History:
- Exposure to heat/gas/chemical
- Inhalation injury
- Time of Injury
- Past medical history
- Medications
- Other trauma
- Loss of consciousness
Significant Findings:
- Pain
- Swelling
- Dizziness
- Loss of consciousness
- Hypotension/shock
- Airway compromise/distress
- Singed facial or nasal hair
- Hoarseness/wheezing
Differential:
- Superficial (1st⁰) : red and painful (don't include in TBSA)
- Partial thickness (2nd⁰) : blistering
- Full thickness (3rd⁰) : painless, charred or leathery skin
- Thermal
- Chemical
- Electrical
- Radiation
- 15% TBSA 2nd/3rd Degree Burn
- Burns with Multiple Trauma
- Burns with definite airway compromise
- When reasonable or reasonably accessible, transport to a Burn Center or Level I Trauma Center
- 5-15% TBSA 2nd/3rd Degree Burn
- Suspected Inhalation injury or requiring intubation for airway stabilization
- Hypotension or GCS < 14
- When reasonable or reasonably accessible, transport to a Burn Center or Level I Trauma Center
- < 5% TBSA 2nd/3rd Degree Burn
- No inhalation injury
- Not intubated
- Normotensive
- GCS>14
TREATMENT
- Oxygen
- Consider Spinal Immobilization
- Fly critical and serious burns to a burn center if possible
- If eye involvement flush with water or Normal Saline for 10-15 min
- Remove rings, bracelets, and other constricting items
- Cover Burn with Dry sterile sheet or dressings
- Protect burns /wounds with sterile dressing; do not attempt to remove clothing that is adhered to the burn area
- Identify entry and exit sites ; apply sterile dressings
Critical or Hypotensive ?
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- Notify receiving facility or contact Medical Control
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- Notify receiving facility or contact Medical Control
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- The IV solution should be changed to Lactated Ringers if it is available. It is preferred over Normal Saline.
- Formula example and a rule of thumb is; an 80 kg patient with 50% TBSA will need 1000 cc of fluid per hour.
Critical or Serious Burns
- > 5-15% total body surface are (TBSA); 2nd or 3rd degree burns
- 3rd degree burns > 5% TBSA for any age group
- circumferential burns of extremities
- electrical or lightning injuries
- suspicion of abuse or neglect
- inhalation injury
- chemical burns
- burns of face, hands, perineum, or feet
- any burn requiring hospitalization.
- These burns will require direct transport to a burn center, or transfer once seen at a local facility where the patient can be stabilized with interventions such as airway management or pain relief if this is not available in the field or the distance to a Burn Center is significant.
Pearls:
- Serious, critical, and circumferential burns should be transported directly to a burn center by ATU whenever feasible
- Burn patients are Trauma Patients, evaluate for multisystem trauma. Most injuries immediately seen will be a result of collateral injury such as heat from the blast, trauma from concussion, etc.. Treat collateral injury based on typical care for the type of injury displayed.
- Assure whatever has caused the burn, is no longer contacting the injury. (Stop the burning process!)
- Early intubation is required when the patient experiences significant inhalation injuries.
- Potential CO exposure should be treated with 100% oxygen and transported to a hyperbaric chamber located at Greenville Memorial.
- Circumferential burns to extremities are dangerous due to potential vascular compromise secondary to soft tissue swelling.
- Burn patients are prone to hypothermia - never apply ice or cool burns, must maintain normal body temperature.
- Evaluate the possibility of child abuse with children and burn injuries.
- Chemical burns: Remove chemical first if possible. Flush as soon as possible with the cleanest readily available water or saline solution using copious amounts of fluids.
- Electrical: Attempt to locate contact points, (entry wound where the AC source contacted the patient, an exit at the ground point) both sites will generally be full thickness.
- If able, identify the nature of the electrical source (AC vs. DC), the amount of voltage and the amperage the patient may have been exposed to during the electrical shock.
- Anticipate ventricular or atrial irregularity, to include V-tach, V-fib, heart blocks, etc.
- Radiation: Determine the exposure type: external irradiation, external contamination with radioactive material, internal contamination with radioactive material. If available, determine exposure (generally measured in Grays/GY).