PreHospital Burn Management Part 2: Burn Care

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Pre-Hospital Burn Management Part 2 Burn Care

• Robert S. Cole
• Paramedic, CCEMTP

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Are You Ready???
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Objectives

• Obtain a basic understanding of infection
  mediation, Airway management and destination
  priorities in the burn pt.
• Gain a basic understanding of escharotomy, Fluid
  resuscitation, Pain Management and other aspects
  of advanced burn care

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Basic Burn Care
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Basic Burn Care Save yourself before you save
others

• Dont be a blue canary
• There are many many potential hazards besides the
  fire,
• Toxic gasses (Especially in industrial sites and
  Meth Labs)
• Gas mains
• Secondary explosives
• Electricity
• Chemical Exposure

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Basic Burn Care Save yourself before you save
others

• BEWARE OF CONFINED SPACES
• 60 of fatalities in rescue situations are would
  be rescuers!
• Dont be a statistic

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Basic Burn Care Stop The Burning Process

• Remove the pt (And You) from the proximity of the
  Burn and other hazards
• If Trauma is associated, Follow BTLS rapid
  extrication Guidelines
• If Chemical, let the experts handle it. Attempt
  dry decon if possible before flushing.
• If Electrical, Let the experts remove him

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Basic Burn CareThe First 10 minutes

• BSI Infection Mediation from the Start!
• C-Spine Secure if indicated.
• LOC Obtunded or lethargic- Think CO, Toxic
  Gasses, Drugs, or Head Trauma
• A Stridor? Intubate! Sooty airways, Be prepared,
  Give O2
• B Severe refractory distress, Intubate. Hacking
  cough, Hoarse Voice, Soot flecked sputum,
  Strongly consider intubation, Give O2

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Basic Burn Care The First 10 minutes

• C Pulse should be elevated, pt should be
  normotensive or Hypertensive. If pulse is weak
  thready or absent at radius, look for other cause
  of shock. Also look for circumferential burns w/
  swelling
• Dysfunction Mini Neuro
• E Expose and examine, Look for other Injuries,
  Leave Stuck clothing in place, remove Jewelry,
  Clothing may be considered evidence.

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Basic Burn Care The First 10 minutes

• F Fluid Therapy- Get your line started, If burns
  are moderate or major, do in transit.
• If you are not already enroute, Ask yourself why?
• Stay and Play or Load and Go?
• Sometimes Tincture of transport is the best
  medicine, especially if you can get Tx done
  enroute.

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Basic Burn Care The second 10 minutes and beyond

• Delegate early notification to the hospital
• Reassess the Complete primary survey, do a head
  to toe evaluation and assessment.
• Estimate BSA, severity.
• If Intubated, Recheck Tube, consider NG, ETCO2,
  Etc. Include other ALS assessments.
• Pain Relief Opiates, Benzos MANDATORY for
  moderate/major burns.
• Less than 10 BSA, may flush with sterile
  saline/H2O

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Basic Burn Care The second 10 minutes and beyond

• Prevent Hypothermia.
• Other Specific injury/burn location related care.
  
• Reassess Frequently, assume nothing
• Fluid Resuscitation Begin calculations (covered
  later)
• Give full report to receiving hospital
• Consider NG, Foley, etc as soon as feasible

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Basic Burn Care Dressing the area

• A Major cause of death after the first 48 hours
  is Infection. In everything you do, consider
  burns to be large open highways for infection to
  travel.
• Use aseptic/sterile tech.

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Basic Burn Care Dressing the area

• lt 10 BSA , cool saline/Sterile H20 is OK , on
  moist dressings, followed by dry outer layers
  (Moisture is a route of infection)
• gt 10 BSA, Dry Dressings,
• consider silvadine ointment or topical anesthetic
  for mild burns.
• Remember, dont promote infection.

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Basic Burn Care Dressing the area

• Facial Burns (protect the airway), raise head 30
  Degrees to minimize swelling.
• Burns to eyes consider continuous saline flush,
  consider Tetricaine ointment after consult, do
  not use steroid containing solutions.
• Hands remove all jewelry, cut free if required,
  no exceptions. Dry dressings if required, elevate
  above heart, active ROM q hour for 5 minutes if
  possible. If wrapped, wrap in position of
  function.

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Basic Burn Care Dressing the area

• Feet Same as Hands, keep elevated.
• Genital Prompt insertion of a Foley is
  essential.
• Tar Burns Focused at cooling down the Tar ASAP,
  it is otherwise non toxic.

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Basic Burn Care Psychological Considerations

• Fear of disfigurement, amputation, death are
  common.
• Be hopeful but honest
• Most burn patients will be alert, keep them
  informed. This will lessen anxiety, O2 demand,
  and cardiac stress
• If no apparent clear mechanism of burn is known,
  consider the possibility of a suicide attempt and
  safeguard appropriately.
• Consider sedation if severely anxious or anxiety
  is having an adverse effect on patient status

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Advanced Burn Care
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Advanced Burn Care

• For the purposes of this lecture Advanced Burn
  care is considered measures or procedures
  normally in the scope of practice of Medics,
  EMT-Is, or advanced practice nurses.
• Follow local guidelines, some of the procedures
  may be out of your scope of practice or may
  require medical control authorization
• All Practitioners should have passing familiarity
  with these procedures.

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Airway Management

• Pre-Hospital Personnel should have a Low
  Intubation Threshold when presented with
  possible inhalation/airway issues.
• Nasal ETT or RSI and Oral ETT is indicated.
  Adequate sedation AND analgesia is indicated in
  addition to any paralytics needed.

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Airway Management

• Consider Etomidate and/or Succs for initial
  induction, with valium/Versed and MS as adjuncts.
• Etomidate 0.3 mg/kg IVP (common dose 20-30 mg)
• Succinylcholine 1 mg/kg, contraindicated after
  first 36 hours

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Airway Management

• Tubes may be Coughed out of place, secure well,
  consider a long acting paralytic like vecuronium
  (0.1 mg/kg every 20-45 minutes) during transport.
• Alternative airways and skills are a must!
• Retrograde
• Surgical
• Blind airways are not likely to be much use in
  inhalation injuries.

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Respiratory Support

• High flow humidified O2
• If intubated, a Transport grade ventilator is
  better than bagging (Only applies to transport
  grade)
• ETCO2 w/ wave form is a valuable tool for
  assessing sedation, gas exchange, use of PEEP,
  effectiveness of ventilation, etc.

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Emergent Escharotomy

• Are you ready for this?
• Often Taboo but potentially Lifesaving.

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Emergent Escharotomy

• Circumferential burns to the chest and neck of
  full thickness or deep partial thickness results
  in swelling.
• This in turn results in respiratory compromise.
• While rare, rapid eval and TX can be lifesaving.
• Rare in the first 3-6 hours.

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Emergent Escharotomy

• While Escharotomies are also done to extremities,
  these are not commonly done in the field.
• While this procedure is uncommon, there are
  paramedic level (non critical care) services who
  do this in the field. Ex King County Medic 1.
• This should be mandatory training for rural
  services, Tactical and back country teams.
• Sterility/aseptic tech. Should be maintained.

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Emergent Escharotomy

• Examples of potential locations for incisions
• Before You get to this, r/o airway obstruction
  and D.O.P.E.
• Most of these patients should be Intubated
  already, If not , you may have your priorities
  out of whack.

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Vascular Access

• Ideally IV access should be 2 large bore IVs (16
  or larger)
• Idealy through non burned tissue
• This is not always an option
• Central lines, if appropriately trained , are an
  alternative if unable to get peripheral access.
• IOs in the burned child are also an alternative
• Sternal IOs in the adult may have value as well.

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Sternal IOs

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Fluid Resuscitation

• Fluid resuscitation is vital to improved outcomes
• Increased Vascular permeability (3rd spacing)
  results in 10-15 reduction of Cardiac Output for
  first 12 hours post burns (this is in proportion
  to severity of burn)
• This combined with cellular destruction means
  fluid administration is vital to prevent organ
  death.

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Fluid Resuscitation

• The goal of (Fluid) resuscitation is to maintain
  vital organ function while avoiding the
  complications of inadequate or excessive (Fluid)
  therapy.- ABLS Text P. 21
• To do this accurate assessment of BSA is
  essential
• Also significantly large bore IVs (14 or 16)

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Fluid Resuscitation

• 2 types of fluids Crystalloids and Colloids
• Crystalloids ( Saline and Ringers Lactate)
• Colloids (Albumin, Plasmanate, Dextran) Colloid
  pulling pressure makes little difference in first
  24 hours, therefore crystalloids are initial
  fluid of choice.
• Outside the military, Crystalloids are all that
  is available to most pre-hospital agencies.

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Fluid Resuscitation

• Formulas for administration
• Many out there, the ABA Consensus is
• Adults 2-4 ml x Kg x BSA a
• Children 3-4 ml x Kg x BSA a
• ½ of a is given over first 8 hours, remainder
  given over following 16 hours.
• Use a Volutrol in children.

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Fluid Resuscitation

• If done promptly, this formula will allow only a
  minimal drop in circulating volume in the first
  24 hours post burn and will allow return of
  normal circulating volume by the time the patient
  enters his second 24 hours. At this time a burn
  center should be consulted.
• If s/s of Cardiogenic shock develop-r/o MI
• If pt is Hypotensive, look for other causes.
• After the first day, colloids are used to keep
  vascular volume intact w/o fluid overload.

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Fluid Resuscitation

• The most reliable indicator of adequate fluid
  resuscitation remains urine output
• Adult 30-50 ml/hour
• Children 1 ml/kg an hour
• (increase or decrease rate by 1/3 if urine output
  is exceeds or does not meet above standards for 3
  consecutive hours)

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Fluid Resuscitation

• Other v/s are not as reliable in gauging fluid
  therapy.
• B/P will maintain normal until the Pre-Code
  downward cycle (CTD)
• HR should be expected to be elevated 100-120 (as
  high as 140 in peds) for other reasons.
  Therefore it is not a good indicator.

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Drugs in brief

• Aggressive well thought out use of multiple
  pharmacological therapies is mandatory
• Sedatives such as Valium, Ativan, or versed.
• Opioids such as Morphine , Fentanyl
• Steroids Not recommended for respiratory nor
  optic injuries.
• Tetanus and Antibiotics.
• IV route is preferred for appropriate drugs.

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Questions?