Burns - Emergency Treatment

Assess airway/breathing 
Circulation 
Remove any sources of heat 
Estimate percentage of total body surface area burned (%TBSA) 
Ongoing losses 
Assess urine output 
Insert nasogastric tube 
Decompression incisions (Escharotomy) 
Medications 
Wound care during transport
General items 
Special considerations with chemical burns 
Special considerations with electrical injuries 
Local Care 
Wound Cleansing –Hydrotherapy and Versajet 
Transportation of the burned patient 
Special Considerations

Assess airway/breathing 

• Careful airway assessment of both flame and scald burns to face and neck. Intubation is generally only necessary for unconscious patients, hypoxic patients with severe smoke inhalation, or patients with flame or flash burns involving face and neck. Keep in mind that the emergency room evaluation may show normal X-ray of the chest and blood gasses. Swelling of the upper airways develops often within hours during resuscitation. Intubation is necessary before the swelling sets in. Indications include: pharyngeal burns,air hunger, stridor, carbonaceous sputum with hoarseness and any of the above. 
• All major burns must receive high flow oxygen for 24 hours 
• Carbon monoxide may present as restlessness, headache,nausea, poor co-ordination, memory impairment, disorientation, or coma.Administer 100% O2 via non-rebreathing face mask. 
  • Useful lab: Blood gases with carboxyhaemoglobin level. 
• If breathing seems to be compromised by tight circumferential trunk burns an escharotomy must be performed urgently. 

Circulation 

• Stop any external bleeding. 
• Identify potential sources of internal bleeding. 
• Establish large bore IV lines. Often the extremities are burnt and then a CVP line needs to be placed. Resuscitation bolus fluid is not a good idea. Gentle increase of fluid gives a much better result and over-hydration of burn patients seems to do more harm than good. Aim the urine out-put at 0.5ml/kg/hr. Perfusion of potentially viable burn wounds is critical.  

Remove any sources of heat 

• Remove any clothing that may be burned, covered with chemicals or are constricting. 
• Cool any burns less than 3 hours old with cold tap water for at least 30 min and then dry the patient. 
• Cover patient with clean dry sheet or blanket to prevent hypothermia. 
• Use of Burnshield® is a very effective means for cooling and dressing for the first 24 hrs. 
• Rings and constricting garments must be removed. 4 

Estimate percentage of total body surface area burned (%TBSA) 

• Initially, use Rule of Nines; for all paediatric patients and for a more accurate assessment, use attached Berkow diagram or patients outstretched open hand representing 1% 

Reminder: Accurate estimation of burn size is critical to ongoing fluid replacement and management 

Ongoing losses (once the patient has been stabilised).Resuscitation must be commenced within two hours of injury 

• Burns <10% can be resuscitated orally, unless the patient has an electrical injury or associated trauma. This needs ongoing evaluation and still may require an IV line. 
• For 10 to 40% burns, secure a large bore IV line or CVP line; add a second if the transport will be longer than 45 minutes. 
• Burns >40% require two large bore IV lines. 
• If the transfer will be less than 30 min. from the time of call, don’t delay transfer for an IV line 

Reminder: IVs may be placed through a burnt area if necessary(suture to secure). 

Avoid saphenous vein if at all possible; avoid cut-downs through unburned skin if possible. 

Intra-osseous is an excellent alternative in the hypovolaemic child. 

• Initiate fluids for ongoing resuscitation and fluid losses:  

Parkland formula: 

3-4ml Ringers lactate x kg body weight x % burn = mls in first 24 hours, 

with half of this total given in the first 8 hours post injury. Children must have their daily maintenance fluids added to the volume of fluids calculated by the Parkland formula (including dextrose). Glucose must be added to Ringer’s lactate in children weighing less than 20kg. 

Example: Patient weighing 70kg with a 50% burn: (4 x 70 x 50) = 14,000ml needed in first 24 hours. 7000mls are needed in the first 8 hours (calculated from the time of burn injury) so IVs are initially started at 900mls/hour. This is only a guideline.Prevent over-hydration by keeping the urine out-put not higher than0.5ml/kg/hr. Decrease the fluid accordingly. 

Reminders: 

Do not give dextrose solutions (except for maintenance fluids in children) – they may cause an osmotic diuresis and confuse adequacy of resuscitation assessment. 

Ideally use Ringers Lactate or Plasmalyte B for ongoing fluid losses and a 5% dextrose balanced salt solution for the child’s maintenance 

This is only a guide and ongoing evaluation is essential. 

Assess urine output (this is the best guide to resuscitation) 

• Insert Foley catheter in patients with burns >15%TBSA. 

adequate urine output is 0.5ml /kg/hr in adults and 1 ml/kg/hr in children. 

Reminder: 

Lasix and other diuretics are never given to improve urine output; fluid rates are adjusted to increase urine output. 

• Observe urine for burgundy colour (seen with massive injuries or electrical burns). There is a high incidence of renal failure associated with these injuries, requiring prompt and aggressive intervention. 

Reminder: 

If the urine is red or brown CONSULT BURN CENTRE. 

Insert nasogastric tube 

• Insert nasogastric tube in any patient who is unresponsive, shocked or with burns >20% if preparing for air or long distance transport.  

Decompression incisions (Escharotomy) 

 Assess for circumferential full-thickness burns of extremities or trunk. Elevate burned extremities on pillows above level of the heart. If transfer will be delayed, discuss with a burn surgeon indications and methods for decompression incisions (escharotomies). If an escharotomy is required, do not delay the procedure. 

Medications 

• Give tetanus immunisation. 
• After fluid resuscitation has been started, pain medication must be titrated or given in small intravenous doses (not intramuscular). 

 Blood pressure, pulse, respiratory rate and state of consciousness should be assessed after each increment of IV morphine. 

Wound care during transport 

• Debridement and application of topical antimicrobials is usually unnecessary; transport patient wrapped in dry sheet, blanket or cling wrap and keep the patient warm. 
• Apply a thin layer of Silver Sulfadiazine to open areas if transport will be delayed longer than 12 hours. 
• Use of Burnshield® is a very effective means for cooling and dressing for the first 24 hr. 

General items 

• Contact the burn unit telephonically and discuss the patient and transfer with the unit staff. If abed is not immediately available then insist on a management regime until the patient can be transferred. 
• Discuss the mode of transfer. Road transferrals are possible in almost all burn patients. Only when the patient is compromised with poly-trauma or other pre-existing disease, then one can look at air transport. 
• A history, including details of the accident and pre-existing diseases/allergies, should be recorded and sent with the patient. 
• Annotate the burn wound in TBSA and depth. 
• Copies of all medical records,including all fluids (calculations of fluids) and medications given, urine output and vital signs must accompany the patient. These specific details maybe recorded on the back of the burn size assessment sheet. 
• The Burn Centre will arrange transport if appropriate. 
• In case of paediatric patients not accompanied by a parent get consent in consultation with your burn centre. 

Special considerations with chemical burns – Consult Burn Centre! 

• Remove ALL clothing. 
• Brush powdered chemicals off wound; then flush chemical burns for a minimum of 30 minutes or until all pain has disappeared, with copious volumes of running water. Be careful to protect yourself. 

Reminder: Never neutralise an acid with a base or vice versa. 

• Irrigate burned eyes with a gentle stream of saline. Follow with an ophthalmology consult if transport is not imminent. 
• Determine what chemical (and what concentration) caused the injury. 

Special considerations with electrical injuries – Consult Burn Centre! 

• Differentiate between low voltage(below 1000v) and high voltage (>1000v) 
• Attach cardiac monitor; treat life-threatening dysrythmias as needed. 
• Assess for associated trauma; assess central and peripheral neurologic function. 
• Special investigations to assess fractures and serious soft tissue trauma/explosion in high voltage injury are necessary. 
• Administer Ringer’s lactate; titrate fluids to maintain adequate urine output or to flush pigments through the urinary tract (see urine output above). 

Useful lab: ABG with acid/base balance. 

• Elevate burned extremities above the level of the heart on pillows. Monitor distal pulses. 

Local Care 

The burn wound is carefully assessed for extent and depth and then treated topically with an antiseptic/antibacterial agent as a prophylactic or therapeutic measure against burn wound colonisation and burn wound infection. 

• The burn wound is washed with water and soap or with chlorhexidine solution and then covered with the selected topical agent. Grease and road contamination can be removed by the application of petroleum jelly. A closed burn wound technique is used and the topical agents chosen according to burn unit protocol. 
• Frequently used topical agents include silver sulphudiazine (changed daily), povidine iodine (changed daily), Mupirison with or without Chlorhexidine (changed daily) and a nanocrystalline dressing (Acticoat) changed every 3 days. 7 

Wound Cleansing – Hydrotherapy and Versa jet 

The initial burn wounds can be washed with soap and water or Chlorhexidine or can be debrided under anaesthesia. 

Transportation of the burned patient 

• Ensure airway is safe. 
• Transport as soon as possible to reach destination within 4 to 6 hours. 
• Intravenous (IV) fluid therapy should be commenced. 
• Ensure IV lines are reliable, especially if long journey. Secure lines with sutures if necessary. 
• Transfer children only after fluid resuscitation has commenced, measures to maintain temperature have been instituted and the wound protected. 
• Transfer with dry dressings or cling film, not wet towels. 
• Arrange appropriate escort. 
• Oxygen should be administered to all major burns or when carbon monoxide poisoning is suspected. 
• Administer adequate analgesia. 
• Infection prophylaxis: tetanus immunisation. Defer antibiotics if for burns only. 
• Provide a full and complete record to the receiving service/clinician: 
• Medication given: dosage and route 
• Dressings 
• Fluids administered: type, volume and time of commencement 
• Urine output: catheterisation for accuracy 
• Procedures performed, if any 
• Contact details of relatives 
• Name and contact details of referring person 

 Special Considerations

• Circumferential Burns: assess distal circulation, remove jewellery. Evaluate for escharotomies as necessary. Contact the regional burn centre for further instructions. 
• High Voltage Electrical Injuries: suspect myoglobinuria or haemoglobinuria. Keep urine output at 1- 1.5ml/kg/hr and urine alkaline. Place on cardiac monitor. Record ECG. 
• Suspect compartmental syndrome, consider fasciotomies. Contact the regional burn centre for further instructions.