It’s 7 PM, and you are working the 3 PM to 11 PM shift in the ED. A call comes in that a serious house fire has occurred. Emergency medical system (EMS) personnel are on their way with a badly burned man, and you haven't cared for a burn patient in several years. Don't panic, here is information that can help you manage, evaluate, and prepare the patient for possible transfer to a burn center. You can start initial care by following your ABCs. Then you can conduct a thorough head-to-toe examination.

Airway and Breathing

A and B are for airway and breathing — always the first concern in any emergency. Inhalation injury is acute respiratory tract damage caused by breathing a fire’s superheated steam, toxic gases, and smoke particles contaminated with chemicals. Direct thermal injury, although uncommon, may also occur if combustion of the smoke particles is incomplete at the time of inhalation. There are three types of inhalation injury: carbon monoxide poisoning, inhalation injury above the glottis, and inhalation injury below the glottis. Risk factors for an inhalation injury include fire in an enclosed space, exposure to noxious chemicals, extended length of entrapment, and whether the victim was found low to the ground or higher where rising smoke or chemicals may be concentrated. Contributing to the risk are extremes of age and concomitant medical conditions. For example, the level of mobility for the very young and very old may inhibit or prevent these individuals from extricating themselves from the fire; the immature lungs of infants and the potential cardiopulmonary disease of the elderly raises the mortality and morbidity for these populations.

Carbon monoxide poisoning is the most common cause of death involving inhalation injury and smoke-induced inhalation injury. Carbon monoxide has an affinity for hemoglobin that is at least 200 times greater than that of oxygen. This competition leads to poor oxygenation and tissue hypoxia. Signs and symptoms of carbon monoxide poisoning vary with levels of carboxyhemoglobin, although a change in mental status with disorientation can be a good indication of this injury.

Inhalation injury below the glottis is caused by the irritation of noxious gases such as hydrogen cyanide, aldehydes, ammonia phosgene, sulfur oxides, and hydrogen chloride, which are byproducts of combustion. Inhalation of these causes direct injury to the tracheobronchial tree, loss of ciliary action, mucosal edema, and diminished surfactant production. Pulmonary edema, chemical pneumonitis, and extensive mucosal sloughing may also occur.

Airway injuries above the glottis occur when superheated steam or noxious chemicals are inhaled, resulting in an inflammatory reaction. Edema and narrowing of large airways can lead to airway obstruction in the first 48 hours after injury.

An inhalation injury can be complicated by restrictive defects that are caused by full-thickness circumferential burns around the neck and chest. Thick burned tissue impedes normal elasticity and movement of the skin and limits lung expansion if the chest and neck are involved. As the burn edema progresses during the first 24 hours to 48 hours after the initial injury, circumferential burns can become restrictive, interfering with ventilation and normal chest expansion by compressing the trachea and thorax. The edema may even obstruct the airway. Pulmonary function may deteriorate further as fluid shifts from the vascular compartment to the interstitial space, reducing lung compliance and producing pulmonary edema and acute respiratory distress syndrome (ARDS).

Diagnosis of an inhalation injury depends first upon obtaining details of the burn injury and assessing the patient. Signs indicative of damage to the airway or lungs are singed nasal and facial hair; soot around the circumoral area; obvious facial or neck burns; blisters, redness, or edema of the oral and pharyngeal mucosa; hoarseness; labored breathing; stridor; dry cough; sooty or carbonaceous sputum; tachypnea; and anxiety or agitation. Measuring arterial blood gases and carboxyhemoglobin levels aids diagnosis of inhalation injury while chest radiography does not, although it provides baseline information for future comparison. A fiberoptic bronchoscopy is the gold standard for diagnosing and confirming inhalation injury. However, this procedure may be deferred until the patient reaches the burn center. Xenon-133 pulmonary scintigraphy occasionally is used to diagnose injury.

Emergency management includes 100% oxygen via humidified nonrebreather facemask to combat carbon monoxide poisoning. Early endotracheal (ET) intubation may be warranted in the event of coma, airway edema with impending obstruction, extensive burns that need intensive management, or circumferential burns of the chest. Early prophylactic intubation may be initiated to avoid emergency tracheostomy. The ET tube should be secured with tape if the face is clear of burns or cotton tracheostomy ties if there are facial burns. Commercial ET tube harnesses may also be appropriate. Mechanical ventilation may be necessary if respiratory failure is present. The ventilatory support mode selected is determined by the patient’s need, including pressure-controlled volume ventilation and synchronized intermittent mandatory ventilation (SIMV).

Circulation

Following the ABCs, circulation is the next parameter that needs assessment. Restrictive clothing, belts, shoes, and jewelry (rings, watches, bracelets, etc.) should be removed immediately to prevent them from constricting circulation as burn edema develops. However, clothing that adheres to the burn should be left intact until burn debridement occurs.

Although damage may be localized in burns of less than 25% total body surface area, or generalized in those that encompass more than 25% TBSA, all burn injuries alter capillary permeability. The first 24 hours to 48 hours postinjury is the time of maximal fluid loss, and the body may respond by going into a hypovolemic state, known as burn shock. Loss of plasma protein and electrolytes can occur, resulting in reduced intravascular volume and elevated extracellular fluid. Clinical manifestations of these changes are hypovolemia and edema. Despite the body’s compensatory effort to retain sodium and water, sodium is lost in excessive edema and exudate fluid, while potassium is released into the extracellular fluid. The blood becomes hemoconcentrated and in severe burns, red blood cells may hemolyze. The fluid shifts cause cardiovascular changes, such as a compromised cardiac output, increased systemic vascular resistance, and reduced peripheral blood flow. Impaired peripheral blood flow can further damage tissue and result in metabolic acidosis.

Prevention of burn shock starts with the placement of large-bore intravenous (IV) catheters in all burn patients and patients with inhalation injuries. Optimal insertion is through unburned skin in the upper extremities, although this is not always possible, and placement through burned skin may be necessary. Place a minimum of two large-bore (14- or 16-gauge) lines in patients with burns involving greater than 20% TBSA. Routine laboratory assessment includes a complete blood count with differential, platelet count, and serum levels of glucose, electrolytes, blood urea nitrogen, and creatinine.

Fluid resuscitation prevents shock and further tissue damage. The primary goal is to preserve tissue perfusion and maintain vital organ function by restoring intravascular volume and avoiding the complications of inadequate or excessive fluid resuscitation. Patients with 15% or greater TBSA burns should have fluid resuscitation. Although there are numerous ways to estimate fluid needs, the American Burn Association advocates use of the Consensus formula. This calculation recommends a fluid volume derived by multiplying 2 ml-4 ml x kg of body weight x%TBSA burn. Half of the total amount is given in the first eight hours postburn, and the other half is administered during the next 16 hours postinjury. An isotonic solution such as Lactated Ringers (LR) is usually used. Colloid solutions are discouraged during early therapy because the protein molecules tend to pass through capillary membranes and elevate colloid pressure and interstitial edema. Colloids are recommended only after the initial 24-hour resuscitation period.

Although fluid resuscitation formulas serve as a starting point for therapy, the individual’s response — especially urine output — is the ultimate guide to fluid replacement. Urine output should be maintained at 30 ml/hr to 50 ml/hr for adult patients. For patients who have sustained high-voltage electrical burn injuries, the output should be 75 ml/hr to 100 ml/hr to prevent renal tubular obstruction from urine myoglobin. Diuretics, which can aggravate dehydration, should be avoided. In addition to output, urine specific gravity, along with the patient’s vital signs and changes in mental status are valuable indicators of the patient’s response to fluid resuscitation.

Deep partial- or full-thickness circumferential injuries of the extremities can compromise circulation. Burn eschar, an avascular area composed of nonviable biological material produced by the burning agent, acts as a tourniquet as edema increases. This effect reduces or eliminates blood supply to distal burn areas, creating the potential for tissue necrosis. Peripheral pulses should be assessed by palpation or doppler ultrasound flowmeter. If pulses are absent, providers may elect to use electrocautery to perform an escharotomy, which is usually performed at the bedside under IV sedation. To relieve the pressure, incisions are made only through the eschar at the midaxillary line on the thorax or laterally and medially on the extremity; the subcutaneous tissue is exposed but not pierced. After completion, the affected area is elevated to minimize edema and pulses are checked hourly. Most burn centers do not advocate performing escharotomies in the ED unless a significant delay in transport to the burn center is anticipated.

Disability and Exposure

D is for disability — other injuries that may occur during the burn. Symptoms unrelated to burns may indicate additional injury, for example, trauma incurred by a burn victim when jumping from a burning building. Assess patients for head trauma, particularly those who are disoriented or unconscious in the absence of inhalation injury or carbon monoxide poisoning. Protect patients from further injury until a thorough evaluation has been completed. For instance, maintain cervical alignment during assessment and while performing necessary interventions such as intubation.

E is for exposure — hypothermia that may occur from wet dressings or environmental factors. Maintain the patient’s temperature between 38 C to 39 C by removing all wet dressings and materials in burns of >10% TBSA and using blankets, heat lamps, or warmed IV fluids.

Estimating Burns

The final priority in burn care is the examination of wounds to determine the depth of the burns and the TBSA involved. Superficial or first-degree burns involve the epidermal layers only. They are typically dry without blisters, erythematous, minimally or nonedematous, and very painful. Partial-thickness or second-degree burns encompass the epidermis and parts of the dermal layer. These wounds are moist, often blistered, and extremely painful; the underlying tissue is mottled pink and white and blanches easily. Full-thickness or third-degree burns extend to the subcutaneous tissue and may affect fascia, muscle, and bone. These burns are insensate and covered by a dry, leathery eschar with a white, waxy, maroon, or soot-stained coloring. Wounds need to be covered with clean, dry sheets. Do not apply topical agents that could interfere with later assessment by burn center personnel.

Clinicians usually estimate TBSA burned by applying the Rule of Nines. A chart divides the body into regions that are assigned multiple values of nine. Identifying second- and third-degree burn areas and totaling their corresponding values from the chart provides the estimate of TBSA burned. The most widely used method in burn centers is the Lund and Browder chart, which more accurately assesses pediatric as well as adult patients by factoring in body size and age factors.

Estimation of depth and extent of the burn injury not only establishes severity, but also determines the treatment plan and the ultimate disposition of the patient, who may need the expertise of a burn center. No matter how extensive the injury may be, communication and support are essential elements of care to reduce the patient’s fear and anxiety while the decision for transfer is being made. Also, the patient should be kept comfortable by administering appropriate analgesia, usually IV morphine. Subcutaneous or intramuscular administration is not recommended for burn patients because fluid shifts interfere with absorption through those routes.

The decision to transfer a patient to a burn center should be guided by the referral criteria of the American Burn Association, American College of Surgeons, Committee on Trauma who recommend that patients with the following types of burn injuries be referred —

1. Partial thickness burns greater than 10% TBSA
2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints
3. Third-degree burns in any age group
4. Electrical burns, including lightning injury
5. Chemical burns
6. Inhalation injury
7. Burn injury in patients with preexisting medical conditions that could complicate management, prolong recovery, or affect mortality
8. Any patient with burns and concomitant trauma (such as fractures) in which burn injury poses the greatest risk for morbidity or mortality. In such cases, if trauma poses the greater immediate risk, the patient may be initially stabilized in a trauma center before being transferred to a burn unit. Physician judgment will be necessary in such situations and should be in concert with the regional medical control plan and triage protocols.
9. Burned children in hospitals without qualified personnel or equipment for the care of children
10. Burn injury in patients who require special social, emotional, or long-term rehabilitative intervention

Teamwork and effective communication can expedite transport to a burn center. The report to burn personnel should consist of a demographic profile of the patient, patient’s height and weight, significant medical history, immunization status, allergies, and current vital signs. Specific to the burn injury, provide as much history about the injury as known or suspected, including time, mechanism (fire, electrical, etc.), whether it occurred in a closed or open space, type of materials and fuels ignited, and type of toxins inhaled. If appropriate, provide the burn center with an MSDS (materials, safety, and data sheet), which describes the hazards and identities of chemicals in a work environment. Provide a summary of the systems assessment, including burn depth and extent; laboratory values; and the current treatment regime and patient response. Ground or air transport methods are used, depending on the patient’s status, severity of the injury, and the distance and time estimated for transfer. Providers should stabilize the patient before transport. In preparation for transport, several factors need to be addressed:

• Patency of airway and securing the endotracheal tube if intubated
• Adequate oxygenation sources
• Stability of vital signs
• Establishment of IV access and adequate fluid resuscitation with LR solution
• Stabilization of the neck with a cervical collar if a spinal injury is suspected
• Measurement of urine output via a foley catheter for burns >20% TBSA
• Withholding anything by mouth and inserting an oral gastric tube (OGT) for burns >20% TBSA
• Covering wounds with dry dressings and avoiding wet ones, which can induce hypothermia, especially in children and the elderly. A clean dry sheet rather than dressing can be used to cover large surface burns. Blankets over the sheet will protect the patient from hypothermia.

It’s now 10 PM and you look around the room to find only remnants of the care you gave to your burn patient. Your patient was a 76-year-old, 180 lb man, who was found at the top of the stairs of his second-story home. At that time, he was irritable and confused, having difficulty breathing, and complaining of generalized pain. Upon arrival at the ED, he was intubated and placed on the ventilator with 100% oxygen. Physical findings and the carboxyhemoglobin level were highly suspicious of an inhalation injury. He also had 60% TBSA partial- and full-thickness burns of his face, neck, torso, upper extremities, and thighs. You inserted a foley catheter, placed two large-bore peripheral IV catheters for LR infusions, and inserted an OGT. You knew that the OGT placement is preferred for burn patients over a nasogastric tube, as NGT placement significantly increases a burn patient’s risk for sinusitis. Then you covered his wounds with dry sheets, applied blankets over the sheets, called a report to the burn center, and transferred his care to a transport team.

Thanks to the care he received in the ED and the timely referral to the center, the 24-hour posttransfer report from the transport team confirmed that the patient was in critical, but stable condition.

From: Pediatric Burn Management Emergency Reference, St. Christopher’s Hospital for Children, Philadelphia, PA.