Caring for burn patients is nothing new to medicine. In fact, many prehistoric civilizations derived natural burn curatives that are still used as modern-day home remedies (i.e., aloe vera extracts).
Many of these therapies were intended to treat burns with the same objectives we have today: reduce pain, hasten healing and protect damaged tissue during repair.1
However, great advances in burn care over the past century, and especially over the past 50 years, have revolutionized the care that burn patients receive, and stifled the mortality, morbidity and disability that result from burns. Most patients with severe burn injuries will survive and lead independent, productive lives following their care.
This wasn’t the case for much of the 1900s, when, as recently as 75 years ago, it was considered a death sentence if a patient sustained non-superficial burns to > 30 % of their total body surface area (TBSA).1 This is certainly not the case today.
Although most of the improvements in the outcomes of burn patients deals with the longitudinal care they receive, the role of prehospital providers in this chain of survival has been realized for decades now.2
This article will provide an in-depth update of the prehospital care for burn patients.
Epidemiology of Burns
Despite great advances in fire prevention and safety, burn injuries are still a major burden on public health on a global scale. Across the world, burns are the fourth leading cause of trauma, with approximately 11 million people seeking medical attention for their injuries.3
Correlations among age, race, gender, income and region vary, depending on any number of circumstances. However, one of the greatest proclivities to burn injuries is socioeconomic status.4
Areas of low- to middle-income populations are far more predisposed to significant burn injuries than their more affluent counterparts. This is likely due to a lack of fire safety education and infrastructure to prevent and decrease the severity of burn-related injuries. This phenomenon is especially noticeable in poverty-stricken regions within developed nations.5
Furthermore, nearly 90% of all burn-related fatalities occur in areas of poverty and socioeconomic depravity.
These facts are imperative to making informed and prudent decisions when responding to these calls and deciding what resources are needed.
Evaluating & Categorizing Burns
Burns are traumatic injuries that damage tissues on a gross and cellular level. The affected tissues (usually skin) are obliterated by one of the mechanisms of burns: radiation, chemical exposure, friction/mechanical, electrical and thermal. The burn itself is a wound created by isolated and hyperacute exposure to one mechanism.6 (See Figure 1.)
Although each of the mechanisms presents with its own host of challenges and specifics, this article will focus primarily on advanced strategies for burn care regardless of the cause. However, some special attention will be given to thermal burns, as they represent nearly 85% of all hospitalized burn injuries.7
In terms of staging the wounds on scene, this is done as part of your initial assessment. There are four means of categorizing burns that need to be quickly evaluated prior to making any transport decision.
1. Mechanics of the injury. This is usually the easiest category to evaluate, as it simply identifies the mechanism by which the patient became burned.
It’s worth noting, however, the mechanism is vitally important to the care that the burn patient receives in the initial phases of treatment. For instance, thermal burns must be cooled to stop the burning process, and chemical burns must be decontaminated before providing care.
2. Depth of the injury. This evaluation seeks to determine the degree to which the burn has infiltrated the skin and possibly deeper tissues (e.g., subcutaneous layer, muscle, bone, etc.). Previously, this category would have been communicated as first, second, third and fourth degree wounds. To standardize and more clearly convey the nature of the wound, they’re now described in terms of the deepest tissues affected: superficial, superficial and deep partial thickness, and full thickness. (See Figure 2.) Wounds staged as superficial aren’t factored into the total area burned, treatment decisions or destination criteria.
Any wounds with the appearance consistent with deep partial thickness injuries should be considered full thickness. The differentiation between the two depths isn’t always easily distinguishable and many deep partial thickness wounds will ultimately progress to full thickness in the days following the injury. Fourth degree is still used to refer to wounds that extend beyond the dermis and subcutaneous layers.
3. Amount of territory affected. At this point, an estimate of the amount of body surface area burned is calculated. This calculation should only include the injuries deeper than superficial. The estimate is given as a percentage of the total body surface area (TBSA). The rule of nines is typically used to facilitate this process. The injuries are reported in terms of the percentage of TBSA and depth. For example, 27% superficial partial thickness and 18% full thickness. This step is vitally important, as it not only effects your transport decisions, but also guides initial resuscitation efforts.
4. Landmarks. Burns to vital landmarks should be quickly identified; they always warrant expert evaluation and care. This includes burns to the face, eyes, ears, airway, neck, hands, feet, genitals and any circumferential wounds to the trunk or extremities. Burns to these areas are considered severe and warrant transport directly to a burn center, if possible.
Once this survey of the patient’s injuries is completed, the injuries will need to be graded in terms of their overall severity.
Minor burns are generally superficial. Superficial partial thickness burns < 2% TBSA that are uncomplicated by other significant injuries may also be considered minor. Minor burns can be treated in an outpatient setting (e.g., physician’s office or ED), and don’t require resuscitative efforts.
Moderate burns are superficial partial thickness burns < 10% of the TBSA. Moderate burns don’t require burn surgeons or burn centers, but may require initial resuscitative measures and admission to a hospital or burn center.
Lastly, burns graded as severe pose a significant risk to the patient’s life. These burns not only require immediate and emergent treatment, they also require the patient to be cared for by burn surgeons at a burn center.
There are several key factors that warrant a burn being classified as severe. Any burns that appear to be deep partial thickness should be considered full thickness and treated as such. (See Figure 3.)
Assessment & Initial Resuscitation
After ensuring that the patient can be safely cared for and that any additional resources are requested, it’s important to move quickly into an initial assessment. Burn injuries of any mechanism are a unique form of trauma. The presence of a severely burned patient can be incredibly distracting and overwhelming. Remembering the sequential basics of practice in caring for such critically injured patients keeps providers focused, efficient and accurate.
In any trauma assessment, providers are taught to rapidly identify life threats and immediately treat them. However, the sequela of burn injuries is a very dynamic process. For instance, burns that appear as superficial partial thickness may ultimately progress to full thickness, and patients with relatively few respiratory complaints can precipitously fall into intractable respiratory failure. Although the initial assessment must be a quick overview of what is critical to the patient, burns are one of those instances where an initial assessment may also shed light on what might kill your patient in the next 15, 30, or even 60 minutes.
It’s important for providers to pay special attention to their general impression. In most cases, the general impression is a subconscious, intuitive process that guides decision-making. Rarely do we make a conscious effort to dissect general impressions, but with burns it can make a difference.
For example, a 25-year-old person with burns of 75% TBSA has a survival rate of more than 50%. However, a 65-year-old with 35% TBSA burns has a survival rate that’s significantly less than 50%.8 Age can also play a role in burn depth. Patients with extremes in age (e.g., very young children and older adults) have thinner skin. Thus, burns to these groups are more severe and complex.
Focus on airway management has always been paramount when caring for hyperacute burn patients. At one time, there seemed to be a categorical directive to immediately intubate any patient with moderate or severe burns.
Although diligence to airway management must still be a priority, the decision to intubate is a bit more systematic and clinical in today’s practice. The provider’s decision should be based on the patient’s clinical presentation, rather than just circumstance.
If a patient was involved in a fire and is showing signs of airway injury and deteriorating patency, emergent intubation is indicated.9 Thermal injuries tend to damage the airway above the glottic opening, while products of combustion (chemical inhalants) damage the tissues below. When making the decision to intubate based on the potential for development of an edematous obstruction, it’s recommended that providers consider these factors: is there evidence of visible thermal injury in the airway and face, stridor, and/or voice changes? If the answer to any of these is yes, intubation is emergently indicated.
Burns are a dynamic process, especially airway burns. An airway that initially appears stable without any risk for edema and obstruction may become compromised as a result of fluid resuscitation. The fluid administered as part of the initial resuscitation may subsequently provide the fluid volume to enable an edematous airway obstruction.10
As noted previously, rarely are the structures below the glottic opening injured by heat. The upper airway is so efficient at heat exchange, superheated inhalants rarely make it past the vocal cords. However, two exceptions to this are steam and explosions, as these two mechanisms carry enough energy to cause thermal injuries deep into the respiratory tract.
Primary chemical burns from substances like chlorine gas can also cause chemical burns to the respiratory tract.
Inhalation injuries progress by way of two very distinct processes: 1) damage to the bronchial tree; and 2) damage to the parenchyma.
The bronchial tree houses an incredibly dense network of nerves. These nerves are stimulated by the noxious gasses. In response to the noxious stimulus, these nerves release inflammatory mediators that have a very potent effect on the smooth muscle of the tree and the inflammatory cascade of bronchial mucosa. The watershed effects of these compounds include bronchospasm, vascular leakage, and vasodilation. These affects trigger a deeper inflammatory response and cause the mucosa of the tree to begin sloughing. This then causes plasma proteins to freely flow into the airways and form casts that plug the airways, leading to profound ventilation/perfusion mismatching.
Bronchoconstriction and initial inflammation leads to excessive coughing and diffuse wheezing within only minutes of exposure. The fluid shifts and airway plugging happen over several hours.
The injury to the parenchyma has a much longer trajectory. The initial signs can take as long as 36 hours to present. Once the chemicals reach the alveoli, an aggressive immune response begins. Copious amounts of pulmonary edema flood into the micro airways, leading to alveolar collapse and atelectasis. These patients initially present with progressively worsening rales and dyspnea. However, the progression of the injury will likely lead to hypoxemic respiratory failure and prolonged mechanical ventilation.
Inhalation injury presents one of the greatest challenges facing burn care. Despite a host of advances, inhalation injury is still the greatest predictor of burn-related mortality.
Pulmonary complications from burn injuries still account for nearly 80% of all burn related deaths.11 Inhalation injuries should be suspected in any patient that is subjected to fire or smoke within an enclosed space or in patients with TBSA burned > 20%.
Treatment of inhalation injuries in the prehospital setting is aggressive administration of 100% humidified oxygen and bronchodilators. If the patient presents with clinical respiratory failure that’s unresponsive to these therapies, providers should be prepared to quickly intubate and take over ventilations for the patient.
Remember, pulse oximetry in these patients is completely unreliable, as carbon monoxide poisoning confounds SpO2 readings and is extremely common in burn victims.
If a patient with inhalation injury was initially stabilized at a community hospital and now being transported to a burn center, the patient is likely several, if not many, hours into their illness. Treatment for these patients involves lung-protective mechanical ventilation and continuation of the aggressive bronchodilators. Steroids are contraindicated in any burn injury, as they increase mortality and morbidity due to infection from immune suppression.
Providers may be asked to administer a relatively novel approach to preventing and breaking up the bronchial casts while transporting these patients to a burn center: inhaled N-acetylcysteine (NAC) and heparin. Traditionally, the casts were removed via frequent therapeutic bronchoscopies. However, this was costly and burdensome.
This new approach allows for a non- invasive means of treating the casts. The NAC breaks up the mucoid proteins of the casts while the heparin breaks up the plasma protein that leaked in to the lungs during the inflammation process.
This approach has been found to be very effective in reducing overall mortality and morbidity, in addition to reducing the reintubation rate and progression to acute respiratory distress syndrome.12
As with all trauma patients, providers should be looking for adequate end-organ perfusion. In most cases, this isn’t an issue during the hyperacute phase of the injury.
However, as burn severity and time from the injury increase, so does the likelihood of profound burn shock.
Burn shock is comprised to two phenomena: 1) myocardial depression (likely due to the inflammatory compounds circulating in response to the burns); and 2) edema and vascular leaking which causes massive extravascular fluid shifts in a surprisingly short amount of time. Burn shock typically presents within 48 hours post-injury.
To prevent burn shock, a formal and regimented resuscitation program has been developed. This was traditionally known as the Parkland formula: 4 mL/kg for each percent of TBSA burned, given over the first 24 hours post-injury. However, it was determined that this equation may have over-resuscitated some patients, while under-resuscitating others; both lead to worse outcomes.
Another idea to consider is the American Burn Association’s recommendation of the Consensus formula.9 The equation is identical to the traditional Parkland formula, except that it gives a range: 2-4 mL/kg for each percent of TBSA burned, given over the first 24 hours post-injury; with 2 mL/kg for adults, 3 mL/kg for pediatrics, and 4 mL/kg for electrical burns.
Half of the total volume is infused over the first 8 hours, with the remaining volume given over the following 16 hours.
The authors concur with the recommendation that prehospital providers administer 500 mL/hr of IV crystalloid, lactated Ringers (LR) if possible. During inter-hospital transports, the authors recommend following the regimen calculated by the referring facility. If no resuscitation calculation has been made, give LR 500 mL/hr via IV pump. All attempts should be made to administer warmed IV fluid to prevent the devastating potential for hypothermia in burn patients.
It’s important to remember that the goal of any resuscitative effort is to maximize end- organ perfusion. The best way to monitor this is by monitoring mental status and urine output (UO).
For patients in transport, a Foley catheter should be placed to monitor UO, if possible. It’s recommended that providers look for a UO of at least 0.5 mL/kg/hr.
If hemodynamics become unstable, boluses of 500 mL should be given. After two boluses, providers should consider starting patients on a pressor to maintain hemodynamics, preferably norepinephrine or epinephrine. Though aggressive fluid management is a must, the administration of fluids isn’t without risk. Patients with progressing inhalation injuries can have catastrophic fluid shifts, leading to severe pulmonary edema as a result of overly- aggressive fluid administration.
Exposure & Wound Management
Chemical burns require providers to decontaminate patients prior to initiating care. Any chemical burns must be decontaminated following local hazmat protocols. Most dry chemicals can be brushed off, and wet chemicals can be flushed with copious amounts of water. It’s also important to remove clothing, as it’s likely contaminated.
Providers are advised never to use water to decontaminate dry chemicals until all the visible residue has been brushed away; moisture may elicit a more aggressive reaction and worsen the burn.
For thermal burns, the debate wages on. Burns can continue to smolder and worsen for hours after the initial insult. Rapid cooling is a mainstay in caring for these patients. Cooling the wound decreases depth, territory and overall severity.
Not only is cooling the only thing that stops the burning process in its tracks, it also helps ease the excruciating pain of these injuries. However, the risk for hypothermia is a very real concern.
Patients with severe burns are already at a very high risk of developing hypothermia as part of the disease process of burn injuries and burn shock.13 Hypothermia is an independent prognostic indicator of poor outcome in these patients.14 Surveillance for and prevention of hypothermia must be an intentional focus of any treatment plan.
Cooling and stopping the burning process is a very delicate balancing act. It’s recommended that, for any patient with burns < 20% TBSA, they should be treated with cool saline (80 degrees F) for several minutes. When administering the cool saline, it’s important to avoid saturating the stretcher or blankets covering the patient, since evaporative and convective heat loss is the enemy to these patients. For patients with burns > 20% TBSA, allow the receiving facility to cool the patient if the patient will arrive within a reasonable amount of time.
It’s important to control the environment as well, making sure that patients are taken out of the cold quickly. The ambient temperature in the ambulance should be as close to body temperature as possible, and warmed IV saline administered.
Providers should refer to local protocols for prehospital guidance and leverage their medical command colleagues for real-time support.
Despite advances in fire prevention, safety and burn care, burn injuries remain a very significant health crisis across the world. The disease process of burn injuries is a highly complex and multi-factorial one that can carry a trajectory that’s measured in weeks to months.
The role of EMS in the care of patients isn’t taken lightly. Aggressive and expert care must be the mainstay of burn care for all prehospital providers.
Though advanced therapies are warranted, the basics of clinical practice will guide and strengthen the chain of survival in these patients.
1. Pinnegar M, Pinnegar F. History of burn care: A survey of important changes in the topical treatment of thermal injuries. Burns Incl Therm Inj. 1986;12(7):508—517.
2. Allison K. The UK pre-hospital management of burn patients: current practice and the need for a standard approach. Burns. 2002;28(2):135—142.
3. World Health Organization. (2008.) The global burden of disease: 2004 update. World Health Organization. Retrieved March 27, 2018, from www.who.int/healthinfo/global_burden_disease/2004_report_update/en/.
4. Peck M, Pressman M. The correlation between burn mortality rates from fire and flame and economic status of countries. Burns. 2013;39(6):1054—1059.
5. Marsden N, Battle C, Combellack E, et al. The impact of socio-economic deprivation on burn injury: A nine-year retrospective study of 6441 patients. Burns. 2016;42(2):446—452.
6. Kagan R, Peck M, Ahrenholz D, et al. American Burn Association white paper: Surgical management of the burn wound and use of skin substitutes. American Burn Association: Chicago, 2009.
7. Burn incidence fact sheet. (2016.) American Burn Association. Retrieved March 27, 2017, from www.ameriburn.org/who-we-are/media/burn-incidence-fact-sheet/.
8. Jeschke M, Pinto R, Costford S, et al. Is there a threshold age and burn size associated with poor outcomes in the elderly after burn injury? Burns. 2016;42(2):276—281.
9. American Burn Association. Advanced burn life support provider manual. American Burn Association: Chicago, 2011.
10. Navar P, Saffle J, Warden G. Effect of inhalation injury on fluid resuscitation requirements after thermal injury. Am J Surg. 1985;150(6):716—720.
11. Darling G, Keresteci M, Ibanez D, et al. Pulmonary complications in inhalation injuries with associated cutaneous burn. J Trauma. 1996;40(1):83—89.
12. Miller A, Rivero A, Ziad S, et al. Influence of nebulized unfractionated heparin and N-acetylcysteine in acute lung injury after smoke inhalation injury. J Burn Care Res. 2009;30(2):249—256.
13. Weaver M, Rittenberger J, Patterson P, et al. Risk factors for hypothermia in EMS-treated burn patients. Prehosp Emerg Care. 2014;18(3):335—341.
14. Singer A, Taira B, Thode Jr., H, et al. The association between hypothermia, prehospital cooling, and mortality in burn victims. Acad Emerg Med. 2010;17(4):456—459.
“¢ Gauglitz G, Williams F. (Nov. 30, 2017.) Overview of the management of the severely burned patient. UpToDate. Retrieved March 27, 2018, from www.uptodate.com/contents/overview- of-the-management-of-the-severely-burned-patient.
“¢ ISBI Practice Guidelines Committee, et al. ISBI practice guidelines for burn care. Burns. 2016;42(5)953—1021.
“¢ Mlcak R. (Feb. 28, 2018.) Inhalation injury from heat, smoke, or chemical irritants. UpToDate. Retrieved March 27, 2018, from www.uptodate.com/contents/inhalation- injury-from-heat-smoke-or-chemical-irritants.
“¢ Peck M. (Jul. 10, 2017.) Epidemiology of burn injuries globally. UpToDate. Retrieved March 27, 2018, from www.uptodate.com/contents/epidemiology-of-burn-injuries-globally.
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Case: Patient Presents with Startling Injuries
On an early summer afternoon, EMS units are dispatched to a suburban area of their community for a burn victim. The algorithm used by dispatch determined that the patient’s condition was severe and warranted the dispatch of a local BLS unit and medic squad, as well as the closest air ambulance to be placed on standby.
As the dispatchers give the pre-arrival information, the discomfort their voices is palpable across the airwaves:
“Your patient is an approximately 30- year-old female. She’s unconscious but breathing. The caller states that the patient was found outside of the residence by her parents, engulfed in flames. The patient was still on fire at the time of the call. Call takers advised the callers to extinguish the fire with a garden hose.
It’s unclear how the patient caught on fire, but she was actively on fire for the first two minutes of the call. Your closest air ambulance has pre-emptively launched based on pre-arrival info. Their ETA is nine minutes. The fire department is working on a landing zone.”
Both BLS and ALS arrive on scene simultaneously. All three providers are immediately overpowered by the scene.
The patient is found in the backyard of the home, in the fetal position on her left side. She’s naked; the only remnants of her clothing are burned scraps of fabric on the ground. Every visible part of her body is some shade of yellowish-brown or black. All of her hair has been burned away. The only evidence that the patient is alive is her constant low, soft moaning.
After a momentary sense of paralysis, the crew begins treating the patient. Despite the patient’s grave appearance, her ABCs are intact (i.e., airway, breathing, circulation).The patient is immediately placed on high-flow O2. Realizing this patient exceeds the resources of the local community and tertiary centers available, EMS crews begin planning for rapid air transport to a burn center.
As the crew goes to lift patient on to the stretcher, they notice her body position doesn’t change; she remains in the fetal position.
Once in the ambulance, it becomes clear why the patient can’t be placed supine; she’s incapable of laying flat. She has full- thickness burns over 80% of her body. Her burns are so extensive and severe that the wounds have become leatherized; her entire body is fixed in the fetal position she was found in while engulfed in flames.
Upon the arrival to the LZ, the crews opt to heavily sedate the patient with benzodiazepines and analgesics. A supraglottic airway is placed for airway protection, as the patient’s Glasgow coma score is 4 (E1V2M1). Endotracheal intubation isn’t attempted as the patient’s fixed position precludes any attempt at laryngoscopy.
The patient is flown to the closest burn center approximately 130 miles away. After emergent escharotomies to almost every bodily surface, the patient succumbs to her injuries 18 hours later. The patient diagnosis at the time of death: full-thickness burns to > 90% TBSA.