pre hospital burn management

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    Objectives:After reading this article, you will be able to:

    1. Explain the basic functions and different layers of the skin.2. Describe the varying degrees of burns.3. Calculate the surface area of a patient affected by burns.4. Describe thermal, electrical, chemical, and radiation burns and their treatment.

    Case StudyIt’s just before noon and you are part of a third-alarm assignment to a warehouse fire in the industrial district. The first arriving unit reportsheavy fire involvement in the northwest corner of the structure and employees self-evacuating through the front door. As you arrive on thescene, secondary explosions rip through the northeast corner of the structure, belching thick black smoke and debris into the crowd ofevacuating employees and advancing firefighters. To call it chaos would be a gross understatement. Command quickly pulls all units backand begins to set up defensive operations, which includes the arduous task of accounting for all companies. The crew from Medic Oneestablishes a medical sector and calls for Medic Two and Engine Eight to begin triaging the mass of bodies that are still on the groundafter the explosions.

    Fourth and fifth alarms are struck simultaneously, and all mobile intensive care units are asked to stage and prepare for critically burnedpatients. It doesn’t take long for you to get into the action; firefighters meet you at the side door of your ambulance with one of their own.He has second- and third-degree burns to his face, chest, abdomen, and right arm. It appears that he was in the process of zipping up his

    coat when the explosions caught everyone off guard. His shirt is charred, and in some places it appears to be stuck to his skin. He is inobvious pain and is starting to show signs of breathing difficulty. The firefighters who brought him to you start him on oxygen andreluctantly rush back into the crowd of patients. Your partner secures a 16-gauge intravenous catheter in the left forearm and records ablood pressure of 110/80 with a pulse of 120. Respirations are becoming more rapid, and lung sounds are diminished with a high-pitchedstridor. Recognizing the need for immediate airway control, you follow your rapid sequence intubation protocol and secure a good tube.You approximate the total burned surface area at 35 percent and calculate your fluid infusion rate accordingly.

    As you begin your secondary assessment, you remove the patient’s clothing and cover him with sterile burn sheets. The clothes that arestuck to his skin are left in place to be removed by the emergency room staff. Your emergency transport to the burn center will take justover a half-hour, so your partner jumps in the driver’s seat and leaves you to continue the patient’s care. The bits and pieces you hearover the radio indicate that there are several patients with varying levels of injuries, ranging from chemical exposures to crush injuries withassociated thermal burns. Your quick airway control and adequate fluid therapy ultimately stabilizes the patient long enough to get to theburn center. He has several weeks of painful treatments and a few close calls with infections, but, ultimately, he walks out of the hospital amonth later and returns to his family and, eventually, to his job.

    If burn cases all went that easily, with that much perfectly choreographed drama, there wouldn’t be a need for any continuing education onburns. In actuality, burns can be very complex and pose safety hazards to both you and your patient. There are several times wheneverything will fall into place perfectly, but for the times that don’t, it’s not a bad idea to have a little refresher at the front of your mind tohelp remind you of some of the dos and don’ts regarding burns.

    First Degree Burn 7

    Functions of the SkinBefore we get into the treatment of the different types of burns, it is important to review some of the basics. To start with, we need tounderstand the functions of the largest organ of our body and the effects that burns have on it. Some of the vital functions of the skininclude protection from infection, temperature regulation, and fluid containment. If the skin is damaged or simply missing, its ability toperform these functions is compromised, and the effects can be profound.

    Infection is one of the most persistent killers of burn victims.¹ Depending on the extent of the burn and the events leading up to the injury,infection can develop in several hours or several days. That is why it is so important for us to be as sterile as possible when we aretreating our burned patients. The use of sterile burn sheets, a clean working environment, and appropriate decontamination and coolingprocedures can give the patient a better chance of remaining infection-free.

    Another function of the skin that is diminished when it is damaged is temperature regulation. Under normal circumstances, our skinregulates our body’s temperature by insulating us from the cold and secreting sweat when we are hot. When it is not intact, not only doesit lose the ability to insulate or cool, the fluids that are freely leaking out rapidly remove heat energy.¹ It might be difficult to think of amassively burned patient as being hypothermic, but it happens and it needs to be monitored. The best thing you can do to try to combat

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    this is to cover the burns with sterile burn sheets. You aren’t going to be able to stop the fluid from leaking, but you can make an attemptto provide some insulation to reduce the amount of heat energy being lost.

    Lastly, the massive amounts of fluids that are being lost can result in something called a fluid shift. The body removes fluid from theintravascular space and sends it to the burn to begin cooling and repairing the damage. When this happens, the patient can becomehypovolemic. Depending on the size of the burn, this can manifest over a period of several hours or several days. The onset is notsudden, so if you are seeing symptoms of hypovolemia early on, look for other causes.¹ One of the widely used formulas for fluidreplacement in patients with 2nd degree and 3rd degree burns was developed by Parkland Hospital in Dallas, Texas. The formula can bea little tricky to calculate in the field, especially if you don’t use it often. It gives you the total amount of fluids to be administered over thefirst 24 hours following the injury. The formula is 4 ml of fluids (preferably Lactated Ringers) X patient’s weight in kilograms X thepercentage of body surface area burned. The total is then divided in half and this amount of fluid is given to the patient over the first 8hours since the burn; the other half will be given over the remaining 16 hours. For example, say you have a 100 kg patient with 50 percentof second- and third-degree burns. 4 ml X 100kg X 50 equals 20,000 ml of fluids. Half of this is 10,000 ml, so for the first 8 hours thepatient needs to get 10,000 ml of fluids. This is not the amount of fluids that you need to cram into the patient during your transport to thehospital. You need to calculate how long you will have the patient to get the amount of fluids that you need to administer. Do this bydividing 10,000 ml of fluid by 8 to give you the ml needed per hour. In this instance, your patient needs 1,250 ml per hour. So if he wasburned at noon and you are going to be at the burn center at 1 p.m., you should be 250 ml into your second bag of fluids when you arrive.Fluid replacement formulas vary from department to department, so follow your local protocols on fluid replacement requirements. Thisformula requires that you know the degrees of burns and a percentage of body surface area involved, which we will get into shortly.Before we get to that, we need to talk about the different layers of the skin.

    Layers of the SkinAs you probably know, the skin is broken up into three main layers. The epidermis is the outermost layer of the skin, and it provides aneffective barrier against bacteria and other pathogens when intact. It also contains pigments that help protect us from ultraviolet radiation

    from the sun.¹ Directly beneath the epidermis lies the dermis. Nerve endings, blood vessels, and oil and sweat glands all occupy this layerof the skin and play a large role in the body’s ability to regulate temperature.¹ Below the dermis, you will find the subcutaneous tissue. It isthe last barrier between the outside world and our internal organs. It is composed mostly of fat and connective tissues. As stated before,all three of these layers play vital roles in keeping us protected from the outside elements. Anytime you break this barrier, you start to runinto problems. Burns can break this protective covering in varying degrees, which we will cover now.

    Second Degree Burn 7

    Degrees of BurnsSeveral years ago, burns were simply first, second, or third degree. Over the years, it was decided that burns are now to be classified assuperficial, partial thickness, or full thickness. Regardless of which terminology you use, it is important to differentiate between thedifferent depths of skin that burns extend into.

    First-degree burns, or superficial burns, involve only the upper layers of the epidermis and the dermis. They are characterized by redness,pain, and minor swelling.¹ A good example of a first-degree burn is a sunburn. The prognosis for these types of burns is usually verygood. Unless the burn has exacerbated some other medical condition, or occurs in people who are very young, elderly, or ill, the patientwill not see any long-term health effects, and the skin will make a full recovery to its original state. There are many myths concerning howto treat a first-degree burn, ranging from butter to toothpaste, but the best treatment is cool running water. 2 If cool water is not available, acold compress will help reduce swelling and pain. Never put ice directly on any burns, as it can lead to further complications, includingfrost bite. Something to keep in the back of your mind is the fact that first-degree burns can mimic carbon monoxide poisoning inappearance. So if you are working on a firefighter at a structure fire and notice that he or she has redness to the skin, don’t just assumethat it is a mild steam burn or sunburn. Something else to consider is first-degree burns that are circumferential around extremities maycause swelling that can inhibit circulation. It can also cause problems if a patient is wearing jewelry and the hands or fingers begin toswell. To be on the safe side, have the patient remove and secure anything that might be difficult to remove in the presence of swelling.

    Second-degree burns, or partial thickness burns, are similar to first-degree burns in that they are usually red in color, painful, and produceswelling. One of the things that differentiate first- and second-degree burns is the presence of blisters.¹ If the second-degree burn is lessthan 15 percent, you can treat it as you would a first-degree burn by cooling it with water. If the burn is larger than 15 percent, the use ofrunning water increases the risk of hypothermia due to the larger surface area that you are trying to cool, so have the burn sheets ready tohelp insulate the patient after the burning process has stopped.¹ The blisters that form are a good visual reference of the fluid shift that wediscussed earlier. These blisters need to remain intact if at all possible. Breaking them can allow bacteria and other microorganisms toenter the body through the broken skin and increases the chances of the wound becoming infected. Even with the presence of blisters,second-degree burns will generally heal without permanent disfigurement. As with first-degree burns, any jewelry or restrictive clothingneeds to be removed so the swelling associated with the injury doesn’t cause problems with circulation. It is also a good idea to checkpulse, motor function, and sensation distal to the injury and report any deficiencies to the receiving facility. As mentioned earlier, anothercomplication of second-degree burns is hypothermia if the wounds are large enough and the blisters have been broken. So be sure tocover the burns with sterile dressings to reduce the heat loss that comes with damaged skin and an increase of fluids leaving the wound.

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    Lastly, and probably most importantly, you need to start thinking about pain management. If you are going to administer narcotics, suchas morphine, be sure to keep an eye on the patient’s blood pressure. Follow your local protocols on which medications to administer.

    Third Degree Burn 7

    The last type of burn that we will discuss is the third-degree burn, or full thickness burn. It is said that third-degree burns are painless. It’strue that third-degree burns destroy the nerve endings and are technically incapable of producing pain, but the second-degree burns thatsurround the third-degree burns can be horribly painful. Third-degree burns destroy the epidermis and the dermis and can burn all the waydown to the bone in severe cases. These burns completely render the skin incapable of protecting the body from infection, controlling

    temperature, or containing fluids. It is of utmost importance that you keep these burns as clean as possible. It is equally important that youcover the wounds with sterile dressings to help with the loss of heat and that you start thinking about long-term fluid replacement. Asstated before, the signs and symptoms of hypovolemia will generally not be acute, but aggressive fluid therapy will be needed over thenext several hours and possibly the next few weeks.¹ Pain management is also very important at this point. Your patients will be inexcruciating pain, and I’m sure that they would appreciate the most pain medications that you are allowed to administer and that they cansafely handle.

    Rule of NinesThe last thing we need to complete the burn formula mentioned earlier is an easy way to estimate the body surface area that is burned.The industry standard for approximating a patient’s burn surface area is the Rule of Nines. It breaks up the body into eleven regions, eachaccounting for 9 percent. The remaining 1 percent is reserved for the genital region. In an adult patient, these regions are broken downinto the entire head, the chest, the abdomen, the upper back, the lower back, the entire right arm, the entire left arm, and the front sideand back side of each leg. Children proportionately have larger heads, so the Rule of Nines needs to be adjusted to include the Rule ofThirteen Point Fives. Basically, children get an extra 9 percent added to their head for a total of 18 percent. Since their total percentage isnow 109 percent, we have to make an adjustment, so their legs get assigned 13.5 percent per leg instead of 18 percent for adults. Whilethis method is an easy to use tool for approximating surface area burned, it has the potential to produce inaccurate results. There areother charts that you can reference that might be harder to use but might also provide a more accurate percentage. One of these charts isa Lund and Browder diagram. 3 If you are having trouble approximating small burns, you can use the Rule of Palms. To use the Rule ofPalms, use the size of the patient’s palm to represent 1 percent of the total body surface area. Since fluid therapy will continue for severalhours, the emergency room can make adjustments to the percentage, if needed, so it is okay if you are off by a little. Use the tools youhave to get as close as possible to an accurate percentage.

    Types of BurnsNow that we have covered the functions and layers of the skin, the degrees of burns, and the approximation of body surface areaaffected, let’s get into the specifics on how to treat the different types of burns. Thermal burns are usually caused by hot objects. It can besomething as complex as a fully involved structure fire to something as simple as a hot curling iron. As with almost any incident, a

    complete and thorough scene size-up must be completed before you begin treating your patient. For example, if you are going to treat apatient that has been burned in a structure fire, make sure that the patient has been moved to an area where it is safe to administer care.Even if the fire is out, deadly levels of carbon monoxide may be present as well as the potential for structural collapse. So take the time toget the patient out of the hazardous atmosphere as soon as it is safe to do so. Once the scene is secure, your first priority is to stop theburning process. This goes without saying, but if your patient is still on fire, you’re going to need to put the fire out. Copious water ispreferred, but if that is not available, use a heavy wool or cotton blanket to smother the flames.¹

    Rule of Nines A: Rule of nines (for adults)B: Lund-Browder chart (for children) for estimating extent of burns.

    Once you have assured scene safety and rendered the patient safe to work on, you can start your treatment. Always start with the basics,which include checking the patient’s airway, breathing, and circulation. Thermal burns can involve burns to the airway, especially if thepatient was in an environment such as a structure fire. If your patient has burns or black soot around his or her nose or mouth, you needto assume that the patient has inhaled super-heated fire gasses. This will produce several problems, a few of which are burns to theupper and lower airway and carbon monoxide or cyanide poisonings. The lungs do not respond well to super-heated gasses. The bodywill flood the lungs with fluids, and your patient will deteriorate rapidly. Also, swelling to the patient’s upper airway as a result of burns willbegin to rapidly shut down the patient’s ability to move air. If you suspect that a patient has burns to their airway, intubation might be yourbest option. If you have a rapid sequence intubation protocol, it would be a good idea to start pulling out the paralytics.

    Equally as bad as airway compromise, fire gasses contain several deadly elements that can cause problems, two of which are carbonmonoxide and cyanide. Carbon monoxide bonds with red blood cells and prevents them from carrying oxygen, and cyanide disrupts

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    cellular respiration by interrupting the formation of oxygen in the mitochondria. Depending on the material burned, there can be numerousother substances in the smoke, and none of them are good for you. Not knowing what the patient has been exposed to, the best thing youcan do is to take control of the airway, if needed, and administer high-flow oxygen.¹

    Many departments have recently started carrying continuous positive airway pressure (CPAP) machines to assist patients who aresuffering from pulmonary edema associated with burns to the lungs, among other things. The increased pressure in the lungs helps toforce the fluids out and increases the ability to effectively exchange oxygen at the alveoli. The last part of your initial assessment is tocheck the patient’s circulation. This means to start thinking about fluid replacement therapy and removing any clothing and jewelry that willrestrict circulation if and when the swelling associated with the burn begins.

    Once scene safety is established and the primary assessment is complete, start with your head to toe assessment. As you make yourway down the body, start approximating the total body surface that has second- or third-degree burns (first-degree burns don’t count whenusing the Parkland burn formula). Depending on your protocol, burns over a certain percentage might need to be treated at a burn center.If your nearest burn center is an extended distance from where you currently are, either get en route as soon as possible or call for ahelicopter. Also, depending on your local protocol, burns to the hands, feet, joints, or face might also meet the criteria for transport to aburn center. Once you have determined where the patient is to be transported, start working on getting intravenous access and begin painmanagement, if appropriate. If at all possible, try to save the larger veins for the hospital. The badly burned patient will be on fluid therapyfor several hours or days, and intravenous sites need to be changed regularly. If you blow both of the patient’s antecubital veins trying toget intravenous access, you limit the hospital’s ability to provide fluid therapy. Having said that, sometimes you don’t have a choice as towhere to get a good vein, so do the best you can for the situation that you are given.

    If available, it is a good idea to monitor your patient for changes to their heart by beginning electrocardiogram recording. Massive fluidshifts might cause imbalances in electrolytes and result in changes to the heart’s electrical activity.¹

    Lastly, try not to focus only on the burns that the patient has. Your patient might have other traumatic injuries that are masked by the painor general appearance of a badly burned body. Once you have completed your primary and secondary assessments and are comfortablethat you have identified all of the threats to your patient, you need to start thinking about what is going to happen next.

    During your time with the patient, be sure to continuously monitor changes in airway, breathing, and circulation. Swelling that was notevident at the time of initial patient contact may begin to produce problems for the patient during transport, so be prepared to act on it, ifnecessary. Also, ensure that you are giving the right amount of fluids by double-checking your burn formula, and ensure that you aren’toverloading the patient with fluids by monitoring breath sounds and vital signs. Another important aspect is to make sure the patient is ascomfortable as possible. Ensure that you are providing adequate and appropriate pain management, and ask your patient if there isanything you can do to make him or her more comfortable. If you are running out of things to do, repeat your electrocardiogram or obtaina 12-lead electrocardiogram. It might be useful to the receiving facility to see what changes, if any, have developed in the patient’selectrical activity.

    Electrical Burns“It’s not the volts that’ll get ya, it’s the amps.” I’m sure you’ve heard that expression before, and for the most part it’s true. Electrical burnscan be incredibly damaging and even lethal under the right circumstances. While that statement is usually true, there is a little more thatgoes on when someone is exposed to electricity. Before we get to the burns, let’s cover some of the basics of electricity.

    Voltage can be defined as the difference between a source of high concentration to a point of low concentration. Think of it as thepressure of water in a fire hose. The rate of the flow of electricity is called the current, and it is measured in amperes.¹ Using the same firehose analogy, the amps would be the gallons of water per minute inside the fire hose. So if you were walking by a fire engine, and one ofthe fire hoses was being drained, the gallons per minute, or amps, would be enough to get your shoes wet. The same hose underpressure flowing at 250 gallons per minute would knock you off your feet. So in either case, your shoes are wet, and you aren’t generallyin a very good mood. In the latter case, you could very well be injured. So while it’s true that it was the gallons per minute, or “amps thatgot ya,” it still wasn’t a good idea to walk in front of the flow of water.

    Another element of electricity is how hard it has to work to get from one place to the next. This is referred to as resistance or Ohms. The

    harder electricity has to work to move, the more heat it generates. The more heat it generates, the more destructive the damage. If youneed another analogy, think about how irritated the firemen who have to put all the hose away, from the previous two analogies, would beif it were 100 degrees outside. The harder they work, the hotter they get and the more likely they are to tear something up. Not unlike atired firefighter, electricity looks for the path of least resistance. This resistance can vary across the body. Places like thick, calloused skinon the hands and feet provide the most resistance. The increased resistance will produce increased damage. Moist skin and mucousmembranes provide lower resistance and will produce less damage.¹ Because of the path electricity follows, you will generally see anentrance and an exit wound. What you can’t see is all of the damage done to the inside of the body where the current flowed through, andthis is an area where electrical contact can be deadly.

    Our hearts, among other internal organs, do not respond well to electrical currents. It is busy enough generating its own electricalimpulses to keep the blood circulating, and when even as little as 50 milliamps cross its surface, it has the potential to stop beating.¹

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    Another dangerous effect of continuous electrical current is its ability to cause muscle contractions that will prevent a person from openingtheir hand and letting go of a charged wire. If the current is not shut off, not only can it stop the heart, but it can also immobilize themuscles of the respiratory system.¹

    The treatment of electrical burns is similar to the treatment of thermal burns in that there can be large areas of skin missing, whichincreases the risks of infection, hypothermia, and hypovolemia. Add to this the internal injuries caused as the current looks for a way outand it can really make for a bad day. Faced with this situation, you are going to need to get started as soon as possible, but not until thepatient is removed from the source of electricity. Pulling meters down, relying on breakers that may have tripped, and assuming that thepower line is dead because you don’t see it sparking anymore are all completely unacceptable actions. In some cases, a neighbor may bestealing electricity and the meter you pulled was not attached to that electrical source. Downed power lines may be dead because of ablown fuse, but nothing says that the power company doesn’t have a way to restore power by switching on another fuse remotely. So assafely as possible, get the patient far away from the source of electricity, and protect others from going near it until someone from thepower company arrives and shuts off the power. Something that stuck out from a half-hour training class put on by a local electricalcompany several years ago and that is very good advice is: “We don’t mess with your fires, so please don’t mess with our wires.”

    Once your patient is safe to treat, start with your basics. Along with airway, breathing, and circulation pay close attention to deformities inthe form of fractures that may have been caused by the muscle contractions associated with prolonged electrical contact. As you moveinto your head to toe exam for trauma, look for entrance and exit wounds. Depending on the source of electrical contact, your patientmight have more than one entrance or exit wound.¹ Begin electrocardiogram monitoring as soon as possible, and look for changes in theheart’s electrical rhythm. Consider intubation early if the current passed through the upper airway, as swelling could shut down thepatient’s ability to move air. Treat any external burns as you would a thermal burn, and depending on the body surface area involved, youmight consider transport to a burn center. If your burn center is an extended transport and your patient is in cardiac arrest from theelectrocution, you might be better off transporting to the closest appropriate facility. Refer to department policies or contact medical controlto get guidance if you need help making this decision. As with the rest of the burns, pain medication should be considered.

    Chemical BurnsWith the thousands of new chemicals being produced every year, it is impossible to know how to treat each and every one of them. Thatis why it is important to have as many resources available to help determine the effects of the chemicals you might have to deal with.Several resources are available to emergency responders free of charge. One of the more common ones is the Emergency ResponseGuidebook. You can also find information about the chemicals from shipping papers if the exposure happens while the product is beingtransported or from material safety data sheets if the emergency occurs at a factory or warehouse. The best and safest option would be tolet personnel trained in hazardous materials remove and decontaminate the patient prior to any patient contact by you. If that option is notavailable, you will have to deal with the patient the safest way you know how. Fortunately, many of the chemicals that are within a certainclass behave in similar ways. So a general understanding of these groups might make patient assessment a little easier and safer.

    Before we get to the chemicals, let’s briefly go over what happens to tissue when it is exposed to chemicals. Rather than destroying tissuewith heat as in a thermal or electrical burn, chemical burns denature the biochemical makeup of cell membranes and destroy the cells.¹ Ifyou have ever had Ceviche at a Mexican restaurant, you have experienced the denaturing of salmon by fresh lime juice. The lime juice,being very acidic, “cooks” the salmon until it is white and flakey. Different chemicals will have different effects on our skin and mucousmembranes. Acids usually form a thick mass or coagulation at the point of contact. This process is called coagulation necrosis.¹ This thickcoagulation of tissue usually limits the depth of the damage. A particularly nasty acid is hydrogen fluoride. It is commercially used forremoving rust, etching glass, and cleaning brass and crystal. It is also found in many automotive cleaning products. When mixed withwater, it forms hydrofluoric acid. The fluoride ion penetrates the skin and binds intracellular calcium and magnesium. 4 Large doses ofhydrofluoric acid may be fatal and the burns are extremely painful. Patients exposed to hydrofluoric acid are usually treated with a mixtureof calcium gluconate and a water-based lubricant, like K-Y Jelly. This mixture is applied to the site of the burn and is continued until thepain is gone.

    Bases, on the other hand, are quite the opposite. They destroy tissue in a process known as liquefaction necrosis. A good example of thisis the slippery feeling you get on your fingers when you spill liquid bleach on them. Alkali burns will travel deeper into the layers of the skinand cause more problems. You might run into chlorine in a pool supply store or at a water treatment plant. When chlorine gas isintroduced to the airway tract, your patient will complain of symptoms ranging from a sore throat to complete lung collapse due to the

    increased fluids the lung produces to deal with the irritation. Dermal contact can cause burning pain, inflammation, and blisters. There isno specific antidote for chlorine. 4 Treatment usually includes dealing with the airway complications and managing pain afterdecontamination has been completed.

    Sometimes, the reaction you get when you mix an acid with a base gives off heat. It is for this reason that you should never try tochemically neutralize one with the other. There are some agencies that are nebulizing sodium bicarbonate for patients with inhalationinjuries from acids. The rational is that the heat from the sodium bicarbonate will do less damage than the heat from the acids if left alone.This decision should be left up to your medical control or your department.

    The best decontamination for most chemicals is flushing with copious amounts of water. “The solution to pollution is dilution,” but whenchemicals react violently with water, the best solution may be alcohol or even oil. Chemicals such as dry lime need to be brushed off prior

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    to being rinsed with water. It is highly reactive and requires copious amounts of water once the majority of the powder is removed. Sodiumis a member of the alkali metals family and can react violently with just the moisture in the air. It acts even worse when exposed to water.It is generally stored in oil, and it is recommended that after quickly removing as much of the material as possible, the wound is coveredwith the oil that it is transported in.¹ Lastly, blister agents that are used as chemical weapons will be very difficult to remove. If thechemicals could be easily hosed off with a garden hose, they wouldn't be very effective weapons. So be prepared to think of alternateways to decontaminate, depending on the specific agents used.

    After your patient has been decontaminated, be sure to remove and safely store all clothes by double-bagging them. If you are working alarge incident, make sure that there is some sort of identification in the bag to tell you who it belongs to. While the clothes are usuallydestroyed, personal effects, such as wallets, keys, and cell phones, can be cleaned and returned to the patient. As you begin yourtreatment, be mindful that patients have the ability to off-gas certain chemicals. It is for this reason that transportation by helicopter isgenerally not a consideration. The effect of the chemical on the pilot and crew in an enclosed space at altitude is never a goodcombination. Provide supportive care during transport, and be very certain to advise the hospital that you are bringing in a patient that hasbeen exposed to chemicals. They have protocols and procedures to follow to make ready prior to your arrival. Also, bring as muchinformation to them as possible regarding the type of chemical that the patient was exposed to. If continuous irrigation to the eyes or othermucous membranes is needed, consider hooking up an IV drip set to a nasal cannula. This can be placed across the bridge of the nosebetween the eyes and provide a continuous flow of fluids. Be mindful of where the runoff is going so you don’t contaminate the patient oryourself.¹

    Radiation BurnsChances are good that you will never have to deal with a true radiological emergency. However, some of you may work near industrialfacilities that either store or use radioactive elements; some of you may be near these types of facilities without knowing it; and you neverknow when some lunatic might go through the mall with a “dirty bomb” and blow up the food court to smithereens. The most importantthings you need to remember with any radiological emergency are time, distance, and shielding. You need to spend as little time as

    possible in the area where the radiation is, stay as far away from the radiation source as you can while still able to perform your jobfunctions, and keep as much “stuff” between you and the source of radiation as possible. A giant sheet of lead would be perfect to hidebehind, but in the absence of that, large piles of earth, concrete, or fire trucks are all better than nothing.

    Not all radioactive materials are immediately deadly. Some smoke detectors have small amounts of Americium 241 or Radium 2265inside, which at a distance do not pose any real threat. Also, X-rays obtained at a hospital in small and infrequent doses do not usuallyproduce lasting harmful effects. So what makes radioactive materials dangerous? Well, it depends on the type of radiation being emitted.

    Ionizing radiation is the most dangerous, and it is commonly referred to as Alpha, Beta, or Gamma radiation. Alpha particles are veryweak and generally can’t pass through a sheet of paper or intact skin, so as long as you aren’t eating them or inhaling them into yourlungs, they don’t pose a significant threat. Beta particles are slightly stronger and can pass through your skin but generally will not travelall the way through your internal organs. However, they still do pose a threat because they can get under the skin and cause externaldamage in the form of burns and internal damage in the form of tissue or cell destruction. Gamma radiation poses the largest threatbecause it passes straight through our bodies, the bodies of whoever is standing next to us, and usually whatever else gets in its way,with the exception of lead. While it is passing through, it causes massive destruction in the form of burns and can eventually lead tocancer if the exposure is strong enough. So it is of great importance to determine the type of radiation that the patient has been exposedto as well as how long he or she was in close proximity to it.

    It is important to differentiate between whether the patient was exposed to or contaminated with radioactive materials because there is adifference. Patients who are exposed to radiation are safer to treat than patients who are contaminated with radioactive material. Forexample, if your patient was sitting in his or her office and a co-worker brought in a warm chunk of metal and said, “Hey, look what I foundburied in the ground behind the army-navy store,” both the patient and the co-worker have been exposed to a radioactive material. Onceyour patient runs out of the room, he or she is technically safe to treat. On the other hand, if someone detonates a suitcase bomb with thatsame chunk of metal in it, everyone in the area has been contaminated with radioactive material and needs to be decontaminatedthoroughly by trained personnel. That is because the radioactive material has been broken into millions of tiny pieces by the bomb and isnow floating through the air on particles of dust and debris. All of those tiny chunks of radioactive material will come to rest on people andcould possibly end up in their lungs or stomachs. This type of bomb is referred to either as a “dirty bomb” or a radiological dispersion

    device. Whatever you call it, it is bad news if you are anywhere near one of these things when it goes off.

    Exposure to radioactive materials is usually classified as acute or chronic. Acute exposure generally consists of a large dose occurringover a short period of time. Symptoms from acute exposure include burns, indigestion, and vomiting. Chronic exposure occurs in smalldoses over a long period of time. These types of exposures generally cause cancer several years later. 5 Any of the physical burns youmight encounter can be treated like a thermal burn: clean, cool, and cover with sterile dressings; monitor the patient for hypothermia andhypotension; and transport to the appropriate facility.

    The decontamination procedures for patients who have been contaminated generally involve a thorough soap and water wash withprolonged irrigations to the eyes and any open wounds. Internal ingestions can sometimes be treated by drinking water or an aluminumphosphate solution over several hours. 6 As with any other incident involving hazardous materials, transport the patient only when it is safe

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    to do so for you and the patient. Lastly, be sure to notify the hospital that you have a potentially contaminated patient so they can preparefor your arrival.

    SummaryIn this article, we discussed some of the basic functions of the skin and how important it is to monitor for the absence of these functionswhen the skin is damaged by burns. We also reviewed the different layers and how to classify burns depending on the depth at which theyextended into the skin. All burn types require that we remove the patient from the source of the heat as soon as it is safe to do so.Thermal burns often require cooling with large amounts of water and a rapid and sterile transport to an appropriate facility. Electrical burnsoften involve internal injuries, and it can be difficult to get access to the patient if the source of electricity cannot be shut off byappropriately trained individuals. Chemical and radiological burns can involve lengthy decontamination procedures and pose a great riskof immediate and long-term problems for the patient and any rescuers who might have been exposed to the same hazardous materials.Nothing is ever easy in EMS and burns are no exception. But with the appropriate safety precautions, and the ability to predictcomplications before they happen, our patients have a good potential for full recoveries.

    Author John Wright, Copyright © CE Solutions. All rights reserved.

    References

    1. Bledsoe, B.E.; Porter, R.S.; and Cherry, R.A. “Paramedic Care: Principles and Practice.” Trauma Emergencies, Volume 4. UpperSaddle River, NJ: Prentice-Hall, 2001. pp. 172–207.

    2. Mayo Clinic Staff. “Burns: First Aid.” Mayo Clinic. 19 April 2008.3. “UTSW / BIOTEL EMS SYSTEM: APPENDIX D.” Biotel. 21 February 2008.4. Department of Health and Human Services, et al. Managing Hazardous Materials Incidents: Medical Management Guidelines for

    Acute Chemical Exposures, 3rd ed. Ed. Scott V. Wright. Agency for Toxic Substances and Disease Registry. 2001.5. Bertell, Rosalie. “The Potential Hazard of Ionizing Radiation in Smoke Detectors.” International Institute of Concern for Public

    Health. 22 April 2008.6. Aguilar, Mike. “WMD Radiological Toxicology.” WMD Hazardous Materials Technician Training. Center for Domestic

    Preparedness, Anniston, AL. April 2003.7. Illustrations by Louis Saldivar.

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