Burn care--Pre-Hospital Care and Emergency

Ron Mlcak
Advances in trauma and burn management over the past three decades have
resulted in improved survival and reduced morbidity from major burns. Because
the care of the burn patient is quite expensive and labor-intensive, regional burn
centers have evolved. This regionalization has created an effective and coordinated
pre-hospital management, transportation and emergency care system which has
resulted in a marked improvement in the clinical course and survival for the thermal
injured patient.
For burn patients, there are usually two phases of transport. The first is the
entry of the burn patient into the emergency medical system with treatment at
the scene and transport to the initial care facility. In the second phase, the patient
is assessed and stabilized at the initial care facility and then transported to a burn
intensive care unit.1 With this perspective in mind, this chapter reviews current
principles of optimal pre-hospital care and emergency management of the thermal
injured patient.
PRE-HOSPITAL CARE
Prior to any specific treatment, the patient must be removed from the source
of injury and the burning process stopped. Always suspect an inhalation injury
and administer 100% oxygen by face mask. As the patient is removed from the
source of injury, care must be taken that the rescuer does not become another
victim.2 All care givers should be aware of the possibility that they may be injured
by contact with the patient or the patient’s clothing. Universal precautions, including
wearing gloves, gowns, mask and protective eye wear should be used whenever
there is likely contact with blood or body fluids. Burning clothing should be
removed as soon as possible to prevent further injury to the patient.3 Remove all
rings, watches, jewelry and belts as they retain heat and can produce a tourniquetlike
effect causing vascular ischemia.4 If water is readily available, pour it directly
on the burned area. Early cooling can reduce the depth of the burn and reduce
pain, but cooling measures must be used with caution to avoid hypothermia with
its clinical sequela. Ice or ice packs should never be used since they may cause
further injury to the skin and produce hypothermia.


Advances in trauma and burn management over the past three decades have
resulted in improved survival and reduced morbidity from major burns. Because
the care of the burn patient is quite expensive and labor-intensive, regional burn
centers have evolved. This regionalization has created an effective and coordinated
pre-hospital management, transportation and emergency care system which has
resulted in a marked improvement in the clinical course and survival for the thermal
injured patient.
For burn patients, there are usually two phases of transport. The first is the
entry of the burn patient into the emergency medical system with treatment at
the scene and transport to the initial care facility. In the second phase, the patient
is assessed and stabilized at the initial care facility and then transported to a burn
intensive care unit.1 With this perspective in mind, this chapter reviews current
principles of optimal pre-hospital care and emergency management of the thermal
injured patient.
PRE-HOSPITAL CARE
Prior to any specific treatment, the patient must be removed from the source
of injury and the burning process stopped. Always suspect an inhalation injury
and administer 100% oxygen by face mask. As the patient is removed from the
source of injury, care must be taken that the rescuer does not become another
victim.2 All care givers should be aware of the possibility that they may be injured
by contact with the patient or the patient’s clothing. Universal precautions, including
wearing gloves, gowns, mask and protective eye wear should be used whenever
there is likely contact with blood or body fluids. Burning clothing should be
removed as soon as possible to prevent further injury to the patient.3 Remove all
rings, watches, jewelry and belts as they retain heat and can produce a tourniquetlike
effect causing vascular ischemia.4 If water is readily available, pour it directly
on the burned area. Early cooling can reduce the depth of the burn and reduce
pain, but cooling measures must be used with caution to avoid hypothermia with
its clinical sequela. Ice or ice packs should never be used since they may cause
further injury to the skin and produce hypothermia.
Burn Care, edited by Steven E. Wolf and David N. Herndon. © 1999 Landes Bioscience
Initial management of chemical burns consist of removing the saturated clothing,
brushing the skin if the agent is a powder and irrigation with copious amounts
of water. Irrigation with water should continue from the scene of the accident
through the emergency evaluation in the hospital. Efforts to neutralize the chemicals
are contraindicated due to the additional generation of heat, which would
further contribute to tissue damage. The rescuer must be careful not to come into
contact with the chemical.
Removal of a victim from contact with an electrical current is best accomplished
by turning off the current and by using a nonconducting device to separate
the victim from the source.5
ASSESSMENT OF THE BURN PATIENT
Assessment of the burn patient is divided into a primary and secondary survey.
In the primary survey, immediate life-threatening conditions are quickly identified
and treated. In the secondary survey a more thorough head-to-toe evaluation
of the patient is undertaken.
Initial management of the burn patient should be the same as for any other
trauma patient, with special attention directed at the airway, breathing, circulation
and cervical spine immobilization.
AIRWAY
Exposure to heated gases and smoke resulting from the combustion of a variety
of materials results in damage to the respiratory tract. Direct heat to the upper
airways results in edema formation which may obstruct the airway. One must
suspect airway injury in those patients who have facial burns, singed nasal vibrissae,
carbonaceous sputum and tachypnea.5 One hundred percent humidified oxygen
by face mask should be given initially to all patients, even when no obvious
signs of respiratory distress are present. Upper airway obstruction may develop
rapidly following injury, and the respiratory status must be continually monitored
to assess the need for airway control and ventilatory support. Progressive
hoarseness is a sign of impending airway obstruction, and endotracheal intubation
should be done early before edema obliterates the anatomy of the area.3
BREATHING/VENTILATION
The patient’s chest should be exposed to adequately assess breathing, and
whether there is a circumferential burn that might restrict ventilation. Airway
patency alone does not assure adequate ventilation. After the airway is established,
breathing must be assessed to insure adequate chest expansion. Impaired ventilation
and poor oxygenation may be due to smoke inhalation or carbon monoxide
intoxication.
Endotracheal intubation is necessary for unconscious patients or those in acute
respiratory distress, or in patients with burns of the face or neck which may result
in edema causing obstruction of the airway.3 Establishment of a secure airway is
of utmost priority for patients in respiratory distress secondary to thermal injury.
If endotracheal intubation is indicated it should be performed early and by the
most experienced clinician.
CIRCULATION
Blood pressure obtained by a cuff is not the most accurate method of monitoring
a patient with a large burn in the initial phase because of the pathophysiologic
changes that accompany such an injury. Accurate blood pressure measurements
may be difficult to obtain because of edema of the extremities; the pulse
rate may be somewhat more helpful in monitoring the appropriateness of fluid
resuscitation, however it may be elevated in the early postburn period.6 To assess
for adequate perfusion use skin color and capillary refill in nonburned sites.
CERVICAL SPINE IMMOBILIZATION
In those patients who have been in an explosion or deceleration accident, there
is the possibility of a spinal cord injury. Appropriate cervical spine stabilization
must be accomplished by whatever means necessary including cervical collars to
keep the head immobilized until the condition can be evaluated.
SECONDARY ASSESSMENT
After completing the primary assessment a through head-to-toe evaluation of
the patient is imperative,7 and a careful determination of trauma other than burn
wounds should be made. As long as no immediate life-threatening injury or hazard
is present, the secondary examination can be performed before moving the
patient and precautions such as cervical collars, backboards and splints should be
used.8 Secondary assessment should include the patients past medical history,
medications, allergies and the mechanism of injury.
IV ACCESS
Never delay transporting burn victims to an emergency facility due to the inability
of establishing IV access. If the local/regional EMS protocol prescribes an
IV line be started, that protocol should be followed. The Pre-Hospital Burn Life
Support course recommends that if a patient is less than 60 minutes from a hospital,
an IV is not essential and can be deferred to the admitting hospital. If an IV
line is established, Ringers lactate solution should be infused at 500 ml/h in an
adult and 250 ml/h in a child 5 years of age or older. In children less than years of
age, no IV lines are recommended if the receiving hospital is close by.4
WOUND CARE
Pre-hospital care of the burn wound is basic and simple because it requires
only protection from the environment with application of a clean dressing or sheet
to cover the involved part.4 The patient should be wrapped in a blanket to minimize
heat loss and for temperature control during transport.
PAIN CONTROL
The first step in diminishing pain is to cover the wounds to prevent contact by
exposed nerve endings. If it is approved for use in the local/regional EMS system,
narcotics may be given for pain, but only intravenously in small doses and only
enough to control the pain. The intramuscular or subcutaneous route should never
be used,4 as drug absorption is decreased due to peripheral vasoconstriction. This
might become a problem later on when the patient vasodilates and gets an increase
in absorption from the area and possible toxicity.
TRANSPORT TO A HOSPITAL EMERGENCY DEPARTMENT
Rapid, uncontrolled transport of the burn victim is not a priority, except in
cases where other life-threatening conditions coexist. In the majority of accidents
involving major burns, ground transportation of victims to the hospital is available
and appropriate. Helicopter transport is of greatest use when the distance
between the accident and the hospital is 30-150 miles or the patient’s condition
warrants.9 Whatever the mode of transport selected, it should have appropriate
size and emergency equipment available, as well as trained personnel such as a
nurse, physician, paramedics or respiratory therapist who are familiar with trauma
patients.
ASSESSMENT AND EMERGENCY TREATMENT AT INITIAL CARE
FACILITY
PRIMARY SURVEY
The assessment of the patient with burn injuries in the hospital emergency
department is essentially the same as we have outlined for the pre-hospital phase
of care. The only real difference is the availability of more resources for diagnosis
and treatment in the emergency department. As with other forms of trauma, the
primary survey begins with the ABCs and the establishment of an adequate airway.
Endotracheal intubation should be accomplished early if impending respiratory
failure or ventilatory obstruction is anticipated because it may be impossible
with the onset of edema following the initiation of fluid therapy. Not usually
thought of and of equal importance is how to secure an endotracheal tube, particularly
since traditional methods often do not adhere to burned skin. One method
of choice includes securing the endotracheal tube with tape under the ears as well
as over the ears.10 While doing assessments and making interventions for life-threatening
problems in the primary survey, precautions should be taken to maintain
cervical spine immobilization until injury to the spine can be ruled out.
SECONDARY SURVEY
Following the primary survey, a thorough head-to-toe evaluation of the patient
should be done. This includes obtaining a history as thorough as circumstances
permit, including an AMPLE history: allergies, medications, preexisting
diseases, last meal and events of the injury. The history should include the mechanism
and time of the injury and description of the surrounding environment,
such as injuries incurred in an enclosed space, the presence of noxious chemicals,
the possibility of smoke inhalation and any related trauma. A complete physical
exam with a careful neurological exam should be done. Those patients with facial
burns should have their corneas examined with fluorescent staining. Routine admission
labs should include a CBC, serum electrolytes, glucose, BUN and creatine.
Pulmonary assessment should include arterial blood gases, chest X-rays and
carboxyhemoglobin.11
All extremities should be examined for pulses, especially with circumferential
burns. Pulses can be assessed by Doppler ultrasound flow meter. If pulses are absent
the involved limb may need urgent escharotomy. If there is associated respiratory
compromise due to a circumferential burn then escharotomies should be
done to relieve chest wall constriction and improve ventilation. Escharotomies
may be performed at bedside under intravenous sedation. Mid-axial incisions are
made through the eschar but not into subcutaneous tissue of the eschar to assure
adequate release. Pulses should be monitored for 48 h.11
EVALUATION OF WOUNDS
After the primary and secondary surveys are completed and resuscitation is
underway, a more careful evaluation of the burn wound is performed. The wounds
are gently cleaned and loose skin and blisters debrided since blister fluid contains
high levels of inflammatory mediators which increase burn wound ischemia. The
blister fluid is also a rich media for subsequent bacterial growth. Deep blisters of
the palms and soles may be aspirated instead of debrided to improve patient comfort.
After burn wound assessment is complete, the wounds are covered with a
topical antimicrobial agent or a biological dressing and an absorbent burn dressing
is applied.
An estimate of burn size and depth assist in determination of severity, prognosis
and disposition of the patient. An accurate assessment is important since burn
size affects fluid resuscitation, nutritional support and surgical interventions. The
size of the burn wound is most frequently estimated by using the “Rule of Nines”
method. A more accurate assessment can be made of the burn injury, especially in
children, by using the Lund and Browder chart (Fig. 2.1), which takes into account
changes brought about by growth.4
FLUID RESUSCITATION
Establishment of intravenous lines for fluid resuscitation is necessary for all
patients with major burns including those with inhalation injury or other associated
injuries. These lines are best started in the upper extremity peripherally, and
a minimum of two large caliber IV catheters should be established through
Fig. 2.1. Burn diagrams.
nonburned tissue if possible, or through burns if no non burned areas are available.
The most critical aspect of the early care of the burn patient is to restore and
maintain adequate tissue perfusion and vital organ function. Fluid needs are based
on the extent of the burn and should be infused initially as Ringers lactate solution
at 2-4 ml/kg%BSA. The two most common formulas for estimating fluid
needs are the Parkland formula which is 4 ml/kg/%BSA burned, and the modified
Brooke formula, which is 2 ml/kg/%BSA burned.4,12,13 These have been combined
and presented as the consensus formula of 2-4 ml/kg/%BSA burned.4 All the formulas
call for one-half of the total amount to be given over the first 8 h from the
time of injury and the second half to be given over the following 16 h (Table 2.1).
Pediatric burned patients should be resuscitated using formulas based on body
surface area, which can be calculated from height and weight using standard
nomograms. The Shriners Hospital for Children Burns Institute formula recommends
initial resuscitation with 5000 ml/m2/BSA burned/day plus
2000 ml/m2/BSA total/day Ringers lactate.14 This formula also calls for one-half
Table 2.2. Galveston formula
Resuscitation Formula
1. Fluid administration-Ringers lactate
First 24 h:
a. 5000 ml/M2 burn + 2000 ml/TBSA m2
b. administer 1/2 in first 8 h postinjury and the 2nd half in the next 16 h.
Example: 15 kg child with an 87% TBSB, height 96 cm.
Body Surface (m2) =.60
Total Burn (m2)=.52
2000 ml x .6 TBSAm2 = 1200 ml
5000 ml x .52 TBSABm2 =2600 ml
Total fluids first 24 h = 3800 ml
Total fluids first 8 h = 1900 ml = 237 ml/h
Total fluids next 16 h = 1900 ml = 118 ml/h
Table 2.1. Fluid calculations
Consensus Formula
2-4 ml/kg/%BSA burned
Give 1/2 of the total amount over the first 8 h from the time of the injury and the 2nd
half to be given over the following 16 h.
Example: 80 kg man with a 40% TBSB:
4 ml x 80 kg x 40% TBSB =12800 ml
Total fluids first 24 h = 12800 ml
Total fluids first 8 h: 12800/2 =6400 ml = 800 ml/h
Total fluids next 16 h: 6400/16 =400 ml/h
of the total amount to be given over the first 8 h and the second half to be given
over the following 16 h (Table 2.2).
All resuscitation formulas are designed to serve as a guide only. The response
to fluid administration and physiologic tolerance of the patient is most important.
Additional fluids are commonly needed with inhalation injury, electrical
burns, associated trauma and delayed resuscitation of patients. The appropriate
resuscitation regimen administers the minimal amount of fluid necessary for
maintenance of vital organ perfusion, and the subsequent response of the patient
over time will dictate if more or less fluids are needed. Inadequate resuscitation
can cause diminished perfusion of renal and mesenteric vascular beds. Fluid overload
can produce undesired pulmonary or cerebral edema.
URINE OUTPUT REQUIREMENTS
The single best monitor of fluid replacement is urine output. Acceptable hydration
is indicated by a urine output of more than 30 ml/h in an adult (5 ml/kg/h)
and 1 ml/kg/h in a child. Diuretics are generally not indicated during the acute
resuscitation period. Patients with high voltage electrical burns and crash injuries
with myoglobin and/or hemoglobin in the urine have an increased risk of renal
tubular obstruction. Therefore in these patients sodium bicarbonate should be
added to the IV fluids to alkalinize the urine, and urine output should be maintained
at 1-2 ml/kg/h as long as these pigments are in the urine.4 The addition of
an osmotic diuretic such as mannitol may be needed to assist in clearing the urine
of these pigments.
DECOMPRESSION OF STOMACH
To prevent any regurgitation with an intestinal ileus, a nasogastric tube should
be inserted in all patients with major burns to decompress the stomach. This is
especially important for all patients being transported in aircraft at high altitudes.
Additionally, all, patients should be restricted from taking anything by mouth
until the transfer has been completed. Decompression of the stomach is usually
necessary because the anxious, apprehensive patient will swallow considerable
amounts of air and distend the stomach.
TEMPERATURE CONTROL
The patient must be kept warm and dry since hypothermia is detrimental to
the trauma patient and can be avoided or at least minimized by the use of blankets
or warm solutions. The patient must be kept warm and wet dressings changed if
possible prior to transfer.
PAIN CONTROL
The degree of pain experienced initially by the burn victim is inversely proportional
to the severity of the injury.8 No medications for pain relief should be
given intramuscularly or subcutaneously, since fluid shifts are from the vascular
spaces to the interstitial (third) space, rendering such dosing ineffective and allowing
for uncontrolled and unpredictable uptake when fluid resuscitation occurs.3
TETANUS IMMUNIZATION
Recommendations for tetanus prophylaxis are based on the condition of the
wound and the patient’s immunization history. All patients with burns of greater
than 10% BSA should receive 0.5 ml tetanus toxoid. If prior immunization is absent
or unclear, or the last booster dose was more than ten years ago, 250 units of
tetanus immunoglobulin is also given.4
SUMMARY
Burn injuries present a major challenge to the health care team, but an orderly,
systematic approach can simplify the initial pre-hospital care and emergency management.
A clear understanding of the pathology of burn injuries is essential in
providing quality burn care. Successful management of burn victims requires careful
attention to treatment priorities, protocols and meticulous attention to details.
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