Medical Wednesday? 20 Nov 2019

Once again I want to apologize for how late this post has been, I have been extremely busy the past week between classes with our new provider, different platoon tasks handed down, me getting sick, and other miscellaneous things have gotten in the way. On to the important stuff though, the post this week will be about burns. This will be a long, so buckle up, grab some coffee and settle in for a long ride.

Burns come in a few different forms. Determined either by the cause or the depth. You might be familiar with hearing them referred to as “degrees” as in first degree, second, etc. Medically they are referred to by how deep they go. Burns, simply put, are tissue damage caused by heat, the sun or other radiation, or chemical or electrical contact. Treat doesn’t vary much by cause, but it does key you into some other issues they may potentially have.

Superficial burns are the ones that almost everyone is familiar with. The most common form of a superficial burn is a sunburn. Superficial burns only reach the uppermost portion of this skin, known as the epidermis. They will be red and painful. Later on, you may see peeling depending on how bad it is. The same goes for blisters, although they are rare for this kind of burn. Treatment for these is relatively simple. Remove from the heat source and apply something to prevent further damage. Aloe Vera gell works very well for this. Sunscreen and full-length clothing is your best protection to prevent this. Wide-brimmed hats work exceptionally well for this task as well. The military still issues out the “boonie” cap to troops for this purpose.

Partial-thickness burns are the next severity of burns. These go partially into the next layer of the skin. There will be more blisters on these and the surrounding tissues may be superficially burnt depending on the cause of the burn. These are the most painful type of burns. Do not pop the blisters unless it impedes your ability to do basic tasks. Keep these dry and clean. STAY AWAY FROM BURN CREAMS. They never work and most of the time make the issue worse. Bacitracin is the only cream you want to put on these burns. Other than that just keep them dry and clean. Depending on how deep into the next layer of skin this burn goes it will scar. Prevention is extremely important here because treatment gets complicated depending on location and your ability to keep the area clean and dry. So no cooking bacon shirtless. Sorry. Keep your collars popped on those combat shirts under your kit and that tactical scarf makes sense now, it’ll keep hot brass from falling down your shirt and getting trapped under your shirt by your kit. Don’t go grabbing the lid for that dutch oven without a heavy-duty glove either.

Full-thickness is the next type of burn. These go beyond the layers of the skin and go into the underlying tissues. Muscle, tendons, ligaments, nerves, all have the chance to be damaged by this depth of burn. The nerve endings being damaged are why partial-thickness burns are more painful. Full-thickness will be surrounded by partial-thickness and then superficial burns. Especially when heat is the cause of the burn. These will have dead tissue with a dry, dark brown appearance. Removal of all dead tissue is a must, gangrene will start if the dead tissue is left on the wound. Skin grafts are normally used in hospitals for this, but I doubt ANYONE has that technology or the support structure to let that be viable. Compression therapy is also used to prevent scarring. For someone working within the idea that the grid and everything surrounding it will not be in full swing, manuka honey (or really any pure honey) has shown great promise and is even preached in the Military Clinical Practice Guidelines, or CPG’s, that govern how we handle medicine in austere environments with limited supplies. The honey works by first creating an airtight barrier that does not allow any bacteria to enter. Honey also only supports the growth of anaerobic bacteria, the kind that only grows in the absence of oxygen. Since the bacteria that can cause harm to us are aerobic or require oxygen to live, this makes honey an excellent choice for wound treatment, and not just for burns. The military has also found that daily dressing changes have little effect on the infection rate of wounds in an austere setting. Once again, prevention is the best course of action for this.

A huge consideration for burns is when the Total body surface area of the burn (partial and full-thickness only) is greater than 20%. At this point, you would have to start worrying about fluid resuscitation. Plasma from the surrounding tissue will leak into the burned tissue due to osmosis in an attempt to make up for the fluids lost. This will cause massive dehydration and a condition called hypovolemia, which is basically decreased blood volumes specifically of the plasma. This can cause a whole litany of complications leading to death. Also between the hypovolemia and the loss of skin hypothermia is also a massive concern. To determine the Total Body Surface Area or TBSA, you can memorize the percentages, or just use a handy reference chart. The DOD included it on the standard trauma documentation form so you wouldn’t have to remember it. It is called the Rule of Nines.

As you can see there are two different sets of percentages. One for infants, and one for adults. If you can’t decide what to use, just use the palmar method. It uses the PATIENTS hand to determine TBSA with the PATIENTS hand being equal to 1% of TBSA. If it is greater than 20% prepare to start pushing fluids. But you’ll need some more information. Like how much fluid to push, and how quickly. And do I have to be able to do an IV or are there other options for those of us not trained in that skill?!?! Well, I’m getting there.

Once you have the TBSA from the Rule of Nines, you’ll then use the Rule of Tens to determine how much fluid to give every hour for an adult who weighs no more than 80 KG (or 176 lbs) simply take the TBSA and multiply by 100. So if the TBSA is 25, your hourly fluid rate would be 250 mL’s an hour. And you want to use Lactated Ringers, not Normal Saline. For every 10 KG over 80 Kg, you will add an additional 100 mL per hour. So if you have a patient that weighs 120 Kg’s with a TBSA of 30 you would take 30 and multiply it by 100 to get 300 mL per hour. Then add 400mL per hour to get a total of 700 mL per hour. And this works for IV and rectal or oral fluids. If you are going to use rectal or oral fluids, take 1 L of water, and mix in 8 teaspoons of sugar, .5 teaspoon of salt, and .5 teaspoon of baking soda. The same rates apply. For children, you are going to use a different formula. 3 mL x TBSA x Bodyweight in Kgs. That will give you the total fluid to push over 24 hours. The first half gets pushed over 8 hours, the second half over the following 16 hours. Same fluid type as adults. This is why I keep enema bags in my kits. Super cheap and no need to store sterile fluids.

All of this information is a baseline to get you on the right track. If you do not have a medical provider in your group, you are seriously wrong. And no, I do not mean a medic or someone who is a nurse. They may have an amazing depth of knowledge, but there is a reason why PA’s and Doctors go to school for as long as they do. That level of knowledge can not be replaced.

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