Burn, baby, burn!

Burns are devastating injuries. They leave physical and psychic scars on the victims. ER staff are often traumatized when they care for patients with burns. Two patients with burns from a MVA, when the contents of a truck exploded, were brought to the ER this week. My young partners expertly cared for these patients and expedited their transfer to regional burn centers.

Thermal injuries can be caused by hot liquids, direct flame, electricity, or hot air. Infrared and ultraviolet rays can burn exposed skin, i.e. a sunburn. Burns are roughly divided into superficial, partial thickness and full thickness.

Superficial burns damage the upper layers of the skin but to not reach the deeper levels. A sunburn or mild scald are examples of superficial burns. The treatment is cool compresses. Topical creams containing aloe are popular and may give some comfort. NSAID's such as ibuprofen are usually adequate for pain control.

Partial thickness burns cause damage to the deeper layers of the skin and subcutaneous tissues. Blistering of the skin is often evident. These burns are very painful. Infection is likely and prophylaxis for tetanus should be given. Careful handling, removal of dead tissue, and burn dressings are used by the ER and burn center team. Fluid loss can be significant. IV fluids are often given to maintain adequate blood pressure and urine output.

Full thickness burns are usually painless. The skin and subcutaneous tissues including the sensory nerves have been destroyed. Muscle, tendon and even bone may be exposed. The treatment requires skin grafting. These burns must be treated at burn centers. The recovery is prolonged and painful. Physical therapy is a must, to recover use of burned limbs and to prevent contractures.

Electrical burns are especially difficult to treat. The external signs of the burn may be minimal. The deeper structures including muscles, nerves, and blood vessels may be severely burned without initial evidence on the surface. Cardiac complications, when the electrical current crosses the chest, are common. The voltage and duration of contact are important in determining the extent of the injuries

The area of the body surface that is burned is a critical factor in the prognosis and treatment of burns. ER staff use formulas to calculate the percentage of body surface burned. The degree of burn is also measured. Fluid resuscitation is guided by these measurements.

The burned patients airway is a critical part of the ER doc's priorities. Burns of the upper body or any burns from superheated gases may damage the upper airway and cause swelling and blockage of the airway. Endotracheal entubation, cricothyrotomy or tracheostomy may be necessary.

Deep burns that involve the neck, trunk or limbs may cause constriction of these structures. Blood flow and or respiration may be impeded. An escharotomy is the required treatment ASAP.
Escharotomy is the incising of the burnt and contracted tissue to restore blood flow or allow the chest to expand.

Early in my career I treated a homeless man who had lighter fluid squirted on his legs and been "lit up" by unknown assailants. He arrived in the ER with full thickness burns from his lower abdomen to his feet. His genitals had been burned off and he had no pulses in either leg. An inexperienced surgeon was present as the "trauma" surgeon. I pointed out that the patient needed escharotomies of both legs and a cystostomy to gain access to his bladder. The surgeon froze. He knew what had to be done but told me that he had never done either procedure solo. My emergency medicine residency was at a hospital with a large burn center. I did what I had been trained to do. Long incisions, fully through the eschar on both sides of each leg, rapidly and thankfully restored circulation. I placed a suprapubic catheter and got good urine flow. The patient was transferred to a burn center but died of his injuries a few days later.

No witty comments in this blog. I still cringe at the smell of burned flesh. ER staff are all too human. We are deeply effected by the suffering of our patients. Be careful. We are ready and able to care for the victims of burns.