The management of thermal injuries and their sequela will soon become top of mind again for EMS agencies as we approach the 4th of July holiday in a few short weeks. Burn injuries are widely considered one of the most painful injuries that a person can sustain. In addition to the intrinsic pain caused by the burn itself, the proper treatment of a burn injury requires painful procedures after EMS transfers care to the receiving facility. The procedures completed in the burn center/trauma hospital include debridement of the wound, daily wound care, and surgery, followed by aggressive physical and occupational therapy.
Burn pain is especially complicated; it is multifaceted and frequently changes over time as the patient undergoes repeated procedures and treatments that require manipulation of their painful burn sites. In EMS we value and understand the importance of pain management in the acute phase as it is directly part of the patients' long journey towards recovery. A mix of opioids and non-opioids rather than opioids in isolation are preferred
Outside of the obvious ABC's and pain management, some of our other initial priorities center around an estimation of total burn surface area (TBSA). Historically, in the heat of the moment (pun intended) we have grossly overestimated the burn percentages. This led to over resuscitation and "fluid creep" Hey human error is inevitable in all areas of medicine, but we used to directly tie fluid resuscitation volumes on this TBSA estimation.... many places still do. Today, the Parkland Formula may still show up on an exam, but several experts have drafted a consensus around fluid administration - you'll be glad to know it has been simplified drastically.
Age < 5 y.o. 125 ml/HR
Age 6-13 y.o. 250 ml/HR
Age > 14 y.o. 500 ml/HR*
*Those with extensive cardiac related problems or those who are > 70 y.o. generally start @ 250 ml/HR
Prevention of hypothermia and sepsis are also top priorities, and most patients rarely die from the burn, they succumb weeks later in the burn unit from an infectious related process. Remember your skin is the largest organ in your body and acting as a barrier preventing foreign invaders from intruding is one of its most important tasks.
As a side note, if the patient has suffered from airway related burns - keep in mind the upper airway will take the heat and it wants to spare the lower airway from injury. The means the pharynx, and glottic opening related structures will likely have some edema. Consider humidified oxygen for these patients -- it can go a long way and may save you from performing an advanced airway procedure that will with certainty be difficult to perform successfully. The added humidity prevents the airway from drying out, but more importantly it prevents secretions from thickening.
A review of burn severity is included below for your convenience.
Source: American Burn Association
In summary, the purpose of burn resuscitation is maintaining tissue oxygenation and perfusion in the setting of intravascular volume loss from increased capillary permeability due to burn shock. Unlike hemorrhagic shock, burn shock causes a slow and steady continuous loss of intravascular fluid (plasma) that occurs first into the thermally injured tissue and then throughout the body.
The best way to manage this fluid loss is by a slow and steady repletion of the intravascular volume by ongoing resuscitation for the first 24 hours with close monitoring of patient response (i.e. urine output in the hospital setting). The classic teaching in the field of burn surgery is that patients with >20% TBSA burns are the only ones that require a formal IV fluid resuscitation.
June 3, 2024
Author: Joshua Ishmael, MBA, MLS(ASCP)CM, NRP
Pass with PASS, LLC