Treatment for Partial Thickness Burns

Robin Asks:

I have a question regarding burn care. The main character in my novel is burned in a house fire and receives second degree burns to his back. How long would the wound be oozing? If it’s second degree burns, would he require skin grafts? What is the general treatment for second degree burns? What pain medications would be ordered?

Jordyn Says:

With burns to the back, it would really depend on what percentage of his back is burned. Burns are always calculated in percentages so it’s hard to know exactly what the treatment would be without knowing that number.

However, in general . . . second degree burns are now called partial thickness burns in medical terminology. Usually, to qualify as a partial thickness burn, the skin is reddened with blistered areas. These will probably ooze quite a bit for a few days.

Current treatment is to slather the burned area with triple antibiotic ointment, generally leaving blisters intact. After the ointment is in place, the burn is covered with something that won’t stick to the leaking fluid (called serous or serosanguinous fluid) like non-stick gauze pads and then roller gauze is applied around. This is why not knowing the burn size is problematic.

If the burn is large, covering most of the back, then the torso may need to wrapped to keep the non-adhesive barrier/dressing in place. The goal is to leave blisters intact. Blisters can be popped if they are problematic in size but the skin may be left over top because it provides a protective barrier. Exposed raw skin is the most painful. Blisters are also left intact because they provide a barrier against infection.

These dressings would likely be done until the skin heals which can take up to two weeks. As far as home pain medications, once the wound is covered it usually decreases the pain dramatically because the raw, exposed nerve endings aren’t coming in to contact with air anymore. These days, the patient might be sent home with a few doses of Lortab or Percocet (three days is becoming more common) with the patient instructed to take Ibuprofen on a schedule as well for pain control. I don’t think this is a situation where skin grafting would be required.

Hope this helped and best of luck with your novel!

This Is US: Jack’s Needless Death

This television episode caused more people to reach out to me over any other. This Is Us has been building up to Jack’s death for eighteen months. It needed to be big. It needed to be dramatic. Can you tell I’ve been watching the show? It was really none of those and medically— well, just weird to be honest.

If you haven’t watched the episode then don’t read this post because it will reveal his cause of death . . . like right now.

Jack’s ultimate demise? A heart attack called the widow maker caused by the stress of the fire.

Jack is in intense smoke and heat for several minutes. He emerges and is first checked by EMS. He is being given oxygen and a dressing to his arm for “2nd degree burns”. The EMS person says she can’t treat the burn and he is seemingly refusing transport, but she does encourage him to be seen. Also, giving oxygen is correct, but it is not the right type of mask. A note on burns. Burns will evolve over the next several days so you don’t really know how severe a burn will be for a while.

Jack does eventually go to the hospital to get his burns checked. The doctor is initially giving him instructions on burn care.  The doctor says, “I’d like your heart rate to come down.” and glances at the monitor— which doesn’t have any readings on it. No waveforms. No numbers. He then says, “There’s soot in your airway so we’ll have to run some tests. The swelling is minor.”

That’s about it. The doctor tells Jack he basically dodged a bullet and seems none too concerned about his potential airway damage.

Just as I mentioned above, airway burns from smoke inhalation are similar to skin burns in that they evolve over time. Smoke inhalation and the potential for upper airway swelling is taken very seriously. There is a nice overview here. At the very least, there should be discussion of admitting Jack to the hospital. As quoted from the article, “Studies have shown that initial evaluation is not a good predictor of the airway obstruction that may ensue later secondary to rapidly progressing edema.” If there is concern about significant injury to the airway then the patient is electively intubated until the airway injury heals. It’s VERY difficult to intubate someone with a lot of airway swelling.

Shortly after this consultation, Rebecca decides to make a phone call and get a candy bar from the vending machine. In that, perhaps under two-three minutes passage of time, Jack codes and dies. Even though she is just outside the ER nurses station, she never hears a code being called. Doesn’t see the commotion.

The doctor approaches her and says, “One of complications of smoke inhalation is that it puts a terrible stress on the lungs and therefore the heart. Your husband went into cardiac arrest. It was catastrophic and I’m afraid we lost him . . . Mrs. Pearson, your husband has died.”

After a few exchanges she goes to Jack’s room where there is a spotlight shining on his chest with a cursory ambu bag at the head of his bead . . . but no other equipment. I’m telling you in two minutes, a code has barely just begun and is never called so hastily . . . like ever. Later, explaining the event to Miguel, Rebecca says he had a widow maker’s heart attack.

The widow maker is a real term for a heart attack. It generally refers to occlusion of the left main coronary artery that feeds the left side of the heart. It is the same heart attack celebrity trainer Bob Harper had and survived. The reason the widow maker can be so devastating is that the left ventricle is the largest, strongest pumping chamber. If it dies . . . well, you’re hosed.

There would be no realistic way the doctors would know it was specifically this kind of heart attack as shown in the episode without an autopsy. Presumably, Jack went into one of the lethal heart rhythms, v-tach or v-fib, at the time of his code. In the time frame given on the show, the medical team would have barely started CPR and given the first line treatment which is electricity. A 12-lead ECG can be a strong diagnostic tool for this type of heart attack, but they never did one. Had they done that early on, they probably would have seen the changes.

Also, he would likely have some signs and symptoms. Chest pain. Nausea. Left arm pain. Sweating. Demonstrating these might make the scenario seem more believable. Having Rebecca witness the code would have been more dramatic.

Also, it would make more sense that he would suffer this cardiac event while he is actually under duress— such as during the rescue of the children and the dog.

The only way to truly know that this is the type of heart attack Jack suffered as presented in the show would be to conduct an autopsy.

This Is Us— thanks for killing off a beloved character in a totally lame way— at least from a medical standpoint.

Care of the Burn Patient

Linda Asks:

In my middle grade novel my main character’s dad was a fireman in NY.
He was present during the collapse of the World Trade Center buildings.
He was burned severely and is in the hospital – near death.

My main character remembers his last conversation with his Dad in the hospital right before he dies.

The dad is hooked up to all kinds of beeping machines and is wrapped in white gauze.
After he talks to his son for the final time, he pushes a button for more morphine.

Questions:

Do they still wrap burn patients in gauze?
Is morphine used on severely burned people?

Jordyn Says:

From the point of view of your character– yes, burns are wrapped in gauze. They are specialized dressings, but a character aged 10-13 could perceive it as gauze only.

Yes, morphine is still used for pain.

My only concern is this character having a conversation with his dad. You don’t describe the nature of how he was burned, but a severely burned patient, particularly one close to death, is likely on a breathing machine and, therefore, unable to speak to his son.

You could change the scene to be that he’s so sick that they are getting ready to intubate the character’s father, and the medical team gives them a few moments to talk before they put the father on the breathing machine. He could still die quickly after from his injuries.

Authors Question: Treatment of Burns in Children

I got this question in my blog comments and thought I would also provide the answer here.

Latedra asks:

How would they treat burns in children? I imagine as they grow the burn scar would shrink right? My heroin received a burn as a child and I write it like she still has this big burn that is a part of her life. Is that possible? Maybe I’m over thinking it. I’m just now taking her burn seriously.

Jordyn Says

Hi Latedra!

Thanks for leaving a question. It depends on what kind of burn you’re talking about. Burns that need a higher level of care would be those that would inhibit function. We get concerned about burns that cover a large portion of the feet, hands, face or genitalia (including breasts). The larger the burn area or the deeper the burn– the more it may require skin grafting to heal.

Let’s take a simple burn. Red with some blisters but covers maybe a palm size of the thigh. We would wash it with mild soap and water. Apply a copious layer of triple antibiotic ointment. Then we put something over top that won’t stick to it– we use a Vaseline impregnated gauze called Adaptic– then it won’t stick as the dressing comes off. More extensive burns would be referred to a burn center.

Scars generally stay the same size. They don’t grow as the child grows so it may appear that they are shrinking because the child is bigger but really they are the same size.

Hope this helps!

Author Question: Treatment of Burns circa 1807


Michelle G asks
:

I’m working on a historical (surprise, surprise) 1807, to be exact, in England, and wondered if you could give me a little medical advice? I’ve burnt the leg of one of my characters, a little boy, like 9, and I want him up and about in 3 weeks or so, but he can use a crutch. What would that leg look like? How much pain? How would he react that first week? I don’t want to overdo it, nor do I want to gloss over it either. What’s your .02?

Here’s what happened to him…

“Thomas leaned over the hearth to scoop a ladle of stew from the pot. He moved too fast, with too much force. The hook broke. The pot fell into the flames. Coals shot out, catching the fabric of his trousers. He tried to whack it out, brave boy, but ended up fanning it larger. He ran. I stopped him. I thought he was…” She gulped back the lump in her throat. “I thought he was dead.”


Jordyn Says:

This sounds like a pretty significant burn– his pants catching on fire. Easily partial thickness and could even be full thickness in some places. Have you considered just having the pot of stew fall on him– maybe with bare legs? This would be more partial thickness and could more likely heal in your time frame.

Full thickness burns are problematic because they usually require grafting so back then treatment was likely very limited. We also do fluid resuscitation for significant burns and if both of his legs were this severely burned– he’d need quite a bit of fluid, and again, I’m not sure this would be available during your time period.

So, I might try to back down the injury to second degree burns. Those should heal up pretty nicely in your three week time frame. Second degree or partial thickness would include skin blistering and peeling, big concern for infection (intact skin is your largest protector against infection) and dehydration initially because burns also leak a lot of fluid. He could probably walk with crutches. It’s not really a muscle injury (it would be if you go with full thickness burns– like his pants catching of fire) so he should be able to walk.
Pain is going to be a big issue. Burns are very painful. So, he’s going to need something.

Here is a very interesting link that has tons of information on the evolution of burn surgery. It will give you some treatment options for your time period. 

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Keep up with the exploits of Michelle Griep at Writer Off the LeashFacebookTwitter, and Pinterest. You can check out her latest novel,  A Heart Deceived, at David C. Cook as well as AmazonBarnes & Noble, and ChristianBook.