EMERGENCY CARE

CARE AT THE SCENEAIRWAY• Once flames are extinguished, initial attention must be directed to

the airway. • Immediate CPR is rarely necessary, except in electrical injuries or in

patients with severe carbon monoxide poisoning• CPR should be performed per Advanced Cardiac Life Support (ACLS)

guidelines. • Any patient rescued from a burning building or exposed to a smoky

fire should be placed on 100% oxygen via a nonrebreather mask if there is any suspicion of smoke inhalation.

• If the patient is unconscious or in respiratory distress, endotracheal intubation should be performed by appropriately trained personnel.

Other Injuries and Transport

• Once an airway is secured, the patient is assessed for other injuries and then transported to the nearest hospital.

• Patients should be kept flat and warm and be given nothing by mouth

• Place an intravenous line and begin fluid administration with lactated Ringer's (LR) solution at a rate of approximately 1 L/h in the case of a severe burn;

• For transport, the patient should be wrapped in a clean sheet and blanket.

• Before or during transport, constricting clothing and jewelry should be

removed from burned parts, because local swelling begins almost immediately.

Emergency Room Care

• The primary rule for the emergency physician is to ignore the burn.

• As with any form of trauma, the airway, breathing, and circulation protocol (ABC) must be strictly followed FIRST.

Emergency Assessment of Inhalation Injury

• Inhalation injury should be suspected in anyone with a flame burn, and assumed until proven otherwise

• Careful inspection of the mouth and pharynx should be done early. • Hoarseness and expiratory wheezes are signs of potentially serious

airway edema or inhalation injury. • Copious mucus production and carbonaceous sputum (i.e.,

expectorated sputum and not just black flecks in the saliva) • Carboxyhemoglobin levels should be obtained, and elevated levels

or any symptoms of CO poisoning are presumptive evidence of associated inhalation injury

Resuscitation Goals

• Effective fluid resuscitation is one of the cornerstones of modern burn care

• Proper fluid resuscitation aims to anticipate and prevent rather than to treat burn shock.

• To provide enough fluid replacement to maintain perfusion without causing fluid overload.

• Without effective and rapid intervention, hypovolemia/shock will develop if the burns involve > 15% to 20% total body surface area (TBSA)

Resuscitation Principles• Adequate resuscitation from burn shock is the single most

important therapeutic intervention in burn treatment.

• Each patient will react uniquely to burn injury depending on age, depth of burn, concurrent inhalation injury, preexisting comorbidities, and associated injuries.

• Lactated Ringer's solution most closely resembles normal body fluids.

• Factors that influence fluid requirements during resuscitation besides TBSA burn include burn depth, inhalation injury, associated injuries, age, delay in resuscitation, need for escharotomies/fasciotomies, and use of alcohol or drugs.

The Parkland Formula/ Consensus Formula

• The Parkland formula has been renamed the Consensus formula because it is the most widely used resuscitation guideline.

• The Advanced Burn Life Support curriculum supports the use of the Consensus formula for resuscitation in burn injury.

4 mL/kg per percentage TBSA– kg represents patient weight– percentage TBSA is the size of the burn injury

• describes the amount of lactated Ringer's solution required in the first 24 hrs post burn.

• Starting from the time of burn injury, half of the fluid is given in the first 8 hrs and the remaining half is given over the next 16 hrs.

Other Fluids • There has not been a clinical advantage with colloids.• One study showed a decreased risk of death when albumin was

used during resuscitation, but was not statistically significance. • A meta-analysis comparing albumin to crystalloid showed a 2.4-fold

increased risk of death with albumin. • Hypertonic saline causes a four-fold increase in renal failure and

twice the mortality of patients given lactated Ringer's solution.• FFP should not be used as a volume expander, according to new

policies on blood product delivery. • The American Burn Association Practice Guidelines for Burn Shock

Resuscitation do not recommend the use of FFP without active bleeding or coagulopathy.

Vascular Access/Other Tubes and Catheters

• No factor other than airway protection is as critical in the early postburn period as vascular access.

• Ideally, obtain peripheral intravenous access away from burned tissues.

• If no intravenous access is available, intraosseous catheters may safely be placed in patients of any age.

• A patient undergoing resuscitation should have a Foley catheter placed.

• Nasogastric tubes should be considered in patients with > 20% TBSA burns, as they will experience gastroparesis and probable emesis.

First-line MonitoringPrimary modalities for monitoring:• Heart rate– A pulse rate < 110 beats/min in adults usually indicates

adequate volume, with rates > 120 beats/min usually indicative of hypovolemia.

– Narrowed pulse pressure provides an earlier indication of shock than systolic blood pressure alone.

• Urine output– The American Burn Association Practice Guidelines for

Burn Shock Resuscitation recommend:• 0.5 mL/kg/hr urine output in adults • 0.5–1.0 mL/kg/hr in children weighing < 30 kg.

• Blood pressure– Arterial Catheter versus Blood Pressure Cuff• Noninvasive blood pressure measurements by cuff are

rendered inaccurate because of the interference of tissue edema and read lower than the actual blood pressure.• An arterial catheter placed in the radial artery is the

first choice, followed by the femoral artery.

First-line Monitoring

Resuscitation End Points• Many authors feel that urine output and traditional vital signs (heart rate

and mean arterial pressure) are too insensitive to ensure appropriate fluid replacement

• In adults, arterial blood pressure is relatively insensitive to the adequacy of fluid replacement; pulse rate is more helpful. In older patients, pulse rate becomes less reliable.

• Urine output can be taken to reflect organ perfusion; however, urine must be nonglycosuric to be accurate.

• Although urine output does not precisely mirror renal blood flow, it remains the most readily accessible and easily monitored index of resuscitation.

Tetanus Prophylaxis

• Burns are tetanus-prone wounds. • The need for tetanus prophylaxis is determined

by the patient's current immunization status. – Previous immunization within 5 years requires no

treatment– immunization within 10 years requires a tetanus

toxoid booster– unknown immunization status requires

hyperimmune serum (i.e., Hyper-Tet).

Gastric Decompression

• Many burn centers begin enteral feeding on admission to reduce the risk of:– gastric ulceration (Curling's ulcer)– prevent ileus– blunt catabolism.

• If patient transport is via air ambulance or is going to take more than a few hours, the safest course is usually to decompress the stomach with a nasogastric tube.

Pain Control

• During the shock phase of burn care, medications should be given intravenously.

• Subcutaneous and intramuscular injections are variably absorbed depending on perfusion and should be avoided.

• Pain control is best managed with small intravenous doses of an opiate until analgesia is adequate without inducing hypotension.

Care of the Burn Wound

• After all other assessments have been completed, attention should be directed to the burn.

• If the patient is to be transferred during the first postburn day, which is almost always the case, the burn wounds can be minimally dressed in gauze.

• However, the size of the burn should be calculated to establish the proper level of fluid resuscitation, and pulses distal to circumferential deep burns should be monitored.

• The patient can be wrapped in a clean sheet and kept warm until arriving at the definitive care center.

Escharotomy

• Thoracic Escharotomy– The adequacy of respiration must be monitored

continuously throughout the resuscitation period.– Early respiratory distress may be due to the

compromise of ventilation caused by chest wall inelasticity related to a deep circumferential burn wound

– Thoracic escharotomy is seldom required, even with a circumferential chest wall burn. When required, escharotomies are performed bilaterally in the anterior axillary lines.

• Escharotomy of the Extremities– Edema formation in the tissues under the tight,

unyielding eschar of a circumferential burn on an extremity may produce significant vascular compromise

– All jewelry must be removed from the extremities to avoid distal ischemia.

– Skin color, sensation, capillary refill, and peripheral pulses must be assessed hourly in any extremity with a circumferential burn

Escharotomy

ESCHAROTOMY

• The occurrence of any of the following signs or symptoms may indicate poor perfusion of a distal extremity warranting escharotomy:

– cyanosis– deep tissue pain– progressive paresthesia– progressive decrease or absence of pulses or the sensation of cold

extremities.

• An ultrasonic flowmeter (Doppler) is a reliable means for assessing arterial blood flow, the need for an escharotomy, and also can be used to assess adequacy of circulation after an escharotomy

Locations for Escharotomies

•The incisions are placed along the mid-medial and mid-lateral lines of the extremities and the thorax (dashed lines). •The skin is especially tight along major joints, and decompression at these sites must be complete (solid lines). •Neck and digital escharotomies are rarely necessary.