I do some volunteer work for the Red Cross, and one thing we can count on is that when the going gets cold, there are a lot more fires. We fend off the cold with the fire, but the fire isn’t very particular about what it bites. Burns make up 2-8% of wilderness injuries (not counting sunburns, even though they can actually be serious in some cases).
Burns are no fun; they hurt a lot. Big news, right? Worse, the only definitive care for serious burns (3rd and 4th degree burns, where the burned area is no longer painful because the nerves are destroyed) is grafting, which won’t be available without advanced medical care. To help avoid the burns, be aware of where most of the injuries come from. In adults, that’s contact burns from tools used for cooking or for light or hot coals, and scalds from very hot fluids. In children, scalds are most common. That’s one reason I love the Kelly Kettle (reviewed here); it’s got a good system for pouring without burning myself or getting a faceful of steam and the fire is safely contained. (Reminder: We have no sponsors, and have zero financial interest in mentioning any particular product. )
Note: I’m not a physician and don’t give medical advice. This is a summary of information from the literature, not recommendations from Spice.
The first thing to do should be done fast, as burns can get worse if the heat level isn’t taken down immediately. Of course, stop, drop, and roll if the person’s actually afire! Cool (not ice cold if you can help it) running water, or if there’s not enough water for that, cool compresses should be applied as soon as possible. If there’s something hot close to the skin, such as a woolen glove soaked with boiling water, remove it immediately. If ice is all you’ve got to cool with, it will obviously cool effectively but shouldn’t be left on for more than a few minutes, as it impedes helpful blood flow and may cause frostbite.
Assess the extent of the burn
First degree burns (no blisters, red and painful) don’t need care, although some of the techniques below may improve comfort.
Second degree (blistering, red, and painful) will be discussed below. Even on a more serious burn, there’s usually areas of second degree burning at the edges.
Third and fourth degree burns (tissue charred or white, hard, without sensation) are not expected to heal without advanced medical care, but one can still treat the second degree burning at the edges and deal with the hydration and pain issues discussed below.
Percentage of total body surface area affected by the burn (%TBSA) is used to describe the extent of the damage, and helps guide treatment. It matters because it can help guide treatment, as will be discussed below. There are two ways to estimate %TBSA easily:
- The palm of the hand represents about 1% TBSA. If both palms would just cover the area of damage, it’s a 2% TBSA injury.
- The Rule of 9s is used for more extensive burns. Each arm is about 9% of your TBSA, each leg 18%, front of torso 18%, back of torso 18%, head and neck 9%
Clean it up
It won’t surprise anyone that you should wash the wound to remove debris. If the unfortunate soul was in contact with plastic that has melted into/onto their surface, don’t try to pull out all the bits. The tissue it’s in contact with is already dead.
But what about the blisters? All the sources I read agreed that blisters smaller than a quarter that didn’t look as if they’d rupture spontaneously should be left alone. It’s more comfortable for the patient and reduces infection rates. One can treat burn blisters like any other sort, using moleskin or foam with a blister-sized hole cut out of it over the blister to pad the blister and provide some protection.
Most, but not all, sources thought that broken blisters should be debrided. Debridement is med-speak for getting rid of the dead tissue (you can read more about it here); in the case of blisters it means trimming away the top skin. There was also a majority opinion that blisters that were larger than a quarter, or were over a joint, or that otherwise looked like they would rupture on their own, should be drained then debrided. An easy draining method is to prick the blister at its lowest point with a needle or safety pin. I generally run the needle through a flame or put some alcohol on it first to sterilize it (c’mon, you Do know to let it cool before using, right?)
Dress it up
You want to keep burns moist but clean while they heal. Good old antibiotic-infused petrolatum (mycitracin or bacitracin-containing, usually … my Mom called it ‘Magic Medicine’ because it worked so well and we kids knew it wouldn’t hurt to get it put on) with gauze overtop is a good choice. There are also several natural dressings that have proven themselves in trials, including honey and aloe vera (more on that here). Potato peel dressings were also useful: Clean and boil potatoes, aseptically (so, use a tool you’ve dipped in alcohol or flamed) remove pulp, put peels with inside surface on burned area. Yarrow, turmeric, and St. John’s Wort also showed some effect in animal trials, but haven’t been well studied yet. Please note: Passing along a message from an urgent care provider friend of mine, PLEASE don’t put anything on the burn if you’re going to take it in for professional care. Also, skip the butter entirely!
If there’s a lot of burned area, an overwrap may be used to keep it moist. Kitchen-variety cling wrap over the top of the moist dressing seems to do well. Amniotic membrane can be used too. What? Don’t have any amniotic membrane in your back pocket? Well me neither; large sections would come only from placentas. Realistically for most people, you can get enough for small burns by harvesting that membrane that lines the inside of an egg shell; the one that annoys you when you try to peel the cold boiled egg. Dressings should be changed at least once a day, they say.
Burns hurt a lot; pain control is your friend. Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDS, all varieties of aspirin, acetominophen/Tylenol, ibuprofen, naproxen/Aleve, Excedrin, etc.) help. Narcotic painkillers such as codeine and oxycontin are ‘the Big Stick’; one can take both those and NSAIDS to reduce how much narcotic is needed). Icing does help control pain, but limit it to 20 min episodes unless you want to over-restrict blood flow and slow healing; also avoid direct ice contact as it can cause frostbite. That’d be a heck of a note, giving yourself frostbite to treat a burn. (What, want to know more about frostbite? Here. I swear I’m not Looking to put in links; I just keep stumbling over them…)
When large areas of skin are burned, there can be a surprising amount of fluid loss. Also some of the blood fluid moves into the swelling, so blood volume gets too low. Rehydration is important in such cases.
If there’s 20% or less of the total body surface burned (20% TBSA), just feeding the person frequent small sips of rehydration fluid should do it. Gatorade and company? They’d probably work. One recipe offered by the World Health organization is:
Per liter of potable water: ⅜ teaspoon salt, ¼ teaspoon salt substitute (KCl, potassium chloride), ½ teaspoon baking soda, 6 teaspoons sugar. If you’re not up to something quite that elaborate, you can drop the salt substitute and baking soda and up the salt to 1/2 teaspoon.
If there’s more than 20% TBSA burned, that’s a real problem. If you’re set up to do IVs, there are a couple of recommendations; this is one of the simpler ones and comes from the Army:
10 ml/%TBSA/hr IV. Make sure they’re maintaining .5 mg/kg/hr urine; 1 mg/kg/hr for children (roughly 50 ml/hr for a 220 lb man). If you want a second opinion on IVs, the Parkland formula has been recommended: 4 mL/kg/%TBSA of Ringer’s lactate solution over the first 24 hours; half of the fluid is given within the first 8 hours after injury and the other half is given over the next 16 hours. (For a 220 lb man, with 5% coverage, that would be 2 L total. Lactated Ringer’s is not too different from 9% NaCl, but has better ion balance and some nutrient molecules, so I imagine 9% NaCl would be a decent sub.)
If you’re not set up to do IVs, you can still give the rehydration drink. It can even be infused into the rectum to increase its uptake, which is helpful if the person can’t tolerate drinking.
Here’s hoping you keep warm … but not too warm.
There was a lot of agreement among various sources I read for this piece. Two sources that summarized a lot of it are below. The second one, a text for a wilderness med course run by the University of Utah, also has good information on other kinds of wounds.
Bitter, Cindy C. et al. Management of Burn Injuries in the Wilderness: Lessons from Low-Resource Settings. Wilderness & Environmental Medicine , Volume 27 , Issue 4 , 519 – 525
Wilderness Med course, U of Utah. Accessed 1-4-18. Chapter 2: Wound Management.
- By Themidget17 (Own work) [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)], via Wikimedia Commons
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