Emergency Burn Management
We have EM residents come on our service and I try to make it my priority to teach them what they need to know when they have a large burn come to their facility. More often than not, our big burns come from an OSH ED. There are some important things that ED providers should keep in mind when they get a big, unstable burn pt patient. Below, I’ll talk about ABLS based emergency management, things to look for, and what to do initially for burns > 20% TBSA. The initial care and tests are pretty much the same for all types of burns but there are some variances based on burn mechanism. Bear in mind, any burn can also co-exist with inhalation injury.
Initial Presentation and Workup
ALL burn pts are TRAUMA pts. Complete your primary survey BEFORE addressing the cutaneous injury. Always.
Evaluation of the burn is a part of the secondary survey
Use the rule of 9s to get a rough estimate of %TBSA affected
ONLY 2nd and 3rd degree burns count when counting TBSA (blisters, slough, skin that appears slick and shiny, skin that appears hyperemic or leathery)
Stick a foley in this patient. We will need to have accurate I/O for resuscitation.
Get a rainbow of labs: CBC, BMP, Mg, Phos, Lactic, ABG, EtOH, Utox
If the pt has additional trauma (broken limbs, etc), get appropriate imaging and work up for that.
You don’t need an ECG for all burn pts. Electrical injury or ROSC pts ALWAYS need an ECG but generally, most don’t unless they have a cardiac history or electrolyte abnormality.
If the patient is so painful that you require fentanyl or morphine drips, the patient will need to be intubated secondary to iatrogenic respiratory depression.
Large burns will continue to swell secondary to their pathophysiology and the amount of fluid they need. This means that the airway could be compromised.
Do you have a chemical burn? - First, pH the skin, then aggressively decontaminate for 20 minute intervals. pH the skin until it is neutral. If there is chemical injury to the eyes, flush with NS via Morgan lenses. Repeat pH testing and continue to flush until neutral. BASES are much worse than acids.
Do you have a child with a scald burn from tap water? Most states require this to be investigated. Get your social worker involved to begin this process. Any suspicion you have with any kind of burn should be investigated.
Fluids: LR is the fluid of choice for resuscitation. Do NOT administer NS as the volume this patient will receive will likely push them into a hyperchloremic metabolic acidosis. Depending on the size of the burn, we will generally recommend a rate of 150-200 cc/h. Large burns may require fluids to be wide open.
Pain Medication: For large burns, PO pain meds won’t cut it. We recommend fentanyl drips for the most part. It’s safe for people with renal disease (unlike morphine) and easily titrated. If the patient does not require intubation and pain can be managed by IV push medication, you can use dilaudid or morphine depending on renal status.
Sedation: We usually recommend propofol. People with large, painful burns are best sedated. No one wants to be awake for that kind of injury. You should not need a paralytic unless the patient is SUPER unstable on the vent and requiring APRV or something.
We do not give antibiotics prophylactically in burn patients. Please don’t start your large burn on an abx.
Recall my previous post about inhalation injury. If the patient was NOT in an enclosed space for a period of time, your suspicion should be low. If the story fits, do the following:
Labs: Carboxyhemoglobin, ABG, VBG, methemoglobin. Not all facilities have methemoglobin testing, but most have carboxyhemoglobin. If the carboxyhemoglobin is >15%, suspect inhalation injury. If your facility has a cyanokit, administer it. A Cyanokit is essentially Vitamin B12; it acts like a mop for the cyanide in the body. Be warned, the urine will look like red wine.
Vent/Airway Mgmt: 100% FiO2 on whatever setting the patient tolerates well. High oxygen concentration helps push carbon monoxide off hemoglobin binding sites. Our first setting we use is pressure control but honestly, vent management is a lot about what works for that patient. If the patient has facial burns, you’ll have to make sure that the ETT is SECURED well. The 2nd degree burns can make the skin very slippery and complicated tube securement.
For a large burn, you should NOT worry about debridement or any kind of burn cream. We recommend that you wrap the patient in saran wrap to maintain moisture and send them to us. The most important thing you can do with a large burn is to keep the skin covered to preserve body temperature as these patients cannot thermoregulate. Pile on blankets and keep them normothermic. Warm fluids help.
I have a post about referral to burn centers. Any burn over 10% needs to be referred. My facility will fluid resuscitate at 15% TBSA but the ABLS criteria is 20%. I think there is wiggle room here depending on the patient, their PMH, and status at the time of assessment. When you receive a burn that is a potential referral, call your nearest burn center once you have your workup done. Send us images of the burns so that we can assess severity. Not all burns have to be air lifted. Though, generally, >30% TBSA we have a big risk of fluid and electrolyte imbalances, so those pts should take priority for air lift. The burn center you talk to will recommend the best transport.
Make sure copies of lab results go along with the rig or chopper. This is helpful to us when monitoring patients.
If you and the burn center do not have the same EMR or have a “care everywhere” share function, make a copy of recent medical records and send them. We are most interested in a summary page with diagnoses, meds, and surgeries.
If you have a chemical exposure, please give us the MSDS information if you have it.
Depending on how long the patient is with you, you need to make sure that they are making urine - goal is at least 30 cc/h (1 cc/kg/hr in kids). You likely will not end up doing any Parkland based fluid resuscitation as most patients are transferred to a burn center soon enough. If there is going to be a delay of some kind in transport, use the Parkland formula (adults) or Galveston formula (kids <30 kg) to calculate fluid needs.
Burns of any kind are intimidating injuries. Large burns coming to a facility with little experience can be completely overwhelming. Breathe, treat this pt like any other trauma pt, and call your nearest burn center. Keep the pt warm and give them fluid. I wouldn’t initially worry about giving too much fluid unless they have a history of CHF. We end up diruesing pts after resuscitation is complete.
