Burns are the result of damage to cellular membranes, producing widespread injury to the integumentary system. This damage can cause severe fluid loss, place patients at heightened risk for infections, and lead to hypothermia. Soft tissue burns can be caused by thermal injuries, chemical exposure, electrical contact, or exposure to ionizing radiation. The mainstay of treatment for burns involves cooling, fluid resuscitation, and pain management. Burns are optimally managed at an appropriate trauma receiving hospital.
Essentials
It is critically important to maintain the airway. Burned patients should receive supplemental oxygen; paramedics and EMRs/FRs must be keenly aware of the potential for rapid development of airway compromise, either from upper airway obstruction or pulmonary edema. Signs of airway burns include cough, voice changes, and soot in the mouth, nose, or in sputum. Consider early advanced airway management in these cases.
Patients must be decontaminated where applicable. Remove clothes and flush burns with cool running water or saline. Hair, hands, and face should be cleaned with water and baby shampoo.
It is recommended that patients with burns receive 15-20 minutes of cooling in the immediate aftermath of the burn. This is inclusive of any time bystanders have provided effective cooling measures. Cooling of burns immediately following injury is a critical intervention to reduce the risk of skin graft requirements, long-term scarring, chronic pain, and sensory disturbances. Cooling is also an important analgesic strategy in these patients. Burns should be cooled with cool (not cold) running water wherever possible, which may involve remaining on scene for over 20 minutes in patients without immediate life-threatening burns or injury, to access a source of cool running water. In patients requiring immediate conveyance, the use of cool saline may be sufficient to help limit the damage caused by the burn. Paramedics and EMRs/FRs should continue to be diligent in monitoring for signs of hypothermia whilst cooling burns patients and avoid whole-body cooling if possible. Consider utilizing ambulance heater if required.
If applying burns dressings, the 'shiny side' faces down/towards the patient.
Burned patients lose fluids rapidly. In the immediate aftermath of a burn, patients should receive up to 2 liters of fluid to maintain a systolic blood pressure > 120 mmHg.
For partial thickness or deeper burns, estimate the body surface area involved using the Lund and Browder chart.
Additional Treatment Information
Burns are often associated with other types of trauma. Fluid therapy to manage shock due to blood loss must strike a balance between the patient’s fluid requirements resulting from the burn and the need to prohibit further bleeding from the traumatic injury.
In any fire environment, carbon monoxide is a by-product of combustion and is one of the many chemical products in smoke. Carbon monoxide poisoning should be suspected in any patient who was in an enclosed space. Provide high-flow supplemental oxygen and monitor SpCO where available. See J02: Carbon Monoxide for additional treatment information.
Hydrogen cyanide is a colourless gas with a faint, bitter, almond-like odor. Sodium cyanide and potassium cyanide are both white solids with similar odours in damp air. Cyanide salts and hydrogen cyanide are used in electroplating, metallurgy, the production of organic chemicals, photography, plastics manufacturing, the fumigation of ships, and some mining processes. Fires involving modern building materials, plastics, and furnishings can also produce large amounts of cyanide, and individuals exposed to the smoke from these fires can have significant cyanide exposures. See J03: Cyanide for additional treatment information.
All patients with burn trauma should be conveyed to the closest appropriate trauma receiving hospital as per local trauma destination guidelines or clinical pathway.
General Information
Trauma Services BC defines a major burn as any of the following:
> 20% total body surface area (TBSA) partial and/or full thickness, any age
> 10% TBSA partial and/or full thickness, age < 10 or > 50
> 5% TBSA full thickness, any age
Burns to face, hands, feet, genitalia, or joints
Electrical burns
Chemical burns
Inhalation injury
Any burns associated with major trauma
The American Burn Association classifies burns as minor, moderate, and major based upon burn depth and size. The traditional classification of burn depth as first, second, third, or fourth degree is being replaced by a system reflecting the future treatment requirements in the continuum of care, although 'fourth degree' is still used to describe the most severe burns.
Superficial: burns involving only the epidermal layer of the skin; they are painful, dry, red, and blanche with pressure
Superficial partial-thickness: burns involving the epidermis and superficial portions of the dermis; they are painful, red and weeping, usually form blisters, and blanch with pressure
Deep partial-thickness: burns extending deeper into the dermis damaging hair follicles and glandular tissue; they are painful to pressure only, almost always blister, are wet or waxy dry, and display variable colour from patchy white to red
Full thickness: burns extending through, destroying the dermis; they are usually painless and the skin can vary in appearance from waxy white to leathery grey, to charred and black
Fourth degree: burns extending through the skin to underlying tissues of the fascia or muscle
Cool burned areas for 15-20 minutes using cool running water wherever possible; this may require remaining on-scene for a prolonged period of time
In patients with life-threatening injuries where it is not possible to remain on-scene, the use of cool saline may be sufficient to help limit the damage caused by the burn
Avoid cooling the entire patient to prevent hypothermia
Provide supplemental oxygen for patients with potential airway burns or inhalation injuries
Consider induction and anesthesia maintenance strategy if airway management is predicted; ketamine is the preferred induction agent; phenylephrine must be available for peri-intubation hypotension; post-induction analgesia is likely to be required
Change to balanced fluids (Plasmalyte/Ringers Lactate)
Goal is urine output 30-50 ml/hr
If urine output ≤ 30 ml/hr increase rate by %20.
If urine output ≥ 50 ml/hr decrease rate by %20.
If urine output < 15 ml/hr for 2 consecutive hours or requiring 2 x the fluid rate for 2 consecutive hours consider Albumin 5% at 1/3 fluid rate while the remainder 2/3 will be Ringers or Plasmalyte.
Call ETP prior to treatment of Albumin
At 12 hours post-injury calculate the 24 hour fluid
If 24 fluid rate exceeds 6ml x kg x %TBSA then initiate Albumin 5% at 1/3 fluid rate while the remainder 2/3 will be Ringers. Titrate the fluid to urine output.
Assess for abdominal compartment syndrome with a bladder pressure.