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This is a conversation about sunburns and burns in general. Sun poisoning is described as radiation poisoning from ultraviolet radiation. Different degrees of burns are explained, including first degree (superficial) burns, second degree (partial thickness) burns with blisters, and third degree (full thickness) burns that extend to the muscle and bone. Methods for estimating the amount of burn using the Palmer method or the rule of nines are discussed. The importance of stopping the burning and assessing the severity of the burn is emphasized. Signs of abuse and the need for reporting are mentioned. Nobody ever had a sunburn so bad they got sick, nausea, vomiting, aches and pains. You know what that is? That's sun poisoning. You know what sun poisoning is? Radiation poisoning. That's literally poisoning from ultraviolet radiation. What do you do against that? Just gotta let it work its way through. Partial thickness or second degree involves the epidermis and some portion of the dermis. Blisters are present because we don't burn away the epidermis so that sealed epidermis is there so that inflammatory response rushes through into the burn, that's when you develop the blister. Whereas full thickness burns, third degree burns, third degree burns extend all the way through to go to the muscle and even the bone. So there's your sunburn, that's a hell of a sunburn too, but there's your first degree burn, we call it your superficial or first degree, there's your second degree or partial thickness as you can see, see the blisters? Do not pop the blisters because the blisters have healthy tissue underneath. If you pop the blisters, you expose the dermis to infection. And then this is full thickness as you can see here, this is an older picture, look at that rescue mask there, this must be, I don't even know what kind of burn, that's a horrible burn. That's probably 90% body surface area burn. That's probably a 90% body surface area burn. See the splits in the tissue? That guy's probably dead, right? Yeah, that guy is dead. Is third degree the most? Third degree is the highest. Well, they talk about electricity being the fourth degree because electricity follows a path within the body so it burns it from the inside, we're going to talk about that in a minute. So they extend the burns, you have to estimate the amount of burn using two methods, it's the Palmer method or the rule of nines. It can be, but the portions are different for infants and adults and this only applies to partial and full thickness burns. So I could have, you know, first degree, second degree, third degree, superficial, partial thickness, full thickness burns, I don't count the superficial. I only count the area that's blistered or charred. And so one of the methods is called the Palmer method where I take the patient's palm, not with the fingers, and I cover the wound with the palm. The number of palms is the percentage of burn. So each palm is one percent. The number of fingers? No, you don't count the fingers, just the palm. So I go like this and each palm is one percent. Oh, okay. Okay? We do that up to ten percent body surface area burn. Anything over ten percent, we use the rule of nines and I'm going to explain that in a minute. A good rule of thumb is if you have a patient where you can assess the burn with the Palmer method, you can put a cool compress on it. You can put cold, you know, blankets or wet blankets on it or something to cool it. If you have greater than ten percent body surface area and you have the rule of nines, do not put cold compresses on it because that can actually cause hypothermia. Okay. Okay. Does anybody know why cold water, ice takes away the pain? No. No. Well, what it does is, like you burn your finger, you put your hand in cold, you burn your finger, right? You put your hand in cold, your finger in cold water and all of a sudden, oh, pain away. If you take your finger on it, it starts hurting again. What happens is you overstimulate the nerve. It's the same thing when you scratch. You get an itch and you scratch it, you overstimulate that nerve and the itch goes away. Same thing with your finger. Your finger is burning right now. It has a sensation of burning. If you put it in cold water, it gets hot and cold at the same time, you overstimulate the nerve and you turn it off. That's why when you take the hand out, it starts hurting again. So, you can put cold compresses or cool compresses on less than ten percent body surface area and that will make it feel better, at least for a short term. All the ten percent don't because you can produce hypothermia. So, the rule of nine takes the body and breaks it down into factors divisible by nine. So, for the adults, my head is nine percent. The front of my thorax, the front of my trunk is eighteen percent. The back is eighteen percent. Each one of my arms is nine, each one of my legs is eighteen and one percent for the genitalia. Okay? And that adds up to one hundred percent. So, in children, you notice the child is a little bit different. Remember how we grow into our heads? We're born with a head sixty percent its adult size. So, the head is proportionally larger to the body in a young child. So, that's why it's twelve. Whereas the legs, when our legs grow into us, they're shorter, so it's only sixteen and a half. Everything else is the same. For an infant, the head is a full eighteen percent, whereas the legs are thirteen and a half. Does body weight matter? No, it's by surface. It goes by surface. So, like in a more... It doesn't matter, it's still by surface. You'd still say that would be eighteen. Yeah. So, this is... And hit, hit, wink, wink, nudge, nudge. You know what I mean? You should learn this, because you'll see this again. You'll have to calculate this. You might even see this in your national exam. You will see it in the state exam where you have to calculate this. I don't like the genitalia is one percent. It wasn't the infant. It doesn't make me feel very good. Let's just clarify. You said national versus state. The state is... No, this is national. This is state and national. Right. That's why we're just... Yeah, we're just doing one... Right. One exam. Okay. Sorry. So, when you are assessing a burn, it's important to classify the victim's burn. Classification is based upon the source, depth, and severity of the burn. Was it a fire? Was it a scalding? The depth of burn, superficial, partial thickness, full thickness, and the severity. Mild, moderate, severe, critical. Remember, hands, face, feet, genitalia, airway, that's critical automatically. Less than five, over 55, or some other medical condition, chronic medical condition, adds one severity level to the burn. So, scene safety. Observe the scene for hazards and safety threats. Don't be burned yourself. Ensure the factors that led to the patient's burn do not pose a hazard to you. And, the number one thing you need to do is stop the burning. That's the first thing we do, stop the burning. If somebody is burning, put out the flame. Do not use anything polyester or plastic, because it will melt to the skin. Bath blankets are great for me. Determine the type of burn that has been sustained and the mechanism of injury. Maybe the patient was burned, but something happened that caused it. They had a stroke, they had a heart attack, they had trauma. Gather information about the patient and the extent of the injury. Assess the scene for environmental hazards. Determine the number of patients. Call for additional resources and consider the potential of other injuries. If you go to a burn, always consider airway and the fact that you may need RSI. You may need to, it might be an airway issue. Begin with your rapid exam. I'm never going to do, unless it's, oh, I burned my finger, I'm always going to do a head-to-toe exam. I'm not going to say, oh, I'll do a focus assessment. Severe burns, we're going to do head-to-toe. Look for clues to determine the severity of the injury and the need for rapid treatment and transport. Be suspicious of clues that indicate abuse. Things like griddle burns, cigarette, cigar burns. If you have gloves, burns with glove distribution, as if I put my whole hand in a pot. Or I put both feet, kids don't just jump both feet into a hot tub. Kids don't put both hands into a hot pot. Circumferential burns are always, in children, they're always questionable. Children should not burn. And it might be innocuous, a child very well could pour a pot of boiling water over them. Yes, it can happen. But that means the child wasn't being watched. Trauma to children are because they are not supervised. Now, it may not be intentional. It could be an accident. But it is still because they're not being, anytime my children were injured, it's because I wasn't watching them. I mean, it is what it is. Yeah. I had a family that, like from our school, when we were kids, and actually that pot fell, and a couple of the kids burned, they got secondary and third degree burns. And child services took them away. I mean, I'm like, live with us for a little while, and then give them back to the parents. Probably while they were investigated. There was something else going on in that house. They saw something. Because courts, especially in Massachusetts, courts, they don't want to take children. They want to leave them with the parents. I have seen parents that I wouldn't want to be with. And they, of course, will give the children back. So, if they took those children, there was a reason for it. And they gave them back. If you suspect that children do... 51A. Do you call them? You have to do a 51A. Okay. You have to. You have to. Do you call them and talk to them, like, I'm going, a child, father, child, don't let the parents get home? No, no, you wouldn't do that. And you wouldn't want to do that. And I'll give you a little advice or a little scenario. You walk up to a, you suspect child abuse, and you start questioning the parents. No, it will not question the parents. But what's going to happen if you start questioning the parents or the parents start getting suspicious? What are they going to do? Oh, never mind, I'll take them myself. No, no, I don't want them to go in the hospital. Now what are you going to do? Now you have to fight the parent to get the child. So, what I like to do is say, oh, you know, my kid's done this a hundred times. My kid's such a klutz. Yeah, let's get them to the hospital. Come in your car, follow us to the hospital. Don't get too close, but follow us to the hospital. So you'll have a car and you can bring them home. They'll probably get checked out in at least an hour or two, you know what I mean? And then you get them back in the ambulance. Now you've got them in the ambulance. Now you can say, okay, son or young lady, I see things that I don't like. Do you feel safe at home? Is this something, how did this injury happen? Because they'll tell you one story in the house that when you get in the ambulance, it'll change. If the parents insist on being in the ambulance. You have to ride up front. For insurance purposes, I need you to ride up front. If I ever suspect child abuse, I keep, and then what happens is there's a door there, and you close the door. I'll have my partner close the door and they get in. You've got to work with your partner that way. And then you call the hospital and say, I'm going to move to your facility with a, you know, 12-year-old patient, sustained questionable burns, parents along. Have the police or security meet us at the loading dock or at the ambulance bay. They'll know exactly what you're talking about. They'll know exactly what you're talking about. Will the radio only work in the, will they hear, they won't hear that message in the front? No. Or does the radio relay? They'll be on the dispatch channel. You'll be on the C-net channel. Oh. So as long as you stay in the microphone quietly, they won't even hear you. Because you've got the ambulance going, the sirens going, they won't hear it. The door closed. Right. Sometimes in the ambulance, if I want, if I have a patient where I don't want the family member to hear what's going on in the back, I turn the heat up on high. I'll turn the AC on high. Maybe I'll turn the radio up really loud. I'll key it a few times. Maybe turn on the car, the radio in the ambulance, like the music radio. Have the doctor sit off with them. Yeah, talk with them. Keep them, keep them occupied. Gotcha. So airway breathing, ensure the patient has a clear and tainted airway. Be alert for signs that the patient has inhaled toxic gas, that hot gas from the ambulance. Things like thin facial hair, especially if they've got a beard and skin, so they've got burns to their face. Or their chest. Or they have, you see, carbonaceous sputum in their nose and their mouth. So they've got a raspy voice. Right. These are all signs that they've inhaled at least smoke anyway, which can lead to an airway compromise. And it won't happen now. It'll happen ten minutes from now when you're driving to the hospital. Heavy amounts of secretions or frequent coughing may indicate that respiratory burn. Quickly assess the airway. Breathing. Use DCAP, DCLS in transport. Call ALS for that. Potential RSI. And don't just call an ambulance. You have to call for an RSI. Like we at MedStar don't RSI. We don't have RSI protocols. You have to get somebody who does it. Circulation. Assess pulse. Do all your vital signs. Control significant bleeding. And assess for shock. Consider rapid transport for any patient with airway or breathing problems. Or suspected airway compromise or airway involvement. Significant burn injuries. Significant external bleeding. Signs and symptoms of internal bleeding. Signs of shock. Or multi-system trauma. They've got a burn with a fracture. A burn with a fracture makes it a serious, that's a serious burn. Because it's a kind of compounding injury. They've got a burn that's multi-system trauma. Be alert for signs and symptoms of other injuries. Look for things like tangling, swelling, blisters, and charring. Your skin might be white, waxy. It might be reddish. It might be charred. It'll be stiff. Sample history. Along with your sample history, ask the following questions. Are you having trouble breathing? Are you having difficulty swallowing? Both sides of the airway is closing up. Are you having any pain? Check whether the patient has any medical alert devices. Things like pacemakers. Or vagal stimulators. Or maybe they've got a colostomy. Or maybe they've got a G-tube. Maybe they've got a trach. Perform a full body scan. Any severe burns, full body scan, no matter what. Look for decaf ETLFs. Make a rough estimate. These are the rule of nines. The Palmer Method probably wouldn't be a severe burn unless it involved a critical area. Determine the classification severity and package the patient for transport. We have special burn dressings. They're blue. They don't adhere to the skin. So you take the blue dressings and you put it between the webbing of the fingers. And you wrap the wound up and then you splint it. The burn. Determine an early set of vital signs. And you want to check your oxygen saturation. But remember, a patient has been exposed to maybe a house fire. Maybe a building fire. Building fires 100 years ago was mostly wood. And so fires were like a big outdoor fire. Now burns encompass PVC piping and insulation and foam and carpets and all kinds of chemicals. So carbon monoxide and hydrogen cyanide and cyanogen hydrochloride. All these different chemicals that the patient can inhale and become toxically exposed. Toxicologically exposed. So you're going to repeat your primary assessment. Constantly talk to your patient. Do your vitals every five minutes. We want to watch the patient to see if they're airway compromised. Check their chief complaint. We want to stop the burning process. Assess and treat any breathing issues. All patients' burns get oxygen. Regardless. Oxygen. And support circulation. Rapid transport. Oxygen is mandatory if the patient has signs of hypoperfusion, i.e. shock. We treat aggressively for that. And rapid transport. Call ALS. One of the worst things you could do is give an IV and burn tissue. Oh, terrible. Provide hospital personnel with a description of how the burn occurred. Describe the extent of the burn. The amount of body surface area by either the rule of nines or the Palmer method. The depth of the burn. Location of burn. To include those specific critical areas. Hands, face, feet, genitalia, airway. Are they under five or over 55? Do they have some other confounding injury or issue? Stop the burning process and prevent additional injury. So thermal burns are caused by heat. Most common by scalds or open flame. Come in contact with hot objects can cause a contact burn. You see this in the fall. People start off the wood stoves. And the kids forgot all about it. They go off and put their hands on the wood stoves. Right? Happens. A steam burn can produce a topical, scalding burn. Now, this is the question. Is steam can be very, can be very, how would I say, stinky? Steam is under pressure. Right? Steam coming, steam is, what temperature does water boil at? 212 degrees. God bless you all. 100 degrees Celsius. I was going to say that. But what temperature does it take to ignite paper? There's a book written about it. 451? Fahrenheit, 451. 451 degrees will ignite paper. Steam can reach temperatures of 500 degrees. If you have a steam in ships or in buildings, high pressure steam lines, that can reach 500 degrees. Technically hot enough to ignite paper. Kind of common intuitive. Right? So, if you've got a rupture of a steam pipe and steam blasts somebody in the face, they just got blasted with a potential of 300 or 400 degrees worth of steam. It's like an oil burn. It's like putting your hand into hot oil. Flash burn is produced by an explosion, like opening the door, and you get the back draft. They briefly expose a person to very intense heat. And lightning strikes can cause flash burns too, like I have. So, management. Stop the burning source, cool the burned area, and remove all jewelry. Get the jewelry off. Necklaces, bracelets, you know, earrings. If you've got those nasal rings, whatever. Take them all off. Because you're going to get that massive swelling. I've seen people lose fingers because their tissue swelled around it and closed off the flow of blood. Increased exposure time will increase damage to the patient. So, we're going to stop the bleeding, cool it, stop the burning, cool it, remove all the constricting jewelry and clothing, and bandage the patient to prevent infection and provide comfort as best as you can. These patients are going to need loads of fentanyl. Call ALS. Inhalation burns can occur when burning takes place in enclosed spaces without ventilation or opening a door with hot flame behind the other side. So, if you've ever opened an oven, you want to look inside to see if something's cooked, you open the oven and you get that black cut there. Upper airway damage is often associated with inhalation of superheated gases, where the lower airway is the chemicals and the particulates. How dangerous it is. I've done it before. You may encounter severe upper airway swelling, which requires immediate intervention. Again, that's what the RSI is for. And it may not happen now. It may happen ten minutes from now. The combustion process produces a variety of toxic gases. Like I said, carbon monoxide, cyanide, hydrogen cyanide, cyanogen hydrochloride, all these different chemicals. Why is the reaction time like multiple minutes? Say again? Why is the reaction time like multiple minutes? Because your inflammatory response takes time to produce that swelling. It just doesn't swell up automatically. It takes a little bit of time. We talked about carbon monoxide. If you walk into a home or into a building and you have a bunch of... you're feeling the side effects, but you're not, and you've been in the room together, then it's not a gas. You've been exposed to something specifically. But if everybody in the room has an unexplained headache, unexplained cough, dizziness, confusion, cherry red flushed skin, those are all classic carbon monoxide signs. Get everybody out of the room. Ventilate. Oxygen. Do not walk in the room yourself. Predominant treatment of a patient with suspected hydrogen cyanide poisoning? Well, they have a couple of different things they can do. They can do sodium thiosulfate or ammonitrate, but they're very expensive, and they're not good for... they have side effects. The most common treatment for hydrogen cyanide poisoning is... what is it? Hydroxycobalamin, which is vitamin B12. But massive doses, like grams of it. You get like three grams of it, and then 20 minutes later you get another three grams by ID. It's about $1,000 a dose. It's extremely expensive. It'd be really good for a hangover, let me tell you. So what you have to do is care for toxic gases, include recognition. Any patient that's involved in any fire today in a home or an industrial setting has some kind of toxic exposure, I guarantee it, and supportive treatment. See if you can get an MSDS. All right, I'm in an industrial setting, there's a fire. What kind of chemicals are we talking about? Chemical burns generally occur whenever a toxic substance contacts the body, usually strong acids and alkalis. Acids produce like a surface destruction. It'll burn the surface of the skin and break it down. Whereas alkalis causes liquefaction necrosis. It disintegrates the tissue. Right? Ever clean with bleach and your fingers feel all slimy? That's your skin breaking down. If you want to dispose of a body, you don't put it in acid, you put it in alkalis. You put it in lye. And that breaks it right down. And I didn't tell you that. You didn't get that idea from that. The eyes are particularly vulnerable. When we talk about a chemical burn, as long as my patient is stable, these are one of the times where I'm going to stay in play. I'm going to soak you until you tell me nothing's burning. I'm going to soak your body, I'm going to soak your eyes, and I'm going to wait a minute, I'm going to stop, wait a minute, do you feel burning? Yes? Okay, another 20 minutes. Because once I'm in the back of the ambulance, I don't have access to a hose. I don't have access to a shower station or an eyewash station or a wash station. So I want to use what I can when I can. I don't want a patient who's contaminated my ambulance. So chemical burns, the severity is related to the type of chemical, the concentration, and the duration. And again, if a patient in an industrial setting, a manufacturing setting, has been exposed and injured, there will be an exposure control or spill control officer that can give you information about the chemical, what he was handling, concentration, all that stuff. And you want to bring that with you to the hospital. You're supposed to wear chemical-resistant gloves and eye protection. Those gloves, the exam gloves that you get at the hospital in your ambulance, those are not chemical-resistant gloves. Don't think you can put on three sets and say, I'm good to touch the chemical now, because they won't. It'll eat right through it. That's not what they're designed to do. As you can see, what's the problem with this picture? What's that? He's wearing gloves. Where's his mask? Where's his goggles? Do this. That's going to get all aerosolized. Everybody's going to get it in. Very gently brush off the powder. You need a mask, probably a HEPA mask, goggles and gloves on you. Put a mask and goggles on him. And then once all the extra powder, then you rinse it off. Remember, there are chemicals like sodium and elemental potassium that can flare up, that can ignite your water. For liquid chemicals, flush the area with lots of water for about 15 to 20 minutes. Same with the eyes. You're going to flood it until the patient tells you there's no more water. Electrical alerts may be the result of contact with low or high voltage. It's not the voltage that kills. It's the current. Voltage is the electrical potential between two points. That's all it is. It's the current, the electrons that move between it that cause the damage. And that's a tenth of an amp can kill. I can hold it for an hour and a half. It's the electrons that move between it that cause the damage. And that's a tenth of an amp can kill. I can hold a million volts as long as it's less than a tenth of an amp. So it's the amperage that kills. So for electricity to flow, there must be a complete circuit between the source and the ground. An insulator is a substance that prevents the circuit from making like rubber. A conductor is any substance that allows current to flow, like you. You're a good conductor. Did you ever see the high-tension lines? The intrastate high-tension lines? The big, big 300-foot towers? Those lines at the top, they run millions of volts. Tens of thousands of amps of current will flatten you like a pancake. You'll just go pow! And there'll be nothing left to use. Do you know how they test those? They have a guy in a helicopter, and he hangs off the door with a special clip, and he clamps onto it, and it tells him if the line is hot or not. Why doesn't he explode? Because the best insulator is the air. It takes 10,000 volts for lightning to travel one inch. So if he's 300 feet off the ground, that's a huge amount to make contact with the ground. If he was standing on the ground and reached up and did that, he'd be gone, because he makes connection with ground, yes. What about, like, birds? Can you, like, watch them? Oh, there. Oh, yeah. They'll go, yeah. That'll sound just like that.