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TOTAL BURN CARE
Reprinted with permission of Elsevier
(excerpt from chapter 6, pages 67-70 and 75-76)
Pre-hospital management, transportation and emergency care
Prior to any specific treatment, a patient must be removed from the source of injury and the burning process stopped. As the patient is removed from the injuring source, care must be taken so that a 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, masks 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.3 All rings, watches, jewelry and belts should be removed as they can retain heat and produce a tourniquet-like effect with digital vascular ischemia.4 If water is readily available, it should be poured 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, since a significant drop in body temperature may result in hypothermia with ventricular fibrillation or asystole. Ice or ice packs should never be used, since they may cause further injury to the skin or produce hypothermia.
On-site assessment of a burned patient
Assessment of a burned patient is divided into primary and secondary surveys. In the primary survey, immediate life-threatening conditions are quickly identified and treated. The secondary survey is a more thorough head-to-toe evaluation of the patient. Initial management of a burned patient should be the same as for any other trauma patient, with attention directed at airway, breathing, circulation and cervical spine immobilization.
The patient's chest should be exposed in order to adequately assess ventilatory exchange. Circumferential burns may restrict breathing and chest movement. Airway patency alone does not assure adequate ventilation. After an airway is established, breathing must be assessed in order 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, for those in acute respiratory distress, or for patients with burns of the face or neck which may result in edema which causes obstruction of the airway. The nasal route is the recommended site of intubation. Assisted ventilation with 100%-humidified oxygen is required for all intubated patients.
Blood pressure is not the most accurate method of monitoring a patient with a large burn because of the pathophysiologic changes which accompany such an injury. Blood pressure may be difficult to ascertain because of edema in the extremities. A pulse rate may be somewhat more helpful in monitoring the appropriateness of fluid resuscitation.6
If a burn victim was 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 a cervical collar to keep the head immobilized until the condition can be evaluated.
There should never be a delay in transporting burn victims to an emergency facility due to an inability to establish intravenous (IV) access. If the local/regional emergency medical system (EMS) protocol prescribes that an IV line is started, then 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 until a patient is at a hospital. If an IV line is established, Ringer's lactate solution should be infused at 500 ml/h in an adult and 250 ml/h in a child 5 years of age or over. In children younger than 5 years of age no IV lines are recommended.4
Pre-hospital care of wounds is basic and simple, because it requires only protection from the environment with an application of a clean dressing or sheet to cover the involved part. Covering wounds is the first step in diminishing pain. If it is approved for use by local/regional EMS, narcotics may be given for pain, but only intravenously in small doses and only enough to control pain. Intramuscular or subcutaneous routes should never be used, since fluid resuscitation could result in unpredictable patterns of uptake.4 No topical antimicrobial agents should be applied in the field.4,9 The patient should then be wrapped in a clean sheet and blanket to minimize heat loss and to control temperature during transport.
Transport to Hospital Emergency Department
Findings of the group at the Army Surgical Research Institute pointed out the necessity of involving many disciplines in the treatment of patients with major burn injuries and stressed the utility of a team concept.¹ The International Society of Burn Injuries and its journal, Burns, and the American Burn Association with its publication, Journal of Burn Care and Rehabilitation, have publicized to widespread audiences the notion of successful multidisciplinary work by burn teams.
Functioning of a burn team
Gathering together a group of experts from diverse disciplines will not constitute a team.43 In fact, the diversity of the disciplines, in addition to individual differences of gender, ethnicity, values, professional experience and professional status render such teamwork a process fraught with opportunities for disagreements, jealousies and confusion.44 The process of working together to accomplish the primary goal, i.e. a burn survivor who returns to a normally functional life, is further is complicated by the requirement that the patient, and family of the patient, collaborate with the professionals. It is not unusual for the patient to attempt to diminish his immediate discomfort by pitting one team member against another or 'splitting' the team. Much as young children will try to manipulate parents by going first to one and then to the other, patients, too, will complain about one staff member to another or assert to one staff member that another staff member allows less demanding rehabilitation exercises or some special privilege.45 Time must be devoted to a process of trust-building among the team members. It is imperative that the team communicate - openly and frequently - or the group will lose effectiveness.
Assessment and emergency treatment at initial care facility
The assessment of a patient with burn injuries in a hospital emergency department is essentially the same as outlined for a pre-hospital phase of care. The only real difference is the availability of more resources for diagnosis and treatment in an emergency department. As with other forms of trauma, the primary survey begins with the ABC's, and the establishment of an adequate airway is vital. Endotracheal intubation should be accomplished early if impending respiratory obstruction or ventilatory failure is anticipated, because it may be impossible after the onset of edema following the initiation of fluid therapy. Securing an endotracheal tube may be difficult because traditional methods often do not adhere to burned skin, and tubes are easily dislodged. One method of choice includes securing an endotracheal tube with woven tape under the ears as well as over the ears.11 While doing assessments and making interventions for life-threatening problems in the primary survey, precautions should be taken to maintain cervical spine immobilization until injuries to the spine can be ruled out.
Following a primary survey, a thorough head-to-toe evaluation of a patient should be done. This includes obtaining a history as thorough as circumstances permit. The history should include the mechanism and time of the injury and a description of the surrounding environment, such as whether injuries were incurred in an enclosed space, the presence of noxious chemicals, the possibility of smoke inhalation, and any related trauma. A complete physical examination should include a careful neurological examination, as evidence of cerebral anoxic injury can be subtle. Patients with facial burns should have their corneas examined with fluorescent staining. Routine admission laboratories should include a complete blood count, serum electrolytes, glucose, blood urea nitrogen (BUN), and creatine. Pulmonary assessment should include arterial blood gases, chest x-rays, and carboxyhemoglobin.12
All extremities should be examined for pulses, especially with circumferential burns. Evaluation of pulses can be assisted by use of a Doppler ultrasound flowmeter. If pulses are absent, the involved limb may need urgent escharotomy for release of the constrictive, unyielding eschar. In circumferential chest burns, escharotomy may also be necessary to relieve chest wall restriction and improve ventilation. Escharotomies may be performed at the bedside under IV sedation using electrocautery. Mid-axial incisions are made through the eschar, but not into subcutaneous tissue of the eschar in order to assure adequate release. Limbs should be elevated above the heart level. Pulses should be monitored for 48 hours.12
If pulses are still present, but appear endangered, chemical escharotomy with enzymatic ointments (Accuzyme, collagenase, Elase) can be effective. Enzymatic escharotomy in hand burns may be preferred since surgical incisions risk exposure of superficial nerves, vessels, and tendons. Enzymatic escharotomy is indicated only during the first 24-48 hours post-burn, and it should be used only in combination with a topical antimicrobial agent or sepsis can occur. With enzymatic escharotomy, there is usually a spike in temperature, which subsides after the enzyme is removed.
Evaluation of Wounds
An estimate of burn size and depth assists in making a determination of severity, prognosis, and disposition of a patient. Burn size directly affects fluid resuscitation, nutritional support, and surgical interventions. The size of a burn wound is most frequently estimated by using the rule-of-nines method. A more accurate assessment can be made of a burn injury, especially in children, by using the Lund and Browder chart, which takes into account changes brought about by growth.4,9 The American Burn Association identifies certain injuries as usually requiring a referral to a burn center. Patients with these burns should be treated in a specialized burn facility after initial assessment and treatment at an emergency department. Questions about specific patients should be resolved by consultation with a burn center physician.
Taking into account the increased evaporative water loss in the formula for fluid resuscitation for pediatric patients, the initial resuscitation should begin with 5000 ml/m²/% TBSA burned/day + 2000 ml/m²/BSA total/day 5% dextrose in Ringer's lactate. This formula calls for 1/2 of the total amount to be given in the first 8 hours post-injury with the remainder given over the following 16 hours.
All resuscitation formulas are designed to serve as a guide only. The response to fluid administration and physiologic tolerance of a patient is the most important determinant. Additional fluids are commonly needed with inhalation injury, electrical burns, associated trauma, and delayed resuscitation. The appropriate resuscitation regimen administers the minimal amount of fluid necessary for maintenance of vital organ perfusion; the subsequent response of the patient over time will dictate if more or less fluid is needed so that the rate of fluid administration can be adjusted accordingly. Inadequate resuscitation can cause diminished perfusion of renal and mesenteric vascular beds. Fluid overload can produce undesired pulmonary or cerebral edema.
Urine Output Requirements
Additional Assessments and Treatments
A patient must be kept warm and dry. Hypothermia is detrimental to traumatized patients and can be avoided or at least minimized by the use of sheet and blankets. Wet dressings should be avoided.
The degree of pain experienced initially by the burn victim is inversely proportional to the severity of the injury. No medication for pain relief should be given intramuscularly or subcutaneously. For mild pain, aspirin 650 mg orally every 4-6 hours may be given. For severe pain, morphine 1-4 mg intravenously every 2-4 hours is the drug of choice, although meperidine (Demerol) 10-40 mg by IV push every 2-4 hours may be used. Recommendations for tetanus prophylaxis are based on the patient's immunization history. All patients with burns should receive 0.5 ml of tetanus toxoid. If prior immunization is absent or unclear, or if the last booster was more than 10 years ago, 250 units of tetanus immunoglobulin is also given.
The primary purpose of any transport team is not to bring a patient to an intensive care unit, but to bring that level of care to the patient as soon as possible. Therefore, the critical time involved in a transport scenario is the time it takes to get the team to the patient. The time involved in transporting a patient back to a burn center becomes secondary. Communication and teamwork are the keynotes to an effective transport system.
When transportation is required from a referring facility to a specialized burn center, a patient can be fairly well stabilized before being moved. Initially, the referring facility should be informed that all patient referrals require physician-to-physician discussion. Pertinent information needed will include patient demographic data; time, date, cause and extent of burn injury; weight and height; baseline vital signs; neurological status; laboratory data; respiratory status; previous medical and surgical history; and allergies.
A referring hospital is informed of specific treatment protocols regarding patient management prior to transfer. To ensure patient stability the following guidelines are offered:
Establish 2 IV sites, preferably in an unburned upper extremity, and secure IV tubes with sutures.
Insert a Foley catheter and monitor for acceptable urine output (30 ml/h adult, 1 ml/kg/h child).
Insert a nasogastric tube and ensure that the patient remains NPO.
Maintain body temperature between 38° and 39°C rectally.
Stop all narcotics.
For burns less than 24 hours old, only use lactated Ringer's solution. The staff physician will advise on the infusion rate, which is calculated based on the percentage of total body surface area burned.
Following physician-to-physician contact and collection of all pertinent information, the physicians will make recommendations regarding an appropriate mode of transportation. The options are based on distance to a referring unit, patient complexity, and comprehensiveness of medical care required. Options include:
Full medical intensive care unit transport with a complete team, consisting of a physician, a nurse, and a respiratory therapist from the burn facility.
Medical intensive care transport via a fixed-wing aircraft or helicopter with a team from a referring facility.
Private plane with medical personnel to attend patient.
Private ground ambulance.
Transport van with appropriate personnel.
One of the primary reasons for a
specialized transport team is to be able to transport a patient in as stable
condition as possible. Current practice has evolved to embrace the concept
that events during the first few hours following burn injury may affect the
eventual outcome of the patient; this is especially true with regard to fluid
management and inhalation injury. Stabilization techniques performed by
the transport team have been expanded to include procedures that are usually not
performed by nursing or respiratory personnel. Such techniques include
interpreting radiographs and laboratory results and then conferring with fellow
team members, referring physicians, and the team's own medical staff, in order
to arrive at a diagnosis and plan for stabilization.
Burn injuries present a major challenge to a health care team, but an orderly, systematic approach can simplify stabilization and management. A clear understanding of the pathophysiology of burn injuries is essential for providing quality burn care in the pre-hospital setting, at the receiving health care facility, and at the referring hospital prior to transport. After a patient has been rescued from an injury-causing agent, assessment of the burn victim begins with a primary survey. Life-threatening injuries must be treated first, followed by a secondary survey, which documents and treats other injuries or problems. Intravenous access may be established in concert with logical/regional medical control and appropriate fluid resuscitation begun. Burn wounds should be covered with clean, dry sheets; and the patient should be kept warm with blankets to prevent hypothermia. The patient should be transported to an emergency room in the most appropriate mode available.
At the local hospital, it should be determined if a burn patient needs burn center care according to the American Burn Association Guidelines. In preparing for organizing a transfer of a burn victim, consideration must be given to the continued monitoring and management of the patient during transport. In transferring burn patients, the same priorities developed for pre-hospital management remain valid. During initial assessment and treatment and throughout transport, the transport team must ensure that the patient has an adequate airway, breathing, circulation, fluid resuscitation, urine output, and pain control. Ideally, transport of burn victims will occur through an organized, protocol-driven plan, which includes specialized transport mechanisms and personnel. Successful transport of burn victims, whether in the pre-hospital phase or during inter-hospital transfer, requires careful attention to treatment priorities, protocols, and details.
2. Dimick AR. Triage of burn patients. In: Wachtel TL, Kahn V,
Franks HA, eds.
3. Wachtel TL. Initial care of major burns. Postgrad. Med. 1989; 85(1): 178-196
4. American Burn Association. Advanced Burn Life Support Providers
5. American Burn Association. Radiation injury. Advanced Burn Life
6. Bartholomew CW, Jacoby WD. Cutaneous manifestations of lightning injury. Arch Dermatol 1975; 26: 1466-1468
7. Committee on Trauma, American College of Surgeons. Burns. In: Advanced Trauma Life Support Course Book. Chicago: American College of Surgeons, 1984: 155-163
8. Rauscher LA, Ochs GM. Pre-hospital care of the seriously burned
9. Goldfarb JW. The burn patient, Air Medical Crew national Standards Curriculum, Phoenix, 1988, ASHBEAMS
10. Marvin JA, Heinback DM. Pain control during the intensive care phase of burn care. Crit Care Clin 1985; 1: 147-157
11. Mlcak RP, Helvick B. Protocol for securing endotracheal tubes in a pediatric burn unit. J Burn Care Rehabil 1987; 8: 233-237
12. Herndon DN, Desai MH, Abston S. et al. Residents Manual. Galveston: Shriners Burns Hospital, and the University of Texas Medical Branch, 1992: 1-17
13. Collini FJ, Kealy GP. Burns: a review and update. Contemp Surg 1989; 34: 75-77
14. Herndon DN, Rutan R, Rutan T. The management of burned children. J Burn Care Rehabil 1993; 14: 3-8
This article was excerpted from the book
Total Burn Care, 2nd edition (2001), edited by David N. Herndon,
M.D. and is posted with permission from Elsevier.
(This link takes you to the "Total Burn
Care" page at the publishers web site.)
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