Glass burn

[Seaglass]

Another thread got me thinking about all the fun that can be had with glass, so I figured I'd throw this one out there.

You're dispatched to the local art center for a burn, and are directed to a glassworking studio which contains both kilns and propane/oxygen torches. The room is extremely warm, and smells of hot glass and propane. There's one bystander, wearing goggles and an apron, who offers some prescription burn cream (Silvadene) but otherwise stays out of the way.

Upon arrival, you find a 30y/o F, also wearing goggles, with a severe burn to the palm of her hand. Fully A&O, RR 20 and a bit shallow, BP 130/80, pulse 130 and seems a little weak. Pt is cool, pale and diaphoretic. She says she feels a bit dizzy, and that her hand really hurts.

Pt states she had been working with nearly-molten glass and automatically reached out to drop a piece when it fell. Upon examination, you find a small area of blackened skin near the center of her palm, surrounded by a larger area of blistering. It’s still very hot to the touch, but does not appear to have retained any glass.

Scene safety considerations?
What else are you going to look for in your initial assessment?
How are you going to treat at the BLS level?
How about ALS?

 

[Shishkabob]

So, 1% of her body is burned?


No safety considerations beyond making sure I don't fall in a kiln myself, and don't lick the broken glass.


I'll make sure the rest of her arm isn't burnt, and check the airway for potential airway burns, ever vigilant for laryngeal edema.


Treat at ALS for the fact of pain medication. 1% 3rd degree burns on the hand don't really worry me too much. Not worried about fluid loss / replacement considering it's just the palm and BP is still pretty good (rather elevated, but that's due to the tachy HR from pain)

 

[Sasha]

So, 1% of her body is burned?


No safety considerations beyond making sure I don't fall in a kiln myself, and don't lick the broken glass.


I'll make sure the rest of her arm isn't burnt, and check the airway for potential airway burns, ever vigilant for laryngeal edema.


Treat at ALS for the fact of pain medication. 1% 3rd degree burns on the hand don't really worry me too much. Not worried about fluid loss / replacement considering it's just the palm and BP is still pretty good (rather elevated, but that's due to the tachy HR from pain)

Dizzy, cool pale and diaphoretic and the only thing you're worried about is pain meds?

Can we get this chick on the monitor please? Also, let's get her out of the extremely warm room, and into the nice comfortable ambulance. And what's her temp?

Just because you're called for a burn doesn't mean it's the only problem. It sounds like heat exhaustion. Cold, sweaty skin, dizziness, hot room...

 

[reaper]

A full thickness burn to the hands or feet are very serious and generally demand a burn center. Make sure the burning has stopped and treat for pain. Monitor pt and complete a full assessment!

 

[Aidey]

Wouldn't something like that hold the heat in quite a bit? Would you want to try and cool the glass an thus stop the burning? (Thinking out loud there, not actually stating that this is what I would do).

 

[Shishkabob]

Anyones protocols allow escharotomy?

 

[nomofica]

Dizzy, cool pale and diaphoretic and the only thing you're worried about is pain meds?

Can we get this chick on the monitor please? Also, let's get her out of the extremely warm room, and into the nice comfortable ambulance. And what's her temp?

Just because you're called for a burn doesn't mean it's the only problem. It sounds like heat exhaustion. Cold, sweaty skin, dizziness, hot room...

That immediately crossed my mind when I read the symptoms and scene description. I wouldn't be surprised if there were anything else going on considering you can smell the propane in the room. Might not be enough ventilation to safely work in for myself, my partner or the patient.

 

[Shishkabob]

Oh jeez I skipped half of the second paragraph totally missing the smell and heat. I resind my joke about scene safety.

 

[usalsfyre]

She needs a burn center consult, not necessarily a trip to the burn center right now, the consult can be done at a local ED by physcian to physican telephone conversation (check out ABA guidelines).

1% of her body is burned. Look for explanations to the pale, cool diaphoresis but keep in mind pain and the sight of a somewhat gruesome (albeit in this case non-life threatening) injury can cause a vasovagal reaction in many people. Get her sitting down, vitals, moist sterile dressing for the hand and IV pain meds. Not everything with hoofbeats is a zebra....

 

[NomadicMedic]

I agree... but, practice BLS before ALS. Remember what you learned in EMT school... "Cool that burn." (We carry WaterJel specifically for this.)

Then start a line and get fluid and some pain meds on board.

I also agree with expeditiously getting out of the hot, propane filled room and getting the woman en route to an ED equipped to deal with burn trauma.

 

[Aidey]

I'm not sure I would go near a gel to cool this one, mostly because you are going to need pretty cold temps to actually cool the glass.

 

[NomadicMedic]

Upon examination, you find a small area of blackened skin near the center of her palm, surrounded by a larger area of blistering. It’s still very hot to the touch, but does not appear to have retained any glass.

Again, I would cool the burn, with water or with a water soluble gel product, like WaterJel. This is a simple thermal burn and aside from allowing the hand to keep on cookin', cooling provides some analgesia.

If you're not familiar with WaterJel, there's a decent monograph here. I didn't really know anything about the stuff, we carry it on the units where I'm riding. Once I read about it, it seems like a decent product. Draws the heat from the burned area, yet doesn't contribute to hypothermia, like damp burn sheets do.

 

[Aidey]

It has nothing to do with being familiar with waterjel or not. It has to do with the fact that glass will retain heat, and there is no way to be sure there isn't small pieces of glass in the wound. If we put something on the wound that cools the skin, but not any potential glass, the glass is going to keep burning.

 

[Foxbat]

Not directly related to this case, but: is it correct that in case of burns you should cool burned area, but if the burns are extensive, cooling is not recommended because it can induce/exacerbate hypothermia?

 

[Aidey]

Yes and no. You do want to try and stop the burning, but you have to be careful not to induce hypothermia or cause a cold injury (like frost bite by using ice). This is why wet dressings aren't recommended for burns over large areas. That doesn't necessarily mean don't cool it at all, you just have to use your judgment and be careful.

I used to work as a wildfire medic, and I've seen some decent burns and also had some extra training because of the potential for bad burns happening. Our MD wanted us to cool large burns via whatever method we had available (which meant resorting to creek water occasionally, I kid you not). If it was a large burn the general instructions were to cool it and then dry it/use a dry dressing. We had a lot of leeway though, especially depending on what kind of time to hospital we were looking at. We had protocols to debride and perform escharotomies if needed.

 

[Scout]

Ok ouch....


Cool with watar i'd be looking at more than 10 min, tap in trhe work shop. Is the small actually propane or just cutting and melting fumes(what does the bystander think)


Normal full work up with vitals and checking for other Injuries. How hot was the glass has it stuck to the hand or is it just burned... I might be inclined to go for o2 even is sp02 is good, just due to the area.

Rings wathces and all that lark off and look at individually wrapping digits,


Is there a debat state side on waterjel? Some contension here wheather its of any benifit...

 

[MRE]

It has nothing to do with being familiar with waterjel or not. It has to do with the fact that glass will retain heat, and there is no way to be sure there isn't small pieces of glass in the wound. If we put something on the wound that cools the skin, but not any potential glass, the glass is going to keep burning.

Speaking entirely from a thermodynamics point of view, if the pieces of glass are too small to be seen in the wound, they will almost certainly have transferred all of their heat to the surrounding tissue by the time you get to the scene. I would flush the area with water for a minute or two, package with waterjel and start worrying about the other signs/symptoms.

Note: the original poster stated that the wound does not appear to have retained any glass.

 

[Akulahawk]

Initial replies inline, in red.

Another thread got me thinking about all the fun that can be had with glass, so I figured I'd throw this one out there.

You're dispatched to the local art center for a burn, and are directed to a glassworking studio which contains both kilns and propane/oxygen torches. The room is extremely warm, and smells of hot glass and propane. There's one bystander, wearing goggles and an apron, who offers some prescription burn cream (Silvadene) but otherwise stays out of the way.

Upon arrival, you find a 30y/o F, also wearing goggles, with a severe burn to the palm of her hand. Fully A&O, RR 20 and a bit shallow, BP 130/80, pulse 130 and seems a little weak. Pt is cool, pale and diaphoretic. She says she feels a bit dizzy, and that her hand really hurts.

Pt states she had been working with nearly-molten glass and automatically reached out to drop a piece when it fell. Upon examination, you find a small area of blackened skin near the center of her palm, surrounded by a larger area of blistering. It’s still very hot to the touch, but does not appear to have retained any glass.

Scene safety considerations?
Yes, I'd be concerned that someone left a torch going, unlit. I'd probably immediately ask EVERYONE to turn off and check all gas torches and verify they're completely off. Even ones not apparently in use. Then get ventilation going. This is assuming that I'm smelling unburnt, odorized propane.
What else are you going to look for in your initial assessment?
She's working in a hot environment. Consider heat exposure, get her to a cooler area, look for splatter burns further down from any nearly molten glass hitting any surfaces after leaving her hand. Shouldn't take more than a couple seconds while I move on to other formal checks.
How are you going to treat at the BLS level?
This is MOSTLY a BLS call, Tx wise. Cool the burn, get rings & watches off, wrap w/ base layer being a sterile dressing, consider wrapping fingers individually, if they show signs of burn injury.

As to her other signs, she appears to be in a psychogenic shock... basically from having to deal with her hand being burnt. The increased HR may be due to having good old Mr. Flight/Fight response triggered by the burn... However, I must also consider heat exposure and ask how long she'd been in there, last had water to drink, and so on. If I detect anything that says she's also a heat injury victim, I'll also treat for that. Is she hoarse? Any chance she's been breathing superheated air? If so, consider the possibility of an unrecognized (by the patient) airway burn.
How about ALS?
IV, Opiate Analgesic of choice in whatever system I'm in. If signs/symptoms develop of an airway burn... get ready for an emergent field intubation. Be conscious of the potential anyway.

This patient will likely ultimately need to be seen by a burn team and a hand specialist. While not a critical trauma or critical burn (life threatening), it's very potentially life-altering. Transport, non-emergently, and request (if possible) to transport to a burn center directly, or go to the facility designated by protocol or patient's choice.

Overall, this is going to be about damage control and getting the patient to the appropriate resource to begin definitive treatment/recovery/rehab ASAP.

 

[Seaglass]

I actually didn't run this call; it happened several months ago to a woman I know. I made up some details based on what she told me and the treatment she received. Her range of motion in that hand is now somewhat decreased, but she's otherwise fine and still playing with hot glass.

Incidentally, that's a really common injury in glassworking studios, though people usually won't call unless it's really bad. Few people wear gloves at torches, and trying to save something you've just spent hours on comes automatically. Nobody does that twice, though.

Anyways, I was curious about whether people would treat it as a critical burn, given the size and location--it's not going to kill the patient, but could indeed be life-altering. I was also wondering about whether everyone would notice the scene safety concerns and the possible heat exhaustion. Some of my thoughts:

Scene safety: good calls on the lack of ventilation or an unlit torch still going. A glass shop will usually smell a bit like propane, but something's not right if it seriously reeks. Either is pretty likely. People set these up with some really beat-up equipment in basements and such, and get distracted if something bad goes on. Neither actually happened in the instance I'm thinking of, but they're really worth considering if anyone finds themselves in one.

For the record, if anyone out there needs to turn off a torch, the oxygen is turned off before the gas. If someone's put together their own shop in a shack, they might not label the knobs or position them in any kind of order. Oxygen hisses.

Another minor thing worth noting is that you shouldn't look too much at the really bright stuff in the room--torches, glory holes, etc. Not going to blind you right then and there, but still not good for you.

Heat exhaustion/dehydration: yep. People get really into what they're doing and forget to drink and take breaks from the room. This woman was treated for that in addition to the burn.

Glass in wound: In this case, there wasn't any. Luckily, hot glass forms a 'skin' around itself very quickly, so it'll often burn without sticking. Even with truly molten glass, I've only heard of a few cases of it sticking. No idea why... perhaps because of the leaking fluid from the wound? If it has stuck, it may be hard to see at first if it's clear and not still glowing, so it's probably best not to actually touch the wound if you feel warmth. Except with really small amounts, glass should become apparent once you start cooling the burn. At that temperature, it will shatter and crack if you immerse it in even lukewarm water. I imagine that would be better than letting it continue to burn the patient, which it can do for quite awhile. Hot glass will crack as it cools eventually anyways, unless placed in a kiln.

Thanks for participating, everyone!

 

[Jeffrey_169]

I agree with several of the other posters; the burn is not the only thing going on with this patient. Althugh the burn is severe (due to its degree and location), there are some other concerns taking presidence.

There are a few scene safety considerations, such as falling into the kiln, an oven, the high tempature of the room conbinated with potential ignition sources with the presence of O2 and flammable gases.

BLS concerns are the airway and possible heat exhaustion. I would certainly assess and maintain airway as needed. Also I would provide O2.

ALS wise I would provide an analgesic (according to protocol), and administer IV fluids as indicated by the parkland burn formula per protocol.

I would continually reassess vitals and titrate Tx to patient condition.