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1. Pre-Hospital Burn Management Part 2: Burn Care Robert S. Cole
2. Are You Ready???
4. Objectives Obtain a basic understanding of infection mediation, Airway management and destination priorities in the burn pt.
Gain a basic understanding of escharotomy, Fluid resuscitation, Pain Management and other aspects of advanced burn care
5. Basic Burn Care
6. Basic Burn Care: Save yourself before you save others Don’t be a blue canary
There are many many potential hazards besides the fire,
Toxic gasses (Especially in industrial sites and Meth Labs)
7. Basic Burn Care: Save yourself before you save others BEWARE OF CONFINED SPACES
60% of fatalities in rescue situations are would be rescuers!
Don’t be a statistic
8. Basic Burn Care: Stop The Burning Process Remove the pt (And You) from the proximity of the Burn and other hazards
If Trauma is associated, Follow BTLS rapid extrication Guidelines
If Chemical, let the experts handle it. Attempt dry decon if possible before flushing.
If Electrical, Let the experts remove him
9. Basic Burn Care:The First 10 minutes BSI: Infection Mediation from the Start!
C-Spine: Secure if indicated.
LOC: Obtunded or lethargic- Think CO, Toxic Gasses, Drugs, or Head Trauma
A: Stridor? Intubate! Sooty airways, Be prepared, Give O2
B: Severe refractory distress, Intubate. Hacking cough, Hoarse Voice, Soot flecked sputum, Strongly consider intubation, Give O2
10. Basic Burn Care: The First 10 minutes C: Pulse should be elevated, pt should be normotensive or Hypertensive. If pulse is weak thready or absent at radius, look for other cause of shock. Also look for circumferential burns w/ swelling
Dysfunction: Mini Neuro
E: Expose and examine, Look for other Injuries, Leave “Stuck clothing” in place, remove Jewelry, Clothing may be considered evidence.
11. Basic Burn Care: The First 10 minutes F: Fluid Therapy- Get your line started, If burns are moderate or major, do in transit.
If you are not already enroute, Ask yourself why?
“Stay and Play” or “Load and Go”?
Sometimes “Tincture of transport” is the best medicine, especially if you can get Tx done enroute.
12. Basic Burn Care: The second 10 minutes and beyond Delegate early notification to the hospital
Reassess the Complete primary survey, do a head to toe evaluation and assessment.
Estimate BSA, severity.
If Intubated, Recheck Tube, consider NG, ETCO2, Etc. Include other ALS assessments.
Pain Relief : Opiates, Benzo’s MANDATORY for moderate/major burns.
Less than 10% BSA, may flush with sterile saline/H2O
13. Basic Burn Care: The second 10 minutes and beyond Prevent Hypothermia.
Other Specific injury/burn location related care.
Reassess Frequently, assume nothing
Fluid Resuscitation: Begin calculations (covered later)
Give full report to receiving hospital
Consider NG, Foley, etc as soon as feasible
14. Basic Burn Care: Dressing the area A Major cause of death after the first 48 hours is Infection. In everything you do, consider burns to be large open highways for infection to travel.
Use aseptic/sterile tech.
15. Basic Burn Care: Dressing the area < 10 % BSA , cool saline/Sterile H20 is OK , on moist dressings, followed by dry outer layers (Moisture is a route of infection)
> 10 % BSA, Dry Dressings,
consider silvadine ointment or topical anesthetic for mild burns.
Remember, don’t promote infection.
16. Basic Burn Care: Dressing the area Facial Burns: (protect the airway), raise head 30 Degrees to minimize swelling.
Burns to eyes: consider continuous saline flush, consider Tetricaine ointment after consult, do not use steroid containing solutions.
Hands: remove all jewelry, cut free if required, no exceptions. Dry dressings if required, elevate above heart, active ROM q hour for 5 minutes if possible. If wrapped, wrap in position of function.
17. Basic Burn Care: Dressing the area Feet: Same as Hands, keep elevated.
Genital: Prompt insertion of a Foley is essential.
Tar Burns: Focused at cooling down the Tar ASAP, it is otherwise non toxic.
18. Basic Burn Care : Psychological Considerations Fear of disfigurement, amputation, death are common.
Be hopeful but honest
Most burn patients will be alert, keep them informed. This will lessen anxiety, O2 demand, and cardiac stress
If no apparent clear mechanism of burn is known, consider the possibility of a suicide attempt and safeguard appropriately.
Consider sedation if severely anxious or anxiety is having an adverse effect on patient status
19. Advanced Burn Care
20. Advanced Burn Care For the purposes of this lecture Advanced Burn care is considered measures or procedures normally in the scope of practice of Medics, EMT-Is, or advanced practice nurses.
Follow local guidelines, some of the procedures may be out of your scope of practice or may require medical control authorization
All Practitioners should have passing familiarity with these procedures.
21. Airway Management Pre-Hospital Personnel should have a “Low Intubation Threshold” when presented with possible inhalation/airway issues.
Nasal ETT or RSI and Oral ETT is indicated. Adequate sedation AND analgesia is indicated in addition to any paralytics needed.
22. Airway Management Consider Etomidate and/or Succs for initial induction, with valium/Versed and MS as adjuncts.
Etomidate: 0.3 mg/kg IVP (common dose 20-30 mg)
Succinylcholine: 1 mg/kg, contraindicated after first 36 hours
23. Airway Management Tubes may be “Coughed” out of place, secure well, consider a long acting paralytic like vecuronium (0.1 mg/kg every 20-45 minutes) during transport.
Alternative airways and skills are a must!
Blind airways are not likely to be much use in inhalation injuries.
24. Respiratory Support High flow humidified O2
If intubated, a Transport grade ventilator is better than bagging (Only applies to transport grade)
ETCO2 w/ wave form is a valuable tool for assessing sedation, gas exchange, use of PEEP, effectiveness of ventilation, etc.
25. Emergent Escharotomy Are you ready for this?
Often “Taboo” but potentially Lifesaving.
26. Emergent Escharotomy Circumferential burns to the chest and neck of full thickness or deep partial thickness results in swelling.
This in turn results in respiratory compromise.
While rare, rapid eval and TX can be lifesaving.
Rare in the first 3-6 hours.
27. Emergent Escharotomy While Escharotomies are also done to extremities, these are not commonly done in the field.
While this procedure is uncommon, there are paramedic level (non critical care) services who do this in the field. Ex: King County Medic 1.
This should be mandatory training for rural services, Tactical and back country teams.
Sterility/aseptic tech. Should be maintained.
28. Emergent Escharotomy Examples of potential locations for incisions:
Before You get to this, r/o airway obstruction and D.O.P.E.
Most of these patients should be Intubated already, If not , you may have your priorities out of whack.
29. Vascular Access Ideally IV access should be 2 large bore IV’s (16 or larger)
Idealy through non burned tissue
This is not always an option
Central lines, if appropriately trained , are an alternative if unable to get peripheral access.
IO’s in the burned child are also an alternative
Sternal IO’s in the adult may have value as well.
30. Sternal IO’s
31. Fluid Resuscitation Fluid resuscitation is vital to improved outcomes
Increased Vascular permeability (3rd spacing) results in 10-15% reduction of Cardiac Output for first 12 hours post burns (this is in proportion to severity of burn)
This combined with cellular destruction means fluid administration is vital to prevent organ death.
32. Fluid Resuscitation “The goal of (Fluid) resuscitation is to maintain vital organ function while avoiding the complications of inadequate or excessive (Fluid) therapy.”- ABLS Text P. 21
To do this accurate assessment of BSA is essential
Also significantly large bore IV’s (14 or 16)
33. Fluid Resuscitation 2 types of fluids –Crystalloids and Colloids
Crystalloids ( Saline and Ringer’s Lactate)
Colloids (Albumin, Plasmanate, Dextran) Colloid pulling pressure makes little difference in first 24 hours, therefore crystalloids are initial fluid of choice.
Outside the military, Crystalloids are all that is available to most pre-hospital agencies.
34. Fluid Resuscitation Formulas for administration
Many out there, the ABA “Consensus” is:
Adults: 2-4 ml x Kg x %BSA = a
Children 3-4 ml x Kg x %BSA =a
½ of “a” is given over first 8 hours, remainder given over following 16 hours.
Use a Volutrol in children.
35. Fluid Resuscitation If done promptly, this formula will allow only a minimal drop in circulating volume in the first 24 hours post burn and will allow return of normal circulating volume by the time the patient enters his second 24 hours. At this time a burn center should be consulted.
If s/s of Cardiogenic shock develop-r/o MI
If pt is Hypotensive, look for other causes.
After the first day, colloids are used to keep vascular volume intact w/o fluid overload.
36. Fluid Resuscitation The most reliable indicator of adequate fluid resuscitation remains urine output:
Adult 30-50 ml/hour
Children 1 ml/kg an hour
(increase or decrease rate by 1/3 if urine output is exceeds or does not meet above standards for 3 consecutive hours)
37. Fluid Resuscitation Other v/s are not as reliable in gauging fluid therapy.
B/P will maintain normal until the “Pre-Code” downward cycle (CTD)
HR should be expected to be elevated 100-120 (as high as 140 in peds) for other reasons. Therefore it is not a good indicator.
38. Drugs in brief Aggressive well thought out use of multiple pharmacological therapies is mandatory
Sedatives such as Valium, Ativan, or versed.
Opioids such as Morphine , Fentanyl
Steroids: Not recommended for respiratory nor optic injuries.
Tetanus and Antibiotics.
IV route is preferred for appropriate drugs.