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.

For more information or to contact a burn center near you Email Us.

PRIMARY SURVEY

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:

Associated injuries

CO poisoning

Substance abuse

Hypoxia

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.

SECONDARY SURVEY

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

  • Electrical injuries

  • Chemical burns

  • Circumferential limb or chest burns

  • Inhalation injuries

 

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

Do's

Cover all large burn wounds with a clean dry sheet

Elevate the burn area if at all possible

Report:

  • 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

Dont's

  • No application of topical medications to wounds

  • No debridement

  • No ice

  • 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.