Thermal Burns: Treatment, special situations and prevention tips for EMS

By Jim Sideas

When assessing the burn patient, there are several things that the provider will need to determine. These will be important for the immediate treatment, and also for the treatment that will be provided in the hospital. This information includes:

• How long ago did the burn occur? This is vital information for determining the burn process as well as administration rates for fluid resuscitation.
• What has been done to the patient? You will need to determine if the patient been given any medications or treatments. This will impact the treatment in the future.
• What caused the burn?
• Was the patient burned in closed space? If the burn occurred in a closed space, there could also be concerns of smoke and carbon monoxide exposure.
• Was there loss of consciousness? This may indicate trauma, and require further investigation for trauma protocols to also be instituted. Burns do not cause unconsciousness.
• Does the patient have allergies to medications (especially pain medications)? This patient may be conscious when you arrive, however that may change. With significant burns, the patient will require pain management. This may include medications such as morphine to effectively control the pain in follow-up care.
• What is the patient’s past medical history?

With any type of burns, quick patient assessment is critical. Keep in mind, a burn will not truly “declare” itself, or reveal the extent of the damage, for up to 24 hours. Airway assessment is critical with any burn. The administration of oxygen should be started with any patient who has:

• moderate to critical burns
• decreased levels of consciousness
• signs of respiratory involvement
• burns that occurred in a closed space
• a history of carbon monoxide or smoke exposure

In addition to oxygen, the patient may need assistance with ventilations. Depending on the extent and nature of the burns, the patient may need to be intubated, and the situation may require rapid sequence intubation (RSI).

Fluid Therapy
Patients with significant burns will need fluid resuscitation. The long-held standard to determine the amount of fluid and administration time is the Parkland Formula. LR is the preferred solution when using the Parkland Burn Formula

Consideration for fluid therapy should be for patients with:

• >10% of the total body surface area (TBSA) with 3rd degree burns
• >15% of the TBSA with 2nd degree burns
• >30-50% TBSA 1st degree burns with accompanying 2nd degree burns
• When in doubt, TBSA > 20%

For adults, the Parkland Formula is:

• 4 cc x weight in kg x total body surface area (%) burned
• 1/2 of the total should be administered in first 8 hours
• 1/2 over the next 16 hours
• The start time for administration is the time which the burn occurred, not when EMS or medical care is started. This may require a catch-up time if there is a delay to care.

For pediatrics, there are several different formulas for fluid resuscitation. This is because the total body surface area differs with the age of the child. The ones listed below are some being used around the country.

• Shriners’ Burn Institute (Cincinnati) - 4 mL/kg per percentage burn plus 1500 mL/m2 BSA
  • First 8 hours - LR solution with 50 mEq sodium bicarbonate per liter
  • Second 8 hours - LR solution
  • Third 8 hours - LR solution plus 12.5 g of 25% albumin solution per liter
• Galveston Shriners’ Hospital - 5000 mL/m2 TBSA burn plus 2000 mL/m2 BSA, using LR solution plus 12.5 g 25% albumin per liter plus D5W solution as needed for hypoglycemia

Fluid therapy should have several outcomes. With a burn, the patient’s pulse rate will elevate while the blood pressure will decrease.

• Objective:
  • HR < 110/minute
  • Normal sensorium (awake, alert, oriented)
  • Urine output - 30-50 cc/hour (adult); 1 cc/kg/hr (pediatric)
• Resuscitation formulas provide estimates. Remember to adjust to patient responses
• If necessary, start IV access through the burn area, upper extremities are preferred locations for IV access
• Monitor for Pulmonary Edema or pulmonary complications

Special Considerations
There are special considerations that need to be taken regarding the care of either pediatric or geriatric burn patients.

Pediatric patients have thinner layers of skin. This will increase the level of burn severity. Due to their size, children have smaller airways which can make intubations more difficult. The smaller airways also lead to a limited respiratory reserve capacity. With any pediatric burn patient, the providers need to consider possibility of abuse. This needs to be a suspected with burns to a child’s feet and buttocks, since it may be the result of dipping a child into a hot water. Responders need to be aware of the warning signs for child abuse:

• Story does not fit the injuries
• Delays in seeking medical care
• No splash marks on body
• Pattern and location of injury
• Developmental age of the child

Be sure to document thoroughly!

Geriatric patients also have special concerns. Their skin is thinner, and they may have decreased peripheral circulation which can slow the healing process. Geriatric patients may also have other underlying disease processes, such as peripheral vascular or pulmonary diseases that can compound burn injuries. These patients may also have a decreased cardiac reserve that can impact the patient’s ability to survive. There is a guide to the potential mortality rate for a geriatric burn patient. That formula is: percent chance of mortality = age + percent BSA burned

Burn Unit Referral Guidelines
The American Burn Association recommends the following patients should be treated at a burn unit:

• 2nd degree burns > 10% TBSA
• Burns involving the face, hands, feet, genitalia, perineum, and any major joints
• 3rd degree burns in any age group
• Electrical burns, including lightning injuries
• Chemical burns

If a burn unit is not close by, know how to contact them and a flight team for possible transfer. Burn units are highly trained in the care of these patients. They work with a multi-disciplined approach and a team of nurses, physicians and therapists to treat the patient and help the family.

Prevention Issues
The fire service and EMS providers can play an important role in preventing burns. It is estimated that 75% of all burns are preventable. There are simple things your department can do which can increase the public awareness of burn prevention. This can be done through media releases that can be sent out for every season.

In early summer, encourage people to fuel lawn mowers before use, and not to refill hot mowers. Hot mowers can easily start on fire. In July, stress the safety of fireworks, and that even sparklers (with a tip temperature of +1,800 degrees) need adult supervision. Fall is the time to discuss kids and lighters since kids may be home after from school and possibly unsupervised. In winter. discuss candles and fireplace safety. Finally, spring is the time to remind parents to turn water heaters to 120 degrees. At 150 degrees (which is what water heaters are often set at), water can cause significant scald burns to children in less than 2 seconds.

Burns are devastating injuries, and we need to prepare to handle these emergencies quickly. They are also difficult for medical providers, since they are not common occurrences. This makes training and preparation vital. The education can be as simple as discussing burn care issues and incorporating these issues into fire training. It can be part of the daily station training routine. Station officers owe this to their crew and the community they protect. Leaders always have to remember the five P’s, “Prior planning prevents poor performance.”