Burns can occur in conjunction with sailing, with mildly annoying sunburn perhaps the most common type. But burns from accidents on board or even in the boatyard while working on your boat can be serious. Because the skin is the body's largest organ-accounting for about 15 percent of the total body weight-burns are possibly the most devastating injury to the skin and underlying tissues. Prevention is obviously the best treatment for burn injuries, but knowledge about burns, how to evaluate severity and proper treatment is key to being prepared in the advent of a burn emergency.Burn classification
Burns are classified by the extent of tissue involved. On initial evaluation, it can be very difficult to determine the depth of a burn. Frequent examination is required to adequately assess and treat the injury. In the past burns have been classified as first-, second- and third-degree. While this classification system is still in use, a more descriptive and accurate method is now used.
A superficial burn (first-degree) involves only the epidermis and will be red and painful. The partial-thickness burn (second-degree) is further divided into superficial and deep. The superficial-partial-thickness burn involves the epidermis and the outer half of the dermis but spares the hair follicles and other skin structures. The area will appear moist and mottled pink or red. The deep-partial-thickness burn destroys the entire dermal layer, which contains the hair follicles, sweat and sebaceous glands. Partial-thickness burns are characterized by intense pain, redness and blistering.
The Rule of Nines Entire head = 9% Each arm = 9% (18%) Chest = 9% Abdomen = 9% Upper back = 9% Lower back = 9% Front of each leg = 9% (18%) Back of each leg = 9% (18%) Groin = 1%
The full-thickness burn (third-degree) is characterized by skin that appears dry, pearly white, leathery or charred. Because this level of burn also destroys nerve endings, a full-thickness burn is not painful. However, a full-thickness burn is frequently surrounded by an area of partial-thickness and this will be the source of the pain. This burn can extend deep enough to involve adipose (fat), fascia, muscle and bone.
In addition to the depth of the burn, it's also important to estimate the extent of the body surface area (BSA) involved. This can be done by using the Rule of Nines (see sidebar #1). This method divides the body into sections of roughly 9 percent. You then add up the percent of BSA affected.
For smaller or patchy burn areas, you can also use the Palm Rule. This rule uses the fact that the patient's palm is approximately equal to 1 percent of his/her BSA. Putting all this information together along with the cause of the burn helps determine the severity of the burn (see sidebar #2).Types of burns
Other than sunburn, a thermal injury is probably the most common type of burn that occurs on board. Thermal injuries are those caused by direct flame (as when cooking with propane or other gas), scalds (again, a galley problem usually occurring in rough seas) and direct heat contact (for example, when working around a hot engine).
When burns are critical Any burn greater than 25% BSA Full or deep-partial-thickness burns greater than 10% BSA Burns complicated by a respiratory or airway injury Most burns involving the face, hands, feet or genitals Burns complicated by a fracture or major soft-tissue injury Electrical or deep-chemical burns Burns occurring in patients with serious pre-existing medical conditions
A chemical burn occurs when the skin contacts strong acids or alkalis. The danger in this type of burn is that the burning process continues as long as the burning chemical, or agent, is on the body. This type of burn is less likely to occur while underway. It is probably most common to the boatyard where, typically, a large variety of caustic materials are used. You will need to know the specific chemical because the treatment will be dictated by the agent.
Electrical burns are divided into type I, II and III. Type I or a contact burn is the most common and is a true electricity injury. The burn is most severe at the entry and exit points. The type II burn is a flash burn and occurs when the victim becomes part of an electrical arc. The type III burn is a flame burn and results from electricity igniting the victim's clothing. Electric burns require high voltage and, like chemical burns, are more likely to occur in the boatyard.
Finally, there is common sunburn. Radiation burns are by far the most common burns because most of our sailing is done while being exposed to an enormous nuclear reactor, the sun. Don't underestimate the potential severity of sunburn. Using the Rule of Nines, it is not uncommon for sunburn to reach the critical stage (any burn greater than 25 percent BSA), but these burns are almost always superficial. Nonetheless, I have seen patients who required skin grafting after prolonged sun exposure.
The key components of burn treatment are: stop the burning, evaluate the injury, relieve pain and prevent shock and infection. Stopping the burning may seem obvious but remember: Even though the fire is out, the burning can continue. Remove all burned clothing as it will continue to conduct heat. If some of the clothing is melted to the skin, continue to flush the skin with cool water. Flushing is crucial to a chemical burn, particularly one involving alkalis, since an alkali burn must be flushed for 1 to 2 hours. Also, keep in mind that burned skin loses heat more rapidly than intact skin and the addition of cool water can cause hypothermia if a large BSA has been burned.
Evaluate the extent and severity of the burn as well as any associated injuries. Pay particular attention to the airway. An airway problem may not be immediately apparent. See if the patient has burns to the face or singeing to the hair and eyebrows. Note the respiratory rate and pattern and listen for any unusual sounds when he/she breathes. If the patient has airway involvement or any respiratory difficulty, advanced rapid treatment is required.
If you are on inland waters, immediately head for the nearest port and notify authorities by VHF. If you are offshore, you need to secure help. A burned airway is a life-threatening injury. The patient should be moved to a professional facility as quickly as possible.
Once the degree of burn has been determined, administer the appropriate level of care. Superficial burns are easily managed with cool compresses and acetaminophen for the pain. An extensive superficial burn will demand a slightly stronger analgesic and should be accompanied by an increase in fluid intake by the patient. There are numerous products on the market to relieve the pain of superficial burns and some of them are quite effective. However, basic systemic pain control along with fluid intake is the best approach.
The treatment of partial-thickness burns follows the same approach of cooling the area and covering the burn with a sterile dressing. Do not break the blisters; they are actually the best burn dressing available. If the blisters rupture later, apply Silvadene as an antibiotic ointment and cover with dry, sterile dressing.
Fluid loss can be an early complication with some burns and is most common with partial-thickness and deeper burns. Depending on the extent of BSA involved, a fluid loss can rapidly lead to shock. If the BSA is greater than 15 percent, fluid replacement is required. This is best managed with I-V fluids. Determine the required amount of fluid by using the Parkland Formula:
Give 4 milliliters per kilogram of body weight times the percent of BSA burned. Give over 24 hours with half given in the first 8 hours and the rest in 16 hours.
Example: A patient weighing 80 kilograms (175 pounds) with 20 percent BSA deep,
partial-thickness burn would need to receive nearly 6.5 liters. Here is the computation:
4 X 80 = 320 X 20 = 6400cc
3200cc in 8 hours (400cc per hour)
3200cc in 16 hours (200cc per hour)
The best way to determine the efficacy of the fluid replacement is to measure urine output, which will be required for severe burns. This is most accurately accomplished by using a Foley catheter. Urine output should be greater than 40 to 50cc per hr.
Another important consideration with all burns is the amount of swelling that occurs. It will be necessary to remove all rings and jewelry before the edema prevents their removal. You may even need to cut off a ring if the swelling has already begun.
Finally, a partial-thickness burn is painful. You will want to give Percocet or Tylenol No. 3, for example, for small, second-degree burns and use morphine if the burn is large enough to warrant I-V fluids. The management of full-thickness burns is essentially the same as partial-thickness. However, it will be even more important with these to prevent infection and manage fluid loss.
Successful burn management depends on preparation and the ability to keep your cool in the face of a potentially life-threatening injury.