Introduction

2. Introduction • On April 28, Patrick Bageant attended an Advanced Burn Life Support (ABLS) class at the Harborview Burn Center in Seattle, Washington • He learned a lot in classroom discussion, practice patient assessment scenarios, clinical time, as well as after-class-discussions of the material • The purpose of this presentation is to share some of that knowledge with your ambulance, so that both your EMT’s and patients may benefit from the class

3. A ‘Road Map’ • This presentation covers the following material: • Initial assessment of the burn patient • Appropriate (and inappropriate) intervention guidelines for specific burn scenarios • Appropriate (and inappropriate) ALS interventions in burn scenarios • Appropriate (and inappropriate) fluid resuscitation guidelines for the burn patient • A recap of important points • Closing discussion of common but incorrect conceptions regarding burn care

4. Step 1: Initial Assessment • Assessment of the burn patient follows the standard EMS assessment pattern: • Airway: does the patient have a patent airway? • Breathing: is the patient breathing adequately? • Circulation: Is the patient’s circulatory and cardiac status stable? • Neurologicalstatus: AVPU/CMS • Note: burns do NOT alter mentation—if your patient is un-alert or disoriented, something else is going on! • Expose the patient, and treat for hypothermia • Notice that none of the initial assessment is burn-specific! It is the standard patient care formula

5. Secondary Survey • Head-to-toe: look carefully for injuries other than the actual burn • Burn injuries are not considered immediate life threats, but they do often accompany traumatic injuries that are life threats! • History: obtain burn specific history • How did the burn occur? • Did the patient’s clothing ignite? • Were accelerants involved? • Was patient found in smoke-filled room? • Did the patient leap from a window, fall, or roll a vehicle? • Are the purported circumstances of the injury consistent with the burn characteristics? Is abuse a possibility? • SAMPLE: Obtain the patient’s medical/surgical history

6. Secondary Survey (Cont’d.) • Detailed physical examination of the burn can now be conducted. Pay special attention to: • Mouth/nose/airway for burns or singed hair • Ears for fluid or burned hair • Hands, elbows, face and other ‘hard-to-heal’ places • Neural status (CMS/AVPU) • Uncontrolled external and internal bleeding • Establish adequate IVaccess (more on what ‘adequate’ means later) • The IV may be placed through the burn, but it must be sutured to secure it in place, so consider waiting until the hospital • Consider that the percentage burned correlates directly to ICU stay. A 50% burned patient will, on average, 50 days in the ICU. They will need an IV for all 50 days—do not blow an IV site! • Wait for the hospital if unless certain you will establish a patent IV

7. Assessment Recap:Burns are not immediately life threatening, but other problems, like MI, diabetic coma, internal bleeding ARE immediate life threats. Thus, only once you are confident you have found and addressed other conditions, including C-Spine, trauma and underlying emergent medical conditions may you assess the burn. Do NOT allow your assessment to be distracted by the burn!

8. Step 2: Determining Burn Severity • Burn severity is determined primarily by assessing the extent of the burn as percentage of total body surface area, and its depth • ‘Partial/full thickness’ and ‘1st/2nd/3rd degree’ are acceptable terminology • First and second degree burns are partial thickness burns • Third degree burns are full thickness burns

9. The Rule of Nines • The rule of nines recognizes the fact that the adult body is fairly evenly divided by nine: • 9% for whole head • 9% for left arm • 9% for right arm • 18% for anterior torso (chest/stomach) • 18% for posterior torso (back) • 18% for left leg • 18% for right leg • (If you are observant enough to notice this only adds up to 99%, you are smart enough to figure out where the other 1% is located!)

10. Burn Size: The Rule of Nines • Another (perhaps easier) way to think of this: • 9% for whole head • 9% for left arm • 9% for right arm • 9% for abdomen • 9% for anterior thorax (chest) • 9% for posterior thorax (upper back) • 9% for posterior abdomen (lower back) • 9% for anterior right leg • 9% for anterior left leg • 9% for posterior right leg • 9% for posterior left leg

12. Burn Size: The Rule of Nines • A third method takes recognizes the fact that the patient’s closed hand is equal to approximately 1% of their body surface area • Small burns, or the unburned area of patients with nearly 100% burns, may be measured in this way

13. Determining Burn Severity (Cont’d) • Once you know how large the total burned area is, you must assess how deep the burns are • This combined information, expressed as percentage and depth, is the burn severity

14. Determining Burn Severity: Depth • Human skin has two major layers followed by fat, fascia and muscle • Theepidermis layer of the skin consists of dry, mostly dead, mostly insensitive skin. It is the ‘top’ and outside layer. Burns to the epidermis are generally 1st degree, or partial thickness, and are not considered clinically significant. Sunburns fall into this category • Thedermis lies beneath the epidermis, is wet, has blood flow, and contains hair follicles and sweat glands. It also houses sensory nerves. Burns to the dermis are 2nd degree, or partial thickness and generally require medical attention • Thesubcutaneouslayer lies beneath the dermis. It consists of a thin layer of fat, fascia and then muscle. Subcutaneous burns are 3rd degree, or full thickness, and always require medical attention

16. Determining Burn Severity (Cont’d.) • Can one actually accurately assess burn depth by visualization? • Well, no. Burn severity is often very difficult to visually assess, but there are some general guidelines….

17. First Degree Burns • First degree burns (epidermal burns) are red, appear DRY, blanch when pressed upon, and blister mildly, if at all:

18. Second Degree Burns Second degree (dermal) burns tend to be red or yellowish, appear WET, usually blister, and may or may not blanch:

19. Third Degree Burns • Third degree (subcutaneous) burns appear very DRY, may be yellow, gray or black, do not blanch, and are ‘leathery’ to the touch. They generally are not heavily blistered:

20. Status Check: Where Are We in the Presentation? • We have assessed the patient • We have ruled out or addressed trauma and c-spine • We have ruled out underlying medical conditions like MI or hypoglycemia • We have fully exposed the patient, assessed the size and depth (which is to say severity) of the burn • What next?

21. Pre-hospital Burn Care • Pre-hospital burn care has three surprising features: • It is surprisingly simple • It is surprisingly non-emergent • It is surprisingly full of misconceptions

22. Initial Care of Thermal Burns • After exposing the patient and assessing the burn, cover the burned area with a dry, clean-ish sheet • Contrary to popular belief, burns are NOT overly prone to infection. The burning process has sterilized the area, and sealed it under dead, sterile skin • Covering with a dry sheet protects the patient from air currents, which can be very painful, and helps stave off hypothermia • Do not apply ice to large burns • Initiate fluid resuscitation (more on that later!)

23. Initial Care of Electrical Burns • Internal burning, bleeding and trauma are often associated with electrical burns. This is impossible to assess by visualizing the burn site. Therefore continuous monitoring of vital signs and patient complaints is important • Cardiac disrhythmias are a second characteristic of electrical burns. Continuous cardiac monitoring is indicated • Cervical trauma is associated with the patient who falls or is thrown back. • Careful assessment for internal and external traumatic injury, including the spine, is indicated

24. Chemical Burns • Whatchemical caused the burn? Determine the nature of the exposure immediately • Decontamination is required before treatment can begin. Preventing rescuer exposure is the first priority. Consider ordering Haz-mat resources through dispatch • All clothing should be cut away, contaminated or otherwise • Flush all chemical burns with copious, copious amounts of water. There is no such thing as too much water, but there is such thing as not enough

25. Airway Burns • Burns to the airway are serious, life-threatening injuries: • As edema develops the airway may close making both intubation and surgical airways impossible. Patients HAVE died in exactly this way • Serious blood gas pollution by inhaled products of combustion like carbon monoxide is a common complication. There is NO reliable way to evaluate blood gasses in the field. • Almost all burns to the airway require immediate, aggressive management. Trans-oral intubation is indicated in apnic or chemically sedated patients. Trans-nasal intubation is indicated in non-sedated patients with respirations. • 100% oxygen is indicated in all patients with airway burns, REGARDLESS OF PULSE OXIMITRY

27. Carbon Monoxide Poisoning • Asphyxiation and/or carbon monoxide poisoning causes most fire scene fatalities • Inhaled carbon monoxide bonds to hemoglobin in the blood, taking the place of oxygen with approximately 200 times greater affinity. • The pulse oximiter, which measures bonded hemoglobin, will deliver a normal reading, even when the patient is hypoxic, or dead • Cherry-red lips, skin and nail beds occur in only 50% of patients with severe carbon monoxide poisoning and are not a clinically reliable indicator • If sufficient carbon monoxide is inhaled, tissue perfusion WILL cease, and the patient WILL die • CO2 removal is not affected, so ET capnography does remain an accurate indicator of ET placement • The only accurate assessment is blood level carboxyhemoglobin, which must be assessed at the hospital.

28. Pediatric Burn Injuries • Pediatric anatomy differs from adults: larger heads, smaller legs, and more surface area per pound of body weight . Burns may be measured by: • Measuring how many of the child’s hands, which are 1% of total body surface area cover your palm • Measuring the burn area with your palm, and then multiplying it by the number of child-hands to your hands. • For example, a child’s hand covers ¼ of yours. The burn is 4 times the size of your hand. So the total burn is 16% of the patient's body. • Abuse is a common cause of scald burns to children. Obtain a careful history, and document inconsistencies. (Hint: kids do not hold themselves under scalding bathwater—they try like hell to get out!) • Remember: a quiet, submissive child is often an abused child

29. Shock and Fluid Resuscitation • Proper fluid management is critical to the survival of patients with extensive burns. • Proper fluid management aims to maintain tissue perfusion while preventing complications of excessive fluid therapy • It is not only possible, but EASY to give excessive fluid to burn patients. This has been very clearly linked to increased mortality and morbidity

30. Advanced Life SupportBurnCare • There are ALS options in burn care, but they are surprisinglylimited • Cardiac problems secondary to electrical burns can be treatable by ALS intervention • Intubation with sedation is the preferred airway-burn management option in EMS systems with RSI protocols • Pain management is indicated for most burns • Morphine is the drug of choice for pain because everyone is familiar with its common effects and antagonists. This simplifies the safe transfer of patient care to the ED and burn center. • Morphine should only be administered IV. This is because subcutaneous and IM morphine becomes trapped in tissues by edema and can induce respiratory arrest if the edema rapidly resolves. Patient have died in precisely this manner • Lorazepam or benzodiazepines like Ativan may be indicated to calm patients in anxiety-induced hyperventilation. Anxiety is common in burn situations • Diuretics are contraindicated in pre-hospital burn care • In general, burn-specific care (aside from pain management) is a BLS (or even lower level) affair

31. Shock and Fluid Resuscitation • Thermal burns cause (among other things) a significant increase in peripheral vascular resistance and a decrease in cardiac output • Basically, it becomes harder for blood to travel through the body’s distal tissues and at the same time, the heart becomes less efficient • This is NOT attributed to hypovolemia. It is caused by neurogenic and humoral (endocrine and immune system) effects • Clinicians should expect a decrease in blood pressure for the first 24 hours of the burn. This is response is normal • Fluid bolus is NOT indicated except in cases of suspected trauma with a systolic pressure of less than 90

32. Shock and Fluid Resuscitation • Excessive resuscitation produces: • Excessive edema formation in burned tissues, which decreases blood flow to burned area, decreases the likelihood of successful skin graft, and hinders healing • Excessive edema formation in airway, which can close it • Inadequate resuscitation produces: • Shock and organ (primarily renal) failure

33. Shock and Fluid Resuscitation • How much fluid is too much, and how much is just right, and what kind should be given, anyway? • The fluid of choice is LR, because chloride accumulation from high volumes of normal saline causes metabolic acidosis. (1-3 liters of NS are fine, and thus not a factor in short transport pre-hospital settings) • Clinical assessment of fluid adequacy can only happen ‘after the fact.’ That is why fluids are given according to a strict formula, and then adjusted according to urinary output • The formula is: • 4 x (pt body weight in kg) x (% of body burned) = cc in first 24 hours • Half of this fluid is administered evenly over the first 8 hours. • Half is administered evenly over the last 16 hours

34. Shock and Fluid Resuscitation • Example: • 80 kg (approx. 175 lb) adult burned over 50% of body • 4 x 80 x 50 = 16000 cc of LR • This means 1 bag per hour, for the first 8 hours, and 1/2 bag per hour for the next 16 • STOP AND THINK ABOUT THIS • This is a badly burned, average size patient! • But what size IV is adequate to deliver fluid at the needed rate? • Is it possible to give to much fluid during our 10 minute transport if the IV is run ‘wide open?’ • It is very, very easy to over resuscitate the patient. Over resuscitation does cause real harm. • It is difficult to over emphasize how easy it is to over resuscitate, and harm, patients. Part of the purpose of the ABLS class is to educate pre hospital providers in exactly this area

35. Recap • Burns are scary forrescuers • But very few burns are immediately life threatening • Burn patient assessment should pay attention to medical, traumatic and social conditions • Few alert and oriented people stay in a hot place long enough to be burned. It just is not rational. • But diabetic patients may stay in burning buildings • Badly injured patients may stay in burning cars • Abused children may stay in burning liquids • Aggressive airway management including aggressive nasal- or oral-tracheal intubation is indicated in patients with airway burns • Rule out other, more time-sensitive medical problems before you focus on the burn

36. Recap • Burns are described in terms of total body area (%) and depth (degree or thickness) • Dry, clean, but not necessarily sterile sheets and transport are appropriate treatment for all burns • No wetdressings should be applied. • No ice should be applied • Cleaning should be avoided (except for chemical burns)

37. Recap • Fluid resuscitation should be initiated as soon as possible, but only according to the strict formula: • 4 x (body weight in kg) x (% of body burned) = cc of fluid in first 24 hours • Half the fluid is administered evenly in the first 8 hours, half over the next 16 • Over-resuscitation is very, very easy. But it causes genuine harm and cannot be undone (diuretics are contraindicated)

38. Commonly Held Misconceptions Regarding Burns • “Burns are very easily infected and must be wrapped in sterile dressings” • False. Burns are inherently sterile—the heat process sterilizes and then seals the affected area under burned sterile skin. As long as rescuers do not remove this ‘protective crust’ the burn is clean • “Burn patients require tons of fluid” • False. Burn patients require just the right amount of fluid. Too much fluid will harm them just as much as too little. Thus it is poor form to run IV’s ‘wide open’ and often tacky to start multiple large bore IV’s • “Burns should be cooled with ice or open air to ‘take the heat out’” • False. Except in chemical burns, burning stops when the heat source goes away. (Duh). They do not need to be cooled. In fact, because burn patients cannot control their body temperature, cooling burns can induce dangerous hypothermia • “Wet dressings may prevent the dressing from sticking to the wound” • False. Wet dressings encourage sticking, and increase hypothermia. Think about the difference between standing in the wind in a dry t-shirt, versus a wet t-shirt. Now imagine your thermoregulation is compromised. Only dry dressings make sense • “When in doubt, go with your gut” • False. When in doubt, consult someone who actually knows the answer. You may call Gritman ER, or the Harborview Burn Center 24 hours a day with medical questions. There is very little excuse for uninformed pre-hospital patient care • False = Dangerous for the patient. Inappropriate intervention harms!

39. A Note On Sources • The purpose of this presentation is education and its subsequent enlightening effect, not profit • All material for this presentation was shamelessly stolen from the internet and from the ALBS class materials. • The architect and messenger of this presentation neither deserves nor claims any credit for the ideas and images presented