Burn Care in EMS

"If all that changes slowly is explained by life-
All that changes quickly is explained by fire!"

-G. Bachelard (1884-1962)1

When you ask EMS providers and ED nurses what patients they most fear, the response typically involves burn victims. This article provides an overview of initial burn assessment and treatment priorities in the field.

Airway Management

In the realm of EMS, from basic First Responder or EMT classes, we are taught about the "ABCs" (airway, breathing and circulation). When confronted with a burn patient, the priorities are no different. Why is "A" such a big issue? If you don't have "A," don't worry about assessing "B and C" because the patient probably won't be alive very long!

When assessing a burn patient, we need to be especially mindful of how the burn occurred, i.e., the mechanism of injury. In many cases, such as explosions or "enclosed space" fires, if the patient is burned on the outside (especially if there are burns to the face), it is likely he may be burned on the inside (upper airway) as well (see Figure 1). More important, if the patient is swollen on the "outside," he may also be swollen on the "inside."

Think of how a victim of a house fire must be breathing. Anxiety, fear and hypoxia all lead to rapid breathing of inhaled smoke, with carbon monoxide and various other toxic gases that accompany the superheated temperatures. Airway tissue edema from the heat injury or from chemical burns can quickly lead to a life-threatening airway emergency. This is a crucial consideration, especially in children, who have proportionately smaller airways, as a little edema goes a long way.2

Not all burn patients present with airway emergencies that require intubation, especially in the prehospital environment. An alert and oriented patient with no respiratory distress and no visible airway injury is highly unlikely to need urgent intubation. But when there are concerns about airway edema, patients, especially children, should be intubated quickly, before the airway becomes compromised.3

"How long does it take an airway to swell, and how much will it swell?" The answer to these two questions is essentially, "We don't know." It might help to think about what happens when a finger is slammed in a car door. The finger swells immediately, but more important, it continues to swell for hours after the initial injury. The same idea applies to a burned airway. Burn center clinical educators teach the following: "We can always take the tube out… We can't always put the tube in!"4 If the opportunity for endotracheal intubation is missed, invasive airways, such as needle (children or adults) or surgical cricothyroidotomy (adults), can be done. But these techniques are challenging in most adult patients, and are significantly more difficult to perform in children.2

The decision to intubate a burned patient at the scene is dependent upon EMS protocols and assessment of the victim. If the patient is in arrest or unconscious without a gag reflex, EMS providers should immediately provide bag-valve-mask ventilation and strongly consider intubation within established protocols. If the patient is unconscious (but still has a gag reflex), or remains conscious with severe facial burns, intubation in the EMS environment using rapid sequence intubation (RSI) techniques should be considered. If RSI is not an option, then 100% oxygen via face mask should be administered until the airway is definitively secured in the ED.2,3