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Prehospital
Care:
- The immediate goal is to remove the victim from the source of
the burn. This must be accomplished without endangering rescue personnel.
- During the assessment of the airway, careful attention should
be given to the signs of inhalation injury. Findings such as carbonaceous sputum, singed
facial or nasal hairs, facial burns, oro-pharyngeal edema, changes in the voice or altered
mental status all suggest the possibility of inhalation injury. Any person whose history
suggests that she/he was present in a confined fire environment should also be assumed to
have an inhalation injury. The airway should be secured by endotracheal intubation as
necessary, and high flow supplemental oxygen via mask or endotracheal tube should be
delivered. (See chapters on Smoke Inhalation and Toxicity, Carbon Monoxide for further
information).
- Concurrent with this, the clinician must stop the burning
process. Charred clothing should be removed and the tissues can be cooled with saline or
clean water. Once the burn has been cooled, the victim should be placed in dry, sterile
sheets. Prolonged irrigation with cool fluids or leaving the victim in wet sheets will not
improve the burn, and will greatly increases the risk of hypothermia.
- After more life threatening issues have been addressed, minor
burns should be cooled with running tap water and dressed.
Emergency Department Care:
- After the airway is stabilized, assess the extent and depth of
the burn injury, as outlined above.
Airway
edema can develop rapidly in a burn victim who has inhaled toxic products of combustion or
heated gasses. Intubation should be considered early on in those patients who show signs
of such inhalation, such as singed nasal hairs, facial burns, oral burns, sooty sputum or
respiratory difficulty manifested by stridor or wheezes. Fiberoptic laryngoscopy or
bronchoscopy can be helpful in assessing the extent of airway involvement.
Maintain a high index of suspicion for airway injury and a
low threshold for intubation, since once edema forms, intubation may be extremely
difficult.
- IV access should be obtained. Two large-bore peripheral lines
should be started and crystalloids administered. With the loss of the vapor barrier
provided by the intact skin, burn victims have very large insensible fluid losses. The
fluid needs for the burn victim, in the acute phase can be calculated using the Parkland
Formula:
(4 cc of crystalloid) x (% burn) x
(body weight in kg)
Example: A 70 kg man with a 30% burn would require: (30) x
(70 kg) x (4 cc/kg) = 8,400 cc in the first 24 hours
One half of the calculated fluid needed is administered in
the first 8 hours, and the balance is given over the remaining 16 hours. Thus, for the
first 8 hours, fluids would be given at 525 cc/hr and then at 262.5 cc/hr for the
remaining 16 hours.
The usual markers of fluid status, such as urine output,
should be followed and the fluids adjusted accordingly. Placement of a Foley catheter
simplifies the following of hourly urine output. Urine output should be maintained at 0.5
cc/kg/hr. Fluid resuscitation needs in electrical injuries are not accurately predicted by
this formula and the presence of co-existing trauma may also increase fluid volumes needed
for resuscitation.
For pediatric patients, an alternative formula for
calculation of fluid needs is the Galveston Formula. It is based on body surface area,
rather than weight. While many pediatric burn centers feel it is more accurate, it is more
time consuming to use:
LR is used at 5000cc/meter squared x % BSA burn plus
2000cc/meter squared/24 hours of maintanence. One half of the total fluid is given in the
first 8 hours, with the balance given over the next 16 hours.
Urine output in pediatric patients should be maintained at 1
cc/kg/hr.
- When circumferential full thickness burns involving the
extremities or chest are present, escharotomy may be necessary. The eschar is tough and
rigid. As edema forms in the injured extremity, following the burn, the eschar restricts
the outward expansion of the tissue. As a result, interstitial pressure rises to the point
that vascular flow is compromised. In short, the eschar behaves like a tourniquet.
Inscising the eschar allows return of flow and prevents further ischemic injury. The
escharotomy should be performed along the lateral aspect of the extremity. Use of an
electrocautery simplifies the procedure and can reduce the amount of bleeding. The
incision should go completely through the eschar. The subcutaneous fat will appear to
bubble up into the escharotomy wound.
If the
chest is involved and the eschar compromises ventilatory motion, an escharotomy, involving
the anterior chest should be performed. The incisions are made along the costal margin,
the anterior axillary lines and across thetop of the chest, freeing up the anterior chest
wall.
- Most burns seen in the ED are minor. The key point in managing
these wounds is to be sure that the patient has adequate follow-up. The burn area should
be cooled with towels moistened with cool sterile saline. Avoid immersion in ice baths.
Burns of areas such as the face are best treated by an open technique,
with the area being washed, any open blisters debrided and the wounds covered with topical
antibiotics, such as Neosporin or Bacitracin.
Minor burns of other areas should be cleansed. A debate
exists as to whether intact blisters should be debrided, as the intact skin serves as a
hermetic barrier, though the blister fluid can serve as an excellent medium for bacterial
growth. Another argument for debridement is that removal of the blister roof allows the
topical agents to reach the burn tissue.
Debride open blisters. Blisters that are intact, but are
located in areas that have a high likelihood of rupture may be sharply debrided or the
blister fluid aspirated. The wounds should then be treated with a topical antibiotic and
dressed. The patient should be discharged with explicit instructions on how to clean and
dress the wound, and follow-up for evaluation of the wound should be arranged.
- It is important to remember to check the tetanus status of all
patients, and to administer a tetanus immunization (Td) as appropriate.
Consultations:
- Critical burns should be referred to a regional burn center for further management.
Burns involving critical areas, if not referred to a burn center, should be evaluated by a
burn surgeon or plastic surgeon.
- Patients whose history suggests the possiblity of inhalation injury should be admitted
for observation.
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