In today's topic, and in a previous Instagram post (see it HERE) that there was a lot of incredible and earnest discussion about appropriate treatment for burns. We wanted to take a few minutes to expand on this subject a little bit and explain on some important topics.
As a point of clarification:
When we post on a topic, we are looking at it from the perspective of a First Responder, Civilian, or Military Medic in the field. We are not expecting the kind of resources, medications etc. that are available in a hospital. Think of it as what YOU could do on the ground with your aid bag for the patient BEFORE they arrive at a treatment facility.
Burns are extraordinarily difficult to treat, create long-term complications for hours and even months and years after initial injury, and depending on the severity, can fit anywhere in the MARCH algorithm of care. We will concentrate on the most severe injuries in this explanation.
WE STILL FOLLOW SMARCH!!!!! This may be abbreviated, but the elements of it still apply!
-- Remove the patient from the situation that caused the burn. Do not try and treat the patient in a hazardous environment! PUT OUT THE FLAMES IMMEDIATELY.
Use common sense at this point to assess the appropriate next steps, some of which can be done simultaneously. Was this person just covered in flames or suffering flash burns from an explosion or IED, or is it something smaller like their leg suffering a bad burn?
Massive Hemorrhage: A quick inspection of wounds can determine if massive bleeding needs to be addressed. Stop all Massive Hemorrhage.
At this point-- STOP THE BURNING PROCESS. Just because you have put out the flames doesn’t mean the skin has returned to normal temperature. Just because you take a hamburger patty off the grill doesn’t mean its room temperature immediately. Actively work to cool the skin with water, hydrogel, burn blankets, or whatever you have available. Getting the skin back to normal temperature asap is important.
Go through the rest of your MARCH sequence quickly but efficiently. If no other life-threatening interventions are necessary-and burns is the primary injury, start thinking about the following.
1) Facial Burns, especially those that occur in closed spaces, could be associated with inhalation injury. You must AGGRESSIVELY monitor airway status and O2 saturation.
- STRONGLY consider early surgical airway (Cric’ing).
- Once an airway has swelled up and shut, it is extremely difficult to open.
I have personally witnessed someone come into a hospital after receiving a flash burn to the face, talking and apologizing to the staff for how silly she felt letting it happen. They immediately RSI’d her and secured her airway—and it’s a good thing they did because not even an hour later her airway had completely swollen and closed off. If it were not for their immediate intervention that seemed unnecessary at first glance, this woman would have died.
From a field providers perspective and something—any suspected or confirmed inhalation injury (look for blackened nose hairs or singed eyebrows as possible sign) will get a pre-emptive lidocaine to the cricothyroid area in preparation for a cric. Any decrease in O2 sats or changes in breathing by the patient gets a surgical airway immediately. We’d rather get punched in the face later for a throat scar than let someone talk me out of it.
2) Estimate the Total Body Surface Area (TBSA) to the nearest 10% using the Rule of 9’s.
3) Cover the burn area with dry, sterile dressings.
4) For extensive burns (over 20% BSA) We’d highly recommend a Heat-Reflective Shield or other LIGHT covering to try and retain the patients heat. Keep in mind that you will be dealing with damaged nerve endings, so while retaining patients body heat is important, putting heavy material on them must be balanced with appropriate pain management if that’s all you have.
5) Fluid Resuscitation (Rule of 10’s)
- We noticed a lot of people were still using the Parkland Burn Formula. This has been replaced with the Rule of 10’s.
Rule of 10’s:
- A) For Burns over 20% TBSA, start fluid resuscitation ASAP once IV/IO has been established.
- B) LR preferred, but NS or Hextend can also be used (no more than 1L of Hextend, but can be followed by LR and then NS)
- C) Initial fluid rate is calculated at %TBSA x 10ml/hr for adults weighing 40-80kg (88lbs-176lbs)
- D) For every 10kg ABOVE 80kg, increase initial rate by 100ml/hr.
- E) If hemorrhagic shock is present, resuscitation for hemorrhagic shock takes precedence over burn shock. Administer fluids for TCCC Fluid Challenge first in Hemorrhagic shock.
6) You can and SHOULD administer analgesic for pain if patient is conscious or drifting in and out of consciousness.
--We had many people suggesting Fentanyl as an analgesic. While an effective method of pain control, in someone we anticipate having breathing complications, it is inadvisable to push opioids that depress respiratory drive. We strongly recommend Ketamine instead.
7) IF TRAINED—you can consider escharotomy for circumferential extremity burns with promised circulation and or/circumferential thoracic burns with compromised ventilation. LIMIT ESCHAROTOMY TO DEPTH OF BURN!
8) Splint burned hands and feet in position of function with dressings separating digits.
9) Consider AGGRESSIVE pain management in critical burn patients.
10) initiate AGGRESSIVE hypothermia management in extensive burn patients.
The more you are able to quickly stop the burning, get the skin back to room temperature, and manage their symptoms, the better their short AND long-term prospects for survival and recovery are. Burns are awful, but how you manage to treat at point of injury will be crucial. Hope this has helped!! Feel free to add comments below.
If you can’t remember the Rule of 10’s, what appropriate analgesia might be, the landmarks for a cric, or a host of other things that as medics we don't have time to second guess ourselves on, we have a solution. Pick up a Medic Quick Reference Guide found HERE !!!! and check out what other guides we offer. We have additional medical topics in our blog, so check them out!