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Medicine for the Outdoors

Dr. Paul Auerbach is the world's leading outdoor health expert. His blog offers tips on outdoor safety and advice on how to handle wilderness emergencies.

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Treatment for Burns

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1. Remove the victim from the source of the burn.

If his clothing is on fire, roll him on the ground or smother him in a blanket to extinguish the flames. If the victim has been burned with chemicals, gallons of water should be used to wash off the harmful agents. If the eyes are involved, they should be irrigated copiously. Phosphorus ignites upon contact with air, so any phosphorus in contact with the skin must be kept covered with water. Do not attempt to neutralize acid burns with alkaline solutions or vice versa; the resultant chemical reaction may liberate heat and worsen the injury. Stick to irrigation with water. If clothing remains stuck to the skin and does not fall away with irrigation, do not tear the clothing away. Cut around it.

2. Evaluate the airway.

Look for evidence of an inhalation injury: burns of the face and mouth, singed nasal hairs, soot in the mouth, swollen tongue, drooling and difficulty in swallowing saliva, muffled voice, coarse or difficult breathing, coughing, and wheezing. If it appears that an inhalation injury has occurred, administer oxygen by face mask at a flow rate of 5 to 10 liters per minute, and transport the victim to a hospital as quickly as possible.

3. Examine the victim for other injuries.

Unless the airway is involved or the victim is horribly burned, the burn injury will not be immediately life threatening. In your eagerness to treat the burn, don’t overlook a serious injury such as a broken neck. Control all bleeding and attend to broken bones before applying burn dressings.

4. Treat the burn.

First-degree

A first degree burn, such as a mild to moderate sunburn, may be treated with cool, wet compresses. If the burn is acquired suddenly (as when a child grabs a hot rock), immediate application of very cold water (not solid ice) may help limit the extent of the tissue damage. Oral administration of an anti-inflammatory drug, such as aspirin or ibuprofen, may provide considerable relief. For severe sunburn (“lobster body”), the administration of oral prednisone in a rapid taper (80 mg the first day, 60 mg the second, 40 mg the third, 20 mg the fourth, 10 mg the fifth) may be extremely helpful. Corticosteroids should always be taken with the understanding that a rare side effect is serious deterioration of the head (“ball” of the ball-and-socket joint) of the femur, the long bone of the thigh.

Topical corticosteroid creams or ointments are of no benefit in treating a burn wound. Anesthetic sprays that contain benzocaine work for a few hours, but may induce allergic reactions. They should be used sparingly. If no blisters are present, a moisturizing cream (such as Vaseline Intensive Care) will help soothe the skin. Aloe vera gel or lotion seems to promote resolution of extensive first-degree burns. Burnaid first-aid burn gel (Rye Pharmaceuticals), which also comes in an impregnated dressing, contains 2 to 4% melaleuca oil and is advertised to provide relief from the pain of minor burns and scalds.

Second-degree

A second-degree burn should be irrigated gently to remove all loose dirt and skin. This should be done with the cleanest cool water available. Never apply ice directly to a burn; this may cause more extensive tissue damage. Cool compresses may be used for pain relief.

After the wound is clean and dry, cover it with a soft, bulky dressing made of gauze or cloth bandages, taking care to keep the dressing snug but not tight. If antiseptic cream such as silver sulfadiazine (Silvadene) is available, it should be applied under the dressing. An alternative is mupirocin ointment or cream, or bacitracin ointment. A nonadherent dressing layer directly over the antiseptic is easier to change than coarse gauze. Another excellent covering is Spenco 2nd Skin underneath an absorbent sterile dressing. Spenco 2nd Skin is an inert hydrogel composed of water and polyethylene oxide. It absorbs fluids (so long as it doesn’t dry out), which “wicks” serum and secretions away from the wound and promotes wound healing. Other occlusive hydrogel-type dressings are NU-GEL (preserved polyvinyl pyrrolidone in water) and Hydrogel, which can absorb up to 21/2 times its weight in exuded (from the wound) fluids. Yet another covering for a burn is a layer of petrolatum-impregnated Aquaphor gauze under a dry (absorbent) gauze dressing.

Do not apply butter, lanolin, vitamin E cream, or any steroid preparation to a burn. These can all inhibit wound healing, and may facilitate infections with increased scarring.

Dressings should be changed each day to readjust for swelling and to check for signs of infection. Be certain to keep burned arms and legs elevated as best possible, to minimize swelling and pain.

Blisters should not be opened, unless they are obviously infected and contain pus (this will generally not occur until 24 to 48 hours after the burn injury). If a blister remains filled with clear fluid, it is an excellent covering for the wound and will minimize fluid loss and infection. There is no rush to remove charred skin from a burn wound. As the wound matures and dressings are changed, gentle scrubbing will lift off dead tissue.

A victim with large areas of second-degree burns may need to be treated for shock.

Third-degree

A third-degree burn should be irrigated gently and covered with antiseptic cream or ointment or Spenco 2nd Skin, and a dry sterile dressing.

If a first-degree burn involves more than 20% of the body surface area and the victim suffers from fever, chills, or vomiting, a physician evaluation is required. If a second-degree burn involves a significant portion of the face, eyes, hands, feet, genitals, or an area greater than 5% of the total body surface area, a physician evaluation is required. Body surface area can be estimated using the “rule of nines.” For an adult, each upper limb equals 9% of total body surface area (TBSA), each lower limb equals 18%, the anterior and posterior trunk equal 18% each, the head and neck combined equal 9%, and the genital/groin area (perineum) equals 1%. For a small child, each upper limb equals 9% of TBSA, each lower limb equals 14%, the anterior and posterior trunk equal 18% each, the head and neck combined equal 18%, and the perineum equals 1%. Another method to estimate involved body surface area is the “palm of hand” rule: The surface area of the victim’s palm without the fingers represents approximately 1 to 1.5% of his TBSA. All third-degree burns are serious and should be seen by a physician.

Wet versus Dry Dressings

If the burn surface area is small (less than 10% of total body surface area), then cool, moist dressings (not ice) may be used to initially cover the burn wound. These often provide greater pain relief than do dry dressings. If the surface area involved is large, however, dry, nonadherent dressings should be used, in order to avoid overcooling the victim and introducing hypothermia. Because the skin is the major thermoregulatory organ of the body, it is difficult for an extensively burned victim to control his body temperature, so great care must be taken when wetting down such a person. If the victim begins to shiver, the cooling is too extreme.

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Tags: Staying Safe

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About the Author

Dr. Paul S. Auerbach is the world’s leading authority on wilderness medicine.

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