Burns and their treatment are a major concern in EMS, firefighting and related fields.
Therefore, it is no surprise that a day-long series of presentations on burns, their treatment and related issues was included among the pre-conference training programs offered at the recent FDNY Search & Rescue Field Medicine Symposium.
These presentations were held, appropriately, in one of the conference rooms at the William Randolph Hearst Burn Center at New York-Presbyterian/Weill Cornell Medical Center in Manhattan. They consisted of a long series of classroom presentations followed by a tour of the burn center given by enthusiastic staff who were clearly proud of what they do.
The presenters were friendly and well informed and seemed to enjoy teaching a program aimed primarily at pre-hospital care providers. When asked, “What is it that you wished more EMS providers knew about your job and how it is done?” Ekta Vohra MSN, Burn Outreach Coordinator answered, “Your care in the first hours of a patient burn is vital and helps the burn center team in caring for the patient once they come through our doors.”
When asked, “What are some of the most important things for EMS providers to remember when confronted with serious burns?” the response from Burn Program Manager Nurse Jamie Heffernan, MSN, was, “Don’t get distracted by the gore of the burn. Remember airway, breathing and circulation.”
Among the most important presentations were on the core fundamental subjects of burn injury pathophysiology, burn wound assessment and stabilization and fluid resuscitation. This article is based on those presentations.
Burn Injury Pathophysiology
After introductions of the presenters and the classroom, the actual medical programming began with a presentation on burn pathophysiology put on by Brenna DeRosa, one of the Burn Center’s RNs.
As burns usually begin at the skin, that’s where the programming began as well, with an introduction to skin, its layers and components, and their functions.
To review and summarize, skin is an organ, and, when healthy, it serves as an important part of the immune system where, it provides important protective and therefore immunological functions. Skin also helps maintain homeostasis of fluids and electrolytes. Healthy skin plays an important part in thermoregulation, regulating metabolism, and providing neurosensory regulation.
Of course, as the presenters said, “not all skin is the same,” and the ability of skin to do these things varies widely depending on factors such as age, health, pre-existing conditions or comorbidities, and genetics.
When skin becomes exposed to excessive heat, it becomes “cooked” or, as the condition is more properly referred to, “denatured.” This means that the skin becomes drier, has less blood flow, and less ability to send signals or sensitivity to changes.
If a burn is serious, hairs are able to be easily removed and can be plucked from the skin with no resistance. During the presentations, more than one presenter repeated this, noting that when assessing or treating badly burned patients, this is a sign that the skin is severely burned.
Temp and Temperature Chart
“All burns are trauma, but not all traumas are burn.” This was one of the themes of the program. And burns, of course, are trauma caused by exposure to heat.
Burn injuries often present with damage radiating out from the point where there was the most contact with the flame or heat source. The areas closest to the heat source are the most damaged. A presentation slide illustrated these zones. The most serious of these is often called “the zone of coagulation.” This is followed by a zone of stasis, and then a zone of hyperemia.
The region of coagulation is the area where tissue was destroyed at the time the burn occurred. The surrounding area, the zone of stasis, is marked by inflammation and low perfusion. Tissue in the zone of stasis has the potential to become necrotic over the 48 hours following the initial burn. Thus, the initial burn can increase in both severity and size. The area of hyperemia is an area where microvascular perfusion is not impaired, but the tissue is at risk of damage if not treated.
The Systemic Response to Burns
As good EMS providers know, “shock” in the medical sense of the word is when there is a lack of perfusion of oxygenated blood where needed in the system. Burns can produce shock. This is known either as “burn shock” or as Systemic Inflammatory Response Syndrome (SIRS).
This syndrome produces a clinical picture that includes tachycardia, tachypnea, fever and leukocytosis (high white blood cell count). The syndrome can progress to refractory hypotension, shock and multisystem organ failure.
“In its simplest form, burn shock is hypovolemic shock in a hyperdynamic state. During burn shock, capillaries leak serous fluid,” said Heffernan. “The body’s compensatory responses combine with the over activated inflammatory response resulting in a state of hypermetabolism which is influenced by the fight or flight response.”
Among the causes of SIRS or burn shock are the release of vasoactive substances from burn wounds. These produce vasodilation. Burns also produce reduction in the volume of circulating plasma, which, of course, reduces the fluid volume. Increased microvascular permeability is also one effect of burns, and increased microvascular permeability makes it more difficult for the blood vessels to contain fluids without letting them leak through. Metabolic acidosis is also a problem.
Other factors in the connection between shock and burns include the edema that comes with burns. Such edema takes fluid from the systems and collects it in swollen tissue at the burn sites.
After a serious burn, the human body tends to be in a hyperdynamic state, subject to rapid change and fluctuation and overadjustment. This is connected with high levels of epinephrine. Other problems caused by burns include an increase in capillary permeability which produces plasma leaks, including slow leaks, into interstitial spaces.
The seriousness of a systemic response to burns increases with the seriousness of the wound. The systemic response to a burn is proportional to the total body surface area, or “TBSA,” that has been burned or affected. Therefore, treating burns successfully requires understanding the percentage of deep injury.
The Rule of Nine
As it is important to estimate the total body surface area affected by a burn as part of assessing the seriousness of a burn, the rule of nines was reviewed. The Rule of Nines is a way to approximate the amount of body surface area affected by a burn. It is a standard part of most comprehensive EMS provider training programs.
It is also important to understand that the patient’s frailty or general level of health greatly effects their ability to withstand the systemic effects of burns and their expectation of a good systemic response to burn injury. Successful treatment requires understanding the systemic response. Long term treatment of burns involves meeting the body’s increased metabolic and nutritional demands after a burn takes place.
Burn Wound Assessment and Stabilization
EMS providers should be familiar with the degrees of burns.
Although different systems of number the degrees of burns exist, with first through third degree burns being the most common, although there are systems that subdivided third degree burns, giving the subdivision numbers, and these systems do have advantages in some circumstances. The Burn Center presentation used a system with four degrees of burns.
A quick review based on the presentation materials:
Degrees of Burns
1st Degree Burns, Superficial/Outer Most Layer of the Epidermis
- Skin functions remain intact
- Local pain, erythema, edema
- No treatment or moisturizers
- Rehydration / fever control
- Heals in 3-5 days
- No scarring
2nd Degree Burns, Superficial or Deep Partial Thickness Burns
- Altered protective barrier
- Vascular leak > exudate
- Temperature control disrupted
- Systemic Reaction
- Intense Pain
- Edema
- Heals within 3-30 days
- Some scarring possible
Superficial Partial Thickness
- Red
- Thin-walled blisters
- Moist
- Edema, weeping
- Hair follicles intact (sometimes)
- Scarring variable
- Pigmentation changes may occur
Third Degree Burns, Full Thickness
- Epidermis or Entire dermis
- All functions of the skin absent
- Painless
- Skin grafting required
- Contraction/epithelialization
- Dry, leathery adherent eschar
- Black or white in color becomes eschar
- Thrombosed Vessels
Fourth Degree, Involves All Layers of Skin and Involves One or More of the Following:
- Subcutaneous tissue
- Fascia
- Muscle
- Bone
- Significant injury
- Charred tissue
- Prolonged exposure
Treatment of Burns in Prehospital Care
Burn Wound Stabilization
A review of best standards for prehospital or early care and stabilization of burns was presented. It included:
- Cool water. Soak the burn in site in cool water. Twenty minutes of soaking is standard. This is one of the most important parts of the early treatment and stabilization of burns.
- If applicable, remove any jewelry or clothing. If it sticks, leave it.
- Evaluate airway for coughing, stridor, soot around nostrils, lips. If ALS is available, intubate before swelling begins or becomes serious.
- If available, start an IV Line for fluid resuscitation.
- Wrap the burn in a loose dressing, Do not use anything that will adhere to the burn site.
And finally:
- Keep the patient warm. Do not let their core body temperature drop if possible. Core body temperature should remain above 36.5 degrees Centigrade ( 97.7 degrees Fahrenheit).
This one is a key point. When asked, “What are the biggest mistakes or areas of improvement that you see among EMS providers when treating or responding to burn emergencies,” Heffernan answered “Not warming the patient. An admission temp of 36.5 has shown an increase in mortality.”
In-Hospital Care and Its Phases
Of course, burn centers take care of patients long after the ambulance or helicopter brings them in. Recovery from severe burns is a lengthy and time consuming process. It’s a long, complicated process that takes a great deal of time, effort, and a team of skilled specialists.
“Working at a verified burn center gives our team the opportunity to strive for excellence and provide the highest level of care to pediatric and adult patients. The resilience of burn survivors and their people is humbling,” said Ekta Vohra MSN, Burn Outreach Coordinator. “Burn care is a team sport. Each team member has input and care is always multidisciplinary.”
Burn treatment in a healthcare facility has three phases: Emergency, Acute and Rehabilitative. The Presentation described each phase and its goals briefly.
Emergent
- 0 – 72 hours post-injury
- Management of the ABC’s
- Fluid resuscitation
- Initial wound assessment
Acute
- 72 hours and beyond Until Sufficient Healing Begins for things to enter the Rehabilitative Phase with 80% wound closure
- Support multi-system organ function
- Wound care
- Infection control
Rehabilitative
- 80% wound closure optimal functional independence
- Maximize cosmetic outcomes
While the most important things in burn care for an EMS provider are the basics such as ABC (Airway, Breathing, and Circulation), cool the wound to stop its spread, and work to prevent and treat shock, its also important for EMS providers to learn as much as they can about burn care both outside the hospital as well as what goes on inside the burn center.
