Notes – Burns

Burns

Special Treatment Considerations

  1. If blast mechanism, treat per the Blast Injury guideline
  2. Airway burns can rapidly lead to upper airway obstruction and respiratory failure
  3. Have a high index of suspicion for cyanide poisoning in a patient with depressed GCS, respiratory difficulty and cardiovascular collapse in the setting of an enclosed-space fire. Give the antidote (hydroxocobalamin), if available, in this circumstance
  4. Particularly in enclosed-space fires, carbon monoxide toxicity is a consideration and pulse oximetry may not be accurate [see Carbon Monoxide/Smoke Inhalation guideline]
  5. For specific chemical exposures (cyanide, hydrofluoric acid, other acids and alkali) [see Topical Chemical Burn guideline]
  6. Consider decontamination and notification of receiving facility of potentially contaminated patient (e.g. methamphetamine (meth) lab incident)

Notes/Educational Pearls

  1. Onset of stridor and change in voice are sentinel signs of potentially significant airway burns, which may rapidly lead to airway obstruction or respiratory failure
  2. If the patient is in shock within one hour of burn, it is not from the burn. Evaluate the patient carefully for associated trauma or cyanide toxicity.
  3. If the patient is not in shock, the fluid rates recommended above will adequately maintain patient’s fluid volume.
  4. Pain management is critical in acute burns
  5. ETCO2 monitoring may be particularly useful to monitor respiratory status in patients receiving significant doses of narcotic pain medication
  6. Cardiac monitor is important in electrical burns and chemical inhalations
  7. TBSA is calculated only based on percent of second and third degree burns – First degree burns are not included in this calculation

Quality Improvement

  1. Burn trauma is relatively uncommon. Providers should receive regular training on burn assessment and management.

Associated NEMSIS Protocol(s) (eProtocol.01)

  • 9914085 – Injury-Burns-Thermal

Key Documentation Elements

  • Initial airway status
  • Total volume of fluid administered
  • Body surface area of second and third degree burns (TBSA)
  • Pulse and capillary refill exam distally on any circumferentially burned extremity
  • Pain scale documentation and pain management

Performance Measures

  • Patient transported to most appropriate hospital, preferably a burn center
  • Pain scale documented and pain appropriately managed
  • Airway assessment and management appropriately documented
  • EMS Compass® Measures (for additional information, see http://www.emscompass.org)
    • PEDS-03: Documentation of estimated weight in kilograms. Frequency that weight or length-based estimate are documented in kilograms
    • Trauma-01: Pain assessment of injured patients. Recognizing that pain is undertreated in injured patients, it is important to assess whether a patient is experiencing pain
    • Trauma-02: Pain re-assessment of injured patients. Recognizing that pain is undertreated in injured patients, it is important to assess whether a patient is experiencing pain
    • Trauma-04: Trauma patients transported to trauma center. Trauma patients meeting Step 1 or 2* or 3** of the CDC Guidelines for Field Triage of Injured Patients are transported to a trauma center.
      • *Any value documented in NEMSIS eInjury.03 – Trauma Center Criteria
      • **8 of 14 values under eInjury.04 – Vehicular, Pedestrian, or Other Injury Risk Factor match Step 3, the remaining 6 value options match Step 4

References

  1. American Burn Association. Advanced Burn Life Support (ABLS) Handbook; 2011.
  2. Chung K, Salinas J, Renz E, et al. Simple derivation of the initial fluid rate for the resuscitation of severely burned adult combat casualties: in Silico validation of the rule of ten. J Trauma. 2010;69 Suppl 1:S49-54.
  3. Fluid Rate charts (based on Parkland formula) and TBSA diagrams courtesy of the University of Utah Burn Center; 2014.