ED/EMS INITIAL BURN CARE
GROSSMAN BURN CENTERS
Initial Emergent care of the burn patient can be daunting as these injuries are not an everyday occurrence. Burn specific management to be incorporated in the ABC’s of initial treatment is highlighted.
Airway – Intubate to protect the airway based on accident history and symptoms; use the largest tube possible as the ensuing edema will not allow for tube change during the next 72 hours and patients with inhalation injuries develop copious amounts of thick secretions. Consider the use of cuffed tubes for children. (Include picture of a soot face / mouth)
Breathing – those with circumferential torso burns may have difficulty with chest excursion. The need for escharotomies of full thickness areas should be considered in the ED. (video of escharotomy)
Circulatory support – 2 large bore IV catheters (preferably through non-burned areas). Consider IO if necessary in adults and children.
≤ 5 yrs. - 125ml/hour
5-15 yrs. - 250ml/hour
≥ 15 yrs. - 500ml/hour
If available, fluid of choice is Lactated Ringers.
Normal heart rates for burn patients should be in range of 100 – 120 bpm as a result of pain, anxiety, hypovolemia, and inadequate oxygenation.
If the heart rate is < 100 bpm (relative bradycardia in burns) consider causes of medication or cardiac abnormality. On the other hand, a persistent tachycardia (>140 beats per minute) is often a sign of under-treated pain, agitation, hypovolemia or a combination of them all.
Definitive hourly rates are established in the Secondary survey – usually in the ED or when the percent of total body surface burn is determined.
Disability – Burn patients are usually alert post burn and pre administration of medication. If patient is not alert, consider:
Pre-existing medical disease/medications
Exposure and Environment - Halt the burning process with cool, not cold water briefly for 3 -5 minutes if during the first 5 minutes post injury. Then maintain body temperature by covering the patient and burns with clean and dry sheets or blankets; Close doors of ambulances.
Evaluate the size and depth of the burn (only 2nd and 3rd degree burns) (insert lund and browder and rule of nines)
Initiate fluids based on the following ABLS 2010 Resuscitation Fluid Formula (not Parkland)
Adults (for burns >20%)
2 ml X (patient ideal weight) X (% of body surface burn)
Use Lactated Ringers
Children (<13 yrs and <30kgs)
3 ml X (patient ideal weight) X (% of body surface burn)
Use Lactated Ringers unless the child is <10 kg – then use D5LR
In addition to the resuscitation fluid, infants and children <30Kg should also receive D5LR at a maintenance rate.
Electrical Current (not flash or arc) injuries
4 ml X (patient ideal weight) X (% of body surface burn)
Half of the calculated amount is administered over the 1st 8 hours post burn and the 2nd half over the next 16 hours. Calculation of fluid resuscitation must be done from the time the burn injury occurred.
Insert a urinary catheter for hourly urine monitoring, if fluid resuscitation is employed. With hourly assessment of efficacy, Increase the fluids by 30% if:
For adults, the urine output is <30 ml per hour
For children, the urine output is <1 ml/kg/hr
For electrical current, the urine output is <75 -100ml/hr until the urine clears of heme pigments (picture of heme urine)
Excessive fluids can result in exaggerated burn wound edema, compromising local blood supply, increasing depth of the injury. Inadequate fluids may lead to shock and organ failure.
The volume of fluid actually infused is adjusted according to the individual patient's urinary output and clinical response.
IV pain medication – Morphine, Dilaudid, Fentanyl – avoid use of IM injections. Consider antiemetics, anxiolytics
Keep NPO – Insert NG or OG if ET tube present
Monitor pulse presence and quality, especially on circumferential burns. Elevate any area burned to influence edema formation, if not otherwise contraindicated.
WHEN TO CALL US
The Grossman Burn Center recommends the following guidelines when assessing the need for burn center consultation or referral:
Partial thickness burns to greater than 10% of total body surface area in patients of all ages
Burns that involve the face, hands, feet, genitalia, or major joint areas
Third degree burns
Circumferential limb or chest burns
We are your Resource. Even if the burn does not fall into the above categories; if you are uncertain about referring, call us. If you have any questions, call us.
TRANSFERRING TO THE BURN CENTER
Cover all large burn wounds with a clean dry sheet
Elevate the burn area if at all possible
Patient name, age & sex
Time & Cause of burn
%, location & depth of burn
Past medical history & allergies
Total IV fluids in and urine output as well as drugs given from the time of the burn
Pulse presence & quality especially on circumferential burns
Other injuries present
Diagnostics done & last set of vital signs
No application of topical medications to wounds
Do not remove adhered clothing
Do not remove tar from a burn prior to transfer. They are often full thickness injuries. Due to the thickness of the tar, longer cooling measures may need to be considered.
Fill out ER Referral form with as much information as possible and send with patient to our ER. To request referral forms Email Us.