G’day everyone and thanks for reading another blog. This one has come about from an article that boss man Andy sent me, found here. In a nutshell, a nine-month-old little fella was playing in his backyard in America with the garden hose, when things went from innocent play to gut-wrenching in minutes. The garden hose had been lying in the yard and the water inside had become heated to such an extent that when it flowed out of the hose on to the little fella, it caused some substantial second-degree burns.
As anyone who is a parent would know, these kinds of stories tug at the heart-strings a bit and you hope with all the hope you possess that something like this will never happen to your own kids. However, we live in a country where daytime summer temperatures are regularly in the high 30’s and more times than is comfortable over the 40 mark. Most households have a garden hose, if not a lawn sprinkler as well. So this article could very well directly translate to any household here in Australia. This blog article will do a deep dive into the what happens when we receive a thermal burn and then what to do about it.
Being a fireman for 14+ years, I’ve been unlucky enough to see the effects of burns on people. Whilst this blog will concentrate on thermal burns (i.e. burns caused by direct heat on to skin – think steam, boiling water, hot coals, etc), they can also be caused by cold (frostbite/cryogenic burns), electricity (see my recent blog on electrocution first aid), chemicals (liquid, powder and gas), friction and radiation (sunburn, welders flash, laser). Before we go into the first aid for thermal burns, it will be handy to know just what a burn does to your body.
Burns are generally classified according to their depth – superficial, partial thickness or full thickness. If you’ve been doing first aid for years, this basically represents first degree through to third-degree burns.
These burns involve the top layer of the skin, called the epidermis. You’ll notice that the burn will be painful and will be red. It will also have some swelling as well. The pain and swelling will generally subside within 48 hours, with skin peeling and complete healing happening within a week.
Partial thickness burns
This is where things get painful, as the burn depth goes down through the epidermis into the dermis proper. This is the area of the skin where you’ll find capillaries, nerve endings (pain and pressure receptors), sweat ducts and hair follicles. These are the burns where you’ll get blistering.
Partial thickness burns are generally divided into two categories:
Superficial partial thickness – typically bright red with a moist surface, super sensitive and painful, even to air movement. Will normally heal in 2 – 3 weeks with minimal scarring.
Deep partial thickness – typically dark red or yellow-white and take longer than 3 weeks to heal. These ones will scar.
Full thickness burns
These are nasty, they go through both layers of the skin and, depending on where the burn is, will go through to the fat, the muscle or the bone (sometimes classed as 4th, 5th, and 6th degree burns). You’ll notice with these burns that they will have either a black, charred leathery look, or they might look a pearly or waxy white. These burns will not be painful to the touch as all nerve endings have been destroyed. It takes a lot to get these burns to heal, which will only be done by scarring or by skin graft.
So now we’ve seen what to look for, let’s take a deep dive into what the skin actually does and how so many things can go wrong if we were to receive a burn. The skin is the largest organ in the body and its most important functions are: to act as a vapour barrier to prevent water loss from the body; to present the body’s major barrier against infection; and as temperature regulation. Consequently, fluid loss and hypothermia are two very real concerns that need to be addressed by first aiders. Infection is also something that should be considered. When we receive a burn, there are two types of response to the skin, a local response and a systemic response. The local response basically looks at the actual burn, how the skin and blood vessels react and how it can improve/worsen, depending on the treatment we give. That’s about as technical as I’ll go because unless you’re heavily into this sort of stuff, you’ll fall asleep!
The systemic (or whole of body) response is where things do get interesting. You see, burns are a pretty unique injury. If we were to get a cut to an arm, or roll an ankle, we’ll get swelling. We’ve all seen or experienced this. With a burn, you’ll get localised swelling to the burn area, generally within the first hour of the burn occurring. However, due to a bunch of things happening at a cellular level within our body, further swelling of the burn area and non-burned area will occur 12 – 24 hours following the burn injury. This typically happens in patients with greater than 20 – 25% Total Body Surface Area. Further, damage and issues can also occur in other organs of the body, particularly the lungs (even though an inhalation injury hasn’t happened).
Whilst not common to determine at a first aid level, I am often asked how do we determine the surface area burnt on a person. It’s a fair question, so there are two ways you can estimate, the palm rule or the rule of nines (a third is the Lund Browder chart which is more accurate but a lot more complicated. Feel free to ask Aunty Google for an explanation and a picture):
1. Palm rule – quite simply the area covering the patient’s palm approximately equals 1% body surface area.
2. Rule of nines – the body is divided into sections and given a percentage using multiples of nine
Now that we know what causes a burn, what to look for, what happens when we get burned and how to calculate how much is burned, let’s refresh what our first aid is.
First aid treatment for burns
Your initial first response should, as always, consider DANGER!!! You don’t want to get yourself cooked, so if you have the training, utilise appropriate first response firefighting equipment such as fire blankets and hoses. Consider fire extinguishers and use appropriate types (water as opposed to dry powder for example). Your patient, if actually on fire, should perform the stop, drop and roll move. Stop moving (movement fans the flames with additional oxygen), drop to the ground and cover your face, roll back and forth to smother the flames. If you have a fire blanket, you can assist your patient by using this to smother the flames. Even though flames may have been extinguished by you, it is still advisable when calling Triple Zero to get the fire service to attend as well.
Treating the burn should include the following steps:
- Run cool water over the burn for 20 minutes. Studies have found that this is still effective up to an hour after the burn (some say within 3 hours, but not everyone agrees). What this does is effectively provides pain relief and reverses the burning process (2nd law of thermodynamics – heat spontaneously travels to cold). Be cautious of hypothermia, COOL THE BURN, NOT THE PATIENT.
- Don’t use ice or icy cold water – if you use ice, you can cause further damage to the flesh that has been burned. Icy cold water will possibly induce hypothermia in your patient. They are already going cold with shock, it’s very important to monitor for hypothermia.
- Remove clothing and jewellery that is not stuck to the skin – clothing that has been burnt or soaked in boiling water can retain the heat, as can nappies on babies. Metallic jewellery can also retain heat. Also, you want to be cautious of anything that can be constrictive for when the burn area swells. However, if it is stuck to the skin, leave it.
- Apply a non-stick dressing – following the cooling of the burn, apply a non-stick dressing or covering. Cling wrap is good, so long as it’s applied in strips down the limb. Do not wrap it circumferentially around a limb because, when the limb swells, the cling wrap won’t stretch and you’ll effectively have a tourniquet applied. Cling wrap is also beneficial in that it helps reduce fluid loss Wet absorbent dressings are good too, such as Melonin dressings soaked in water, or your commercially available burn dressings soaked in Hydragel. Do not apply any dressings that contain lint, such as gauze or cotton wool. This will stick to the flesh and not be fun to remove.
- Cover unburnt areas with blankets or use space blankets to retain body heat.
Elevate limbs to minimise swelling
- Do not burst any blisters – this will greatly increase the chances of the patient contracting an infection. The skin of the blister provides a very nice barrier protecting the sensitive stuff underneath.
And that pretty much wraps up all you ever wanted to know about burns and how to treat them! As with all blogs, you only get so much out of reading them. It’s far better to put theory into practice, so it’s always recommended that you take part in one of our first aid courses run either at Helensvale, Mermaid Beach or our new location at Harbour Town. We can also come to you, just get in touch with our office and the good folk there can help you out. It was a bit of a longer one than usual, so thanks for reading and as always, stay safe.
Cameron, P., et al. Textbook of Adult Emergency Medicine (3rd ed.). 2009
Curtis, K and Ramsden, C. Emergency and Trauma Care for Nurses and Paramedics. 2011
Herndon, D. Total Burn Care (5th ed.). 2018
ANZCOR Guideline 9.1.3 – Burns
Queensland Ambulance Service – Clinical Practice Guidelines: Trauma/Burns