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Fire disasters can occur above the ground (in high-rise buildings and on planes), on the ground (wildfires), and below the ground (in mines). Before the 20th century, fires were a major hazard to urban and rural areas and the cause of massive amounts of damage to cities, for example, San Francisco after the 1906 earthquake and fire. Fire disasters may occur in buildings, as well as, during transportation by ships, air planes, and trains. Transportation crashes result in more fatalities and in multiple victims with injuries ranging from minor to life-threatening. Increased transportation by air planes, huge ships, and rapid trains are leading to many injuries and deaths, and are requiring both time and resources at maybe very risky, chaotic and remote disaster scene.
Communities in which industrial sites are located or through which hazardous material pass are at risk for technological disasters, that may cause chemical or radioactive burns. Sudden eruptions of fuel tanks at motor vehicle accidents, and combustion of vapors at industrial accidents can cause devastating burn injuries. Most residential fires occur during the winter months. Smoke alarms are not installed in many homes, or they are not working properly.
Extended explosive fires in connection with crowded populations mean a very serious type of disasters, for example, the San Juanico industrial disaster, November 1984. A major fire and a series of catastrophic explosions occurred when 54 liquid petroleum gas containers exploded into huge fireballs at a LPG Terminal at San Juan Ixhuatepec (outside of Mexico City, Mexico). The explosions destroyed the facility and devastated the local town of San Juan Ixhuatepec, with 500–600 people killed, and 5,000–7,000 others suffering severe burns. Victims in indoors disasters can beside deep thermal burns suffer from smoke inhalation (for example, Nightclub fires), or crush injuries from falling from a height (for example, fires in high-rise buildings; MGM Grand Hotel fire in Las Vegas, Nevada, 1980, kills 87; and in Amsterdam, the Netherlands,1992, kills 43). Disasters caused by Boiling Liquid Expanded Vapor Explosion (BLEVE) have an increased number of deaths, and injured compared to earlier periods.
There are often a number of occurrences close to each other that will cause the disaster. Sometimes they occur in circumstances that are unexpected or unpredictable. Deep and extended burn injuries require both intensive care, surgeries, long-term treatment and rehabilitation. When a serious disaster happens with many burn injuries, there might not be enough with specialty care places, so the staff at the general intensive care unit or different surgical units needs to have some basic skills in the management of patients with burns and inhalation injuries.
Earthquake, volcanic eruption and lightning-generated fires are types of natural fires. The fire and explosion hazard related to earthquakes can constitute a substantial risk. Damage to natural gas systems and power systems during an earthquake is a major cause of large fires. Volcanic ash is formed during explosive volcanic eruptions. The eruption in the volcano near Eyjafjallajoekull glacier in Iceland 2010 was notable because the volcanic ash plume disrupted air travel in northern Europe for several weeks. Once in the air, the wind can blow these tiny ash particles tens to thousands of miles away from the volcano. Life-threatening and costly damages can occur to aircraft that fly through an eruption cloud. Lightning is a major threat during a thunderstorm. Florida is the state with the highest number of thunderstorm days. Forest fires can be either due to natural or manmade reasons. Wildfires often begin unnoticed, and can stretch firefighting rescue to the limit. They spread quickly igniting brush, trees, bushes, and homes. They can cause burns, inhalation injuries, respiratory problems, and cardiovascular events (such as exhaustion and myocardial infarction from fighting and fleeing the fire).
On September 11, 2001, a jet craft crashed into the north tower of the World Trade Center (WTC) in lower Manhattan, and minutes later, a second aircraft crashed into the south tower. The impact, fires and subsequent collapse of the high-rise buildings, after the terrorist attack, resulted in the deaths of thousands of people. Most survivors of the World Trade Center attack treated at sampled hospitals had inhalation and ocular injuries caused by smoke, dust, debris, or fumes. Other injuries among survivors were crush injures, burns, fractures, and closed head injuries. Rescue workers sustained significantly more ocular injuries than survivors, and also significantly less burns than survivors (Centers for Disease Control and Prevention, 2002).
Blast injuries, explosions can inflict multi-system life-threatening injuries to many persons simultaneously. Penetrating and blunt trauma is most common. Explosions in mines, buildings, or large vehicles and structural collapse are associated with the greatest morbidity and mortality (American Public Health Association, 2005, 1).
Your first impulse in fire should be to escape. Smoke, not flames, is the real killer in a fire. Whenever there is smoke, there is a potential danger, so get out fast. Children often lock themselves in closets or hide under beds, waiting for someone to rescue them. Other fire victims don’t try to get out because they may underestimate the power and speed of fire. No matter how insignificant a fire seems, evacuate everyone immediately, alarm or call the fire department. Smoke alarms and fire drills periodically are excellent safety measures. The only way to prevent panic is to know what you are going to do before a fire happens.
There is a lot of fire dangers in your daily life, such as smoking, electric wires, television set, cooking, fireplaces, and chimneys. Don’t leave your children alone. Gasoline and other explosive substances should be used with extreme caution. Highly volatile liquids, when they are allowed to mix with air, form vapors that can explode into flame if touched off by the tiniest ignition source. If a fire starts in an electric wire, or in grease or flammable liquids, you need a fire extinguisher. In any event, always notify the fire department, even if you think you have extinguished the fire. Fire can smolder for hours. When it comes to ordinary combustive fire (wood, paper, fabric, curtains, bedclothes) plain water especially from a garden hose is potent. Use potentially dangerous volatile substances only in well ventilated areas.
For high-rise building fire survival: Call the fire department; alert others in the building, activate fire alarm; evacuate the area; close doors as you leave to delay the spread of the fire; do not use elevators – use the closest safe stairways. For fire outside your room: If the door feels hot, do not open it. If the door is not hot, open it cautiously. Stand behind the door prepared to close it fast. Place a blanket or towel along the bottom of your door to keep out the smoke. Escape through a window. If you cannot escape, hang a white or light-colored sheet outside the window, alerting fire fighters to your presence. If there is smoke present, stay low. Be prepared to crawl. Smoke and heat rise. The air is clearer and cooler near the floor. Crawl low under any smoke to your exit - heavy smoke and poisonous gases collect first along the ceiling. Plan ahead. Know all exit stairway locations.
Burn is any injury to tissues of the body caused by heat, electricity, chemicals, light, radiation, friction, or gases in which the extent of the injury is determined by the amount of exposure of the cell to the agent and to the nature of the agent. In the United States more than 2 millon people are burned each year, and an estimated 500,000 burn injuries receive medical treatment yearly. It is estimated that approximately 4 out of every 100 people with injuries from burn will die from their injuries. The majority of these fatalities (75%) occur either at the scene of the incident or enroute to medical facilities (American Burn Association, 2011).
The most common cause of burns reported is fire/flame followed by scalds. The highest incidence of burns occurs in the 18- to 35- year age group, while the highest incidence of scalds occurs in children under the age of 5 and adults over 65. About 85% of all U.S. fire deaths in 2009 occurred in homes (Karter, 2010). Cooking is the primary cause of residential fires, whereas smoking is the leading cause of fire-related deaths (Ahrens, 2010). Most victims of fire die from the smoke or toxic gases and not from burns.
Burns often accompany other injuries. Disfigurement, disabling scarring, and amputation is common after serious burns, and long-term treatment and rehabilitation are often necessary. Treatment for severe burns has improved dramatically in the past 20 years. Newly developed artificial skin holds great promise for treating severe burns. Today, patients can survive with burns covering up to about 90% of the body, but they often face permanent physical impairment. In addition to deaths resulting directly from burns, an estimated 10,000 Americans die every year of burn-related infections, pneumonia being the most common infectious complication among hospitalized burn patients.
The response at the scene of a burn injury can shape the victim's future. The first tasks are to remove victims from the source of injury and stop the burn process. Once they are in a safe area, assessment, interventions, and transport can take place. The goal is to stabilize and safely transport the victim to an appropriate facility for treatment. According to CDCs Field Triage Decision Scheme, burns without other trauma mechanism should be triaged to burn facility, and burns with trauma mechanism should be triaged to trauma center. Burns that compromise the airway are often the most time-limited burn emergency one will encounter, except for electrical burns that can disrupt cardiac activity and cause cardiopulmonary arrest.
The skin, the largest organ of the body consists of a superficial cellular layer called the epidermis and a deep connective tissue layer called the dermis. The subcutaneous tissue which contains fatty tissues and blood vessels is covered by the two layers of skin. The mechanism of injury in burns is the application of heat, radiation, electricity, or chemicals to skin that subsequently disrupt the continuity and integrity of the skin. The destruction of skin and tissue may be minor or life-threatening. Motor vehicle accidents and residential or industrial accidents may result in burns. Burns take their toll especially among the very young or the very old.
Thermal burns are caused by exposure to, contact with, or inhalation of the products of thermal agents such as fire/flame, steam, hot liquids or hot objects. The skin protects the body, but extreme heat applied to the skin can sear through the skin and injure tissue even below the skin. Burn injuries from flames occur when the victim's clothing or immediate environment ignites, and clothing and jewelry can melt and adhere to the hot skin. Scald burns is caused by hot liquids (water or oil) or steam, most commonly occurring from exposure to high temperature tap water in baths or showers or spilled hot drinks. Other contact burns can occur when a hot object meets and adheres to the skin, for example picking up a hot pan or spilling tar on the skin. Heat and smoke inhalation injury are often associated with flame injury. Inhaled hot air, smoke, and carbon can damage air passages, especially in a closed space.
Electrical burns are caused by contact with an electrical current, either electric shock or an uncontrolled short circuit. Lightning (during thunderstorms) is also a rare cause of electrical burns. When electrical forces races through the body, the major damage is often to the heart and muscles. Electrical burns may produce devastating internal injury with minimal external evidence. The points of entrance and exit on the skin are frequently burned, along with the muscle and subcutaneous tissues through which the current passes. These entry and exit wounds may appear minor, but the passage of electrical current through the body can cause fatal cardiac arrhythmias, cardiac or respiratory arrest, seizures, unexpected falls, and violent muscle contractions that fracture or dislocate bones. Electrical burn injuries associated with low-voltage (<500 AC volts), sufficient to cause cardiac arrest and ventricular fibrillation may not produce any skin burns or burn marks at all. Lighting injuries (high-voltage injuries) may affect multiple organ systems. The electrical burn itself is often marked on the skin by a charred, zigzag entrance wound and another charred exit wound; but the more dramatic damage is inside the body. They can cause respiratory arrest secondary to central nervous system damage and cardiac arrest (fibrillation or asystole). In addition, violent muscle contractions may result in fractures or dislocations or may cause falls that result in further injury. Spinal injury is not uncommon and edema, muscle death, and internal hemorrhage may also occur in the early stages following lightning injury.
Chemical burns are caused by contact with or ingestion of chemical agents, such as acids, alkalis, phenols, creosols, mustard gas, or phosphorus. The burn will progress as long as the chemical agent remains in contact with the skin, or eyes. The cornerstone of therapy is removal of the chemical from contact with the victim’s body with copious amounts of water.
Radiation burns are caused by protracted exposure to UV light (the sun), tanning booths, sunlamps, X-rays, radiation therapy, and accidental spill of radioactive material. More severe cases of sun burn may result in sun poisoning or heatstroke.
The longer the patient is in contact with injuring agent, the worse the burn will be. Thermal and chemical injury disrupts the normal protective function of the skin, causing local and systemic effects. The extent and degree of these effects depend on the type, duration, and intensity of exposure to the causative agent, a closed space, age and sex, significant heart disease, pulmonary problems, other underlying illnesses (diabetes), and also associated injuries. With electrical burns, heat is generated as the electrical current passes through body tissues, causing thermal burns along the path taken by the current. Burns can cause massive shifts of fluid within the body. Local damage is marked by histamine release and severe vasoconstriction, followed in a few hours by vasodilation and increased capillary permeability, fluid leaks from the vasculature into extracellular space, resulting in edema. Systemic effects, which are caused by vascular changes and tissue loss, include a functional hypovolemic state, hyperventilation, increased blood viscosity, and suppression of the immune system. Hypotension and shock can occur even when no blood loss is visible. Thermal injuries also can cause massive edema and occlusion of the airway. The severity of the burn determines the extent of local and systemic effects. Potential complications in serious burns include circulatory collapse, renal damage, infections, septic shock, multiple organ failure, electrolyte imbalance, respiratory complications, gastric atony, paralytic ileus, and stress ulcer (Curling's ulcer), characterized by hematemesis and peritonitis.
In caring for the burned patient in the field, it is most important to observe the scene of the injury, obtain information, extract critical data, and react. Be aware that other injuries are often associated with burns, such as chest injury from a blast or explosion, or inhalation injuries. A hazard in assessing and managing the burn victim is removing the victim from the source of the burn. Do not go to the victim until you are sure that your own safety is not compromised by downed power lines, fires or potential explosive situations, and gases in the air. When both you and the victim are in a safe place, take steps to stop the burn process, evaluate the airway, breathing, and circulation and assess the patient. The goal is to stabilize and safely transport the patient to an appropriate facility for treatment. A network of burn centers has been established throughout the United States and Canada to provide care for victims who have been severely burned.
In the emergency room, try to get the following information:
Thermal burns are classified according to depth or degree of tissue injury they produce, and as partial thickness and full-thickness. The extent of the body surface area burned, the seriousness of the burn, is determined by the rule of nines. Mortality and morbidity from burns are influenced by the patient's age, sex, and health before the incident in addition to the depth and extent of the burns and other associated injuries. The depth and degree of the burn is determined as follows:
First-degree burns are limited to the most superficial layer of the skin. The inflammatory response of the body is indicated by redness (erythema) in the injured area, and injured nerve endings. They are very painful initially, but they usually heal in one week or less, with peeling of the outer epidermal layer. A scald or moderate sunburn can cause a first-degree burn.
Second-degree burns (also called split thickness) penetrate the skin deeper, both the epidermis and the dermis are injured. Second-degree burns (superficial partial thickness) extend into superficial (papillary) dermis; blanches with pressure, and second-degree burns (deep partial thickness) extend into deep (reticular) dermis; less blanching, may progress to third-degree over time even after initial treatment. Pain is intense because of damage to nerve endings and tissues; the area is red and mottled and sometimes swollen. Clear or bloody blisters form in reaction to the injury, and weeping wounds may be present. Second-degree burns are most commonly caused by contact with hot liquids. Healing can take 2-3 weeks, or several weeks, depending on the depth of the burn.
Third-degree burns (full-thickness burns) involve damage or destruction of the skin, subcutaneous tissue, and underlying muscle, nerves, bone, and other structures. Third-degree burns are dramatic and disfiguring, but they cause no pain, because the nerve endings in the skin, have been destroyed. The remaining tissue may appear charred or leathery or look white and dry. Because the skin is destroyed, surgical excision and skin grafts will be required. Patients with third-degree burns are prone to lose massive quantities of fluid, since they lack the usual protective mechanism of the skin. Shock may be a major problem in these patients.
The rule of nines determines the extent of a burn, the amount of body surface damage by the burn and therefore the seriousness of the burn. Burn professionals may modify the rule of nines for children, patients who are pregnant, and certain other patients. The following percentages are used:
When assessing children who have burns or scald injuries, view both the injury and the scene with suspicion unless it is obvious that the burns were incurred in a fire, motor vehicle accident or other accident. An immersion scald is created when an extremity is held under the surface of hot water, and is a common form of burn seen in child abuse. The rules of nine for an infant, the age of 1, are counted as 18% for the head; 9% for each upper extremity; and 14% for each lower extremity. The torso is counted as 18% for the front and 18% for the back. The genitals and perineum counts as 1%. The rules of nine for children, the age of 5, are counted as 14% for the head; 9% for each upper extremity; and 16% for each lower extremity. The torso is counted as 18% for the front and 18% for the back. The genitals and perineum counts as 1%.
Severity is judged by quantity of tissue involved and the depth of the burn. The percentage of body surface area (BSA) system classifies quantity as follows: small, <15% BSA; moderate, 15%-49% BSA; large, 50%-69% BSA; and massive, >69% BSA.
Burns can also be assessed by total body surface area (TBSA), which is the percentage affected by partial thickness or full thickness burns. Burns of 10% in children or 15% or greater in adults are potentially life-threatening injuries (because of the risk of hypovolemic shock) and require formal resuscitation and monitoring in a burn treatment center.
In order to determine the need for referral to a specialized burn treatment center, the American Burn Association devised a classification system to aid in the decision-making process. Burns are classified by severity as major, moderate and minor. This is assessed by a number of factors, such as age, type of burns, total body surface area (TBSA) burnt, the involvement of specific anatomical zones and associated injuries. Major burns typically require referral to a specialized burn treatment center. Persons suffering moderate burns often need to be hospitalized for burn care. Minor burns usually do not require hospitalization.
Critical burns are those that involve any of the following factors:
Flame injuries are common in house fires. Burn injuries to the head and neck may compromise the airway because of massive tissue edema.
Chemical burns occur when the skin comes in contact with strong acids, alkalis, or other corrosive materials. Management include removing the chemical from contact with the victim, removing the victim from the scene, and immediately flushing the chemical from the skin or eyes.
Inhalation injuries. Whenever a person’s skin is burned by heat or chemicals the air passages also can be injured by heat, smoke, or toxic fumes. Common inhalation injuries include carbon monoxide poisoning, smoke inhalation and heat inhalation. Assume that any victim who has a burn has sustained an inhalation injury until it is proved otherwise.
Carbon monoxide poisoning is a toxic condition in which carbon monoxide gas has been inhaled and binds to hemoglobin molecules, thus displacing oxygen from the red blood cells and decreasing the capacity of the blood to carry oxygen to the cells of the body. Carbon monoxide (CO) is a colorless, odorless, tasteless gas produced during the incomplete combustion of carbon and organic fuels, emitted in automobile exhaust fumes, space heaters and is find in smoke from fires and even cigarettes. The affinity of hemoglobin for CO is 200 times that for oxygen. It can poison both victim and rescuer. The result is suffocation at the cellular level. Anything that increases the need for oxygen, such as fever or physical exertion, will increase the severity of the poisoning. Children, whose metabolic rate is higher than that of adults, tend to develop more severe symptoms, for their higher demand for oxygen makes them feel the oxygen deficiency earlier. Usually the exposed victim of accidental inhalation does not realize what is happening until it is too late, and death occurs eventually if the victim is not removed from the source of the carbon monoxide. Warning signs include a sensation of pressure in the head and roaring in the ears. With acute poisoning, the patient shows confusion and inability to think clearly, and there will often be vomiting and incontinence, followed by convulsions and coma. Patients will not appear cyanotic despite the hypoxia, they may instead appear quite pink. Unconsciousness and apnea occurs in sequence as the level of carbon monoxide in the blood increases. Cherry-red skin is a late sign most commonly noted in fatalities.
Smoke inhalation, toxic fumes or vapors can damage air passages, especially if the victim is confined in an enclosed area during the accident. Air exchange may be impaired. Suspect smoke inhalation injury in any burn victim who has been exposed to smoke, has burnt nares or sooth in the mouth.
Heat inhalation, when the victim is trapped in a fire can damage the upper part of the airway from high temperatures; swelling of the airway may develop slowly and obstruction of air flow may occur. Suspect heat inhalation injury in any burn victim who has been exposed to hot gases, has swollen lips, hoarseness, or respiratory distress. The airway, irritated or damaged by the heat injury, is prone to sudden closure from laryngospasm.
Serious and critical burns are major injuries and a devastating tragedy in patients' lives, and the initial interventions by responders can have a major impact on the patients' future. The paramedics should alert the facility and report the number of victims, extent of injuries, estimated time of arrival, and whether additional burn casualties from the incident may be anticipated. The challenges are to remove the victim from the source of the burn injury, stop the burn process (put out the fire), protect the victim from further injury, and stabilize and maintain his or her vital functions until arrival at an appropriate emergency facility. Treatment at the scene is aimed at ensuring the airway and trying to promote the best possible outcomes in the severely burned patient. Your interventions should be within the scope of your professional license, skills and training, consistent with your state’s nurse practice act, and adherent the facility’s standards of practice.
Never compromise your own and fellow rescuers safety to reach a burn victim. Doing so may endanger your life and delay rescue of the original victim. If you can get to the patient safely, but a threat may still exist, move the victim from harm as quickly as possible and to not stop to assess or treat the patient until you are both in a secure area. When a building is on fire, do not get caught in the “flashover” (when everything in the room will spontaneously burst into flame without warning). Extract victims from a burning building immediately. Sudden eruption of fuel tanks at motor vehicle accidents, and combustion of vapors at industrial accidents can occur. Do not attempt to move downed power lines or wires, or reach the victim of the electrical shock until the power source has been turned off and removed. Poisonous substances as carbon monoxide and vapors may be present in the immediate environment or on the victim’s clothing or skin even when you cannot see or smell these chemicals.
Surgical management include: surgical excision, wound debridement, escharatomy to relieve circumferential burns and constrictures caused by scarring; fasciotomy with some electrical burns; skin grafting or flaps; amputation of severely burned limbs; and reconstructive and plastic surgery to correct deformity.
Special considerations in the burned infant and small children. Burns in infants and small children (especially under the age of 5) pose a special problem because the surface area in children is much larger in proportion to the total body mass than in adults. Potential fluid loss through extensive burns can be massive. When you encounter a seriously burned infant try to start an IV if possible; otherwise wrap the baby in a moist, sterile sheet and enough blankets to keep the baby warm, and transport rapidly to the hospital. Children have an elevated basal metabolic rate, and a higher need of protein. They are also more sensitive for infections in burned tissues, and also the airways and gastrointestinal tract. The lungs are still immature the first three months of their lives, and the kidneys have less ability to correct serious disturbances in the water and electrolyte balance. Infants and children have a smaller blood volume than adults, and shock and hypovolemia may develop quickly. Children are also less able to maintain their body temperature. Acknowledge the child’s fear. Get down on the child’s eye level when possible so you will be perceived as less threatening. Allow the child to take a favorite toy or blanket to the hospital and encourage parents or caretakers to be with the child as much as possible.
The burned elderly. Many of the changes that occur with aging diminish the body’s ability to respond to the challenge of trauma. They may survive the initial traumatic injury but then succumb to medical complications from the trauma. Cardiovascular, respiratory, metabolic and hepatic, renal, and skeletal changes can be significant. The elderly are also prone to heat loss and chilling and become dehydrated sooner than the young.
Infection is a major complication in burns. Risk factors of burn wound infection include: Burn >30% TBSA, full-thickness burns, burns in infants, small children, and the elderly, other underlying diseases (diabetes), virulence and antibiotic resistance of colonizing organism, failed skin graft, improper initial burn wound care, and prolonged open burn wound.