Thermal Injury Care

Part of First Aid

Burns from fires, boiling water, hot metal, and steam are among the most common injuries in a world where open flames are the primary energy source. Proper immediate treatment dramatically reduces scarring, infection, and death.

The Critical First Minutes

The single most important action for any burn is immediate cooling. This is not optional --- it is the difference between a burn that heals in days and one that deepens into permanent damage over hours.

Cooling Protocol

1. Remove the heat source. Strip away clothing near the burn unless it is stuck to the skin --- in that case, leave it and cool around it.
2. Cool with clean, running water at approximately 15-20 degrees Celsius (cool but not ice-cold) for a minimum of 20 minutes. This is non-negotiable. Even if 2 hours have passed since the burn, cooling still helps.
3. If running water is unavailable, immerse in a container of cool water, or apply continuously refreshed wet cloths.
4. Never use ice or ice water. Extreme cold causes vasoconstriction, reduces blood flow to the injury, and can convert a partial-thickness burn into a full-thickness one.

What Not to Apply

• No butter, oil, grease, or animal fat --- these trap heat and dramatically increase infection risk.
• No toothpaste, egg whites, or mud --- folk remedies that introduce bacteria into open wounds.
• No adhesive bandages directly on burn surfaces --- they will tear healing skin when removed.

After Cooling

1. Assess the burn --- see Severity Assessment for determining depth and area.
2. Cover loosely with a clean, non-adhesive material. Boiled and dried cotton cloth works well. Do not wrap tightly.
3. Elevate the burned area above the heart if possible to reduce swelling.
4. Hydrate aggressively. Burns cause massive fluid loss through the damaged skin. The patient should drink water continuously --- aim for at least 500 ml per hour for the first several hours with any significant burn.

Treating Burns by Severity

Minor Burns (First-Degree and Small Second-Degree)

These involve redness, pain, and possibly small blisters covering less than the area of the patient’s palm.

Day 1-3:

• After initial 20-minute cool water treatment, apply a thin layer of honey or aloe gel if available.
• Cover with a single layer of clean cloth, changed daily.
• Pain management: willow bark tea (thumb-sized piece of inner bark steeped 15 minutes).

Day 3-14:

• Continue daily dressing changes. Wash gently with clean water before reapplying dressing.
• Small blisters (under 2 cm) --- leave intact. The blister fluid is sterile and protects the healing skin beneath.
• Large blisters (over 2 cm) --- if they are tense and painful, drain from the edge with a fire-sterilized needle. Leave the blister roof in place as a natural dressing.
• Watch for infection: increasing redness spreading beyond the burn edge, pus, foul smell, or fever.

Moderate Burns (Larger Second-Degree)

Burns covering more than 3 palm-sized areas, or burns on the face, hands, feet, groin, or over joints.

Immediate priorities:

1. Cool for 20 minutes as above.
2. Begin aggressive fluid replacement --- this patient needs to drink as much clean water as they can tolerate. Add a pinch of salt per liter (approximately 1/4 teaspoon) to replace electrolytes.
3. Immobilize burned joints in a position of function:
   • Hands: fingers slightly curved, wrist slightly extended (as if holding a cup).
   • Elbows: at 90 degrees.
   • Knees: straight or slightly bent.
4. Apply honey dressings (see Aloe, Honey Treatments) and change every 12-24 hours.

Ongoing care:

• Range-of-motion exercises 3 times daily once pain allows --- burns over joints will contract and freeze the joint if not actively stretched during healing.
• High-protein diet is critical for healing. Prioritize meat, fish, eggs, beans, and nuts.
• Healing time: 2-4 weeks for most second-degree burns.

Severe Burns (Third-Degree and Large Area)

Life-Threatening Emergency

Third-degree burns (white, waxy, leathery, or charred skin with no pain in the burned area) or any burn covering more than 20% of body surface area is a life-threatening emergency. Without modern medicine, survival depends entirely on preventing infection and managing fluid loss.

Survival priorities in order:

1. Airway. If the face or neck is burned, or the person was in an enclosed fire, watch for swelling that closes the airway. Keep them upright. If their voice becomes hoarse or breathing becomes noisy, this is progressing airway compromise.

2. Fluid replacement. A person with 30% body surface area burns needs approximately 4-6 liters of water in the first 8 hours, with salt added (1/4 teaspoon per liter). This is the single biggest factor in survival.

3. Temperature regulation. Badly burned patients cannot regulate body temperature. Keep them warm but not hot. Cover unburned areas with blankets.

4. Wound care. Clean daily with boiled and cooled water. Apply honey liberally. Change dressings every 12 hours. Expect weeks to months of healing.

5. Nutrition. Caloric needs double or triple with major burns. The body is rebuilding tissue at a massive rate. Provide the highest-calorie, highest-protein diet available.

Estimating Fluid Needs

For significant burns, use this simplified guide:

Body Surface Burned	Fluid Needed (First 24 Hours)
10%	2-3 liters
20%	4-6 liters
30%	6-9 liters
40%+	8-12 liters

Give half the total in the first 8 hours, the remaining half over the next 16 hours. Add salt: 1/4 teaspoon per liter of water.

Infection Prevention

Burns are the most infection-prone of all injuries because the skin barrier is destroyed. Without antibiotics, prevention is everything:

• Hand hygiene --- anyone touching the burn or dressings must wash hands thoroughly with soap and water, or wood ash and water.
• Clean dressings --- boil cloth before use and allow to air-dry. Change at least daily.
• Honey --- raw, unprocessed honey is a proven antimicrobial dressing. Apply a layer 3-5 mm thick directly to the burn surface.
• Keep insects away --- flies are the primary vector for wound infection. Cover wounds at all times and keep the patient in a screened or enclosed area if possible.
• Watch for signs --- redness spreading beyond burn edges, green or foul-smelling discharge, fever, confusion. Infection in a major burn without antibiotics is often fatal.

Special Situations

Chemical burns (lye, acids from battery or tanning processes): Flush with enormous quantities of water for at least 30 minutes. Do not try to neutralize the chemical --- just dilute and wash it away.

Steam burns: Often worse than they appear because steam carries more energy than boiling water. Treat aggressively with the standard cooling protocol. Watch for airway involvement if steam was inhaled.

Tar or molten material: Do not try to peel off adherent material. Cool the area with water for 20 minutes. The material can be gradually softened and removed over days using oil or animal fat worked gently under the edges.

Key Takeaways

• Cool every burn with room-temperature water for 20 minutes --- this is the single most effective treatment.
• Never apply butter, oil, toothpaste, or any folk remedy to a burn.
• Fluid replacement is the primary survival factor for major burns --- track intake carefully.
• Honey is the best available antimicrobial wound dressing in a post-apocalyptic setting.
• Burns over joints must be actively stretched during healing to prevent permanent contracture.