One of the greatest challenges in healthcare is the management of burn-injured patients. There are important, unique aspects that must be considered when managing this population. This the first in a series of articles on burn management during the first 60–90 minutes following injury. This article will examine the basics of thermal burn injury and address the role of prehospital providers in initial management of these patients.
Burn injury involves the largest body organ, the skin. The skin makes up the largest part of the integumentary system (skin, hair and nails). There are 450,000 burn injuries each year in the United States.2 According to the American Hospital Association (AHA), there were 5,795 hospitals in the U.S. in 2011, with 944,277 staffed beds.4 With 123 self-identified burn centers reporting 1,895 beds collectively,3 this yields a ratio of approximately one burn center for every 47 hospitals and one “burn bed” for every 498 beds. Because burn injuries are relatively rare, there are very few locations where serious burn injuries are routinely managed. Regardless of prevalence, it is essential that patients with thermal injuries be managed in dedicated burn centers,5,6 not unlike the need for trauma victims to be cared for at dedicated trauma centers.7–9
Stages of Burn Care
The stages of burn care include what are described as the 6 Rs: rescue, resuscitation, recovery, rehabilitation, restoration and research. The first five deal with managing burn-injured patients, but the overarching theme is research and innovation. Research and innovation is required not only to better understand the phases of burn injury and help develop novel therapeutic interventions, but also to improve prevention programs and produce better methods of public and clinician education. Clearly, the best way to manage a burn is to prevent it altogether. Prevention programs must start early and focus on preschool and school-age children and seniors, who are the most vulnerable to burn injury. EMS and fire service involvement with prevention programs has been shown to reduce incidence of burn injury with at-risk populations.10–13
Rescue starts with a 9-1-1 call and involves the initial response of locating the burn-injured patient and taking steps to get them to a safe area. No rescue should be attempted that places the responder at risk unless they are equipped and trained and the effort is consistent with the mission and direction of their agency.
Resuscitation efforts start with initial patient contact once removed to a safe location and continue through the local hospital emergency department and potential transfer to a burn center. Successful resuscitation efforts require everyone involved to provide care consistent with the current science and body of knowledge for managing burn-injured patients. The teams involved may include EMS, the local ED, a regional ED and trauma center, critical care transport, and helicopter or fixed-wing transport. Everyone involved must be current with a skill set that is not always used on a frequent basis. Airway management, burn injury assessment, fluid resuscitation, wound care and pain control are all critical components of this care, but all have unique features related to the care of burn-injured patients.
Much of the initial care of burn patients is based upon military experiences. As with the Korean and Vietnam conflicts, medical lessons learned from the contemporary Iraq and Afghanistan conflicts have contributed greatly to improving how the acutely injured patient—and specifically the burn-injured patient—is managed.15,16