Describe the pain response to burns and their pharmacological interventions
Explain the EMS supplies needed for burn calls in the field
Identify the differences between minor, serious, and critical burns
This three-part review of thermal burn injury began in April with an overview of surface area and burn injury classification and continued in May with a focus on general assessment, ABCDEs, and wound care. This final part covers pain management and complex and critical burn injuries.
Pain and Other Medications
The most common pain medication used for burn injury continues to be morphine sulfate (MS).1 The drug is given in 2-mg increments every five minutes until the desired pharmacological outcome or side effects are noted. Side effects may include hypotension, nausea and vomiting, and hypoventilation.
Due to drug shortages or patient intolerance to MS, other medications that can be used to manage pain include fentanyl (Sublimaze) 50–75 μg IV, then 25 μg until either a maximum dose of 200 μg or clinical improvement is noted. While MS and fentanyl are commonly used, always follow your local protocol.
Aside from opioids, another medication shown to be a useful anesthestic with burn injury is ketamine. Ketamine is an N-methyl-d-aspartate (NMDA) antagonist. It may also be selected when strong analgesic and sedative effects are warranted and there is a desire to minimize the adverse effects of opiates.1–4
Ketamine has become more common in EMS, with a third of paramedics currently using it under the protocol.1,2 Ketamine’s most common indication is followed by sedation for intubation or agitation. Ketamine use will preserve hemodynamic stability, and it’s been shown to demonstrate better analgesia compared to MS and reduce secondary hyperalgesia and windup pain.4 Ketamine can be intravenously dosed at 0.5–2 mg/kg/hr or 0.1–0.35 mg/kg IV one time to treat moderate to severe pain. Alternatively, it can be administered intranasally at 10 mg every 90 seconds as needed up to a total dose of 50 mg.5
The endpoint for the use of these medications can be different for burn-injured patients. While MS typically has an endpoint of 10 mg, it is not unusual for critically burn-injured patients to receive 30–40 mg total in the first 24 hours following the injury. This is an important consideration when transferring patients over long distances from community hospitals to regional burn centers. Plan ahead, as you may need additional medication.
One side effect of using large doses of pain-management medication is gastrointestinal discomfort and vomiting. An antiemetic can resolve this complication. Have phenothiazine antiemetics readily available, given the amount of pain medication that may be used. Antiemetics include ondansetron (Zofran), prochlorperazine (Compazine), and promethazine (Phenergan).
Also have naloxone available, given the tenuous balance of managing pain while not substantially suppressing critical life functions. In this situation naloxone can be administered either IV or intranasally.
The most effective means of administering pain medication is through the existing IV. If an IV cannot be secured, then IO access is sufficient, provided it is consistent with your local protocol and scope of practice. Intramuscular (IM) injections are generally contraindicated for burn-injured patients. For burn injuries classified as serious or critical, the quality and quantity of absorption for an intramuscular injection is unpredictable, and multiple IM-administered doses can be dangerous. While there are other methods of administering pain medication, for burn-injured patients the preferred routes are IV and IO. Any other means of administration should be based on your protocols with the guidance of your physician medical director.
If the initial evaluation determines a burn injury is superficial only and does not include either partial- or full-thickness burns, the patient is best managed with rest, limitation or elimination of continued exposure to the heat source, and provision of oral hydration. While typically outside the bounds of EMS operations, personal care may include over-the-counter (OTC) treatments such as ibuprofen or a topical anesthetic. Nevertheless, evaluate the use of OTC remedies on a case-by-case basis based on underlying history and indications/contraindications. Superficial burn injuries do not typically include a 9-1-1/EMS activation or management in the hospital.
Partial- or full-thickness burns that are circumferential to an extremity or involve significant portions of the chest or abdominal area are critical injuries. With partial- and full-thickness burns, the skin loses its elasticity and contracts. If the burn is circumferential to an extremity or covers a significant portion of the chest or abdomen, the contraction will lead to decreased circulation distal to the injury site.
Signs and symptoms include a taut or leathery appearance to the impacted tissue, cyanosis or pallor in the area distal to the wound, numbness or a tingling sensation, and diminished or loss of pulses. These signs and symptoms point to a condition known as compartment syndrome. This is life- and/or limb-threatening, depending on where the injury is located. For circumferential chest wall burns, as the burn injury begins to manifest, the skin will shrink and impede the inspiration and expiration. This increased workload on the cardiovascular system can be life-threatening.
Compartment syndrome can only be relieved by escharotomy/fasciotomy. Technically, an escharotomy is a cut through the dead tissue, and a fasciotomy is a cut into the subcutaneous fatty tissue. However, the terms are routinely interchanged when discussing the surgically urgent management of a circumferential burn and basically describe the same procedure.
This procedure is typically performed by a trained surgeon. The critical factor is recognizing the problem during the assessment and rapid evacuation to a destination where definitive care can be provided. The closest hospital may not always be the most appropriate; destination plans and protocols should reflect hospitals where appropriate specialty services are available.
What to Purchase/Stock?
The first recommended addition to the ambulance stock for burn care is lactated Ringer’s (LR) solution, provided it’s on the approved formulary. LR is inexpensive and similar in composition to the fluid lost during the burn injury.
Silver-impregnated dressings may be cost-prohibitive to stock on each ambulance, and if the time between injury and arrival at a burn center is less than 12 hours, their benefit may be minimal, since they will be promptly removed during the initial debridement process. However, maintaining a supply of silver-impregnated dressings in an MCI cache may be a cost-effective strategy. These dressings are particularly useful when many patients have burn injuries, which could potentially extend times to definitive treatment, or when the distance to a burn center is significant.
Minor, Serious, and Critical Injuries
Relying on the American Burn Association’s burn center referral criteria (Figure 1), minor burns generally are not referred to burn centers. These are superficial burns and normally do not involve EMS. Minor burns also include small partial-thickness burns (less than 5% total body surface area, or TBSA) that do not impact key areas of the body (ears, face, hands, feet, genitalia, perineum, or major joints).
These injuries are best managed with over-the-counter analgesic medications. Additional care includes OTC topical analgesics, fluids by mouth, rest, and limiting sun exposure during recovery. For EMS agencies that routinely deal with these patients at mass gatherings, a simple care guide for patients once they leave your aid station can be useful.
Serious burns include partial- or full-thickness burns between 5%–15% TBSA. These can include inhalation injuries, which can be serious even though there may be no obvious sign of a thermal burn injury. Small (less than 5% TBSA) full-thickness burns also fall within the definition of serious burns. Serious burns should be evaluated by a physician at a hospital and may be referred to a burn center for further treatment. Full-thickness burns typically require skin grafts regardless of size.
A critical burn is classified as a partial- or full-thickness burn that involves a key area of the body or more than 15% TBSA. These can include steam inhalation injuries, electrical shocks with contact points or lightning injuries, significant chemical burns, and radiation sources. Although it may seem an overstatement to call burns of less than 30% “critical,” the mortality rate for burns covering 0.1%–29.9% TBSA is more than 12%.
Note also that the critical burn classification in the U.S. and most developed countries is different than for patients in the developing world, where there is little to no advanced burn care. As an example, in one study focused on Malawi, the lethal TBSA at which 50% of patients died (the LA50, a common measurement in burn care) was 39%.7 Comparatively speaking, in the U.S., the LA50 falls in the 70%–79% TBSA range.8
Patients who meet the criteria for a serious or critical burn should be referred to a verified burn center. Depending on your location, that may include bypassing the local hospital.
Care of the burn-injured patient can be challenging for health professionals. This is due to the complexity of the physiology as well as the infrequency of exposure for most clinicians to the burn injury process. This article incorporates the latest available science as the foundation for a best-practice approach to managing patients with burn injury. Nonetheless, the final word for the care of all patients remains with local protocols and medical control.
FIGURE 1: Burn Center Referral Criteria
Seriously and critically injured burn patients are best managed in burn centers. Patients most likely to benefit from admission to a burn center include those with:
Partial-thickness burns greater than 10% TBSA;
Burns involving the ears, face, hands, feet, genitalia, perineum, or major joints;
Electrical burns, including lightning injury;
Preexisting medical conditions that could complicate management, prolong recovery, or affect mortality, such as end-stage renal disease;
Burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality. Evaluate trauma patients first to determine the extent of the traumatic injury, and if in doubt, go to the trauma center first;
Pediatric patients with burn injuries: Not all burn centers accept pediatric patients. Check with your regional burn center to determine any age limitations and develop a plan that addresses your needs;
Patients who require special social, emotional, or rehabilitative intervention.
Call now, create that relationship, and understand their capabilities and limitations.
—Source: American Burn Association6
1. Griggs C, Goverman J, Bittner EA, Levi B. Sedation and Pain Management in Burn Patients. Clin Plast Surg, 2017 Jul; 44(3): 535–40.
2. Buckland DM, Crowe RP, Cash RE, et al. Ketamine in the Prehospital Environment: A National Survey of Paramedics in the United States. Prehosp Disaster Med, 2018 Feb; 33(1): 23–8.
3. Zorumski CF, Izumi Y, Mennerick S. Ketamine: NMDA Receptors and Beyond. J Neurosci, 2016; 36(44): 11,158–64.
4. Edrich T, Friedrich AD, Eltzschig HK, Felbinger TW. Ketamine for long-term sedation and analgesia of a burn patient. Anesth Analg, 2004; 99(3): 893–5, table of contents.
5. Epocrates Essentials for Apple iOS [computer program], Version 19.10; http://www.epocrates.com/mobile/iphone/essentials.
6. American Burn Association. Resources for Optimal Care of the Injured Patient, http://ameriburn.org/wp-content/uploads/2017/05/burncenterreferralcriteria.pdf.
7. Tyson AF, Boschini LP, Kiser MM, et al. Survival after burn in a sub-Saharan burn unit: challenges and opportunities. Burns, 2013; 39(8): 1,619–25.
8. American Burn Association. National Burn Repository 2005–2015. In. Vol 2016: American Burn Association; 2016.
Randy D. Kearns, DHA, MSA, FACHE, FRSPH, CEM, is an assistant professor in the College of Business Administration at the University of New Orleans and a retired clinical assistant professor from the School of Medicine at the University of North Carolina.
Christopher K. Craig, DMSc, MMS, PA-C, is assistant professor of surgery and senior physician assistant of trauma/burn services and disaster and prehospital services at Wake Forest University.
Michael W. Hubble, PhD, MBA, NRP, is an instructor in the Emergency Medical Science Department at Wake Technical Community College.
Amanda P. Bettencourt, PhD, APRN, CCRN-K, ACCNS-P, is a research fellow and TACTICAL Scholar at the University of Michigan School of Nursing.
James C. Jeng, MD, FACS, is a physician at Crozer-Keystone Health System and Nathan Speare Regional Burn Treatment Center, professor of surgery at Icahn School of Medicine, Mount Sinai Healthcare System, and chair of the Disaster Subcommittee of the Organization and Delivery of Burn Care Committee for the American Burn Association.
Jeffrey E. Carter, MD, FACS, is associate professor of surgery at the Louisiana State University Health Science Center New Orleans and medical director of the University Medical Center Burn Center, New Orleans.