Burn injury treatment: Extended cooling reduces chances of survival
In this article, CTIF´s Associate Member IFA - International Fire Academy - discusses how burn victims should be treated with Johannes Horter, a German burn treatment expert and plastic reconstructive surgeon.
How should burn victims be treated until the paramedics arrive? And what is important for firefighters if they suffer from a burn injury themselves? Information on this topic is given by Johannes Horter, since 2014 head of Department of Hand, Plastic and Reconstructive Surgery, and intensive care center for burn injuries at the BG Hospital Ludwigshafen.
By CTIF Associate Member IFA
Mr Horter, at the 2nd Symposium on civil defence and emergency medicine in Stuttgart at the end of last year, you discussed the subjects of burn injuries and burn treatment. What should firefighters do when they give first aid to a victim with burn injuries?
Johannes Horter: The information I am giving here is not so much towards the question of what professional paramedics of a fire service can do, but rather what firefighters can do to support the medical rescue service. This, of course, depends strongly on the incident situation. Let us, therefore, assume that individual medical care can be given and that there are sufficient firefighters on scene.
As soon as the burning clothes are extinguished, everything of the clothing should be removed, what can still be a heat storage and, for example, evaporates or releases heat and is easy to remove. If clothing adheres to the body, this area is to be cut out. After that, it is important to protect the patient from further cooling and to give him or her encouragement until adequate medical help arrives. Naturally - as with every first aid - the vital functions are to be checked regularly and, if necessary, appropriate measures must be taken.
Long-term firefighters recollect cooling the victims with burn injuries. What should today's practice look like?
Johannes Horter: In the mid-1990s, the topic of cooling could still be found in medical literature. After severe burn injuries, emergency physicians would have the patient while lying on a stretcher rinsed and cooled down with a fire hose. Today we know that when the clothes are extinguished and mostly removed, there is no further increase in the temperature of the upper dermal layers. Cooling is not an advantage - but it can lead to serious complications: hypothermia.
It is absolutely necessary to prevent the patient from hypothermia. If patients are brought to a centre for burn injuries with hypothermia, starting at a body temperature below 36 °C, it has a measurable influence on the prognosis, i.e., the severity of the disease, the development in the next hours and the survival of the patient. We, therefore, recommend that the cooling on small-area burns, e.g. on the hand, is limited to pain reduction and is recommended to amateur helpers rather than to medically professional helpers.
What impact does this have for the initial treatment of patients by the firefighters, for example at an incident in a tunnel with long rescue routes?
Johannes Horter: After the rescue from the immediate hazardous area the wounds should be covered sterile and dry. In principle, avoid applying any ointments, powders or even cooling bandages. The patient should at least be protected with an emergency blanket against drafts and further cooling. If transport distances are long, self-heating blankets are a good measure. The rescue aid should always be pre-heated when treating major burns, and during the transport a temperature measurement of the patient must be carried out, to be able to document and influence the effect of heat retention.
Should cooling of small burns also be avoided?
Johannes Horter: Everyone of us does it: if we, for example, touched a hot iron or a hot pan with our hand, we first run to the water faucet and cool the affected area of the skin. This is not harmful at all, as long as the patient is conscious and awake, can assess the temperature, experiences the treatment as pleasant and does not start to shiver. Typically, we see this behaviour from patients with manageable burns. For reference, we say: in the case of an adult, burn injuries of up to 5% to 10% of the skin surface can be cooled locally under the stated conditions with a clear, normal temperature fluid and without pressure. Ice water or ice bags should always be avoided.
How can one imagine the extent of a burn injury of 10 percent?
Johannes Horter: This can be assumed, for example, if the injuries cover the bottom side of both arms or one complete arm.
Do firefighters nowadays have to expect to be ordered by a doctor to cool a patient?
Johannes Horter: The likelihood that a colleague working as an emergency doctor has to deal with serious burn injuries on a regular basis is nearly zero. A certain amount of uncertainty in the rescue services and with emergency doctors is quite evident. This can only be met with regular information and training offers. We do this here in Ludwigshafen on a regular basis - as do the other medical centres.
When should firefighters see a doctor if they suffered burns during an operation?
Johannes Horter: First, a preliminary remark: firefighters who are subject to the German accident insurance law are insured by the employers' liability insurance association. They must have a high interest in presenting, documenting and treating with all available means any thermal injury that may affect their workability. It is no use, for example, to want to deal with a burn injury on a hand at home for 14 days, until a scar may form, which could subsequently impair the function of the hand considerably.
Can you provide concrete indications as to when treatment is necessary?
Johannes Horter: As is known, we distinguish between different degrees of severity of the burn injury. The first degree is similar to a sunburn. Redness and pain occur, and it usually heals without consequences if there is no large-scale thermal damage present.
When blisters form, it is a second-degree burn injury. Here, a special wound treatment and regular monitoring are necessary. A layperson cannot judge whether or not the wound underlying the blister still has its own regeneration potential and if an operative treatment is necessary. I would also recommend for minor burns of second degree to see a transit physician; these are typically specialised surgeons, such as plastic surgeons, hand surgeons or traumatologists. In the case of an occupationally incurred injury, a transit physician must be consulted to decide whether further treatment in a burn centre is necessary.
For all more severe burns, that is, when blisters are formed with sagging skin, I would recommend contacting a specialist clinic directly; this applies in particular when areas are concerned that are aesthetically or functionally important. I would recommend contacting a centre for burn injuries in case of burns on hand, foot, face and the anogenital area, with chemically induced burns as well as with heavy electro-trauma, i.e., burns caused by lightning or electric arcs.
When more than 5% are covered with third-degree burns, a burn centre should be contacted in any case. Third-degree burn wounds are typically white-pale or even charred or black with soot.
Johannes Horter (* 1973) studied human medicine at the Ruprecht-Karls-Universität Heidelberg. He has worked amongst others at Harvard Medical School in Boston (USA), at the Lachen Hospital (CH) and since 2009 at the BG Hospital Ludwigshafen of the Statutory Accident Insurance. His clinical focus as head of the Department of Hand, Plastic and Reconstructive Surgery and intensive care centre for burn injuries, is intensive care, emergency medicine and intra-hospital emergency management.