Burning Issues

Overview of burn types and their prehospital assessment and treatment by EMS


 

      A paramedic ambulance is dispatched to the scene of a house fire. En route the fire department advises that one victim has been removed from the house.

   Upon arrival the EMS crew finds a single-story house with smoke pouring out of the back windows. The fire department has secured the scene and extricated an elderly male from a bedroom in the back of the house. The patient is loaded into the ambulance, and EMS begins its assessment. The patient appears to be at least 60 years old and is only wearing underwear. He has significant burns all over his body, with blisters as well as black tissue starting to appear in some areas. The patient is unconscious and has occasional gasping respirations. His carotid pulses are weak and rapid, and his skin is hot to the touch, dry, and feels leathery in the more severely burned areas. The crew rolls the patient onto his side for a moment. They find no other signs of trauma, and roll him onto his back using in-line stabilization. There are no bystanders, and no medical history can be obtained. It is suspected that the man was asleep when the house caught fire. When the fire department arrived, the patient's bedroom was fully engulfed in flames and filled with thick black smoke.

   The EMS crew estimates that the patient has 95% total body surface area involvement of partial- and complete-thickness burns. They initiate airway management. Due to the extent of the burns, intravenous access is not possible. They place an intraosseous infusion in a lower extremity and initiate fluid resuscitation with normal saline. They transport the patient to the regional burn center for evaluation and treatment. There he's admitted to the intensive care unit. Two weeks later he succumbs to injuries sustained during the fire.

BACKGROUND

   It is estimated that 1.2 million Americans are burned each year, and that more than 50,000 require hospitalization. Nearly a million a year seek emergency department treatment for burns. Burns also account for roughly 5,000 deaths per year. Fires and burns are the second-most common cause of unintentional injury leading to death in children and the third-leading cause of unintentional injury leading to death for those older than 1. Half of all burns may involve smoking or substance abuse. Burns occur primarily at home or the workplace. When fire is involved, it is sometimes difficult to determine if burns or smoke inhalation resulted in a death. This makes the reporting of accurate numbers more difficult.1-4

   Approximately 8% of burns result in death. The number of deaths from burns has declined over the past several decades. This can be credited to several factors, including better burn care, improvements in the quality of burn centers, and the recognition and effective management of shock related to burns. Improved wound management and antibiotic use have also decreased deaths from infections related to burns. Another factor is the use of smoke detectors: In the United States, most people killed in house fires die from smoke inhalation rather than burns.5,6

ANATOMY

   The skin has three layers: the epidermis, dermis and hypodermis. The epidermis is the top layer; the dermis is directly beneath it. The epidermis has varying levels of thickness. For example, the epidermis of the forearm tends to be thinner than at the sole of the foot. The epidermis acts as a barrier between the body and the external environment. The dermis has two layers, the papillary (superficial) and reticular (deep) layers. The hypodermis is a layer of adipose and connective tissue between the skin and underlying tissues. Subcutaneous tissue is located under the dermis and is not considered a layer of skin. Other structures, such as muscle and bone, are located beneath the subcutaneous layer.2-5

   The skin has several functions, including being a barrier to water, protection from vapors, and resisting infection. The skin influences the body's temperature through its ability to retain and release heat. It is one of the body's most important protective organs.2,3,5,6

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