Burn injuries are among the most devastating and complex injuries that emergency medical services (EMS) professionals encounter. They present unique challenges in pre-hospital care and require a meticulous and informed approach to management. This article, designed to provide essential insights for managing burn injuries, is equally valuable for seasoned professionals and newcomers, ensuring everyone has the knowledge to deliver optimal care.

Types of Burns and Their Classification

Understanding the types of burns and their classification is not just a part of the job; it's a crucial aspect of your expertise. Burns are generally classified by their depth and extent, and this knowledge is foundational for effective management.

1. Superficial Burns (First-Degree Burns):

• Affects only the epidermis.

• Symptoms: Redness, pain, and minor swelling without blisters.

• Example: Sunburn.

2. Partial-Thickness Burns (Second-Degree Burns):

• Extend through the epidermis into the dermis.

• Symptoms: Red or mottled skin, blisters, severe pain, and swelling.

   Divided into:

• Superficial Partial-Thickness Burns: Affect upper dermis.

• Deep Partial-Thickness Burns: Extend deeper into the dermis.

3. Full-Thickness Burns (Third-Degree Burns):

• Destroy both the epidermis and dermis, potentially affecting underlying tissues.

• Symptoms: White, leathery, or charred skin; insensate due to nerve damage.

4. Fourth-Degree Burns:

• Extend through skin to underlying fat, muscle, or bone.

• Symptoms: Blackened, charred tissue; often painless due to extensive nerve damage.

The extent of burn injury is commonly estimated using the 'Rule of Nines' or the Lund and Browder chart, particularly for pediatric patients. These tools are not just aids; they are your trusted companions, equipping you to calculate the total body surface area (TBSA) affected, which is crucial for guiding fluid resuscitation and further treatment.

Initial Assessment and Management

Scene Safety and Initial Assessment:

• Ensure scene safety for responders and patients.

• Perform a rapid assessment using the ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure/Environment).

Airway Management:

• Assess for signs of inhalation injury, such as soot around the mouth/nose, singed nasal hairs, or hoarseness.

• Administer high-flow oxygen and prepare for advanced airway management if necessary.

• Consider early intubation in patients with significant facial burns or inhalation injury.

Breathing:

• Monitor for signs of respiratory distress and administer supplemental oxygen.

• Beware of potential carbon monoxide and cyanide poisoning in fire-related burns.

Circulation:

• Establish intravenous (IV) access, preferably in non-burned areas.

• Monitor vital signs and assess for signs of shock.

• Begin fluid resuscitation using the Parkland formula (4 mL/kg/% TBSA burned), adjusting based on urine output and patient response.

Disability:

• Conduct a neurological assessment to establish the patient's baseline mental status.

• Reassess frequently as changes may indicate evolving hypoxia or other complications.

Exposure/Environment:

• Remove all clothing and jewelry to prevent constriction and allow thorough assessment.

• Cover burns with clean, dry, non-adherent dressings.

• Maintain normothermia, as burn patients are at high risk of hypothermia.

Specific Considerations in Burn Management

Fluid Resuscitation:

• Critical in the first 24 hours, particularly for burns involving >20% TBSA.

• Use Lactated Ringer's solution initially, titrating to maintain urine output of 0.5-1 mL/kg/hr in adults and 1-1.5 mL/kg/hr in children.

Pain Management:

• Administer analgesics early and adequately, using opioids as necessary.

• Consider adjuncts like NSAIDs and anxiolytics for comprehensive pain control.

Wound Care:

• Avoid application of ice directly to burns; cool with tepid water if within the first few minutes post-injury.

• Apply clean, dry dressings and avoid topical ointments in the pre-hospital setting.

Infection Control:

• Burns compromise the skin barrier, increasing infection risk.

• Use sterile techniques when handling wounds and administering medications.

Transport and Communication:

• Transport to a burn center for patients with significant burns (>10% TBSA in children or elderly, >20% TBSA in adults, burns involving face, hands, feet, genitalia, perineum, or major joints, third-degree burns, electrical or chemical burns, inhalation injury, or associated trauma).

• Provide thorough handover to the receiving facility, detailing TBSA burned, initial treatments, fluid administration, and patient response.

Special Situations

Electrical Burns:

• Assess for entry and exit wounds.

• Monitor for cardiac arrhythmias and other internal injuries.

• Administer fluids more aggressively due to the potential for deep tissue damage.

Chemical Burns:

• Identify and neutralize the chemical if possible.

• Flush with copious amounts of water unless contraindicated (e.g., dry lime, phenol).

• Avoid attempting neutralization in the field due to potential exothermic reactions.

Inhalation Injury:

• High suspicion in enclosed space fires.

• Administer 100% oxygen and prepare for early intubation.

• Consider hyperbaric oxygen therapy for severe carbon monoxide poisoning.

Continuing Education and Training

For EMS professionals, ongoing education and training are not just requirements but the keys to maintaining proficiency in burn management. This includes regular participation in courses such as Advanced Burn Life Support (ABLS) and continuous review of current guidelines and best practices. Simulation training and interprofessional drills can enhance readiness and teamwork in managing complex burn cases, and your commitment to these activities sets you apart in the field.

Psychological and Emotional Support

Burn injuries are not only physically traumatic but also psychologically distressing. EMS professionals should be attuned to the emotional needs of burn patients and their families. Providing reassurance, involving mental health support early, and facilitating access to burn support groups can significantly impact the patient's recovery journey.

Conclusion

Managing burn injuries requires a comprehensive and informed approach, integrating clinical knowledge with practical skills. By staying current with best practices and maintaining a compassionate and systematic approach, EMS professionals can significantly improve outcomes for burn patients. Whether you are a seasoned veteran or a newcomer, mastering burn management is essential to providing high-quality emergency medical care.

Sources:

1. American Burn Association. (n.d.). Advanced Burn Life Support (ABLS) Program.

2. Hettiaratchy, S., & Dziewulski, P. (2004). ABC of burns: Introduction. BMJ, 328(7452), 1366-1368.

3. National Institute for Health and Care Excellence (NICE). (2019). Burns and scalds: NICE guideline [NG61].

4. Stokes, M. A., & Johnson, W. D. (2017). Burns in the emergency department: Management and prevention. Emergency Medicine Clinics of North America, 35(2), 301-315.

By leveraging these insights, EMS professionals can ensure they are prepared to effectively manage burn injuries, delivering the best possible patient care.