Forum: Medicine in Middle Earth

Discussing: Burns


I'd like some information on the treatment of burns and effects of smoke inhalation please.  There's a lovely research resource here on HASA, but unfortunately burns aren't covered.

I expect an  immediate response would be to immerse the burn (on the victim's hands)  in cold water to reduce pain and on-going damage.  What next?  It's not a clean burn with blisters, but broken skin as well, and a dirty wound.





Re: Burns

Jay, I happened across this article re: herbal treatments for burns, and recalling your query, am passing it along. While the article deals mainly with burns that don't involve broken skin, some of the information may be of use to you.




Re: Burns

This is actually is a complicated subject (nuzgul of new medicine article sinks fangs in.) Good questions!

In general, immediate treatment would be cool, clean water for the burns, and remove the person from the smoky area.

Symptoms of smoke inhalation vary. Some factors that are important are whether it is purely smoke inhalation, or whether it is something like steam, which carries more heat. Also important are the components of the smoke, whether wood smoke, or containing other noxious chemicals. Being too near the Fire of Orthanc would be much worse than an ordinary wood fire.

Carbon monoxide poisoning can occur in smoke inhalation, but it does not have to. The more surface area of the character is burned, the more likely that character is to have smoke inhalation injury. However, it is possible to have smoke inhalation and no visible burn.

Such injury does not always show up immediately. If it does, then your character is much worse off. Symptoms should show up within several hours, but may be delayed as much as 24 to 36 hours.

Some questions, and then I can give you more information.
- How much of the person does the burn cover?
- Would this be "field" treatment, or in a medical facility like the Houses of Healing (or you may want both)?
- Since there is a huge variation, we can tailor this to the needs of your story. Do you want immediate symptoms, indicating a very severe injury, or something that surfaces hours later?

Some of the "immediate" symptoms would be:
Hoarseness, change in voice, complaints of throat pain, and difficulty swallowing. Rapid breathing or difficulty breathing even in fresh air. Difficulty breathing is a very bad sign in someone who is now in fresh air. Such a person has an extremely high chance of dying with the limits of M-e medicine.
The person might wheeze or spit out sooty phlegm. These are also not good signs, but more survivable.




Re: Burns

In general, immediate treatment would be cool, clean water for the burns

Of course we're talking about M-e, but cool, running water is only recommended for first degree burns,which seem to be considered minor across the board, or minor second degree burns, which are determined by the size. I did a little research on burns for a Denethor-survives-the-fire-for-a-short-period-of-time story - if you go Googling, be aware that some sites have pictures, and they're not pretty.

This is a very basic rundown on the Mayo Clinic's site. I can look and see if I've still got my notes on that story, if you like. I ended up winging and making it all very vague.

eta Lyllyn, if you're an EMT or medical personnel, I didn't mean that to sound snooty, because I'm neither one. Since Jay didn't say what degree of burn, I just thought it might be a helpful thing to point out.



Re: Burns

No problem, EdorasLass. I do have some training in this, but it was quite a while ago. And in any case, I could easily forget to put in something important.

In RL, third degree burns call for an ER visit, which M-e won't have. The main reason you have to be careful with cool water for third degree is that you can make your patient hypothermic if a large surface area is burned. In a modern ER, they'd be using sterile saline on gauze dressings initially.

A lot depends on the location and surface area involved.




Re: Burns

Thanks to Nessime, Lyllyn and Edoras Lass for your input here. 

The situation is this:  a stable fire, so plenty of burning wood and straw, but no toxins in the smoke.  Injuries include burns across the back and shoulders (caused by a fallen beam) and burns to the hands (caused by lifting said beam off first victim).

It's in Rivendell, so there are medical facilities available - but unfortunately Elrond is not around at the moment.  There are other healers, though.

Nessime, I'll check out that botanical site now!



Re: Burns - warning, long!

There's lots of material, so I'm going to post in chunks over the next day or two. If it's covering more than you want, let me know and I'll narrow down the next post. Also, if there are things you particularly want me to cover, let me know and I'll focus on that.

You’re describing a burned area that could be approximately 25% of the body’s area, if all of the back (including buttocks) and the entire hand and a bit of the wrists and lower forearms were involved. It could be less if it were only parts of the back and parts of the hands. Again, we can tailor this to the needs of your story. In RL, doctors have been using "the rule of nines" which you can see here

Most burn professionals now speak in terms of partial and full thickness burns, but more people are comfortable with 1st, 2nd, and 3rd degree burns, so I’ll talk in those terms.

1st degree burns are the equivalent of sunburn, the skin is still intact, and burn professionals don’t worry about these. The difficult part is that something that looks 1st degree at first, over hours to a day or two can prove to be deeper.

2nd degree burns blister. In a large scale burn, the healer may not see blisters because they are so large that they rupture fast. The healer would see red, weepy skin. Any touch, even cool air, would be extremely painful. These burns should heal over weeks to a few months, and may leave the patient with discolored skin in the area, but no real scarring.

In 3rd degree burns the skin is completely dead, all layers. The skin may appear charred, or white, either way it will be dry and may feel hard. The nerve endings have been destroyed, so these have no sensation. Usually areas of 3rd are bordered by areas of 2nd, so there is pain on the edges. Sometimes it can be hard to distinguish the two at first - Healers check this with a sharp object, if the patient feels it, it’s not 3rd.

Edit I left out that third degree burns heal by scarring, as if someone had cut a chunk of skin out. These scars hard, raised, and will be apparent to the casual observer on exposed skin. If they are across a joint, they can cause limited motion. In Rivendell, I'd expect the healers to be sophisticated about this, and to use a form of physical therapy to keep the joint mobile. It doesn't guarantee full mobility, though.

There is an additional category, 4th degree, which is a burn that involves deeper structures, like muscle, tendon, and bone.

I'll post another chunk on treatment, later today or tomorrow.

This is a good site for the layperson, but does have gruesome photos




Re: Burns - warning, long!

On to treatment (first of two parts)

From the injuries described, your character could go on either side of the border between moderate and major burn. The cut off for a major burn in adults is 25% partial thickness (2nd degree) or 10% full thickness (3rd degree).

Once you get to 15- 20% burn, the issue is replacing fluid. The patient loses large amounts of fluids through the raw areas, and before modern burn treatment, many who survived the burn died a day or two later from the fluid loss. You will need to get large amounts of fluid into your patient. IV fluids are generally given as 4 cc/kg of body weight/percent burn. Inhalation injury can increase the need for fluid by up to 30 –40%, say to 5.5 cc. Putting this in nontechnical terms, if you have a 70 kg Man (154 lb for the nonmetric) with a 20% burn, the patient must get about 5 1/2 liters over 24 hours, preferably half of that within the first 8 hours. The patient with smoke inhalation will need 7.7 liters over 24 hours. (Note that the clock starts at the time of the burn, not when the healers first get to work.)

Without smoke inhalation, this translates to about 12 ounces (360 cc) of fluid per hour for the first 8 hours. With smoke inhalation, it’s 16 ounces (480 cc, nearly half a liter) per hour. The fluid should not be water, but something with electrolytes in it as well. I’ll have to look for the best oral equivalent that M-e could be expected to have. These are rough guidelines; ideally the healers would be checking how much urine the character is putting out and adjusting accordingly, but that’s probably more technical than you want to know.

One important question - how well or badly you want the character to do? Smoke inhalation considerably adds to the chance of dying, as does size of burn and age of patient. If you want the character to survive, I’d suggest keeping the burn percentage down, and the smoke inhalation less severe. All this applies to men, and I'd expect Elves would be more resistant to dying of burns. Dwarves and Hobbits would roughly correlate to children, with lower burn percentages putting them into the moderate and major burn categories.

Some late issues to consider is the risk of infection of the burns, which is very high. Smoke inhalation has a risk of pneumonia.

One substance that has scientific evidence for good effect in burns is honey




Re: Burns

Injuries include burns across the back and shoulders (caused by a fallen beam

Because I am a big giant spaz, the first thing I thought of when I read this was the book "The Outsiders".

Accordingly - you said "injuries include", which leads me to believe that you may have already taken this into consideration.

But don't forget that a heavy wooden beam falling across the neck and back could break or crack bones in those areas as well -- collarbone, shoulderblade, vertabrae etc., which could be bad. It might be possible for ribs to be damaged, depending on how the beam fell, or how the person fell after the beam struck them.

And if you've already thought of that, never mind!



Re: Burns - warning, long!

I'm glad I didn't know all this when I wrote my story, Lyllyn - I might have talked myself out of the premise altogether as just waaaaaay too unlikely! But I will remember this is here -- never know when I'm going to need more info on burn treatment. Thanks!



Re: Burns

EdorasLass wrote:   ' the first thing I thought of when I read this was the book "The Outsiders".  '

I read that at school - a very, very long time ago now!  It was great, though I've not thought about it for years.  I'd forgotten that part.



Re: Burns - warning, long!

But I will remember this is here -- never know when I'm going to need more info on burn treatment. Thanks!

Your welcome!

I expect to eventually put all this together, maybe add a few things, and then post it as an article. Lyllyn



Re: Burns - long

Treatment part 2

Assuming the character has been removed from the building, the healers would immediately assess him or her, with particular attention to breathing. Edoraslass makes a good point about the possibility of other injuries such as broken bones.

After assessment:
Smoke inhalation - Any indication of smoke inhalation (and without good diagnostics, I'd assume it) and they should humidfy the air. A pot of water over a fire or a large candle, placed near the bed, would help. In M-e, there isn't a heck of lot more they can do. In RL, respiratory distress demands intubation and a ventilator.

The first two interventions after assessment and attention to breathing would be starting fluid replacement as discussed above, and pain relief. Give whatever pain relief is available, as soon as possible. There have been discussions of whether opiates would be available in M-e, and there are certainly parts of M-e where opium poppies would grow. I'd have to find it, but someone posted a link to an article showing that opium poppies can grow in temperate climates much more widely than many people realize. If you aren't postulating opiates in M-e, then you should either consider some Elven method of reducing pain, or expect your patient to be in very severe pain for a long time. If using opiates, a healer should monitor this carefully as large doses of opiates can suppress breathing. The patient should feel reasonably comfortable, but should not get enough to "knock him out."

Immediate burn care –The burns should be washed with clean cool water and mild soap. The healers will have to be careful not to make the character hypothermic, so the room should be kept warm. Areas of the patient that don't need to be worked on should be covered to prevent heat loss. Wash away or trim off as much dirt and dead skin as possible. There isn't consensus in RL as to whether to rupture intact blisters, so you can choose either way. Keep the wash fairly brief to avoid hypothermia – the surface should no longer feel hot, but don't let it get to cold.

I mentioned above the success of honey dressings, but the healers make sure the skin is cooled before applying as the honey will hold heat against the skin.

Don't put ice on anything, as that can cause further injury.

Dressings shouldn't be put on the face, use just the ointment or honey.

Although it's an old folk remedy, don't use butter – too much risk of bacterial growth.

For the hands, make sure there is gauze between the fingers so they don't rub together or stick to each other. Any rings should come off immediately (right after the assessment) as the fingers can swell, turning the ring into a tourniquet.

There are some additional complicating factors I suggest you avoid; circumferential burns can constrict breathing if on the thorax, or blood supply on a limb, calling for an incision to permit chest expansion or circulation.

Continuing daily care Keep everything very clean; infection is the worst enemy.
Working on the burn wounds often results in fever. Give the patient willow bark tea before treatments. If your healer has opiates, give a dose of that as well before treatments.

The dressing should be checked daily. The dressings should consist of a thin layer of gauze, with a thicker layer over the first to absorb drainage. You don't have to change the first layer of dressing, if it appears stuck to the wound. There may be a clear yellow discharge through the first layer, and in that case change the outer layer of gauze. If there is a thick opaque discharge, soak the old dressing off with warm clean water, and put on a clean one.

Burns on the face should have honey or ointment reapplied two or three times a day, and any crusting gently washed off.

Any dead skin should be removed at each dressing change.

Note that the patient will need more calories than usual.

Please ask for clarification or additional information where needed on any of this!





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