What are the special considerations for treating propane burns?

Special Considerations for Propane Burns

Propane burns require heightened vigilance because they often cause deeper tissue damage than initially apparent, combining both thermal injury from ignition and potential cold injury from liquid propane contact, necessitating careful assessment for compartment syndrome and early consideration of burn center transfer. 1, 2

Unique Pathophysiology of Propane Burns

Propane injuries present a dual mechanism of tissue damage that distinguishes them from standard thermal burns:

• Liquid propane exposure causes severe freeze injury that appears superficially as a partial-thickness burn but conceals significantly deeper tissue damage than visual inspection suggests 1
• The cutaneous injury pattern is deceptive, with deep tissue necrosis extending beyond what is initially visible on examination 1
• Propane fires and explosions account for approximately 3,000 incidents yearly, with over 9% resulting in bodily injury and a mortality rate exceeding 7% among those injured 2

Critical Initial Assessment Priorities

Immediate Scene Safety and Exposure Assessment

• Remove the patient from the propane source immediately and ensure no continued exposure to liquid propane or combustion products 2
• Remove all clothing and jewelry before swelling occurs to prevent constriction and vascular ischemia 3
• Assess for inhalation injury, particularly if the burn occurred in an enclosed space or from explosion—look for facial burns, difficulty breathing, singed nasal hairs, or soot around the nose or mouth, which mandate immediate EMS activation 3

Depth Assessment Caveat

• Do not rely solely on initial visual appearance to determine burn depth with propane injuries, as the freeze component causes deeper damage than apparent 1
• Maintain high suspicion for full-thickness injury even when the wound initially appears partial-thickness 1

Immediate First Aid Management

Cooling Protocol

• Cool immediately with clean running water for 5-20 minutes to limit tissue damage and reduce pain 3
• For adults with burns <20% TBSA and children with <10% TBSA, cooling should be performed in the absence of shock 3
• Monitor children closely for hypothermia during cooling, especially preadolescent children 3
• If clean running water is unavailable, it may be reasonable to cool superficial burns with ice wrapped in cloth, but never apply ice directly to the burn 3

Pain Management

• Administer over-the-counter analgesics such as acetaminophen or NSAIDs for pain control 3
• For severe pain, titrated intravenous ketamine combined with other analgesics may be necessary 3

Wound Care After Cooling

• After cooling, apply petrolatum or petrolatum-based antibiotic ointment for small partial-thickness burns 3
• Cover with a clean, non-adherent dressing such as Xeroform or Mepitel 4
• For burns with intact skin or blisters, loosely cover with a clean cloth or non-adherent dry dressing while awaiting evaluation 3

Heightened Risk for Compartment Syndrome

Given the deeper tissue damage characteristic of propane burns:

• Monitor closely for signs of compartment syndrome, particularly with circumferential burns—look for progressive pain, paresthesias, pallor, pulselessness, and paralysis 3
• Circumferential third-degree burns can cause acute limb ischemia with neurological disorders and downstream necrosis 3
• Escharotomy should be performed within 48 hours if circulatory impairment or intra-abdominal hypertension develops, but this procedure should only be performed at a burn center due to complication risks 3

Mandatory Burn Center Transfer Criteria

Lower threshold for burn center transfer with propane injuries due to the deceptive depth of tissue damage:

• All partial-thickness burns involving face, hands, feet, or genitals require burn center evaluation 3
• Burns >10% TBSA in adults (>5% in children) require specialized burn center care 3
• All full-thickness burns regardless of size require burn center transfer 3
• Any signs of inhalation injury (soot around nose/mouth, difficulty breathing, singed nasal hairs) mandate immediate transfer 3
• Direct admission to a burn center is preferred over staged transfer when possible, as this reduces time to excision and improves morbidity and mortality 3

Fluid Resuscitation Considerations

If the burn meets criteria for fluid resuscitation:

• Adult patients with TBSA ≥20% and pediatric patients with TBSA ≥10% should receive 20 mL/kg of intravenous crystalloid solution within the first hour 3
• Use balanced crystalloid solutions (Ringer's Lactate preferred) rather than 0.9% NaCl to reduce risk of hyperchloremia and metabolic acidosis 3

Common Pitfalls Specific to Propane Burns

• Do not underestimate burn depth based on initial appearance—propane's freeze component causes deeper injury than visible 1
• Do not delay transfer to a burn center if any concerning features are present, as the hidden depth may require early surgical intervention 1, 2
• Do not apply butter, oil, or other home remedies to the burn 4, 5
• Do not break blisters, as this increases infection risk 4
• Avoid prolonged cooling that could induce hypothermia, particularly in children or extensive burns 3

Additional Systemic Toxicity Concerns

While propane itself has relatively low systemic toxicity compared to other hydrocarbons:

• Monitor for systemic complications if there is concern for significant hydrocarbon absorption, including pulmonary, cardiovascular, neurologic, renal, and hepatic effects 6
• Consider immediate surgical debridement if there is suspicion of continued absorption of toxic compounds from the wound 6