Pre-hospital Management of Burn Patients

In order to have improved survival rates for burns, regional burn care has been established so there are only a few burn centers available in each state (and some states have no burn centers). This means that pre-hospital care needs to be timely and excellent in order to get the burn patient to a burn center to receive the care they need.

The first step in burn management is to remove the individual from the source of the burning.  Of course, in order to do this safely, it must be done so that the rescuing individual doesn’t become a victim as well.  Burning clothing must be removed, including watches and jewelry.  If available, pour water on the burned area to cool it, making sure the individual does not become hypothermic.  This is done by frequently measuring the body’s core temperature, stopping the procedure if the patient becomes too hypothermic. Don’t use ice packs or ice as this can damage the tissue.

If the burn is chemical, rinse off any chemical liquid or brush off any chemical powder.  Wear gloves so as to avoid getting the chemical on yourself. It is not a good idea to neutralize the chemical using another chemical as this can generate heat which can further damage tissue.  If the burn is electrical, shut off the electrical source before removing the person from the site.

When a burned patient is looked over for the first time after sustaining a burn, there should be a “primary survey” and a “secondary survey”.  The primary survey involves doing a once-over to check for anything that can be life-threatening.  The secondary survey is a head-to-toe observation of all areas of the body for other injuries, including non-burn related injuries.

The primary survey should look into whether or not there has been a lung or airway exposure through inhalation of hot gases.  All victims should be given 100 percent humidified oxygen by mask whether or not there is evidence of exposure to the airway with smoke.  Progressive hoarseness, if present, could mean the presence of airway obstruction, indicating the need for an airway.

Before the swelling becomes too severe, a ventilator tube should be inserted properly into the victim’s trachea. The chest should be observed to make sure it is expanding with each breath.

In the secondary survey, the patient may need to be placed in a cervical collar or backboard to protect this area from non-burn related injuries.  The emergency medical technician should establish an IV access as soon as possible before swelling interferes with getting an IV in.  An IV solution is given at 500 ml per hour for those over the age of 14 because a great deal of fluid from the blood vessels will leave these areas to go to the burned areas and the patient can go into shock.

Cover up the patient with clean dressings or a clean sheet to keep the burn away from the environment while the patient is being transported.  Place a blanket over the clean sheet. The IV access should otherwise be all that is needed; it can help with  pain management as well as fluid resuscitation.  The pain medication should be given in small amounts and never orally or by intramuscular injection.

At the Initial Hospital

Unless the burn happens close to a burn center, the patient will be transported to the nearest facility that can handle the situation.  The evaluation is a lot like the pre-hospital evaluation with the exception that there are more resources to assess the patient with.  X-rays can be done to make sure there aren’t any broken bones.  If a good airway has not been established in the pre-hospital phase, it should be done at this time.   A thorough history, including the time of the incidence, the nature of the incidence, and past medical history can be obtained while arrangements are made for transport to a burn center.

An examination of all the major pulses should take place at the initial facility, especially if the burns are circumferential around the trunk or limbs. Perform an escharotomy immediately if pulses are absent by palpation or by Doppler ultrasound detection so that the burned area does not constrict the trunk or extremity, slowing or limiting the blood flow to distal areas.  

The burned area should be evaluated for depth and extent.  If there are any blisters larger than an inch in diameter, these can be deflated with bacitracin or other burn ointment applied to the burn.  Dress the wounds with sterile dressings so they can be further transported. A second IV site should be established as soon as possible so that if one site fails, another IV can take over.  Ringer’s lactate solution is the preferred solution for the burned patient.  There are formulas for how much fluid to give based on the amount of body surface area involved. In the absence of a formula, staff should keep track of the output of the Foley catheter and ensure that there is as steady flow of urine. Pass a nasogastric tube into the nose that reaches to the stomach so as to relieve excess gas from the stomach during resuscitation.

Transportation to a Burn Center

At the initiating facility, the patient should have IV access, a nasogastric tube in place, a Foley catheter in place and a body temperature that is steadily between 38 and 39 degrees Celsius.  The use of narcotic pain relieve during transportation should be discontinued. Options for transport depend on the patient’s condition as well as on the distance to be travelled.     

Options for transport include a full medical intensive care unit transport vehicle, an airplane or helicopter, a private plane with the proper staff in attendance, a commercial airliner, or ambulance transport.  Staff can include people with a minimum of six month’s burn experience.  A good transport team consists of at least one registered nurse, a physician and a respiratory therapist.  Each individual on the team should be adequately trained and certified in Advanced Cardiac and Trauma Life Support, trained in CPR or certified in Pediatric Advanced Life Support in order to ensure clinical competency for the transportation of the patient.

The patient should be placed on a cardiac monitor with an Ambu bag available with IV pumps that can accurately measure the amount of fluid the patient is receiving.    IV infusion pumps should be available to regulate the amount of fluid the patient is given.  Extra battery packs should be available in case the transport time is long.  Staff should be cross-trained in as many pieces of equipment as possible.

A serious burn is a catastrophe. Anyone who has a serious burn thru the negligence of another should contact an experienced catastrophic injury lawyer.
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