Burn injuries account for more than 300,000 deaths worldwide each year.1 In the U.S., burn injuries are the third leading cause of fatal home injuries, usually resulting from the inhalation of smoke and toxic gases. Of the 25 developed countries that maintain records of burn mortality, the U.S. comes in eighth, leaving much to be desired in burn treatment.2
Major risk factors for burns include male gender, extreme youth or old age, alcohol use (a factor in 40% of burn deaths) and substandard housing residence. More than 60% of burns are thermal, with the majority of other burns being caused by chemicals and radiation. Electrical burns are infrequent but require important considerations. Burn morbidity and mortality increase with both the depth and the extent of the burn. Prehospital treatment of a burn can greatly decrease future disability and mortality.2
A 14-year-old boy has called 9-1-1 to report that the handle of a boiling pot of water broke while he was removing it from the stove, splattering droplets of water on his right leg from mid-thigh to his foot. He is home alone, panicking, and in a tremendous amount of pain. After determining that the burn is a smaller splatter burn, the 9-1-1 dispatcher instructs the boy to irrigate the affected area with cool, running water and unlock the door for EMS.
You arrive on scene and head through the house toward the sounds of a boy crying. As you walk through the kitchen, you see a pot on the stove on high heat. You quickly turn off the stove. You find your patient, still anxious and appearing in significant pain, holding his leg in the shower.
The first concern when treating the burn patient is scene safety. As soon as the scene is determined to be safe, you should move the patient away from the source of the burn while maintaining spinal precautions if indicated. If the patient remains smoldering, the provider will need to stop the burning process. Remember that while the burning process should be stopped, attempts shouldn’t be made to “cool” large burns. In addition, irrigation of greater than one minute on a large burn will increase the risk of hypothermia. Next, the provider should ensure that the patient’s airway is open and begin resuscitative measures as necessary.3
The provider should keep in mind that a burn patient will rarely immediately die as a result of a burn itself. These patients generally die from airway injury or other trauma. Death from burns primarily stems from inhalation of gases or smoke.2
Signs of inhalation injury include burns to the face, soot in the airway, singed nasal or eyebrow hairs, and black sputum. The patient’s voice may be hoarse, and they may have a cough or present as tachypneic. Auscultation of airway sounds may reveal stridor or rhonchi. It’s important to treat victims of major burns, especially those who were trapped in an enclosed space, as though they may have inhalation injuries. Altered level of consciousness (ALOC), lethargy, worsening hoarseness, and cardiac or respiratory arrest should be taken as strong indicators that inhalation injury has occurred.4
Suspicion of inhalation injury warrants immediate application of high-flow oxygen and consideration of intubation. Burns of the airway can cause rapid swelling, and chemical irritants that may exist in house fires will likely cause mucosal irritation and increased edema in the airway. Histamine release may cause severe bronchospasm, worsening the patient’s ability to maintain their own airway.5
Intubation should be performed by the most experienced provider on scene. This is because the additional trauma of repeated intubation attempts will cause further injury and swelling, and it may distort the upper airway so much that intubation may become nearly impossible. This provider should use the largest tube they can successfully place to facilitate suctioning.3 Rapid sequence intubation (RSI) should be considered where available but should be used only when absolutely necessary in patients with neuromuscular disease; the use of succinylcholine in these patients can cause hyperkalemia or malignant hyperthermia.6
Airway adjuncts, such as Combitube, may be considered in some protocols but may not be effective. An airway adjunct placed in the esophagus might not divert oxygen into a trachea that’s extremely swollen. Continuous positive airway pressure has been shown to decrease mortality following inhalation injury by decreasing the development of pulmonary edema, helping keep the airways open and increasing the amount of oxygen that remains in the lungs at the end of each exhalation.3
As soon as permitted, providers should remove jewelry and clothing near the site of the burn to prevent tissue damage as edema progresses. Artificial fabrics, such as nylon, may adhere to the skin. Don’t make any efforts to pull these fabrics from the skin. As the patient is exposed the provider can estimate the depth and extent of burns, taking care to immediately cover the patient with a clean sheet to prevent hypothermia. A burn itself will decrease the insulation between a patient and the burn source so that prolonged contact with a heat source will increase damage exponentially.5
Burn depth is measured in degrees of severity from first to fourth. A first-degree burn is superficial, pink and slightly edematous. Pain will often subside as the burn cools. These burns affect the epidermis.
A second-degree or partial thickness burn may be superficial or deep. Superficial second-degree burns are painful, red, blistered, moist and more edematous than a first-degree burn.7 Scald burns tend to be superficial and are the most common type of burns seen in firefighters, where the firefighter sweats under their gear and the sweat scalds them.8 Deep second-degree burns appear both white and red, will have a lack of hair to the area and may or may not be painful. Second-degree burns affect some amount of the dermis, which contains lymph vessels, small blood vessels, sweat glands, collagen bundles, fibroblasts and nerves. The dermis is responsible for maintaining the strength and elasticity of the skin.
Third-degree burns, also called or full thickness burns, involve the nerves that supply the skin. Therefore, they aren’t painful. Color ranges from white to black, and the skin will be dry and leathery. Third-degree burns extend through the dermis and tend to cause hemolysis, worsening the patient’s condition.
Fourth-degree burns extend through subcutaneous fatty tissue, which is responsible for maintaining heat, into muscles, larger blood vessels and often bone tissue. This causes rhabdomyolysis and puts the patient at great risk for renal failure, limb loss and death.1
Deep burns are associated with direct contact with flame. When circumferential full thickness burns represent an additional problem, the stiffening of the skin along with internal edema cut off venous blood and lymph flow, creating a tourniquet effect. Blocked venous and lymphatic flow impedes recovery, and the swelling will ultimately cause nerve compression and the blockage of arterial flow. In burns encompassing the torso, chest expansion will become restricted. These patients warrant rapid transport for escharotomy to restore circulation and to maintain adequate tidal volume.9
Once the total burn surface area (BSA) of a patient is equal to 30%, inflammatory response may become systemic.5
The extent of the burn injury should be determined in all burns of more than first-degree thickness by using one of two methods. Small or limited splatter burns can be estimated using the rule of palms. Using this method, the size of the palm of the patient’s hand is equal to 1% BSA.
Larger burns greater than first degree are calculated in the prehospital setting using the rule of nines. This method splits the body into several major parts. The head (front and back, including the face and neck), anterior chest, abdomen, upper back, lower back (including the buttocks), the front of each leg, the back of each leg, and each arm represent 9% BSA each, and the groin represents 1% BSA. The rule of nines is used in an adjusted form with children and infants due to their anatomical differences, with the head representing a higher BSA and the legs a lower BSA proportionally with decreased age, where an infant’s head represents 19% BSA and each leg totals only 13.5%.7
A burn creates multiple zones of injury. The zone of coagulation is the area of close contact with the heat source. Absence of blood flow to the area produces coagulation and necrosis. The zone of stasis borders the zone of coagulation and will often blanch on pressure or have petechial hemorrhages, giving the appearance that circulation is intact; however, the circulation to this area will stop within 24 hours in a major burn. The zone of hyperemia borders the zone of stasis and may not be identifiable until 72 hours after the zone of injury, when the white color becomes deep red. Ischemia from edema secondary to histamine and other immune cell response may cause the zone of coagulation to spread into the zone of stasis.
Chemical burns are most frequently the result of industrial accidents. However, with more than 25,000 chemicals with a potential to cause burns in common use, chemical burns can occur in a variety of settings.10 Burns from chemical sources account for only 3% of all burns.. Therefore, they aren’t frequently seen, however, they carry a serious risk of death and disability.
If the chemical is relatively weak, a chemical burn may occur over an extended period of time before the patient realizes they’re being burned. Some chemical burn processes won’t stop without a neutralizing agent. This means EMS will be transporting a patient who remains actively burning. Chemical burns tend to be deeper than thermal burns, although the skin may not appear as damaged. Assessment of chemical burns based on appearance is further thwarted by the tendency of some chemicals to discolor the skin. For example, a painful hydrochloric acid burn will appear brown and similar to a third-degree burn, while silver nitrate, which generally doesn’t cause a burn with brief contact, will stain the skin black.11
For the benefit of the healthcare provider, chemicals can be divided into two broad categories: acids and alkalis (bases). Strong acids with a pH of 2 or less, such as hydrochloric acid, cause coagulative necrosis at the point of skin contact. While extremely painful, this allows for some protection of structures deep to the necrotic site. Alkalis, such as cement, break apart cell structures, loosening tissues through liquefaction necrosis. Alkali burns are deeper. For this reason, they are generally more severe than acid burns.11
Patients presenting with chemical burns will need to be irrigated copiously with water for an extended period of time, often up to 30 minutes and sometimes up to two hours. Different chemicals require different lengths of irrigation and types of neutralizing agents. If possible, the provider should locate the chemical and consult the MSDS, and should transport the chemical label to the hospital with the patient.11
Once EMS providers realize they’re dealing with a chemical burn, they should don the appropriate personal protective equipment (PPE) and brush off any dry chemical found on the patient to prevent further burns once irrigation has begun. This is best accomplished by using a chemical shower or a hose. Take care to contain all runoff in containers. This will avoid burns to providers from the used contaminated water. All contaminated clothing will need to be removed prior to or during irrigation. The patient shouldn’t be immersed in water because that might spread the chemical to unaffected parts of the body. Irrigation may need to be continued en route to the hospital but should be done only if fluids can be contained (i.e., in a bucket). The provider should take care to prevent hypothermia in the patient by covering unaffected areas.
Chemical burns to the eyes should be continuously irrigated during transport. If only one eye is affected, take care to avoid contaminating the unaffected eye. Hold the eye open manually and remove contact lenses with a clean gloved hand as soon as possible. Irrigate the eye by running normal saline through IV tubing—or through a nasal cannula when both eyes are affected.7
EMS providers should administer high-flow oxygen to all patients with major burns. In burns involving the airway (through aerosolization of chemicals or the drinking of chemicals), consider early intubation. Keep in mind that chemical airway burns irritate mucosa and a missed tube may cause the airway to swell significantly. Airway adjuncts that are blindly inserted, such as the Combitube, are generally contraindicated.11
Take special note if a patient is burned with one of three specific chemicals: Clorox, white phosphorous and hydrofluoric acid. Clorox should be first flushed with milk, followed by water irrigation.11 White phosphorous burn sites should be soaked in water and transported to the hospital for neutralization by copper sulfate. Hydroflouric acid, used in glass etching and in methamphetamine production, is highly toxic and causes death at a lower percentage BSA than most burns.
Methamphetamine use increases metabolism, furthering damage and doubling the amount of IV fluids needed.7 These patients are at high risk for hypocalcemia leading to ventricular fibrillation.10
Electrical burns may not appear as gruesome as thermal burns, but they have a great amount of internal injury with only entrance and exit wounds visible. A patient who has electrical burns may have no exit wounds or may have multiple exit wounds. Tissues between wounds are damaged as the current travels through the body. The current takes the paths of least resistance—usually nerve pathways and vasculature.12
The extent of damage to tissues is determined by voltage. Domestic electricity tends to be considered low voltage. These electrocutions create small, deep contact burns at entry and exit points.10 Low voltages may create such dysrhythmias as asystole, atrial fibrillation and ventricular fibrillation, and may cause sudden respiratory failure by paralyzing respiratory muscles.10,12
High-voltage burns will either be true electrocutions or arc burns. True high-voltage electrocutions are greater than 10,000 V and are associated with fourth-degree burns, necrosis, fatal dysrhythmias, limb loss, rhabdomyolysis and renal failure. Electrocutions at greater than 70,000 V are considered unsurvivable.12 A patient with an arc burn has experienced a thermal burn that may have been upwards of 4,500° F and is hot enough to set the patient’s clothing on fire.7
Scene safety is especially important when dealing with burns. Fumes should be considered hazardous, liquids caustic and electrical wires live until absolutely cleared.12 When safe to do so, the patient should be separated from the hazard and decontaminated as necessary. Immediate brief cooling of small burns with cold water helps to inhibit histamine release. This decreases edema and inhibits thromboxane, which helps to decrease ischemia secondary to thrombus formation.6 Spinal precautions should be taken as necessary. Aggressive airway management is critical in the burn patient, and supplemental oxygen should be used. Intubation, CPAP and RSI should be considered early on. Cardiac monitoring should be initiated immediately and dysrhythmias corrected.
Burnt areas of the body have decreased lymphatic flow and often don’t have an intact barrier against infection. When BSA is less than 10%, gauze moistened with sterile water may be applied to the burn for patient comfort.7 The major cause of death from thermal burns is infection, so EMS providers should cover all larger burns with dry sterile bandages to minimize the risk of infection as much as possible. Providers should also cover burn patients a clean dry sheet and keep them warm. Two large-bore IVs should be initiated in large veins. Although the preference is for IVs to be placed on undamaged skin, they may be established over a burn site and secured using bandages if impossible to place on undamaged skin. Remember not to place intraosseous devices on burnt areas.
An inadequate amount of fluids in the burn patient leads to end-organ hypoperfusion, which can lead to ischemia.5 Decreased plasma volume, increased afterload and decreased cardiac contractility cause a decrease in cardiac output. “Burn shock” is a combination of distributive, hypovolemic and cardiogenic shock and may be countered by fluid administration. Hypotension is a late sign of burn shock. The patient’s pulse is a more accurate measure of their shock status, and patients with burns of more than 15% BSA should be suspected of shock and treated.13 Check out jems.com/discover-simulation for more on shock treatment.
In the prehospital setting, isotonic crystalloids, such as normal saline, are administered to combat fluid loss and increase neutrophil activation. However, these fluids have their drawbacks. High volumes are associated with creating a hypercoagulable state and with hyperchloremic acidosis—a form of metabolic acidosis. Very high dosages are associated with “fluid creep.” This is the progressive edema in locations unaffected by burns. Fluid creep leads to acute respiratory distress syndrome (ARDS) and abdominal compartment syndrome, increasing mortality.13
EMS systems tend toward a moderate amount of fluid administration by using the Parkland formula. In this formula, the patient’s weight in kilograms is multiplied by the percentage BSA multiplied by four. Half of this total is given over the first eight hours; the remaining amount is given over the next 16 hours.7 Patients under the influence of alcohol or methamphetamine may require an increased amount of fluid, as will electrical shock victims (to increase urinary output in an attempt to alkalinize the urine). Brown or dark red urine indicates myoglobinuria secondary to rhabdomyolysis and an increased need for fluids to help prevent acute renal failure.13 Adjustments to the Parkland formula should only be made with base hospital approval.
Burns are excruciatingly painful. Although decreased renal clearance and increased metabolism make medication uptake unpredictable in the burn patient, providers shouldn’t withhold pain management. All pain medication should be administered via IV only to allow greater control, and dosages should be small and titrated to relief. Adults may require in excess of 20 mg of morphine to obtain adequate pain control.7 The use of opioids increases fluid requirements, which increases the likelihood of fluid creep. This means pain medication should only be administered as the need arises.13
Causes of Burns
Underlying issues that may have contributed to causing the burn should be addressed. Serious burns require either prolonged contact or an extremely high temperature. Prolonged contact may occur secondary to unconsciousness, intoxication, epilepsy or other medical causes.10 Contact with high temperatures may be accidental. However, these burns are not accidental in 3–10% of children.
Symmetrical burns occurring in patterns or circumferential burns lacking splash marks, as in an immersion, are cause for concern. Two specific patterns that may indicate abuse are the doughnut sign and the tide line. A doughnut sign is a scald to the buttocks where an area of more burnt skin (the area exposed to hot water) surrounds an area of less burnt skin (where the skin was in contact with the tub, allowing for some protection). A tide line is the sparing of flexion creases so that when a child is placed into a defensive (often fetal) position, his burns will match up. Burns should be examined for multiple stages of healing, for resemblance to common objects like irons and cigarettes, and for locations that aren’t normally burned, such as the genitals and buttocks.14
Up to 30% of these patients who are repeatedly abused will die as a result of the abuse, and EMS plays a key role in connecting injuries to the scene.14 Read “EMS Providers Can Identify Child Abuse” at www.jems.com/article/patient-care/ems-providers-can-identify-child-abuse for more on how to identify child abuse and which steps to take when you suspect abuse in a pediatric patient.
Positioning of the burn patient is an important consideration in the patient’s ultimate outcome. In burns, it’s said that “comfort equals contracture,” meaning a position of comfort promotes deformity. To prevent neck flexion contractures, the patient with neck burns should have their head hyperextended but not to the point where the jaw opens. Blankets may be used under the back to facilitate this position. Pillows shouldn’t be used under the head of a patient with neck burns.Burns to the axilla should be splinted so that arms are away from the body in an airplane splint. A patient with burns to the hand or foot should have each digit wrapped individually and then splinted. This allows each digit to maintain a normal anatomic distance from the next. Burnt limbs should be splinted.14
Burns with an unsecured airway should be transported to the closest emergency department (ED) to establish a secured airway. Emergency escharotomy, plasma and albumin administration, and the neutralization of chemical burns can all be performed in the ED setting. Trauma centers are the location of choice for burn patients. A trauma center will be capable of dealing with emergencies related to burns and will often have equipment used in burn rehabilitation, such as hyperbaric treatments.
Initial transport to a burn center should only be considered when the burn center is the closest ED or when the patient is stable, has no underlying trauma, inhalation or electrical injury, and doesn’t have a burn in a location that will likely cause debility (e.g., hand, foot, face or genitals). Burn centers have limited beds, and burn patients tend to require extended recovery times. Therefore, initial transport to these specialty centers should only occur with base hospital approval.
In our case study, your 14-year-old patient has multiple first- and second-degree splatter burns. He has some blistering to his thigh and maintains distal function. His burns total approximately 5% using the Rule of Palms. You dry the unaffected parts of the leg and apply moistened sterile bandages for comfort. You establish IV access and determine the patient’s weight to be 50 kg.
After applying supplemental oxygen, warming the patient by covering him with a clean sheet and obtaining a set of vital signs, you administer an initial dose of 2 mg of morphine via IV. Using the Parkland formula, you’ve determined the patient will need a total of 1 L of fluids over the next 24 hours. You begin to infuse 62 mL an hour and begin transporting the patient to the hospital for further treatment. You administer another dose of morphine en route.
The severity of a burn injury can range from the brief contact of scalding hot water to a chemical burn that continues to inflict injury until a neutralizing agent is applied in the hospital. Prehospital treatment is focused on halting the burning process, protecting the airway, preventing potential disability, maintaining homeostasis and providing pain control.
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