Approach to burn treatment in the rural emergency department

Quality of evidence

Current and local guidelines were compiled by a plastic surgeon (S.A.) and were reviewed to develop a systematic approach to burn treatment. PubMed and other databases were searched for current literature on emergency care for patients with burns to support the proposed treatment algorithm.

Main message

Rural EDs often lack staff with the specific expertise and experience required to assess and manage patients with severe burn injuries. We developed a standardized protocol to bridge such gaps and to optimize care for patients with burns. A summary of this approach can be found in Figure 1.^1,9-11

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Figure 1.

Assessment and management of patients with burns in the ED

Often patients will arrive via emergency medical services, and providing a standard approach to acute care for patients with burns following their arrival at the ED may be helpful. The initial focus should be on resuscitating the patient, covering them with a clean dry sheet to keep them warm, and providing pain control. Most patients will not need immediate resuscitation unless they are hypotensive and they will require only maintenance fluids to start. To facilitate transportation to a burn or trauma centre, consider early transport before the patient arrives at the hospital to expedite care. Coordination of the transport should occur while the patient is being medically stabilized.

Primary survey. The ABCDEF (airway, breathing, circulation, disability, exposure, and flight or transport) initialism can simplify the approach to the primary survey. When the patient presents to the ED, a primary survey and a proper airway assessment must be done.¹ Burns to the face or neck should prompt immediate evaluation of the patient’s airway and identification of potential inhalation injuries.¹² The decision to intubate the patient early should be based on clinical findings such as deep burns to the face and neck, blisters or edema of the oropharynx, stridor, accessory muscle use, respiratory distress, and hypoventilation.^13,14 Soot in the mouth, facial burns, body burns, and edema of the true or false vocal folds have been positively correlated with the need for early intubation.¹⁵ Using an endotracheal tube of 7.5 mm or larger will allow a bronchoscope to pass through to assess lung injury without extubating the patient. Oxygenation and ventilation should be optimized. Circumferential burns of the chest should be assessed since these burns can cause a tourniquet effect that may compromise adequate circulation and respiratory muscle movement.¹⁶ All patients can be started on 125 mL/h of Ringer lactate solution (RL), and if they are hypotensive a 500-mL bolus can be given before the initiation of maintenance fluids. If the patient is hypotensive, it is imperative that the source of hypotension is investigated, which is often not the burn, to adequately stabilize the patient. With burns that occurred indoors it is crucial to consider sources of toxicity such as carbon monoxide and cyanide. Cyanide is a deadly poison and exposure is rare; clinical findings are vague and mimic other conditions with hypoxia or hemodynamic insufficiencies.¹⁷ Exposure can occur due to smoke inhalation and burning plastic in an enclosed structure fire.^18,19 There is currently no point-of-care test for cyanide poisoning on scene at a fire. Hydroxocobalamin is an ideal antidote due to its rapid onset, minimal side effects, and ease of administration, whereby it removes cyanide from tissue by forming cyanocobalamin, which is then excreted unchanged in the urine.¹⁹ Exposure of the patient’s burns across the extremities is an important consideration; pulses on the extremities should be located and marked early. Transport should be considered before the patient arrives at the hospital to expedite the process if needed.

Secondary survey. The initialism ABCD (anthropometric characteristics, blood work, calculate the percentage of total body surface area [TBSA] burned, and degree of the burn) provides a simple way to remember the steps of the secondary survey to follow once the primary survey has been completed. Anthropometric characteristics, specifically the patient’s weight before the burn injury, are needed to calculate fluid requirements from the time of the injury; fluid requirements need only be calculated for second- and third-degree burns. Initial blood work is required only for second- and third-degree burns and should include a complete blood count, basic metabolic panel, carboxyhemoglobin levels (if smoke inhalation is suspected), and blood type and screen.^1,20 It would be beneficial to obtain these laboratory test results but it may not always be possible, and the focus should remain on the primary assessment and overall well-being of the patient. Calculating the percentage of TBSA is indicated only for second- and third-degree burns to avoid complications of fluid overload such as pulmonary edema. Burn degree is based on thickness and is classified as superficial, superficial partial thickness, deep partial thickness, and full thickness.¹ Superficial and deep partial thickness burns are considered second-degree burns and full thickness burns are considered third-degree burns.¹

Burn assessment. Burn characteristics to observe other than depth include blistering, colour (pink, white, or brown), blanchable versus nonblanchable, and painful versus nonpainful. The Lund and Browder chart is the most accurate method of estimating the percentage of TBSA burned for the purpose of predicting the amount of resuscitation fluid needed.^10,21 Although it is the most accurate method, it is often the most time consuming and the most difficult. The “rule of 9s,” which divides the body into areas of 9% and 18%, can be a faster method.⁹ The “rule of palms” is a quick and easy way to estimate the percentage of TBSA burned, where the patient’s palm is assumed to be about 1% of the body’s surface area and can be used to measure the burned areas.²²

Burn management. Once it has been established that the patient’s condition is stable, special considerations should be paid to burn management using the acronym PID-DOT (pain management, intravenous [IV] fluids, deroof or debride, dress wounds, other level of care, and tetanus prophylaxis). With regard to debridement, it is ideal to deroof blisters greater than 1 cm in diameter and gently wash burns with soap and water or with saline solution. However, since most rural EDs have only 1 physician covering the department, this would be very time consuming and may not be realistic. Large, painful blisters, those located over creases or joints, and those that have spontaneously drained should be deroofed while leaving other blisters intact. Blisters should also be deroofed to the edge of the burn area to promote healing and to minimize the risk of infection.²³

Intravenous fluid resuscitation is recommended for burns covering more than 15% of TBSA in adults, while fluids can be started in children with burns covering more than 10% of TBSA.¹¹ Importantly, fluid resuscitation should start as soon as possible after the time of the burn; fluid volume should be calculated using established formulas. The Parkland formula is often used to calculate fluid requirements, usually RL: 4 mL × percentage of TBSA × weight in kilograms, giving a final volume in millilitres. The first half of the calculated volume of solution is given over the first 8 hours and the second half of the solution is given over the next 16 hours.²⁴ Ringer lactate solution is the preferred fluid for burn treatment in both children and adults, although 5% dextrose solution can be added to the RL for children who weigh 30 kg or less.¹¹ For flame or scald burns in adults and children 14 years and older, use RL at 2 mL/kg/% TBSA.¹¹ For flame or scald burns in infants and children younger than 14 years, RL at 3 mL/kg/% TBSA should be used.¹¹ Maintenance fluids should be administered at 4 mL/kg/h for the first 10 kg of the patient’s weight, at 2 mL/kg/h for the next 10 kg (maximum up to 20 kg), and add 1 mL/kg/h for any weight above 20 kg.¹¹ For electrical burns, regardless of age, 4 mL/kg/% TBSA of RL is recommended.¹¹

Pain management must be prioritized at the onset of care—before blister care—and throughout the entire process. Intravenous or oral morphine is an effective choice to use during initial wound cleaning and dressing changes and for procedural pain.²⁵ Midazolam is considered first-line treatment to address anxiety and fear in patients with burn injuries owing to its fast onset, high potency, and short duration of action.²⁶ Although it does not provide any analgesic effects, intranasal midazolam has been shown to be an effective option for pediatric patients due to its sedating, anxiolytic, and amnesic effects.^27,28 Ketamine is a safe and reliable analgesic option²⁹ and it has a distinct advantage over opioids since it preserves airway and spontaneous respiratory function, causes less respiratory depression, and maintains cardiovascular stability; it is the anesthetic of choice in rural EDs.^30-32

Before wounds are dressed, take photographs of burn areas to provide useful information for consultation. Burns heal best in moist environments and dressings should be selected based on minimizing frequency of change.¹¹ Most rural EDs carry the following dressing supplies: gauze, nonadherent dressings, antibacterial creams, conforming bandages, petrolatum ointments, and other basic wound care supplies. Dressing options we recommend include the following: 1) apply a sterile, amorphous hydrogel dressing and cover with moist gauze; self-adhesive, nonwoven tape for dressing fixation, a conforming bandage, and netting to secure it, and change the dressing every 3 days; or 2) apply a nonadhering dressing, cover with gauze and a conforming bandage, and change the dressing every 2 days. Dressings should not be tightly wrapped circumferentially on limbs, and digits should be dressed individually. Injured areas should be elevated if possible to allow mobility, which decreases the risk of contracture. Full thickness or deep partial thickness burns will require consultation with a plastic surgeon for debridement and skin grafting. Finally, tetanus vaccines should be given to all patients with more than a first-degree burn.³³

Guidelines for admission, referral, and transfer. If a patient meets any of the following criteria, they should be transferred to a burn centre for specialized treatment¹¹:

• partial thickness burns with a TBSA greater than 10%;

• burns involving the face, hands, feet, genitals or perineum, or major joints;

• third-degree burns (full thickness) at any age;

• electrical burns, including lightning injury;

• chemical burns;

• inhalation injury;

• patients with pre-existing medical issues that would complicate management, prolong recovery, or affect outcomes;

• patients with burns and concomitant trauma (fractures) in which the burn poses greatest risk of morbidity or mortality;

• children with burns in hospitals without qualified personnel or equipment to care for children; and

• burn injury in patients who will require special social, emotional, or rehabilitative interventions.

If the patient does not require transfer, they should be admitted to hospital and wound care or plastic surgery should be considered, or they should be managed in the ED, as outlined in Figure 1.^1,9-11 If patients are discharged without admission or consultation, follow-up should occur within 48 to 72 hours given that burns can extend or deepen and evolve rapidly with infection.

Suspicion of abuse. Being able to detect potential signs of abuse can be challenging but it is a very important consideration. Most burns in children occur between the ages of 0 and 4 years old and are scald injuries caused by hot liquids.³⁴ Evaluation of the burn pattern should be precise and findings of a detailed history and physical examination should inform the suspicion of abuse. If there is a high index of suspicion, the clinical assessment and evaluation should include an understanding and recognition of intentional injury features so that potential signs of abuse can be investigated and managed appropriately to protect the child.