CE Article: Thermal Burn Injury—Part 2

Part 2 of a three-part series.

Objectives

• Describe scene safety, assessment, and triage of burn injury;
• Explain effective pain management, wound care, and dressings for burns;
• Identify common obstacles to proper assessment and treatment of burns.

This three-part review and update of thermal burn injury began last month with an overview and discussion of the area impacted and burn injury classification. This second part will focus on general assessment, ABCDEs, and wound care. The final part next month will conclude with pain management and complex and critical burn injuries. 

Scene Safety, General Assessment, and Triage

If prearrival information suggests the source of the burn injury is potentially a chemical/hazardous material, explosion, or radiation source, rely on local protocols for PPE guidance when approaching the scene. While this article does not address these risks, scene safety must remain a critical component  of all responses.

The airway, breathing, circulation, disability, and exposure (ABCDE) steps for the patient with a burn injury include the following components.¹ 

Airway—Assess for airway patency. Critical components of airway assessment include the history (e.g., burn in a confined space) and differentiating between steam and dry heat (steam signifies a more serious injury). Administer oxygen as the condition indicates. Also ask family or friends if the patient’s voice seems altered, which indicates an inhalation injury.

If an advanced airway is indicated by your protocol, endotracheal intubation is preferred. The appropriate-size tube is essential. You may see the patient well before significant laryngeal edema takes place, and if endotracheal intubation is indicated, your tube may be left in place for several days throughout initial care. A blind-insertion airway device is not preferred in this situation.

Breathing—The breathing assessment should include lung auscultation and assessment of oxygen saturation (SpO₂) and chest wall movement. Auscultation may include findings such as a hoarse-sounding cough or stridor noted with breath sounds, as well as soot-tinged sputum and decreased oxygen saturation. Assess for circumferential burns involving the chest wall. A positive finding is a true emergency, and the patient needs transport to a location where a fasciotomy can be performed. 

Circulation—Patients with obvious burn injury who show signs and symptoms of hypovolemia require immediate assessment for concomitant trauma. Patients with burn injury in isolation will also need fluid resuscitation but are less likely to show signs of hypovolemic shock early in the incident. 

Assess distal neurocirculatory function in all extremities, paying particular attention to limbs with significant circumferential burn injury. The blood pressure may be within normal limits and the pulse rate either within normal limits or mildly tachycardic. Initiate an ECG on all patients with burn injury, particularly those with electrical or chemical burns. 

Fluid resuscitation for patients with burn injury is best accomplished using lactated Ringer’s, the intravenous fluid that most closely mimics the fluid lost in a burn injury. If it’s not available, 0.9% sodium chloride (saline) solution is sufficient. Nevertheless, as soon as LR is available, it should replace the saline. 

The American Burn Association (ABA) has updated recommendations for fluid resuscitation infusion rates for those involved in the initial care of burn-injured patients. Its aim was to create a simple guide given the chaos EMS may face on scene. The approach was to remind responders that fluid resuscitation remains important, but of equal importance is the concern of overresuscitation—infusing too much fluid.

For adult patients with an injury that’s less than 20% total body surface area (TBSA), obtain intravenous access and initiate an infusion at a rate of 125 cc/hr. It’s also essential to provide nothing by mouth (NPO), meaning withhold food and fluids. For adult patients with an injury of 20% TBSA or more, obtain IV access and initiate an infusion at a rate of 500 cc/hr. This patient should also be considered NPO.

For pediatric patients the rate will depend on age. With patients under 5 years, regardless of burn size, if your assessment suggests the importance of infusing fluid, obtain intravenous access and initiate an infusion at a rate of 125 cc/hr. For pediatric patients with burns comprising 20% TBSA or more, if they are 6–13 years of age, obtain intravenous access and initiate an infusion at a rate of 250 cc/hr. If they’re 14 or older, the infusion rate is 500 cc/hr. 

Disability—Also assess patients with burn injury for their level of consciousness. The AVPU scale is well suited and evaluates subjects as alert, responsive to verbal stimulation, responsive to pain, or unresponsive. The additional components of limb movement and pupillary light response are also relevant. Testing the blood glucose level has a higher degree of urgency for pediatric patients, who are more at risk for becoming hypoglycemic as a complication of burn injury.² 

Exposure—A significant burn injury includes a substantial injury to the body’s protective covering, the skin. This injury compromises the body’s ability to maintain normothermia. With a room at an otherwise-comfortable temperature of 70°F (21.1°C), hypothermia can develop due to the damage to the skin. To help offset this, the typical hospital burn ICU has environmental controls allowing higher temperatures, with patient rooms routinely in the 80°F–90°F (26.67°C–32.2°C) range. Note that increased mortality has been observed in patients with 20%–39% TBSA burns as well as the 40%-or-more TBSA population who arrive at the hospital by EMS with a core temperature of 97.7°F (36.5°C) or below.^3,4 

If a thermal injury was produced by a mechanism such as an explosion, this rather distinct and somewhat gruesome injury might be distracting, leading the responder to overlook their assessment for concomitant trauma, including the immediate life threat of internal hemorrhage. 

Wound Care and Dressings 

Wound care and pain management for partial- and full-thickness burns should include only enough water to stop the burning process. For minor burns (less than 5% TBSA), sterile or clean water can be used to stop the burning process and manage the pain. However, for moderate and significant burns, using excessive water for pain management is contraindicated and can lead to hypothermia, depending on the size of the burn. 

Do not attempt to drain the blisters or debride the wound site. Palpate the area contiguous to the burn injury and use water to achieve normothermia. Once the wound temperature is no longer hot to touch, pain management should include either IV or IO morphine or a similar pain medication. 

Slightly elevate all extremities with burn injuries (above the level of the heart) to minimize the risks and complications associated with swelling. This can be accomplished with a pillow.

Cover the partial-thickness burn injury with a clean, dry dressing, and a physician should evaluate the patient. This is a potentially serious burn. Do not continuously flush the area with water unless the source of the burn is a chemical.⁵ 

A clean, dry dressing is also preferred for moderate and severe burns, which are typically managed at burn centers. Everything applied to the injury before reaching the burn center will be removed during the debridement process shortly after arrival. Debridement is a process whereby burn-injured patients are appropriately medicated/sedated and taken to a room where warm water under pressure is used to remove dressings and other foreign material and necrotic tissue to fully expose the injury. 

There are many commercially made burn-specific dressings impregnated with various additives. Commercially manufactured dressings that include some aspect of a silver solution have historically been recommended for situations in which the time between the burn injury and admission to the burn center is greater than 6–72 hours. Soldiers and Marines over the past 15-plus years had these dressings applied early in their management in Iraq and Afghanistan and maintained until arriving some 72–120 hours later at Brooke Army Medical Center (BAMC) in San Antonio.^6–8  

For civilians, when a burn center can be accessed in less than six hours from the time of the injury, there is no conclusive evidence that the use of impregnated dressings offers a significant benefit for the burn-injured patient. In fact, it may delay definitive care. 

There are other commercially sold dressings reported to have wound-healing properties, but the active ingredient does not include a silver-based product. These dressings may aid in the healing process for a burn-injured patient if you have an extended transport time to a burn center. However, as with the silver-impregnated dressings, they tend to be expensive, and there is no conclusive evidence of their added value to a patient whose injury is managed at a burn center in the first few hours. 

Traumatic vs. Burn Injuries

While burn injury is commonly associated with trauma and the two share many similarities, they are not the same. Patients with penetrating or blunt-force trauma can exsanguinate or suffer other grave consequences even when the most optimal care is provided in the prehospital and community hospital setting. The one definitive solution for this patient is the rapid movement to a trauma center and the care of a trauma surgeon. 

However, a burn injury properly managed in the prehospital and community hospital setting is far less likely to lead to grave consequences over the same period. As noted with the military experience, burn-injured patients who receive appropriate care have good outcomes following much larger windows of time from initial injury to arrival at the burn center.

While this is not a reason to delay the transfer of a burn-injured patient, it is critical to note where concomitant trauma is suspected. The patient must be cleared of the traumatic injury that could take their life first. In these cases patients with burn injuries and potential traumatic injuries are best managed at burn centers where trauma services are contained within the same hospital.  

References

1. Thim T, Krarup NH, Grove EL, et al. Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. Intl J Gen Med, 2012; 5: 117–21.

2. Jeschke MG, Pinto R, Herndon DN, et al. Hypoglycemia is associated with increased postburn morbidity and mortality in pediatric patients. Crit Care Med, 2014; 42(5): 1,221–31.

3. Weaver MD, Rittenberger JC, Patterson PD, et al. Risk factors for hypothermia in EMS-treated burn patients. Prehosp Emerg Care, 2014; 18(3): 335–41.

4. Du Pont B, Dickinson E. Identifying and managing accidental hypothermia. J Emerg Med Serv, 2017; 42(11).

5. Kearns RD, Cairns CB, Holmes IV JH, et al. Chemical Burn Care: A Review of Best Practices. EMS World, 2014; 43(5): 40–5; www.emsworld.com/article/11362795/chemical-burn-care-review-best-practices.

6. Cancio LC, Horvath EE, Barillo DJ, et al. Burn support for Operation Iraqi Freedom and related operations, 2003 to 2004. J Burn Care Rehabil, 2005; 26(2): 151–61.

7. Chung KK, Blackbourne LH, Wolf SE, et al. Evolution of burn resuscitation in operation Iraqi freedom. J Burn Care Res, 2006; 27(5): 606–11.

8. Kearns RD, Holmes IV JH, Cairns BA. Burn injury: What’s in a name? Ann Burns Fire Dis, 2013; 8(3): 6.

Randy D. Kearns, DHA, MSA, FACHE, FRSPH, CEM, is an assistant professor in the College of Business Administration at the University of New Orleans and a retired clinical assistant professor from the School of Medicine at the University of North Carolina. 

Christopher K. Craig, DMSc, MMS, PA-C, is assistant professor of surgery and senior physician assistant of trauma/burn services and disaster and prehospital services at Wake Forest University.

Michael W. Hubble, PhD, MBA, NRP, is an instructor in the Emergency Medical Science Department at Wake Technical Community College.

Amanda P. Bettencourt, PhD, APRN, CCRN-K, ACCNS-P, is a research fellow and TACTICAL Scholar at the University of Michigan School of Nursing.

James C. Jeng, MD, FACS, is a physician at Crozer-Keystone Health System and Nathan Speare Regional Burn Treatment Center, professor of surgery at Icahn School of Medicine, Mount Sinai Healthcare System, and chair of the Disaster Subcommittee of the Organization and Delivery of Burn Care Committee for the American Burn Association.

Jeffrey E. Carter, MD, FACS, is associate professor of surgery  at the Louisiana State.  University Health Science Center New Orleans and medical director of the University Medical Center Burn Center, New Orleans.