Textbook of Maritime Medicine

10.6.1   Incidence    

Minor burn injuries are frequent and familiar to everybody: 600 cases are reported per 100.000 inhabitants a year. In contrast severe and extended burn traumata are explicitly less frequent: 2 – 5 cases per 100.000 inhabitants a year. The causes for burns are multiple: accidents at home, in leisure time, in the transport sector, working environment and attempted suicides – to name a few.  

10.6.2   Areas of risk and mechanics of thermal trauma

Aboard a ship two areas are especially susceptible:  engine room and galley. Over a period of 5 years Germany’s Seaman’s Health Insurance recorded 43 cases out of a hundred burns to affect personnel in the engine room. In 33 cases galley personnel and stewards were concerned.

(private note Bartz, Schepers, See - BG Germany, 09/2008).

In the engine room burn injuries usually are caused by flames, explosion or scalding by cooling fluid or steam. In the galley contact with hot fluids or objects often cause burn injuries.       

10.6.3   Extension of burn injury

To assess the severity of burn injuries the extent and depth of the burned area must be thoroughly determined. To estimate the extent of the total burned surface area (TBSA) the „palm - rule“is used (Figure 10.5.1).

The palm of the casualty (not of the examiner) is approximately equivalent to 1 % of his total body surface. 

   Figure 10.5.1      Palm rule                  

 10.6.4   Depth of burn injury

The depth of burn injuries is classified in four grades. The characteristics of the different grades are shown in the table 1.

Table 10.5.2  Depth of burn injury

Courtesy of:    Leitlinien der Deutschen Gesellschaft für Verbrennungsmedizin

10.6.5   Emergency treatment

First aid measure of choice by a lay person at the site of accident will consist of cooling with tap water at a temperature of 15 - 20 °C. This will reduce the sensation of pain, the release of histamine and the occurrence of oedema. In case of extended burn injuries in adults, burns in children or impaired consciousness in burn patients, extensive or prolonged cooling may lead to hypothermia. In general cooling with water should be continued until analgesia is achieved, but not longer than about 20 minutes. Following transportation of the burned patient to the hospital aboard, or to any other sheltered room on the ship further treatment includes stabilisation of circulation, pain treatment, cleaning and sterile covering of the wounds.

  First measures

-                     self protection

-                     rescue of the burned patient from the hazardous area

-                     shut off and removal of the heat source, extinguish fire in clothing, local cooling

-                     check  vital signs

-                     transport to the ship hospital

In case of small injuries cooling with water until pain reduction. Be careful in case of extended burn injuries, avoid hypothermia. In case of chemical burns, rinse with water.         

Further treatment

After rescue of the burned patient all remaining garment has to be removed and the wounds need to be cleaned.  After removal of soot and dirt the extent and depth of the burn injury can be estimated. The medical history like previous illnesses, allergies and other important medical information must be recorded. The immunisation protection against tetanus has to be checked. If necessary, the vaccination must be completed, if the vaccine is available on board. The circumstances of the accident may indicate special kinds of other accompanying injuries. A careful clinical investigation according to the situation on the ship is essential.

If an early evacuation of the burned patient to a hospital ashore is not feasible, some surgical emergency procedures in the ships hospital may be considered.

This includes for example the escharotomy, optionally the fasciotomy in case of third or deep second degree burns of the whole circumference of hands, arms, legs or the trunk. In these cases the blood circulation in the tissue is at risk because of swelling and high pressure in the tissue. In case of circular deep burns of the trunk with disability of breathing, the escharotomy of the chest is indicated to save the life. The transections will be covered with artificial skin or some other kind of wound covering.

All burn wounds are to be covered with sterile wound dressing.

A sufficient debridement is generally only possible in a specially equipped burn centre ashore. On board a full body shower with antiseptic cleansing lotion should be done instead. Affected areas will be shaved. Above 20 % TBSA a complete shaving is done except for eyelashes and eyebrows.

In addition to the exploration in case of clinical suspicion specific x-ray has to be done. After completion of debridement the assessment of extent and depth of burn injury can be done.

Aboard ship such a sophisticated initial treatment is not possible in the majority of cases.

Information about the approximate extent, depth and localisation of a burn injury should be relayed to the rescue coordination centre and telemedicine consultation be sought for further treatment

The extent is given in percent of body surface, the depth in degrees (1^st to 4^th degree). In emergencies and under the limited facilities aboard exact diagnosis may hardly be possible but even an estimate will help to plan further handling of the case. 

10.6.6   Concomitant traumas 

Less experienced examiners may overlook additional trauma because of the dramatic aspects of the burn injury. A careful history of the burn accident however will give information on potentially secondary injuries, which must be investigated.

Eventually x - ray will be required.

Additional injuries of head, thorax and abdomen obtain first priority in treatment because of vital indication. Also injuries of pelvis, spine and big tubular bones have to be treated without delay.

Aboard ship the facilities for diagnosis and treatment are clearly limited.

If an immediate transport into a hospital is not possible further surgical procedures on board have to be considered.

Severe thermal damage of the face or explosion trauma can lead to injuries of the eyes.  In case of clinical indication a specific examination should be performed. 

Foreign bodies will be removed by irrigation. Penetrating injuries of the eyes require immediate ophthalmologic surgical treatment.

In case of explosion trauma the tympanic membrane can be affected. This too should be investigated and auditory canal must be inspected.

5.6.7   Systemic treatment

Pain therapy

The superficial burn injuries are very painful. Deep second degree and third degree burns are characterised by damage of the afferent nerves of the skin and less painful. Pain therapy adapted to the actual condition of the patient  has to be given immediately. If the intravenous therapy is not possible, sufficient oral medication with analgesics should be performed. 

According to the „International Medical Guide for Ships“of the World Health Organisation (3^rd edition), ships are equipped with several painkillers for oral and i.v.  application, for example Acetylsalicylic acid, Ibuprofen, Paracetamol, Morphine (injectable, oral). In case of severe burn injuries, as a rule, morphine should be given, in case of small burns peripheral efficient analgesics, for example Paracetamol or Ibuprofen can be used. Acetylsalicylic acid has side effects with regard to coagulation and is less recommendable if surgical procedures are considered in the course of the treatment. 

Infusion therapy

Rehydration shock therapy is obligatory above 15 % TBSA II° - III° in adults.  And above  8 % TBSA in children. Electrolyte solution like Ringer’s solution,  Sodium chloride 0,9%  and oral rehydration salts as listed in the  WHO  „International Medical Guide for Ships“ would be suitable.

Calculation of the amount of fluid is done with the Baxter (Parkland) - formula:  

4  x  kg  body weight  x  %  burned surface (II° - IV°)  =  ml  Ringer lactate  /  24 h).

(Maximum 50% TBSA)

Half of the volume is given within the first 8 hours, the other half is distributed through the second and third 8 - hour interval. 

In emergency treatment with 1000 ml infusion / h , maximum in the first  2 hours can be given

Patients with cardiac failure gets less infusion, patients with hemodynamic instability gets more.  

If an adequate infusion therapy is not possible, the substitution can be done oral with a solution of oral rehydration salt or clear fluid.

Local treatment

Upon completion of debridement and estimation of extent and depth of burn injury the local treatment of wounds can be performed. The wound is covered with sterile dressing material. If at hand silversulfadiazin or polyhexanid is used for moist wound treatment especially on the extremities and in the face.

In case of large and deep burns, a dry wound treatment can be done and is especially suited for areas the patient is lying on. Repeated use of  10 %  Povidone Iodine - solution  results in a dry and hard coating of the wound surface. This is a good way of wound treatment, if the injured has to stay on board of a ship for a longer period and enough other material is not at hand.

If the casualty can be treated in a qualified hospital ashore after a short time of transportation, a sterile covering is sufficient.

According to the „International Medical Guide for Ships“ of the  WHO, 3. edition,

ships are equipped with  Sterile sheet for burn patients, Sterile gauze compresses

5 x 5 and 10 x 10 cm as well as  gauze dressing 10 x 10 cm and  Povidone Iodine solution 10%. 

All burn injuries and in particular inconsistent findings regularly need re-evaluation.  Concomitant diseases as diabetes mellitus and obstructive diseases have effects on wound healing and course of the burn injury. After re-establishing normal temperature and stability of circulation, a more favourable picture of the depth of burn injury may be revealed.

This is relevant only if the burned patient has to be treated aboard for several days because of meteorological or geographical terms. For a longer stay aboard the wound dressings should be changed if they are soaked. Especially superficial second degree burns show strong secretion in the first days after injury.

Special  emergency and surgical treatment  (for example intubation, artificial respiration, escharotomy, tracheotomy, special wound treatment, amputation) can be performed on board ship only in a few convenient cases. In addition to a well equipped hospital a fully qualified ship’s doctor is required in these cases. 

5.6.8   Emergency surgery

Escharotomy

Deep second and third degree burned skin looses its elasticity. The eschar is hard and cannot give way to the subcutaneous oedema. Thereby the pressure in the tissue increases and the capillary flow is broken down. The nullified blood flow causes necrosis of the affected tissue. This results in loss of function or requires ablation of limbs.  

The swelling increases from the first hours for days after burn injury. Assessment of wound situation and perfusion should be repeated during the course of treatment.

In case of circularly deep second and third degree burns the indication for escharotomy (relief cut) must be checked. If the escharotomy alone is not successful, fasciotomy must be performed to achieve release of the tissue with intention of restoring blood flow to a limb damaged by burn and subcutaneous oedema leading to compartment syndrome.

The direction of incision  in the hand and in the region of joints must follow  functional aspects and ensure a favourable future course of scars. The usual incision lines are mapped in figure 10.5.2.

In case of complete or nearly complete circular deep second and third degree burns of the chest the pressure may obstruct ventilation. In extreme cases normal breathing and assisted ventilation is no more possible. In this case only immediate escharotomy can assure further ventilation. 

 Figure 10.5.2: Escharatomy. Guide for incision

 Courtesy: G.Zellweger: Die Behandlung der Verbrennungen

Tracheotomy

Patients with deep burns of head, face and neck who suffer from a rapid and increasing oedema often require an early intubation or tracheotomy to save the airway. On board ship this will be possible only in particular cases. For this procedures a special equipment and experience is needed. In case of burns of the upper part of the body as a first aid measure an elevated position of head and thorax should be secured to avoid more swelling. Oxygen may be administered if possible. 

Amputation

Burns or high voltage injuries with complete 4th degree injury (charring) of arms or legs are  life - threatening due to the decay products of muscles.  In most of these cases the life can only be saved by amputation of the concerned part of the body.  This surgical procedure needs a well trained physician and special medical equipment.

Treatment in hospital on board

• cleaning of lesions under analgesia
• local treatment 
• shock treatment  with 15 % TBSA in adults, or  8 %  in children
• full electrolytic solution for infusion

Generally, in emergency fluid may be given be given with:maximum 1000 ml infusion 
 per hour for the first  2 hours.

In patients with cardiac failure the infusion volume may be less, in patients with  hemodynamic instability it may be more. If an adequate infusion therapy is not possible, the substitution can be done orally with clear flui intubation if needed,pain treatment

         Further treatment depends on severity of burn injury  

         small burns:  treatment  aboard  

         every extensive  burn injury: treatment in a qualified hospital, evacuation of the

         patient, if conditions allows

10.6.9      Indication for treatment in a specialist burns centre         

The criteria of the German Society of Burn Treatment (DGV), the European Burns Association (EBA) and the American Burns Association (ABA) correspond.

All patients who meet the criteria mentioned in table 4 should have an early transport to a burn centre.

Limited burn injuries can be handled in dedicated hospitals. Definitive treatment on board is possible in case of minor traumas.

In coastal areas the casualty should be transported to the next qualified hospital by adequate rescue vehicles (usually rescue helicopter or rescue ship). Under favourable conditions (closeness to shoreline, good weather) the next burn centre can be approached directly. The communication should involve the responsible rescue coordination centre and the receiving hospital.

Criteria for transfer to a burn centre

          ( Guidelines of the German Society of Burn Treatment  - DGV - )

      All patients with burn injuries of head, hands, feet, anogenital - region, axle, big
       joints or other difficult regions

      Burns above 20 % second degree TBSA

      Burns  above 10 % third degree TBSA

      Burns with additional injuries

      Burned with inhalation trauma causing reduction of lung function

      Burns with pre-existing diseases, age below 8 years, or above 60 year

      Burns with electrical injuries

Summary

        Rescue out of danger zone, self protection

        Protection of vital functions

        Transport to hospital aboard or sheltered room

        Short cooling, avoiding hypothermia

        Adequate pain therapy

        Adequate infusion - / shock therapy,

           if intravenous infusion is not possible, oral substitution of clear fluid

        Thorough and complete cleaning of burn injuries

        Look for additional injuries

        Estimation of extension ( % TBSA ) and      depth  ( I° - IV° ) of burn injury

        Sterile wound dressing, in case of a longer stay aboard specific local treatment

        Burns with electrical injuries early contact with coastal medical consultant
           service

        If possible, send pictures per e-mail

        If necessary, surgical emergency treatment in ship
           hospital  ( requires specific equipment and experience )

        Except for minimal burn lesions early transportation of the burned patient into a
           qualified hospital ashore

Literature 

Bartz,  Schepers,   Pers. Mitteilungen ,See-BG,   September 2008    

Bruck, Müller, Steen ,  Handbuch der Verbrennungstherapie   Ecomed  Verlag,    September 2002

Bisgwa, F., Pitzler, D., Partecke, B.D.  Die Erstversorgung des schwerbrandverletzten Patienten aus chirurgischer Sicht. Unfallchirurg   1995,   98:  180 - 183

Fachausschuss „Erste Hilfe“ der Deutschen gesetzlichen Unfallversicherung Stationäre Überwachung nach Stromunfall?

Der Notarzt,   2008,   24,   220 -221

Gliwitzky, B. Präklinische Therapie von thermisch Verletzten    

Rettungsdienst   2000,   23:   1190 – 1193

Herndon, D.N. Total Burn Care, W.B. Saunders Company Ltd, London 1996

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Striepling, E., Bisgwa, F., Pitzler, D. Die Erstversorgung Schwerbrandverletzter aus plastisch - chirurgischer Sicht Medizin & Praxis,   Spezial „Thermische Verletzungen“,   Juli 2002,   21 - 24

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Unfallchirurg   2006,   109:   270 – 277

WHO International Medical Guide for Ships 3. Auflage

Zellweger, G. Die Behandlung der Verbrennungen, 2. Auflage 1985,   Deutscher Ärzteverlag