By Dr. Ken Lavelle, MD, NREMT-P
One of the more prototypical injuries that may be found on the fireground is, of course, burn injury. Burns are common — one million people will have some degree of burn every year and 700,000 will go to an emergency department. Fortunately, most burns are minor. Only about 50,000 patients are admitted to the hospital for further management.
It is easy to be distracted when initially confronted with a burn victim. There is often a chaotic scene as these victims are usually pulled out of the fire early (at least the ones we can help). There may be multiple victims requiring triage, as we have discussed previously in this column section. The victim may have gruesome injuries, and may be screaming in pain, making an assessment difficult. By following a systematic approach, we can provide maximal and effective care to our patient.
Start with the ABCs. Victims with burns may have inhalation injury. This type of injury is caused by super-heated gases that damage both the upper and lower respiratory tracts. Of immediate concern is swelling that may occur in the upper respiratory tract. Recognition is important — look for singed nasal hair and scalp hair, burns to the face and soot in the mouth. Ask the patient about their ability to speak and if they note any change in their voice or hoarseness.
The problem is what to do about an upper airway injury in the field. If the patient is awake, intubation will be quite difficult. Attempting a nasal intubation may not be ideal due to the trauma and increased swelling the attempt may cause. If you are a paramedic and have the ability to do rapid sequence or drug assisted intubation, use caution as well. If you paralyze the patient and then are not able to secure their airway, this could be a fatal error. Even in the Emergency Department, we will usually not attempt an intubation without a significant amount of assistance at the bedside including anesthesia, surgery and ENT (ear, nose and throat) colleagues. As someone who was a medic for 10 years before becoming a doctor, I still sometimes forget I don’t have to do it all myself. It may be best to provide high-flow, humidified oxygen and rapidly transport the patient to a facility that has these resources in-house. If the patient is unconscious, then the decision-making is a bit easier, although increased swelling of the airway during the attempt is still a risk. If you do choose to intubate, use a tube that is one-half to one size smaller than normal, and have the most experienced provider perform the intubation. For BLS providers, recognition and rapid transport is ideal, and it may even be preferred to the more advanced modalities.
For breathing, assess work of breathing and lung sounds. Provide high flow oxygen. The utility of pulse oximetry is limited in a victim of smoke inhalation, due to the fact that the normal pulse oximiter cannot tell the difference between oxygen and carbon monoxide. So a pulse oximetry of 100 percent is not very helpful. However if the pulse oximetry is 70 percent, then you know the most oxygen present is 70 percent and your patient is quite sick.
The circulatory status of the patient who has only burn injuries should be intact. Tachycardia is common due to the pain, but we don’t expect to see significant hypotension early in the care of the burn patient. Carbon monoxide and cyanide inhalation may contribute to hypotension, however. If you do find the blood pressure to be low, look for and consider other traumatic injury. Traumatic injuries usually take precedence over the burns, with the exception of airway involvement. Burns, even those extensive enough that make death likely, will usually not be fatal in the first few hours. However, a missed traumatic injury may be.
Consider cervical spine immobilization if spinal trauma is likely. Even if it is not, you may find that it is easier to move the patient if he or she is placed on a longboard. Prior to moving to a board, place dry sterile dressings on the board if the patient has burns to his or her back. Initiate transport.
The destination hospital will depend on your local resources. If there is a combined burn and trauma center close, the decision is a bit easier. If this resource is not close, or if your patient’s airway is a concern, then a local hospital for stabilization and transfer is a reasonable option. Follow your local protocol.
Part of this decision also includes assessment of the burn area. Burns are classified into three categories: first, second and third degrees. Second degree burns are also termed "partial thickness burns" and can be further divided into superficial and deep partial thickness. Calculation of the TBSA (Total Body Surface Area) that is burned takes second and third degree burns into account, but not first degree burns, which can be characterized as redness only, like a sunburn.
To calculate the TBSA use either the Rule of Nines or the palm method. The Rule of Nines assigns certain percentages to parts of the body in multiples of nine: nine percent for each arm, 18 percent for each leg, 18 percent each for the back and for the chest/abdomen and nine percent for the head. The percentages are changed slightly for children. The problem with this method is that few if any burns cover the entire extremity or assigned area. The palm method is an alternative and uses the patient’s palm as representing one percent and then the area is estimated using the palm as a unit of measurement.
One reason to estimate the TBSA is to assist in determining which patients need to go to a burn center. The American Burn Association has criteria for a burn center listed on their Web site. Some of these criteria include:
• TBSA over 10 percent
• Burns to critical areas such as major joints, the hands or feet, the face or the genitalia
• High voltage electrical burns
• Chemical burns
• Concurrent traumatic injury
• Medical history that may complicate healing
• Inhalation injury
• Third degree burns of any size
En route, cover burns with dry burn dressings. While wet dressings may offer some degree of pain relief, it will be only temporary, and it predisposes the patient to hypothermia. Remove rings and jewelry. Place IVs in non-burned areas as soon as possible as later swelling may make venous access difficult. An IV is indicated for pain medication and for fluids.
Follow your protocol for pain management, but I encourage my medics to be quite liberal. Fentanyl is a good option, and morphine is acceptable as well. If you have to call medical command for the order, don’t hesitate to ask for an initial dose and subsequent doses during transport. If your command physician is reluctant, make sure they can hear the patient if he or she is screaming in pain — it may persuade them!
There is a formula for the administration of IV fluids to a serious burn victim. Formerly known as the Parkland Formula, the Consensus Formula is a good initial guideline. The total 24 hour fluid administration should be two to four cc per kilogram per TBSA. So if the victim weighs 100 kg, and has 25 percent TBSA, then the total volume in the first day should be 5,000 to 10,000 cc or five to 10 liters. Half of this should be given in the first eight hours, and the remainder over the next 16 hours. This includes pre-hospital fluids so keep track of what you have administered so the hospital can take this into consideration. Lactated Ringers have been preferred by some centers, but saline is acceptable initially if you do not carry LR.
Be sure to reassess often, in particular the airway status. Continue to administer oxygen, IV fluids and analgesia as necessary. Reassure your patient and even hold their hand. They often have a completely intact mental status and are terrified. Prehospital providers may not recognize the value of this simple act, or may feel they don’t want to be known as that "touchy-feely" medic, but put yourself in the patient’s position. They may be looking for a lifeline. Throw it to them.