillation or 2 minutes of CPR initiated immediately after the strike.

Chemical Burns
Chemical burns result when certain types of chemicals come in direct contact with a patient’s skin. The burn severity depends on conditions similar to those of a flame burn:

- Chemical State. No amount of gaseous O2 will hurt a person in the near term. However, liquid O2n, such as what may be found in concentrators for home O2 therapy, can cause significant burns if the tank were to rupture.
- Concentration. This plays a big role in how long the patient needs to be exposed to the agent for the burn to occur. Some very dilute chemicals no longer pose a hazard, whereas for other chemicals, dilution slows or limits the damage done. Pure ammonia, for example, is a very strong base and can cause significant burns; however, when diluted, it works as a very effective household cleaner that can be used without a mask or gloves.
- Depth of Penetration. Certain chemicals can burn deeper into layers of the skin, causing more damage.
- Duration of Exposure. In most cases, the longer the patient has been exposed to the chemical, the worse the burn is. That said, some chemicals will do their damage in mere seconds, regardless of the concentration.

The type of chemical the patient was exposed to impacts the damage the patient will experience.

- Acids. Acids release hydrogen ions, which are responsible for the burning effect. As they react with the skin, a tough callous is formed, which limits damage to the skin. This is called coagulative necrosis.
- Bases. Bases release hydroxide ions into solution and essentially liquefy the skin. Fat deposits react with strong bases and essentially turn into soap (a process called saponification). Because cellular structures have a relatively large component of lipids as part of the cell membranes, the cells will liquefy and dissolve. Therefore, until all the hydroxide has reacted with fat in the area of contact, cellular destruction will continue to occur.
- Oxidizers. These help other items burn. Therefore, when they come in contact with skin, they can cause such a powerful reaction that the skin or clothing will actually catch on fire.

Special consideration must be given to chemical burns of the eye. Any of the previously mentioned chemical types can cause burns in the eye. Because of the presence of tears in the eyes, even dry, water-soluble chemicals become more of a concern than they would be if they just got onto clothing or the skin. If chemicals get into the eyes, the eyes should be flushed for no <15 minutes with clean water. Never use antidotes in the eyes to try and counter the effects of the chemical because this can worsen the burn because of the heat released during the reaction or purely the chemical activity of the new chemical being introduced.
When flushing with water, remember to flush away from the other eye and minimize splashing. Hold the eyelids open and ensure that the water makes its way under each eyelid. Have the patient roll his or her eyes as well so that the water can more easily wash all areas of the eye. If contact lenses are present, remove them as quickly as possible because this can hold the chemical against the cornea, worsening the burn.

Radiation Burns
Although rare, radioactive materials are commonly found in industry and are sometimes associated with terrorist attacks and bombings. Response to such incidents should be limited to people who are specially trained and equipped in working in latent dangerous environments. Simply being in the area of a radiation exposure does not immediately make a person contaminated or able to expose others. However, being at an area where there was an explosion and having radioactive debris on the person does make the person contaminated and capable of contaminating the ambulance, the providers, and the emergency department.

Three kinds of radiation are released from radioactive material. What kind of radiation is purely dependent on the material in question.

- Alpha Particles. The alpha particles have the lowest energy of the 3 types of radiation. They can easily be stopped by skin or clothing. Alpha radiation is a cause for concern only if the source is embedded in the patient, such as shrapnel, or ingested.
- Beta Particles. These have a higher energy but are stopped by aluminum and glass, so the ambulance will provide adequate protection from beta radiation, assuming it is not allowed on the patient. Beta particles are capable of causing damage to DNA, cancers, and other problems.
- Gamma Radiation. This is high-energy radiation that has extensive penetrating power. It can be stopped only by thick concrete, lead, or thick steel. The smaller the wavelength, the more energy the gamma ray possesses. As a result, it has more penetrating power. This also is dependent on the source.

Radiation is measured in radiation absorbed dose (rad) or radiation equivalent in man (rem). One hundred rad is equal to 1 Gray (Gy). People are exposed to radiation every day in small doses. This small dose is called background radiation and is about 0.36 rad per year. Major radiation exposures are measured on the Gray scale, which translates into about 1,000 times the amount of background radiation.
Acute radiation sickness is dependent on the dose of radiation received and the duration of time for which it was received.

Radiation sickness involves 3 presentations:

(1) hematopoietic involves a drastic drop in both red and white blood cells and can lead to profound infections; (2) gastrointestinal occurs when the GI system receives the radiation dose and results in extensive vomiting and diarrhea; and (3) neurovascular, which is seen when the brain is involved in receiving the radiation dose and presents with neurological symptoms, including confusion, dizziness, and headache.
Mild radiation sickness begins from 1 to 2 Gy, is completely recoverable, and rarely results in long-term problems. Exposure to 2–5 Gy will result in moderate radiation sickness, and people at this level may experience long-term problems. Mortality rates exceed 50% of those exposed. Exposure to greater than 5 Gy, particularly with involvement of the GI system, is fatal within 1 week. If vomiting presents within 1–2 hours, death is assured. Exposure to greater than 8 Gy is fatal within 48 hours regardless of the area of the body primarily exposed.
Assessment is largely related to the onset of vomiting. Those who vomit outside of 1 hour of exposure have a greater than 95% survival rate from the exposure. If vomiting occurs within an hour, mortality rates exceed 80%. And, finally, if vomiting occurs within the first 10 minutes, death is guaranteed.
Radiation contact burns may occur when a patient handles or otherwise comes in direct contact with a radiation source. This may happen in certain places of employment or during the detonation of a dirty bomb. The appearance in the area of the exposure may resemble a localized chemical burn or sunburn. Radiation burns, in contrast to regular chemical burns, tend to appear hours or days after contact.
Treatment for radiation exposures involves determining the level of exposure and, first and foremost, the need to protect the EMS crew from harm. Once the providers are safe, assessment of the vomiting time frame is essential. Although radiation exposure–related vomiting is not treated the way other sources of vomiting can be, it is helpful to know the survivability of the exposure. Long-term treatment in the hospital will involve treating for the widespread infection and neutropenia (low neutrophil count) that results from exposure.