How to Evaluate and Treat a Burn Patient in the Pre-Hospital Setting

Pre-hospital 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.

   Initial management of chemical burns involves removing saturated clothing, brushing the skin if the agent is a powder and irrigation with copious amounts of water, taking care not to spread chemical on burns to adjacent unburned areas.  Irrigation with water should continue from the scene of the accident through emergency evaluation in the hospital.  Efforts to neutralize chemicals are contraindicated due to the additional generation of heat which would further contribute to tissue damage.  A rescuer must be careful not to come in contact with the chemical, so gloves, eye protectors, etc. should be worn.
   Removal of a victim from an electrical current is best accomplished by turning off the current and by using a nonconductor to separate the victim from the source.⁵
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.

Primary Assessment
   Exposure to heated gases and smoke 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.  Initially, 100%-humidified oxygen should be given all patients 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 in order to assess the need for airway control and ventilator support.  Progressive hoarseness is a sign of impending airway obstruction.  Endotracheal intubation should be done early before edema obliterates the anatomy of the area.³
   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.
Secondary Assessment
   After completing a primary assessment, a thorough head-to-toe evaluation of a patient is imperative.⁷  A careful determination of trauma other than obvious burn wounds should be made.  As long as no immediate life-threatening injury or hazard is present, a secondary examination can be performed before moving a patient; precautions such as cervical collars, backboards, and splints should be used.⁸  Secondary assessment should examine a patient's past medical history, medications, allergies, and the mechanisms of injury.
   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
   Rapid, uncontrolled transport of a burn victim is not the highest priority, except in cases where other life-threatening conditions coexist.  In the majority of accidents involving major burns, ground transportation of victims to a hospital is available and appropriate.  Helicopter transport is of greatest use when the distance between an accident and a hospital is 30-150 miles or when a patient's condition warrants.¹⁰  Whatever the mode of transport, it should be of appropriate size, and have emergency equipment available as well as trained personnel, such as a nurse, physician, paramedic, or respiratory therapist.
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.

Evaluation of Wounds
   After surveys are completed and resuscitation is underway, a more careful evaluation of burn wounds is performed.  The wounds are gently cleaned, and loose skin - and in large wounds, blisters - are debrided.  Blister fluid contains high levels of inflammatory mediators, which increase burn wound ischemia.  The blister fluid is also a rich medium for subsequent bacterial growth.  Deep blisters on the palms and soles may be aspirated instead of debrided in order to improve patient comfort.  After burn wound assessment is complete, the wounds are covered with a topical antimicrobial agent and appropriate burn dressings or a biological dressing is applied.

   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.

Fluid Resuscitation
   Establishment of IV 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.  A minimum of 2 large caliber IV catheters should be established through non-burned tissue if possible, or through burns if no unburned areas are available.  Ringer's lactate solution should be infused at 2-4 ml/kg/% total body surface area (TBSA) which is burned.^1,4,9  Children must have additional fluid for maintenance.¹⁴

   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.

Transportation guidelines

   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.

*  Commercial airline.

*  Private ground ambulance.

*  Transport van with appropriate personnel.

Stabilization

   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.
   The transport team may perform such procedures as venous cannulation, endotracheal intubation, arterial blood gas interpretation, and management of mechanical ventilators.  Team members may request new radiographs, in order to assess catheter or endotracheal tube placement or to assess the pulmonary system's condition.  Team members may aid in the diagnosis of air leaks (pneumothorax) and evacuate the pleural space of the lung by needle aspiration as indicated.  All of these procedures may be immediately necessary and life-saving.  Cross-training of all team members to be able to perform the others' jobs is recommended in order to safeguard patients in the event that any team member becomes incapacitated during transport.  All these skills can be learned via experience in a burn intensive care unit, through formal training seminars, and via a thorough orientation program.  Mature judgment, excellent clinical skills, and the ability to function under stress are characteristics needed when selecting candidates for a transport program.