How burn patient treatment and destination are affected by severity

By David Wright, MS, PA-C, NRP; Kate Randolph, BS

Every 60 seconds, somebody in the U.S. suffers a burn severe enough to require medical treatment [1]. There is a high probability that you will encounter someone who will require burn treatment at some point in your career.

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These situations are often stressful for emergency medicine clinicians, not only because of the injury caused by the burn, but because burns are more likely to happen to children and older adults, two age groups that already elicit larger amounts of stress from emergency clinicians [1].

Many of these burn injuries could often be avoided with basic household safety and maintenance [2]. As EMS clinicians, we are in a unique position to be able to provide proactive education to patients as we enter their homes. It is imperative for EMS clinicians to understand how heat energy is transferred, how burns are classified and immediate treatment of those burns [3].

Burn classifications

There are multiple characteristics used in the classification of burns. The three most common characteristics used are cause, depth and extent of the burn. Classification by cause would be classified as either thermal or inhalation [4].

Thermal burns involve the skin and may be seen as any of the following:

• Scalds. Caused by hot liquid or steam
• Contact. Caused by hot solids or items such as a hot cooking item
• Flame. Caused by flames
• Chemical. Caused by exposure to reactive chemicals such as acids
• Electrical. Caused by electrical current passing from electric outlet

Inhalation burns are the most serious immediate life threat that can present both with or without an accompanying thermal burn. Inhalation burns occur as the result of breathing superheated gases, hot liquid or steam, etc [4]. EMS clinicians should be on heightened alert for these types of burns as they can cause chemical or thermal damage to the airway and lungs, and in some cases lead to death.

When initially assessing a burn victim, there should be an immediate assessment of the face and airways, examining for signs of inhalation damage, as this is the most common cause of death among those suffering fire-related burns [4,5]. Patients who have airway compromise should have their airway controlled as soon as possible by someone skilled in endotracheal intubation, and taken to a medical center that can visualize the airways with a bronchoscope.

The most important factor in determining how a burn is treated is the depth of the burn. The skin, the largest organ of the body, is divided into the outer epidermis and the inner dermis. The epidermis is composed of a layer of cells that play a major role in protecting our body from harmful substances. The dermis contains blood vessels, nerves, hair follicles, sweat glands, and sebaceous glands. The dermis layer of the skin assists in providing nourishment to itself and the epidermis [5].

When examining a burn’s depth, appearance, blanching to pressure, pain and sensation need to be taken into consideration.⁶ The following points describe the types of burns based on depth:

• Superficial (first degree) burns only involve the epidermis of the skin and appear red or pink with no blistering. Superficial burns are normally dry with moderate pain, typically healing within the next week [6].
• Partial thickness (second degree) burns involve dermis of the skin. When the partial thickness burn only involves the top layer of the dermis, then it will appear red, blistering and wet. This burn will blanch with pressure and is associated with severe pain, typically healing with minimal to no scarring within 3 weeks [6]. Partial thickness burns involving the deeper dermis have a deep cherry-red color, are dry, and will not blanch with pressure [5]. These burns are associated with minimal pain due to loss of sensation, and healing typically occurs within 3 to 8 weeks with considerable scarring [6].
• Full thickness (third degree) burns involve the entire thickness of the skin and subcutaneous structures. These burns appear white, black or brown with a leathery, dry texture [6]. These burns have minimal to no pain due to loss of sensation. Full thickness burns will take over 8 weeks to heal, usually require skin grafting, and, unless treated surgically, will result in scarring, sepsis, and/or death [5].

Classification of Burn Depth

Classification by the extent of the burn is completed using the total body surface area burned (TBSA).

Estimation of total body surface area (Rule of 9s)

To estimate the total body surface area affected by burn injury, the EMS clinician can utilize the rule of 9s. This commonly used tool can be used on both adult and pediatric patients, but it is important to note there are some differences when using this tool on smaller patients [7]. This calculation of burn affected area is critical in determining fluid resuscitation as massive amounts of fluid is lost in burn victims due to the removal of the protective skin barrier. When calculating burn TBSA, it is important to note that only partial thickness and full thickness burns are used to assess the severity of fluid loss [7]. The rule of 9s estimation of TBSA is based on assigning percentages to each body part, as seen below [8].

• Head/neck: 9% TBSA
• Each arm: 9%TBSA
• Anterior thorax: 18% TBSA
• Posterior thorax: 18% TBSA
• Each leg: 18% TBSA
• Perineum: 1% TBSA

Once the TBSA is determined, calculation for fluid resuscitation can be performed via the Parkland Formula. This formula requires the knowledge (or estimation) of the patient’s weight in kilograms (kg). The total fluid volume (TFV) to be infused is calculated using the formula TFV = 4(ml) x (TBSA) x (weight in kg). After the total volume of IV fluid is calculated, the first half is given in the initial 8 hours, with the other half given over the next 16 hours [7]. Fluid resuscitation is critical in the initial management of moderately to severely burned patients, especially in those with >20% TBSA, as mortality in these patients is known to be significantly higher [7]. While it is always important to follow your local protocols, initial fluid management is often performed with normal saline, or normal saline with dextrose, until electrolytes can be evaluated. If potassium is normal, it is then commonly switched to lactated ringer’s solution.

Parkland Formula

Initial burn treatment

For EMS clinicians, the most important treatment for those injured by burns is to remove the offending agent - i.e., stop the burning process. After the patient is removed from the environment, the triage process should begin.

Initially, a rapid assessment of the burn injury should be performed and include the following:

• Is the airway affected?
• Is the patient breathing adequately?
• If electrical - are they in a deadly cardiac dysrhythmia?
• How severe are the burns?
• What percentage of the body is burned?
• Is this a minor, moderate or severe burn?
• Does this patient need a dedicated burn center?

Primary management of burns should include respiratory and cardiovascular support, pain control, fluid resuscitation and management of wounds associated with the burns. Patients with severe burns are at increased risk for end-organ dysfunction primarily from under resuscitation, superimposed infection or underlying medical conditions. Under resuscitation is often the result of lacking fluid resuscitation, resulting in acute kidney injuries [9]. Infections, leading to sepsis, are often due to the contamination of the burns. It is critical that burn wounds are kept as clean as possible and covered with a clean dressing.

Extreme pain is often experienced by patients who have mild and moderate thickness burns. Pre-hospital pain management should be a priority utilizing local protocols appropriately.

After completion of the initial evaluation, is it important the patient does not become hypothermic. Emphasis is often provided to clinicians to complete their assessments by disrobing the patient and exposing the skin, yet it is equally important to ensure that the patient is not placed at unnecessary risk for hypothermia, either during transport or on scene management. Those patients at greatest risk for hypothermia receive prehospital rapid sequence intubation (RSI), or have a documented GCS of less than 8. Patients who experience either of these two incidences are twice as likely to be hypothermic on arrival to the hospital than their non-intubated or more alert counterparts [10].

Wound treatment for superficial and partial-thickness burns primarily includes keeping the wounds clean, preventing additional prehospital injury by removing them from the offending environment and maintaining a warm moist healing environment.⁹

Deeper full-thickness burns are often definitively managed with surgical intervention. For wounds that are dry, a clean dry covering will be effective. If an area of proximal skin is burnt and a distal area is unaffected, it is important to ensure the distal portion of the burned limb continues to be neurovascularly intact throughout treatment and transport [9].

Determining hospital destination

Burn treatment can be increasingly complex, thus patients should be triaged and dispositioned to the appropriate hospital. Level 1 burn centers are hospitals that have complex burn management teams comprised of a wide range of caregivers, including surgeons, anesthesiologist, nurses, social workers, respiratory therapists, therapy, nutrition specialist and psychosocial experts [11].

This multi-dimensional approach to burn management, often results in improved outcomes and better recoveries without the morbidity and disability that can occur in non-burn centers [12].

It is highly recommended that patients presenting with complex, moderate-severe or severe burns are transported to complex regional burn centers [12]. Those patients include those with the following criteria:

• Burns involving face, hands, feet, genitalia or crossing major joints
• Full thickness with no pinprick sensation in the burned area
• Burns with a total body surface area of greater than 10%
• Electrical or chemical burns
• Patients with pre-existing medical conditions that can complicate recovery

Each EMS clinician should be aware of the regional resources available to their patients and system. After accurate triage and assessment, EMS clinicians should determine which type of burn center is the most appropriate for the patient. If a Level 1 burn center would best suit the patient, it is important to evaluate how to get the patient there.

In some urban/suburban communities, a short simple drive will get you there, but in some rural/super-rural communities, a burn center may be many miles away. In those instances, it is important to have prior knowledge of burn centers, local resource capabilities, and what modes of transportation is available to patients to get them to where they need to go.

EMS transportation options

EMS often has three primary modes of transportation available to them:

• Ground ambulance
• Helicopter (rotor wing)
• Plane (fixed wing)

Pros and Cons of each mode of emergency transportation

When evaluating the need for a helicopter for transporting a burn patient, the paramedic should ask themselves the following questions [13]:

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• Does the patient require minimal transport time outside of the hospital or critical care setting?
• Are there time critical evaluations or treatments for the patient which are required but unavailable at the closest facility?
• Are ground units able to access the patient for timely transport?
• Are the predicted and current weather conditions along the expected path and nearby areas amenable to rotor-wing flight?
• Do the patient and all accompanying equipment fall within the size and weight limitations of the aircraft?
• Are helipads, airports or landing zones available near the referring and receiving hospitals?
• Can ground-based personnel provide the patient’s care requirements, or does the patient require a higher level of care only available on a HEMS unit?
• Can local ground transport services adequately provide a local response if a unit is taken out of service for a prolonged transport?
• Is regional ground-based critical care transport a viable alternative to HEMS transportation?

When evaluating the burn, HEMS activation should be considered for the following criteria:

• Greater than 20% total body surface area (TBSA) burns
• Burns to the face, head hands, feet or genitals
• Inhalation burn or injury
• Electrical or chemical burns
• Burns with associated injuries (fractures, crush)

Burn treatment considerations

Treating burn patients can be anything from a routine small burn to a very complex burn requiring specialized medical care and support. No matter what the severity of the burn, it is important to always consider the following:

• Remove from burning area
• Keep clean and dry
• Control hypothermia
• Ensure pain control
• Pick the right destination
• Make the right transportation decision

By keeping these things in mind, you can make sure you are treating your patients appropriately and efficiently, providing the best possible care at the right time to your community.

Read next: Superficial burn care

Test your knowledge. Take the quiz: Burn classification and treatment

References

1. National Fire Protection Association (2020) Burn Awareness. Accessed from: https://www.nfpa.org/burnawareness
2. Stanford Children’s Hospital (2020). Preventing Burn Injuries. Accessed from: https://www.stanfordchildrens.org/en/topic/default?id=preventing-burn-injuries-90-P01750
3. Navarro, K. (2010). Prehospital Management of Burns. Accessed from: https://www.dshs.texas.gov/emstraumasystems/JA10CEArticle.pdf
4. Johnson, N. J. (2017, March). World Report on Child Injury Prevention. https://www.who.int/violence_injury_prevention/child/injury/world_report/Burns.pdf?ua=1
5. Hussain, A. (2018). Surgical treatment of acute burns. Wounds UK, 14(2), 30–37.
6. Warby, R. (2020, July 18). Burn Classification - StatPearls - NCBI Bookshelf. NCBI. https://www.ncbi.nlm.nih.gov/books/NBK539773/
7. Moore, R. A. (2020, July 10). Rule of Nines - StatPearls - NCBI Bookshelf. NCBI. https://www.ncbi.nlm.nih.gov/books/NBK513287/
8. University of Wisconsin Hospitals and Clinics Authority. (2017). Assessing Burns and Planning Resuscitation: The Rule of Nines. UW Health. https://www.uwhealth.org/emergency-room/assessing-burns-and-planning-resuscitation-the-rule-of-nines/12698
9. UpToDate (2020). Overview of the Management of the Severely Burned Patient. Accessed from: https://www.uptodate.com/contents/overview-of-the-management-of-the-severely-burned-patient?search=burn%20treatment&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2
10. Page, D. & Trembley, A. (2014). Are We Keeping Out Burn Patients Warm Enough?. JEMS Vol 9 (39). Accessed from: https://www.jems.com/2014/09/15/are-we-keeping-our-burn-patients-warm-en/
11. Al-Mousawi, A. M., Mecott-Rivera, G. A., Jeschke, M. G., & Herndon, D. N. (2009). Burn teams and burn centers: the importance of a comprehensive team approach to burn care. Clinics in plastic surgery, 36(4), 547–554. https://doi.org/10.1016/j.cps.2009.05.015
12. Wilson Shupp, J. (2018) When to Seek Treatment at a Burn Center. American Burn Association. Accessed from: https://ameriburn.org/when-to-seek-treatment-at-a-burn-center/
13. Godfrey A, Loyd JW. EMS, Helicopter EMS (HEMS) Activation. [Updated 2020 Aug 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513336/
14. Mayo Clinic (2020) Burn Safety: Protect your child from burns. Accessed from: www.mayoclinic.org/healthy-lifestyle/infant-and-toddler-health/in-depth/child-safety/art-20044027
15. American Academy of Family Physicians. Burns: Preventing burns in your home. Accessed from: https://familydoctor.org/burns-preventing-burns-in-your-home/
16. Center for Disease Control and Prevention (2020). Burn Prevention. Accessed from: https://www.cdc.gov/safechild/burns/index.html

About the authors

Kate Randolph, BS, recently graduated in May 2020 from Central Methodist University where she graduated with honors with a Bachelor of Science Degree in Biology. She is highly motivated to continue working to complete the pre-requisites before pursuing admission as a physician assistant student in 2021. She is currently employed at Mercy Hospital in Creve Couer as a patient care associate in the Medical Progressive Care Unit where she is able to provide excellent patient care and follow her passion for medicine, while obtaining valuable experience in the healthcare field. She hopes one day to work as a pediatric physician assistant taking care of infants and children in their time of need.

This article was originally posted Feb. 4, 2021. It has been updated.

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