Pre-hospital Management of Burn Patients

Regional burn care has been established to have improved survival rates for burns, so there are only a few burn centers available in each state. This means that pre-hospital care needs to be timely and excellent 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, it must be done to do this safely so that the rescuing individual doesn't become a victim. Burning clothing must be removed, including watches and jewelry. If available, pour water on the burned area to cool it, ensuring the individual does not become hypothermic. This is done by frequently measuring the body's core temperature and stopping the procedure if the patient becomes too hypothermic. Don't use ice packs or ice as this can damage the tissue.

Rinse off any chemical liquid or brush off any chemical powder if the burn is chemical. Wear gloves 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 appropriately inserted into the victim's trachea. The chest should be observed to make sure it expands with each breath.

The patient may need to be placed in a cervical collar or backboard to protect this area from non-burn-related injuries in the secondary survey. The emergency medical technician should establish 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 and fluid resuscitation. The pain medication should be given small amounts and never orally or by intramuscular injection.

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, except 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. At the same time, arrangements are made for transport to a burn center.

An examination of all the major pulses should occur 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 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 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 a steady flow of urine. Pass a nasogastric tube into the nose that reaches to the stomach to relieve excess gas from the stomach during resuscitation.

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

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 months' burn experience. A good transport team consists of at least one registered nurse, a physician, and a respiratory therapist.  

If you have been hurt in a severe burn injury accident, call our Sacramento Burn Injury lawyers for free and friendly case advice at (916) 921-6400 or (800) 404-5400.

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Editor's Note: This page has been updated for accuracy and relevance. [cha 5.26.22]

Image from Pixabay by Sasin Tipchai [cs 1055]