Burning Issues

 

      A paramedic ambulance is dispatched to the scene of a house fire. En route the fire department advises that one victim has been removed from the house.

   Upon arrival the EMS crew finds a single-story house with smoke pouring out of the back windows. The fire department has secured the scene and extricated an elderly male from a bedroom in the back of the house. The patient is loaded into the ambulance, and EMS begins its assessment. The patient appears to be at least 60 years old and is only wearing underwear. He has significant burns all over his body, with blisters as well as black tissue starting to appear in some areas. The patient is unconscious and has occasional gasping respirations. His carotid pulses are weak and rapid, and his skin is hot to the touch, dry, and feels leathery in the more severely burned areas. The crew rolls the patient onto his side for a moment. They find no other signs of trauma, and roll him onto his back using in-line stabilization. There are no bystanders, and no medical history can be obtained. It is suspected that the man was asleep when the house caught fire. When the fire department arrived, the patient's bedroom was fully engulfed in flames and filled with thick black smoke.

   The EMS crew estimates that the patient has 95% total body surface area involvement of partial- and complete-thickness burns. They initiate airway management. Due to the extent of the burns, intravenous access is not possible. They place an intraosseous infusion in a lower extremity and initiate fluid resuscitation with normal saline. They transport the patient to the regional burn center for evaluation and treatment. There he's admitted to the intensive care unit. Two weeks later he succumbs to injuries sustained during the fire.

BACKGROUND

   It is estimated that 1.2 million Americans are burned each year, and that more than 50,000 require hospitalization. Nearly a million a year seek emergency department treatment for burns. Burns also account for roughly 5,000 deaths per year. Fires and burns are the second-most common cause of unintentional injury leading to death in children and the third-leading cause of unintentional injury leading to death for those older than 1. Half of all burns may involve smoking or substance abuse. Burns occur primarily at home or the workplace. When fire is involved, it is sometimes difficult to determine if burns or smoke inhalation resulted in a death. This makes the reporting of accurate numbers more difficult.1-4

   Approximately 8% of burns result in death. The number of deaths from burns has declined over the past several decades. This can be credited to several factors, including better burn care, improvements in the quality of burn centers, and the recognition and effective management of shock related to burns. Improved wound management and antibiotic use have also decreased deaths from infections related to burns. Another factor is the use of smoke detectors: In the United States, most people killed in house fires die from smoke inhalation rather than burns.5,6

ANATOMY

   The skin has three layers: the epidermis, dermis and hypodermis. The epidermis is the top layer; the dermis is directly beneath it. The epidermis has varying levels of thickness. For example, the epidermis of the forearm tends to be thinner than at the sole of the foot. The epidermis acts as a barrier between the body and the external environment. The dermis has two layers, the papillary (superficial) and reticular (deep) layers. The hypodermis is a layer of adipose and connective tissue between the skin and underlying tissues. Subcutaneous tissue is located under the dermis and is not considered a layer of skin. Other structures, such as muscle and bone, are located beneath the subcutaneous layer.2-5

   The skin has several functions, including being a barrier to water, protection from vapors, and resisting infection. The skin influences the body's temperature through its ability to retain and release heat. It is one of the body's most important protective organs.2,3,5,6

HOW BURNS DEVELOP

   A burn occurs when more heat is absorbed than the body's tissues are able to manage. Burns can affect any anatomical structure, including skin cells, muscle, bone and subcutaneous structures. Burns cause damage by direct injury and by releasing local mediators. The depth and severity of a burn are influenced by factors such as duration of exposure, energy source, conductivity of tissues, patient age, and the patient's underlying health. For example, when very young or very old victims are exposed to the same source of heat for the same duration as others, they are more likely to experience more severe burns, because their skin tends not to be as thick. Tissue resistance can also influence the severity of the burn. Bone is the most resistant to heat accumulation, followed by nerves, blood vessels and muscle tissue.3,5,6

   As the severity and intensity of heat increases, its impact on the body increases. When skin is heated, proteins within the skin begin to unfold. This leads to their denaturing. When the skin begins to cool, eschar scar tissue begins to form. Eschar is dead, inelastic dermis tissue. Over time it separates from the underlying tissue. If eschar is circumferential, such as around an arm, it can restrict blood flow. If it is located on the chest wall, breathing can be impaired. An escharatomy may be required to allow for muscle movement and the return of circulation.3,5,7,8

   Burns can occur internally and externally on the body. While the term burn may be commonly associated with injury to skin, internal damage can occur as well. This is of paramount importance when a patient may have inhaled smoke/heat or ingested a substance that can cause burns. If a patient has external burns, providers should try to determine if they also have internal burns. This is important when dealing with high-voltage electrical injuries, where external damage tends to be just the tip of the proverbial iceberg.2,3,5,6

BURN SEVERITY

   Burns are classified according to depth of injury, with first- and second-degree burns being superficial and partial-thickness, and third- and fourth-degree burns being full-thickness. The following provides an overview of the various degrees of burns. Table 1 provides a summary.2,3,5-9

   Superficial (first-degree): The least severe burn is a superficial, or first-degree, burn. This injury is isolated to the epidermis. The skin tends to become red in color because the underlying blood vessels dilate and blood flow to the tissue increases. In this injury the nerves are often irritated, and the skin becomes painful with or without touch. The pain tends to resolve after 2-3 days. There is usually no scarring. Sunburn is a common example of a first-degree burn.2,3,5-9

   Partial-thickness (second-degree): Partial-thickness/second-degree burns are more severe than superficial burns. A superficial partial-thickness burn involves the epidermis and upper layer of the dermis. Fluid-filled blisters may form. This can be within minutes or can take up to 24 hours. In general, the deeper the burn, the faster the blisters develop. When blisters are removed or rupture, the skin is often pink, moist and sensitive to air movement. Superficial partial-thickness burns blanch, or turn white, when pressure is applied to the skin. The skin tends to be shiny, raw, weeping and mottled. Superficial partial-thickness burns are painful and tend to remain well-perfused. They usually heal within three weeks, and scars do not normally develop.2,3,5-9

   Deep partial-thickness burns extend into the reticular layer of the dermis. The reticular layer is the deepest layer, composed of special white fiber. Involved areas tend to be white and can be moist or dry. Blisters and patchiness from the pink and white colors lead to a mottled appearance.2,3,5-9

   Deep partial-thickness burns may be less painful than one would expect, because nerves may be damaged. Capillary refill time may be delayed or absent. Wounds may appear white and dry. Healing may occur over a few weeks or months. Scarring is possible. If scar tissue is located over a joint, it may lead to a reduced range of motion, and physical therapy may be needed to preserve function.2,3,5-9

   Full-thickness (third-degree): A more severe injury is the full-thickness, or third-degree, burn. This injury involves the epidermis and dermis. These injuries often require grafting to heal. Burns can appear dry, white or waxy, cherry red, charred, black or leathery. The appearance will depend on the source of the heat and depth of the burn. Full-thickness burns tend to feel hard, with a firm texture, and do not blanch. They appear to be depressed inward when compared to normal skin at the edges. In some cases, clotted blood vessels may be involved, and they may have a translucent appearance. Although full-thickness burns are very painful for victims, the burned tissue itself is often insensate and therefore not tender to the touch.2,3,5-9

   Fourth-degree: Fourth-degree burns penetrate beyond the dermis and involve subcutaneous structures such as fat tissue, muscle and bone. Burns involving internal organs are fourth-degree burns. They are commonly found in individuals who are unable to remove themselves from a burn source—for instance, an unconscious or postictal patient who leans against a hot radiator or a patient trapped in a burning vehicle. Fourth-degree burns may also occur from high-voltage electrical injuries.2,3,5-9

SIRS

   In addition to being familiar with the various types of burns, providers should be aware of a condition referred to as systemic inflammatory response syndrome, or SIRS, that may develop.2,3 When a deep burn occurs, blood plasma leaks out of capillaries and into surrounding tissues. This is referred to as third-spacing. The patient also begins to experience a systemic inflammatory response syndrome, which involves a number of responses in the metabolic, cardiovascular, gastrointestinal and coagulation systems.2,3

   As plasma leaves the bloodstream and enters the subcutaneous tissues, swelling or edema results. Vascular permeability increases in blood vessels adjacent to the burned tissue, and plasma levels drop as fluid leaves the bloodstream and moves into damaged tissue. Histamine is released from dying cells and causes an increase in vascular permeability. This results in additional fluid loss from the bloodstream. A hypermetabolic state begins to develop, and the patient's heart rate increases in an effort to circulate the remaining blood volume and maintain cardiac output.2,3

   As this process continues, white blood cells leave the bloodstream in response to chemical signals from dying cells. Because there is a loss of volume in the vascular system while the number of red blood cells remains constant, increased viscosity results. The hematocrit, or measurement of the ratio of RBC to plasma fluid, increases, and the blood thickens. In response to this, peripheral resistance increases within the vascular bed, and a near-normal blood pressure is maintained.2,3

   When the systemic blood volume begins to decrease, cardiac output eventually begins to fall. At the same time, intravascular fluid continues to third-space. As the vascular volume decreases, the patient appears to be hypovolemic, even though the total fluid volume has not been reduced. Blood plasma shifts from the vascular system to the peripheral body tissues and causes a burn-induced shock.2,3

   This cascade of events results in general edema of the body tissues, especially among those that were injured. Edema often develops within 4-6 hours following the initial event, and may reach its maximum at 24 hours. Blood volume may continue to leak, and hypoproteinemia can develop from a loss of proteins in the blood. When there is not enough protein, blood vessels become increasingly permeable and can be more prone to losing fluids. As cells die, their contents are released into surrounding tissues. Sodium may begin to shift into injured cells. Potassium may be released as a result of cell injury and lead to hyperkalemia, which can result in lethal cardiac arrhythmias.2,3

ZONES OF INJURY

   Burns have three zones of injury: hyperemia, stasis and coagulation. The injured area most distant to the point of contact of the burn source is the zone of hyperemia. It has an appearance similar to a sunburn. The next-closest area to the burn source is referred to as the zone of stasis. In this area tissue damage and capillary permeability result in fluid leaking into the extravascular space. This can lead to edema and burn shock. The area closest to and including the point of contact with the burn source is the zone of coagulation. This zone involves necrosis and destruction of microcirculation that inhibit the effectiveness of the defense system. Zones of injury are dynamic. A zone of hyperemia may progress and become a zone of stasis if not treated appropriately. The provider's goal is to limit such progression of injury.2,3,10,11

MORTALITY FACTORS

   The pathophysiology of burns, including SIRS, results in the all-too-common situation where burn victims survive the initial event, only to succumb to their injuries days or weeks later. Factors that must be considered when determining the prognosis of burn victims include the total body surface area (TBSA) involved, the patient's underlying health, the depth of the burn, toxic gas inhalation, degree of airway compromise, electrolyte imbalances, and the potential for the wounds to become infected. Providers are encouraged to thoroughly assess burn victims and anticipate the potential for complications. Underestimating or underreporting the severity of an initial situation may not support a positive outcome. Also, recognize that the burns visibly present on the patient's skin may only be part of the picture--internal burns and edema may be present as well. The patient who appears stable on scene can become critically unstable in a short period of time.2,3,10,11

BURN TYPES

   There are several types of burns. Thermal burns are caused by contact with hot substances, like liquids, flames or solid objects. Electrical burns occur when electrical current flows through the body. Chemical burns involve liquid, solids or gases that are either acidic or alkaloid and result in tissue injury through chemical reactions. The following examples describe various types of burns/injuries that may be encountered in the prehospital setting.2,3,10,11

THERMAL BURNS

   Scald injuries: Scald injuries are common among children between the ages of 6 months and 2 years. They are often caused by hot food or liquid spilled onto the skin. The most common cause is hot water. At 140°F water can cause a deep partial-thickness or full-thickness burn in less than three seconds. At 156°F, a deep scald burn can occur in one second. To put this into perspective, freshly brewed coffee has a temperature around 180°F.2,3,7-10

   Scald injuries can involve both covered and exposed skin. Exposed skin tends to be burned less severely than clothed areas, because scalding clothing often remains in contact with the skin. Scald injuries can involve extremely high temperatures—substances such as cooking oil, grease, tar and asphalt can reach temperatures that exceed 400ºF.2,3,7-10

   Scald injuries by immersion are also possible. These may occur when a victim, often a child or elderly adult, is dipped or plunged into hot water. This can result in deep and severe burns, because the hot liquid remains in contact with the skin for a greater period of time. Injuries may be seen on the heels, buttocks or genitalia/perineum.2,3,7-10 In patients under 14, hair curlers, curling irons, room heaters, ovens and ranges, irons, gasoline and fireworks are common causes of fires resulting in thermal burns.2,3,7-10

   Steam burns: These burns often produce extensive injuries from the high heat-carrying capacity of the steam and the release of pressurized steam and liquid. In addition to skin injuries, steam inhalation can also result in thermal injury to the respiratory system. Industrial accidents and opening hot car radiators are common causes of steam burns.2,3,7-10

   Flame injuries: Flame injuries are the second-most common type of burn injury. Damage occurs when the heat from the flame causes proteins within the skin to denature. When the skin cools, it refolds into inelastic tissue. Common causes of fires that result in flame injuries include careless smoking, improper use of flammable liquids, motor vehicle collisions and ignition of clothing by stove and space heaters.

   Contact burns: Burns that involve the direct contact of skin with the source of the heat, such as metal, plastic, glass or hot coals, are referred to as contact burns. The size of the burn tends to be limited to the size of the surface contacted, but the burns can be deep and severe.2,3,7-10

ELECTRICAL BURNS

   Electrical burns account for 3%-7% of admissions to burn centers in the U.S. each year. Many of these are occupational injuries. In an electrocution, the injury pattern differs from other types of burns. While exterior injury to the skin may occur and be readily visible, internal injuries may not be as obvious but can be severe.2,3,7-10

   Electrical injuries can occur from direct contact with a source or from a source's arc. In contrast to other burn types, electrocutions may involve entrance and exit wounds. When a person comes in contact with an electrical charge, the charge seeks a path out of the body. As the electricity passes through the victim, resistance to the flow of the current generates heat and damages tissue between the electricity's points of entry and exit. In most cases, the flow of electricity is from low to high resistance. Resistance is lowest in nerves and increases in blood vessels, muscle, skin, tendon and fat; the most is offered by bone. When the current flows through the body, massive electrical charges with extensive contact can leave tissue blackened and scarred.2,3,7-10

   Various types of injuries can occur with an electrocution. For example, an arc injury can occur up to 10 feet away from an electrical source. A flame injury may occur if the patient's clothes ignite. Musculoskeletal injury can occur if muscle spasms develop. The patient may also develop traumatic injuries during or after the initial electrocution if they fall or are thrown from the source.2,3,7-10

   Flash burns may also occur with electrocutions or lightning strikes. In flash burns, clothing can be protective. However, if the clothing ignites, thermal burns may result. Flash burns tend to be seen on areas of exposed skin where contact was made with the source. The most severe occur on skin that was facing the ignition source.2,3,7-10

   With these cases, providers need to maintain a heightened awareness of the potential for internal damage. Thorough assessments and close monitoring should be part of prehospital treatment.

CHEMICAL BURNS

   Exposure to chemicals results in about 60,000 injuries and 3,000 deaths a year. Chemicals can have various effects, ranging from minor skin irritations to acute respiratory compromise. Because the signs and symptoms associated with chemical burns may take time to develop, injuries can appear benign early, but become considerably more severe.2,3,7-10,12

   A number of factors can influence chemical burns, including the strength and concentration of the chemical, quantity involved, duration of contact, mechanism of action, extent of penetration and mode of entry into the body. Modes of entry include absorption through skin or mucous membranes, inhalation through the respiratory system, or the agent being swallowed, eaten or injected by needle or through an opening on the skin.2,3,7-10,12

ASSESSMENT

   The assessment of any burn patient must be deferred until the scene is secured and deemed safe. In the opening presentation, the ambulance was staged in a secure location. Firefighters then moved the patient out of the danger area to the ambulance. This type of approach is key in ensuring the safety of responders and protecting the patient from additional injury.

   Assessment of the patient should begin before physical contact is made. As you approach the patient, be aware of their surroundings. What is the patient's overall appearance? Are there any clues or signs to what happened on scene? Factors such as medicine bottles and medical supplies may provide insight to the patient's medical history. Evidence of substance abuse should also be noted.2,3,5,6

   When assessing a burn victim, consider some specific questions: What was the source of the burn? How long was the exposure? Was there direct contact with the burn source? Was the patient in an enclosed room when the incident occurred? Were any chemicals involved? Is specialized decontamination required? If an electrical burn is involved, what was the source, and is it possible to determine the voltage? High voltage is generally considered 1,000 volts or more, although some authors have argued that the risk of significant injury increases with exposures exceeding 600. Typical household circuits in the United States are 110 volts, with bigger appliances operating on 220-volt circuits. Power lines in residential areas can carry more than 7,000 volts.

   In addition, when possible, providers should try to determine details such as the patient's medical history, events that preceded the incident, and any prescribed medications. A quick method that may assist is the AMPLE technique.2,3,5,6,10,11

   When assessing a burn patient, consider the potential for abuse and/or neglect. Certain burn patterns, such as those on the soles, palms, buttocks, genitalia or perineum, or pinpoint burns, as might be seen from contact with a cigarette, should be carefully evaluated. These burn patterns have been seen in children and the elderly who are unable to defend themselves. In children, approximately 10% of abuse cases involve burns.2-4

   Patient assessment should begin with the primary survey, including assessment and management of the airway, breathing and circulation. Consider immediate intervention when any component of the ABCs is at risk.

   The primary assessment may be expanded by adding D for disability, or performing a quick neurological assessment, and E for exposure of the patient to identify the presence of trauma. Clothing should be removed for visualization of the skin and, depending on the mechanism, to prevent trapping heat next to the skin. If clothing is adhered or burned to the skin, cut any loose garments away from the wounds while leaving attached clothing in place.2,3,5,6

   Obtain a baseline assessment of vital signs as soon as possible. Include heart rate, respirations and blood pressure. If available, cardiac monitoring and pulse oximetry may also be used. Vitals should be reassessed at least every 10 minutes, and more frequently when indicated by patient condition.2,3,5,6

   Subtle findings may be present in a burn patient. For example, while the patient's respiratory rate may not be out of the normal range, their respiratory effort may be significantly increased. Depending on the nature of the burn, this may be a significant early predictor of how severe the burn really is. If a patient is experiencing dyspnea, assume the burn is serious.

   Other findings, such as profound hypotension immediately following a burn, should alert the provider to consider other causes of fluid and/or blood loss. Traumatic injuries may be present and require immediate intervention. The general rule is to treat trauma first—trauma trumps burns.

   Restrictive items such as clothes and jewelry should be removed as soon as possible. If these are left in place, edema may occur, resulting in a variety of complications, including distal circulation compromise.2,3,5,6

TBSA

   A key component when assessing the burn patient is estimating the amount of body surface area with partial- or full-thickness burns. This is referred to as the total body surface area, or TBSA. Estimating TBSA is important for communicating the extent of the injury to other healthcare providers, guides treatment in the field and hospital, and may affect EMS transport destination decisions. There are several tools to assist in determining the extent of a burn injury, including the rule of nines, rule of palm, and Lund and Browder chart.13-15

RULE OF NINES

   To use the rule of nines, the adult body is divided into 11 parts, with each section representing approximately 9% of the TBSA. These parts are:

  • The front of each leg;
  • The back of each leg;
  • Abdomen;
  • Chest;
  • Lower back;
  • Upper back;
  • Left arm (front and back each 4.5%);
  • Right arm (front and back each 4.5%);
  • Head (front and back each 4%, front and back of neck each 0.5%).

   The groin/genital area accounts for the last 1%. Table 2 provides a summary of the rule of nines.13-15

   The rule is modified for pediatric patients. For them, the front and back of the head account for 18%, the anterior chest and abdomen 18%, the posterior chest and abdomen 18%, each arm 9%, each leg 13.5%, and the groin 1%.3,16

RULE OF PALM

   The rule of palm uses the patient's palm and fingers for the assessment. Each "palm" is equal to 1% TBSA. Practically, the rule of palm may be most useful for estimating small or isolated burns. Use the patient's palm, not the provider's.2,3,13,15

LUND AND BROWDER

   The Lund and Browder chart is considered a more accurate tool for assessing TBSA and fluid replacement. It is most commonly used in hospital settings, including burn centers. While the chart is very accurate, it may not be practical in the prehospital setting, as it may require additional time for use and field calculations.13,15

   The Lund and Browder chart assesses burn severity based on the patient's size and age. It involves drawing on charts to indicate the burn's severity, such as red or blue to indicate partial- and full-thickness burns. The percentage of affected TBSA is then determined. This tool is effective for both burn size estimates and recommending the correct amount of fluid that should be considered.

   Table 3 provides links to burn calculation resources.13,15

TREATMENT

   Treatment will be influenced by a number of factors, including the patient's severity, distance from the hospital and/or burn unit, level of services available in the field and local protocols. The presence of trauma must be considered when weighing destination. While a multisystems trauma patient may have serious burns over much of their body, it is appropriate to take them initially to a trauma center, then transfer them later as needed.1-7

   Determining burn depth is not always easy, especially in the prehospital setting. Providers should focus on recognizing the presence of a burn, estimating its severity and TBSA, and managing it accordingly. Extensive time should not be spent attempting to differentiate depth or severity in the prehospital setting. The provider's attention and energy should be focused on assessment and treatment.1-7,10,11

   Treatment should always start with securing the ABCs and managing any life-threatening injuries. Consider supplemental oxygen for victims of more than minor burns.

   Because heat exchange in the upper airway is very efficient, distal airway involvement may be spared. However, the upper airway is at risk for injury and edema. This can present a significant challenge in the field, as airway edema can develop quickly after seemingly benign initial presentations. Distal airway injury is more likely to be due to the direct effects of the products of combustion on the mucosa and alveoli. As a result, aggressive airway management may be required.2,3,5,6

   Airway management should be accomplished using manual support as needed. This can range from the simple jaw thrust to endotracheal intubation. Early intubation may be indicated in patients who show signs of respiratory tract injury. This includes patients with singed nasal hairs, facial burns, oral burns, sooty sputum and/or respiratory difficulty with stridor or wheezes.2,3,5,6 Extensive information is available regarding optimal airways in the field. Providers are encouraged to become familiar with the various techniques. Consult local protocols regarding the use of any advanced airway techniques.2,3,5,6,8

   After the ABCs and life-threatening injuries have been managed, subsequent treatment can be initiated. This may include wound care, establishing IV access, fluid resuscitation and pain management. It is generally recommended that the patient be undressed and covered in a dry, sterile sheet. This will be influenced by scene dynamics and factors such as weather. Only nonadherent clothing should be removed. Once the patient has been uncovered, the extent of the burn (blister formation, etc.) may become more apparent. In the prehospital setting, leave blisters intact. If a blister ruptures spontaneously, cover it with a dry, sterile dressing.2,3,5,6,10,11

   Ice should not be directly applied to burn injuries, as complications such as frostbite can result. If TBSA is less than 10%, a dressing can be moistened with sterile water and applied over the wound. To reduce edema, extremities with burns may be elevated, depending upon overall condition.2,3,5,6, 7,10

   Intravenous fluid administration is recommended for adults with TBSAs of 18% or more, and pediatric patients with TBSAs of 12% or more. The goal is to allow for the perfusion of vital organs without overhydrating the patient. Initiate fluid resuscitation in the field. Normal saline and lactated Ringer's are both appropriate crystalloid solutions for initial resuscitation. Flow rates will vary depending on a variety of factors, including the age of the patient and TBSA involved. For adults with 20% or more TBSA, 500 ml/hr. is recommended. For 5-15-year-olds with TBSAs of 15% or greater, it's 250 ml/hr. For patients under 5 with 15% or more TBSA, it is 250 ml/hr.2,3,5,6,7,10

   For fluid replacement guidance, the Parkland system can be used. This considers the TBSA as well as the patient's weight: Volume equals the TBSA percentage multiplied by the weight in kilograms. Links to specific burn tools and fluid replacement can be found in Table 3.13-15,17

   Depending on the extent and severity of the patient's burns, it may not be possible to obtain traditional peripheral intravenous access. In these cases, intraosseous access and infusion is an option for the prehospital setting. Consult your local protocols regarding use of this procedure.2,3,5,6,16

   When pain management is indicated, initiate it in the prehospital setting. Consider factors such as the patient's age and location and the extent and severity of the burn. While medications and routes of administration may vary from system to system, morphine, fentanyl and Dilaudid are all effective in managing burn-injury pain. Be aggressive in managing the pain a burn victim experiences.2,3,5,6,10,11

   Chemical burns present a particular challenge because it may not always be clear what chemical was involved. If chemicals are encountered or suspicious or unknown substances involved, trained personnel should assist. Contaminated clothing should be removed and placed into appropriate bags for the decontamination team to manage. If a powder is present on the patient, brush it off before performing any rinsing or irrigation (unless the decon team requests irrigation first). When brushing chemicals off a patient, wear eye and respiratory protection to avoid inadvertent ingestion. Applying the same protection to the patient may assist in avoiding additional exposure.2,3,5,6,11,12

   A key component of prehospital treatment is determining patient destinations. If a patient has both trauma and burns, the most appropriate facility may be the local trauma center, which can then transfer the patient to a burn center when indicated. Where trauma and burn centers are not immediately available, providers may need to transport to a local hospital for initial resuscitation efforts. Once resources such as air transport are available, the patient may need to be transferred to a higher level of tertiary care. Examples of guidelines regarding burns and burn center criteria can be found in Table 4. Providers should be familiar with the burn capabilities of their local facilities.2,3,5,6

CONCLUSION

   Burns can range from relatively simple to lethal, but their severity may not be immediately apparent in the prehospital setting. Prehospital providers should thoroughly assess burn victims and anticipate both their immediate and long-term needs. By having a thorough understanding of the pathophysiology of burns, providers can support their patients' chances of recovery and good outcomes while reducing morbidity and mortality.

References

1. American Burn Association, www.ameriburn.org.

2. Chapleau W, Burba A, Pons P, Page D. The Paramedic. Boston: McGraw-Hill, 2008.

3. Hubble M, Hubble J. Principles of Advanced Trauma Care. Albany: Delmar Thompson, 2002.

4. Naradzay J, Alson R. Burns, Thermal, www.emedicine.com/emerg/topic72.htm.

5. Bledsoe B, Porter R, Shade B. Paramedic Emergency Care. Upper Saddle River, NJ: Brady Prentice Hall, 1997.

6. Campbell J. Basic Trauma Life Support for Paramedics and Advanced EMS Providers. Englewood Cliffs, NJ: Brady, 1995.

7. U.S. Department of Health and Human Services, Radiation Event Medical Management. Burn Triage and Treatment: Thermal Injuries, www.remm.nlm.gov/burns.htm.

8. Oliver R. Burns, Resuscitation and Early Management. www.emedicine.com/plastic/topic159.htm.

9. MobileHome. Parkland Formula for Treating Burn Victims, www.josephsunny.com/medsoft/iparkland.html.

10. Medline Plus. Burns, www.nlm.nih.gov/medlineplus/burns.html.

11. BurnSurgery.org. Section III: Burn Wound: Histological Assessment (Zones of Injury), www.burnsurgery.org/Modules/BurnWound%201/sect_III.htm.

12. Emergency Medicine Health. Chemical Burns, www.emedicinehealth.com/chemical_burns/article_em.htm.

13. Wedro B. Burn Percentage in Adults: Rule of Nines, www.emedicinehealth.com/burn_percentage_in_adults_rule_of_nines/article_em.htm.

14. OrganizedWisdom. Parkland Formula for Burns, http://organizedwisdom.com/Parkland_Formula_for_Burns.

15. Iredell County EMS. Burn Calculations, www.iredellems.com/protocols/employees/ICEMS%20Protocol%20Web/Appendix%20Pages/burn%20calculations.htm.

16. Fenlon S, Nene S. Burns in Children. Anaesethia Critical Care & Pain, http://ceaccp.oxfordjournals.org/cgi/content/extract/mkm011v1.

17. Allnurses.com. Parkland Formula Help, http://allnurses.com/forums/f110/parkland-formula-help-298300.html.

Table 1: Degrees of Burns
Name Structure Signs/symptoms Healing time
Superficial
"First degree"
Epidermis has been injured Pink or light red appearance.
Considered to be minor
Dry and painful without blisters
Similar to sunburn.
5 - 10 days
Partial thickness
"Second degree"
Epidermal layer and various degrees of dermal involvement Bright red, mottled appearance
Moist surface
Extreme sensitivity to stimuli
Skin soft, pliable, edema possible.
1 - 2 weeks
Deep partial-thickness burns
"Deeper second degree"
Epidural and dermal layers involved.
Sweat glands and follicles intact
Dark red or yellow-white in appearance
Slightly moist surface
Very painful because sensory nerve endings are partially destroyed
Deep pressure sensation is intact
More than 3 weeks
Full thickness
"Third/Fourth degree"
Epidermis, dermis, subcutaneous tissues, muscle, and bone possible White waxy appearance.
Skin is hard, dry, leathery.
Edema from tissues leaking and the wound absorbing the fluids
Lack of sensation and pain because the nerve endings have been destroyed.
Delayed or lacking capillary refill time
Several weeks; grafting is required
Table 3: Burn Calculation Resources
www.remm.nlm.gov/burns.htm
www.emedicine.com/plastic/TOPIC159.HTM
Parkland Formula
http://allnurses.com/forums/f110/parkland-formula-help-298300.html
w ww.iredellems.com/protocols/employees/ICEMS%20Protocol%20Web/Appendix%20Pages/burn%20calculations.htm
Additional Chemical and burn resources
www.emedicinehealth.com/chemical_burns/article_em.htm
www.fema.gov/pdf/emergency/usr/unit4.pdf
Table 4: American Burn Center Criteria
Full-thickness (third-degree) burns over 5% BSA
Partial-thickness (second-degree) burns over 10% BSA
Any full-thickness or partial-thickness burn involving critical areas (e.g., face, hands, feet, genitals, perineum, skin over any major joint), as these have significant risk for functional and cosmetic problems
Circumferential burns of the thorax or extremities
Significant chemical injury, electrical burns, lightning injury, coexisting major trauma, or presence of significant preexisting medical conditions
Presence of inhalation injury

Paul Murphy, MA, MSHA, has administrative and clinical experience in healthcare organizations.

Chris Colwell, MD, is medical director for the Denver Paramedic Division and Denver Fire Department, as well as an attending physician in the Denver Health Medical Center emergency department.

Gilbert Pineda, MD, FACEP, is medical director for the Aurora (CO) Fire Department and Rural/Metro Ambulance of Aurora, as well as an attending physician in the EDs at the Medical Center of Aurora and Denver Health Medical Center.

Tamara Bryan, BS, EMT-P, has more than a decade of healthcare experience, including clinical and project management roles. She is currently pursuing her physician's assistant credentials.

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