There are fire apparatus lining the street as you arrive. The air is smoky and thick. Incident command has requested you stage behind Engine 7. As you get closer, you see several fire fighters carrying a man from the smoking house, so you and your partner grab the stretcher and quickly move the patient into the ambulance.
Firefighters report the patient was working in the garage with an unknown accelerant when the fire ignited. It took them several minutes to find the patient but they were able to remove him from the burning structure quickly. There are no obvious signs suggesting the patient had fallen or been hit by any part of the structure.
The patient is an approximately 40-year-old male responding to noxious stimulus by moaning. He has a rapid, shallow respiratory pattern with noisy breathing. First- and second-degree burns cover his face. His shirt is burned off, with only portions of the material melted to his burned flesh. His entire anterior chest and part of his abdomen have sustained second- and third-degree burns, as well as the anterior portion of both of his arms. His lower extremities don’t appear injured or burned.
The burn area is extinguished. Your partner uses a bag-valve mask and begins to assist the patient’s breathing with high-flow oxygen. You establish an IV in the patient’s right antecubital and begin a slow infusion of fluid. His pulse rate is 130 with strong pulses at the radial artery. Dry sterile dressings are loosely placed over the patient’s chest burns and he’s covered with a blanket. The patient is rapidly transported to the closest ED with early notification from you about his status and possible need for transport to the burn center.
EMS providers must always remember to consider their safety before performing any type of rescue from a structure that’s burning or has burned. As you are able, remove any clothing that has been burnt or that is smoldering. Remove jewelry because, first, metals can hold heat and continue to burn, and, second, as the tissue swells, jewelry can create a constricting band around fingers, wrists or necks.
In the event of an explosion or structural collapse, EMS providers must consider the possibility of sustained trauma in addition to the burn. If there’s the potential for neck or back injuries, providers must consider the risk vs. benefit of immobilizing patients vs. management of other life-threatening conditions and rapid transport.
Airway management becomes a leading priority in the care of burn patients. Any patient who’s been exposed to smoke or super-heated gas should be assumed to have airway burns. If burned, airways can swell quickly and result in significant or total airway obstruction. Signs such as noisy breathing, coughing and the complaint of dyspnea are all signs of impending airway obstruction. High concentrations of oxygen and ventilation assistance should be provided for these patients. In systems where it’s allowed, chemical sedation and intubation may be implemented.
In addition to the airway swelling, a patient exposed to smoke may also have high levels of carbon monoxide (CO) and cyanide in their system. Both of these chemicals alter the body’s ability to transport and use oxygen. Be aware that both CO and cyanide can result in a high pulse oximetry reading, but the body is unable to receive or use oxygen.
Burns can cause significant fluid loss as fluid leaves the damaged tissue. The Parkland or modified Brooke formula can be used as an estimated starting point for fluid resuscitation. The formula suggests administering 4 mL/kg of fluid per body surface area burned with second- or third-degree burns. Half of this fluid should be administered in the first eight hours. EMS should, if allowed, administer pain medication during transport.
Severely burned patients may need to be transported to a burn center. The American Burn Association recommends the following criteria for burn center transport:
- Partial-thickness burns greater than 10% of total body surface area
- Burns that involve the face, hands, feet, genitalia, perineum or major joints;
- Third-degree burns in any age group;
- Inhalation injury;
- Burn injury in patients with pre-existing medical disorders that could complicate management, prolong recovery or affect mortality; and
- Any patient with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk for morbidity or mortality.
There’s a lot to consider in the care and management of patients who have been burned. Local protocols will guide EMS providers in how best to transport severely burned patient. Be aggressive with airway management, watch for rapid deterioration, transport appropriately and be safe.