Beware of Burns!
Shock may be the most serious consequence of a burn ... A doctor tells what to do for both —and what NOT to do
W. W. BAUER, M.D.
BURNS have been a serious problem to the doctor for centuries. Even today, when all is said and done, the treatment of burns remains controversial.
The traditional carron oil method of treatment is now a thing of the past; so is picric acid. Warm sprays of paraffin, popular 25 years ago, are used only rarely today. Ten years ago tannic acid spray was used with greater success than any previous method. Now it is almost universally discouraged, partly because of its occasional injury to the liver. Certain aniline dyes were found helpful in some cases when applied in a thin spray—their effect was the same as that of tannic acid—the formation of a scab, or eschar. But infections tended to occur under the eschar. Tanning, or leatherization, by any method, is now discouraged.
Even so, the burned patient today has a better chance than he ever had before to live and be. restored to normal appearance. He suffers comparatively less from burns than in any previous time.
And that is something that’s important in wartime, for burns are among the most frequent causes of war casualties. Actually in the North African campaign there were more casualties caused by accidental burns than from the effects of enemy action, with accidental burns almost two and one-half times as frequent as action burns. The latter in their most common form are the so-called “flash burns” and are due to exposure to the hot but brief flash of inflammable gases in closed spaces, such as tanks, turrets, pillboxes and the like. The soldier’s instinctive effort to protect his face by throwing his hand up in front of it results in severe burns of the back of the hands in almost every instance.
But you don’t even have to go to war to get burned. Of accidents in the home, almost one out of six is due to burns, this cause being exceeded only by falling.
A few causes of burns in the home, gleaned from several of the latest statistical reports, suggest their own remedies in the line of prevention: A woman was fatally burned when she went to sleep on too hot a hot-water bottle. An elderly man used kerosene to rid his bed of bugs; he died from burns due to absorption of kerosene onto the surface of his skin. A small child pulled a pot of boiling beans off the stove onto himself.
What Is a Burn?
WHAT, actually, is a burn? Everybody thinks he knows that, and yet the true nature of burns has been understood by scientists only within comparatively recent times, and this understanding has not yet spread into the circles of general knowledge. A burn is the injury or destruction of skin or underlying tissue, or both, as the result of exposure to heat—moist or dry; flame—electric or gas; chemicals, ultra-violet rays —sunshine or X-rays—or friction.
Burns are minor or serious, depending on their extent or their depth, or both. Least dangerous is the common kitchen burn from a small splash of hot grease or from picking up a hot pot without thinking; this is minor because it is neither large nor deep. A
scald of a large part of the body surface, such as happens when a child falls into a tub of hot water, may be serious because of its extent even though it is not deep. A smaller burn, resulting perhaps from clothing on fire, which may not be large, but is deep and destructive, may be very serious. A burn which is both large and deep is always cause for concern. The United States Army estimates, for example, that burns involving 30% of the body surface are always serious, and of those more than 70% are hopeless, especially if part of the burned surface is deeply injured. Burns are classified for convenience as first, second and third degree.
A first-degree burn is one that results only in redness, without blistering, and, of course, without deep injury; if very large, such burns can be serious. A second-degree burn is one in which blistering occurs. A blister is formed when the blood fluid or serum leaks into the injured tissues and forms a layer of fluid between the outer layer of skin and the deeper layers. A blister is a form of protection. Most blistered burns have some surrounding areas of reddening, thus becoming both secondand first-degree burns. Thirddegree burns are deeper than blistered burns, and involve destruction of the skin and deeper tissues. The outer skin is shrivelled and seared. Deeper down, if the burn is severe, skin structures are obliterated— hair follicles, sweat glands, nerves, blood vessels, all are destroyed, and their functions with them. A raw,
defenseless surface leaking vital blood and tissue fluids remains. Most such burns also have secondand first-degree burns areas adjacent.
Burns are serious, when large or deep, because they constitute more than a local injury. They affect the entire body, often constituting an immediate and serious threat to life.
The first effect is what is known as shock. Shock, in the medical sense, is very much like what the nonmedical person means when he says something is a great shock to him. Great pain, loss of blood, or serious injury to any part of the body, such as a severe burn, may cause shock. As one physician expressed it, shock is a state in which the individual may “bleed to death into his own blood vessels.” How this can happen, even if no blood vessel is cut, is explained on the basis of great relaxation in the tone of the veins, especially the large abdominal veins, so that they drain off blood which is needed elsewhere. Also, the smaller blood vessels actually “leak” blood into the tissues through their walls.
The reaction has a nervous basis, due to paralysis of the sympathetic nervous system, which controls the automatic processes of the body. As a result the patient looks bloodless pale, ashen, cold, with beady perspiration and a pulse rapid, thin, or sometimes difficult or impossible to find. If conscious the patient . is apathetic; often he is unconscious. The importance Continued on page 42
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of shock, and its immediate danger to the patient, is so great that emergency measures demand attention to shock first, to save the patient’s life. The burn itself can wait.
The Skin Safeguards
A burn obviously destroys the skin first. The skin is more than merely a covering for the body—a “hide.” It has important functions. It controls body heat through perspiration. It retains moisture within the body, and protects against infection from outside. If enough skin is burned these functions are seriously impaired. Infection may be introduced at any point from the time of the burn until it is fully healed; it is one of the doctor’s problems from beginning to end of the course of treatment.
Retention of fluid in the body is of much greater importance than is commonly realized. The great rawsurface of an extensive burn “weeps”; that is, it exudes fluid. This fluid comes from the tissues and the blood: it is the well-known plasma which, dried from the blood donated to Red Cross societies, is saving lives on the world’s battlefiekfs. Loss of plasma threatens the life or the burned patient, too, unless such loss is prevented or lost plasma replaced by injection. Not only water is lost when burns weep plasma, hut proteins, vitamins, minerals, and anti-infective substances.
Loss of fluid also causes excessive concentration of the blood. The concentration of the blood is normally held constant by a complicated process, which makes possible the interchange of food supply and waste products,
oxygen and carbon dioxide, between the blood and tissue fluids and the cell substance. When this balance is upset, nutrition and oxygen supply are disturbed. Finally, the presence in burned areas of large amounts of dead tissues causes absorption of poisonous products into the blood, which are cast off through the kidneys and the intestines, where they may cause kidney injury or peptic ulcers. The toxic or poisonous effects of a severe or extensive burn affect the entire living organism. Next to shock they constitute the greatest immediate source of danger; the danger of toxic absorption persists until the burn is healed. The local damage, painful and disabling as it is, is of less importance than either shock or poisoning.
The purpose of the doctor in treating burns, based on the principles just briefly outlined, must therefore be fivefold: 1. to save the patient’s life
by treating shock; 2 to relieve pain by local and general measures; 3. to prevent infection with local cleanliness, sulfa drugs or penicillin, and dressings; 4. to prevent loss of plasma; 5. to prevent poisonous absorption.
Later the doctor will concern himself with recovery of appearance and function; his emergency measures must be such as not to interfere with the success of these later procedures. He is interested also in speeding the recovery of the patient.
Many different approaches have been made, and will continue to be made, in the search for the best treatment for burns. Perhaps there will never be one method so superior to all others that it will automatically crowd them out of use. In the meantime a few outstanding attacks on the problems are worth mentioning. The fact that differences of opinion may be found in the several
methods outlined is no discredit to any of them; it simply reflects the complexity of the problem and the determination with which workers attack it.
One type of treatment is reported in the Canadian Medical Journal by Dr. George J. Coloviras, Jr., Royal Victoria Hospital, Montreal, and his associates, which utilizes a spray of sulfadiazine and triethanolamine (an antiseptic emulsifying agent) to form a filmlike layer of eschar over the burned areas. A plastic (polyvinyl alcohol) to form a layer over burns is reported from the University of Western Ontario by Drs. R. A. Waud and George A. Ramsay. At Montreal General Hospital and McGill University work has been done with sulfathiozole powder applied by a spray.
Burn treatment in the United States Army is now usually carried out by placing over the burned area a boric acid ointment or plain petroleum jelly and a layer of fine-meshed sterilized gauze, plus a pressure dressing. Later the patient may be placed in a tub bath and dressings are changed. The United States Army now recommends the pressure dressing in preference to any leatherizing method.
The pressure bandage is used in conjunction with many forms of burn treatment. It is quite simple. Over the immediate dressing is placed a considerable amount of ordinary machine-shop type cotton waste, well sterilized, of course. Over this, pressure is applied by a firm bandage. The nature of the cotton waste, with its meshed fibres and airspaces, is such that it distributes the bandage pressure gently and evenly over the burned surface, helping to prevent “weeping” of serum from the surface of the wound.
At the exhibit on burns during the 1944 meeting of the American Medical Association the treatment of burns was outlined in the following general terms, much simplified here, but essentially complete:
John Smith, 23 years old, enters the hospital severely burned after falling asleep in bed with a cigarette. He has extensive secondand third-degree burns—blistered and deeply destructive. His suffering is so intense that he has fallen into a state of shock— eyes dull, manner apathetic, skin cold and covered with clammy sweat, pulse almost too thin to feel, breathing shallow and irregular. He looks, and is, extremely and dangerously ill as well as burned. The emergency requires immediate action to overcome shock. The patient must be kept warm and quiet—but not too hot. As quickly as possible plasma must be administered or, if not available, solutions of glucose and salt must go into the veins. Oxygen inhalations may be needed. Morphine is literally a lifesaver in such a situation. It is plain that the nonmedical person up against this emergency should first call a doctor, then do the simple things he can do while waiting for the doctor to arrive.
After 28 to 36 hours the patient slowly rallies, and the second phase of the treatment begins. Now there is danger to the victim’s general condition from absorbed poisons generated in the burned area, and from infection of the injured tissues. He continues to be acutely ill, often with fever, nausea and vomiting. Good nursing care is essential now, to guard against infection in the burned area. Plenty of fluids are requir®d, to dilute and assist in eliminating poisonous absorption products. Alkaline drugs may be needed to protect the alkalinity of the blood, threatened by the infection and absorpticn. Food, especially proteins,
starches and sugars, are required; if the patient cannot eat then the need must be supplied by injection into the veins. Plasma may need to be continued, or whole blood may now he required if there is anaemia, as there often is. During all this time the patient suffers, not alone from the pain of his burn, which is much alleviated by appropriate dressings, but from the general sickness which arises from the burn. During this time the local dressings, of which various types have been mentioned, are used.
When the battle against shock, toxicity and infection has been won, the healing phase begins. It may still be necessary to continue blood transfusion. Feeding continues to be important, or, if necessary, the supply of foodstuffs through the veins. Liver, greens, eggs and vitamins are required in the diet to supply sulphur and iron. Sulfa drugs or penicillin may still be necessary. Local treatment may now include skin grafting if necessary. Now the patient is gradually improving; the dangers to guard against are mainly infection of unhealed areas, and formation of scars which may disfigure dr, as they grow older and contract, interfere with use of the injured part. The local dressings now used, plus skin grafting, have gone far to overcome the dangers of deformity or disfigurement.
What to Do
When you are confronted with a badly burned person, what are you going to do? You are not a doctor; nevertheless what you do and what you do not do may mean the injured person’s life or death, plus considerable influence on the course of healing of the burned surface. What to do depends largely on the degree and extent of the burn and the general condition of the patient.
Small first-degree burns are frequent around the home. The immediate concern is to relieve pain. There is no shock involved. First aid may include the following measures: Apply a thick paste of baking soda in water. Or apply a simple boric acid ointment or plain petroleum jelly, or any unsalted cooking fat such as olive oil. Simple oily applications are permissible on burns which are strictly first degree and of limited area, but never under any circumstances should oily or greasy applications of any hind be made to blistered burns or extensive reddening burns; to do so hampers the doctor in his subsequent healing procedure.
If the burned area is fairly large, immerse the hand, or foot, or other part in warm water as near body temperature as possible. If a burn is very extensive the patient should be put completely into a tub of warm water, without removing clothing.
Small second-degree burns, blistered, but not involving any general illness or shock, offer little problem.
The blisters should be protected, not ruptured. A simple dressing to guard against infection, until the doctor can see the condition, is all that should be done by the first-aider. A simple and safe pain-relief drug is aspirin, which may be taken by adults in five-grain doses an hour apart if pain is severe; children in half doses under 12 years, quarter doses under five years. Immersion in warm water of the burned portion gives relief. DO NOT APPLY ANY OÍLY OR GREASY SUBSTANCE. If the second-degree burn covers an extensive area of the body, a warm tub is advisable. If there are any evidences of shock this is the emergency, not the burn.
The treatment of shock has been radically modified during the past few years. Books and pamphlets only a year or two old may still advise wrap-
ping the patient in heavy blankets and j surrounding him with hot-water bottles, improvised if necessary. THIS IS WRONG AND HARMFUL. The patient should be protected against losing heat, but should not be exposed to excessive beat from outside sources. Strong coffee or tea may be given internally. If there is no burned area to interfere a firm abdominal binder may be applied. Of course, the doctor j should be called at the first sign of j shock.
Third-degree burns involving de; struction of tissue beyond blistering, even when this occurs only in a small portion of the burned area, demand medical attention at once. The firstaider should not endeavor to do anything with the burn. All handling favors infection. One medical school of thought even recommends that the burned person, and those who attend him, should wear face masks of gauze or keep their mouths shut as much as possible to keep from infecting the burn with germs from the breath. Relief from pain may be had by tubbing and aspirin. A sterile dressing to protect the burn from infection may be used to cover it, but usually immersion in warm water is simplest and best. DO NOT APPLY ANY OIL OR GREASY SUBSTANCE.
Finally, it should be recognized that a burn is a burn, no matter what its source. Steam, dry heat, flame, chemical, electricity, friction, X-ray—all cause burns. A few special hints about special first-aid procedures in one special type of burn may save the patient from being subjected to the wrong kind of treatment. Burns of the eye occur most often from splashing chemical into the eye. The correct and safe first aid is to wash the eye promptly and gently with large amounts of sterile clean water. Do not try to neutralize the chemical. The same advice applied to chemical burns of the skin; wash the irritating substances away with copious but gentle washes of sterile or of clean water. Sterilized water is best if available without delay, but do not wait to sterilize it. Speed is the essential in this situation. Electrical burns differ in no way from burns due to any other cause, as far as first aid is concerned.
The final consideration in the burn question Is healing and restoration of function and appearance. The horrible contracting scars and consequent deformities formerly so common can now largely be avoided. Many burns heal so much better under the new types of dressings that motion and appearance are not impaired. In other cases prompt and successful skin -rafting brings about a good result. Where scarring has impaired usefulness and looks, plastic surgery may be brought into play after healing is complete.
As we shake our heads in sadness j over casualties from overseas, we might profitably give some thought as well to
the continuous casualties, in peace as well as war, which occur on the home front without attracting much attention, except from doctors, statisticians, the insurance business, the burn victims and their relatives. Prevention of burns in the home is very much worth while, and not too difficult.
Here are a few simple suggestions;
Keep matches in a safe place and out of reach of children.
Store oily rags, if at all, in fireproof receptacles. Store inflammable liquids —gasoline, kerosene—away from buildings, in a suitable place marked with fire warnings.
Have a screen in front of open fireplaces. Never start or encourage fires in fireplaces or stoves with gasoline or kerosene.
Never smoke in bed or anywhere else if you are sleepy. Have plenty of big enough ash trays in all rooms.
Provide metal receptacles for furnace or stove ashes.
Protect all walls or partitions near pipes, stoves, beaters or fires with fireproof material.
Keep children out of the kitchen or laundry where hot water or hot fat may burn them; turn handles of pans so that they do not project over the edge of the stove where they can easily be upset.
Do not try home dry cleaning with inflammable liquids.
Do not try to be funny in dangerous ways; especially with fire or inflamable substances.
Have electric wiring and extensions done by someone who knows bow to do them safely.
Keep Christmas, festival or decorative candles away from inflammable decorations.
Women’s and children’s flimsy dresses catch fire easily and caU for special care near open flames.
Search in dark closets with flashlights only, never matches or candles.
If there is a gas leak, or you think there is, let a professional find it.
Oil lamps or lanterns should always be set on firm bases to avoid upsetting, and away from inflammable materials.
When preparing wash or bath water, draw or pour the cold water first then add hot water to the proper temperature.
In camp, hunting lodge or summer home handle fire with special care. Always have water barrels or buckets ready, and sandboxes for gasoline or kerosene fires, which water merely spreads. A chemical extinguisher is good.
Much more can now be done for the burned patient than ever before. Even so there is too much pain, loss of time, expense, and disability involved in burns. Many burns are needless and preventable. If you don’t get burned in the first place, you save yourself many severe trials. The best person to keep you from getting burned is YOU !