Emergency Care of the Burn Patient

Treatment of the Burn Victim

Now it is time to start treating the burn wound. This part of the information is left towards the middle for a good reason. You don't want to start treating the burn wound until you have:

1. Stopped the burning process
2. Assessed Airway, Breathing and Circulation
3. Evaluated the extent and depth of the burn
4. Assessed the criteria for referral to a burn center
5. Have observed for and treated associated injuries.

Fluid replacement is the prime object of initial burn treatment. When someone gets burned, to put it very simply, their capillaries begin to leak. Instead of sticking together, keeping blood inside of the vessel, the endothelial cells separate and become very porous. Huge amounts of fluid pour out into the tissue. In small burns this fluid accumulates only in the burned areas but in very large burns fluid can accumulate everywhere in the body. These patients can develop a significant amount of edema at the expense of your vascular volume. The blood volume goes down as you become more edematous, or rather, they develop hypovolemic shock.

Who gets resuscitated? Any burn greater than 10%, but this is dependent on the age and health of the patient. For instance if you are treating a healthy 20 year old with a 15 % burn, they can probably resuscitate themselves with oral fluids but nonetheless, they should be observed to make sure they take in enough fluids, is not vomiting and that they produce a satisfactory amount of urine. Anyone with an inhalation injury, associated trauma or electrical injury gets fluid resuscitation. When in doubt, over treat. Make sure they get through the first 24 hours.

There are many formulas for fluid resuscitation. These are not aimed at treating burn shock because burn shock will reverse itself. The goal in resuscitation is to maintain the volume of the patient during the period of hypovolemia. The formula that we use at the Burn Center is the Parklund Formula. It is a good formula for two reasons:

1. It calls for a large amount of fluid
2. It is easy to remember.

Please remember that the resuscitation time is calculated from the time of the burn injury. If a person gets burned at 1:00 A.M. and resuscitation is delayed until 8:00 A.M. that person is 7 hours behind. You will need to increase the rate of the fluid to catch up, in order to get back on schedule.

The criteria to judge whether or not fluid resuscitation is adequate is measured by urine volume.

Why do we use lactated ringers? Because lactated ringers is most like normal extracellular fluid. If you must give a couple liters of normal saline to a burn patient, you will not harm them but remember that normal saline contains a large amount of chloride. If you give very much chloride to a burn patient there is a potential for metabolic acidosis. Fluid which contains dextrose is not used for two reasons:

1. Does not contain any electrolytes,
2. There is potentially a large amount of adrenaline in the bloodstream which makes these patients glucose intolerant. Their blood glucose levels will increase which will cause their urine output to increase, therefore they will not be getting resuscitated appropriately.

Perfusing the kidneys is one of the goals of therapy. If the kidneys are perfused adequately, the patient will make enough urine. If the patient does not make enough urine they are not getting enough fluid. Even if you are following the Parklund Formula guidelines correctly, some people require more fluid. Turn the rate of the IV fluid up, DO NOT GIVE DIURETICS!

Patients with electrical injuries or very deep tissue damage may have myoglobin in their urine, therefore they will require double the urine output to flush the kidneys of the large myoglobin cells. The amount of fluid resuscitation required is difficult to assess because you can't go by the size of the burn. If the urine is very dark, such as in the picture, increase the rate of the intravenous fluids to maintain a urine output of 100 cc/hr.

All of these criteria are important, but this doesn't help you very much if you are in the field. If there is only one criteria which you can assess, it must be urine output.

The complications of edema get worse as resuscitation proceeds. Any major burn of an extremity of the torso tends to swell very tightly. This is because the skin in third degree burns become very rigid and hard. Elasticity is drastically compromised. As you pour fluid into these patients during resuscitation, the extremity or torso will swell and the burns become tighter and tighter. This tightness can become so great that the circulation may become compromised. This happens over several hours. The patient may loose peripheral pulses, motor function and nerve function in the extremity. The extremity can become cyanotic. Instead of surface pain, the patient may start complaining of a deep, throbbing pain. This can be difficult to evaluate in the field. The best way to evaluate this complication is by watching extremities closely for tightness, loss of pulses and complaints of numbness and tingling.

The procedure of choice is an escharotomy. What we have done in this man's arm is to cut through the burned tissue with a scalpel medially and laterally to ensure restoration of pulses. Notice how far apart the edges are. We did not remove any tissue. The skin simply spreads apart as a result of the tension and tightness caused by the swelling. Initially, even a badly burned extremity will feel soft. The complications of edema occur only after several hours.

The complications of edema may also effect the ability of the chest to expand. Ventilation is mechanical. The chest needs to be able to expand during breathing. When this occurs an escharotomy may be performed to the chest in the shape of a square. It is important to connect all sides by incision.

This is a picture of a man with escharotomies to the upper legs and fasciotomies to the lower legs.

Initially there will be very little bleeding, but after the extremity becomes perfused, the potential for bleeding becomes great, therefore the wounds must be dressed appropriately with bulky dressings and pressure wraps.

We are not advocating that this be done in the field. There is the potential for blood loss, severe hypotension, contamination of the wound and damage to the nerves.

The other complication from edema is swelling of the airway. This young boy got burned while sniffing gasoline. He has a very deep burn to the face which is difficult to appreciate in this photo. This picture was taken immediately after admission and shortly after the burn injury.

This is that same boy, just one hour later. The facial swelling that occurs in these injuries is very profound. That is about as far as the mouth can be opened. His eyes are completely swollen shut. If you feel his face you would appreciate that all of the skin in the face and neck is swollen very tight. If this boy had not been intubated prior to swelling, it would have been impossible to intubate him at this point because the swelling also occurs on the inside. The tongue swells, the pharyngeal tissue swells, and if you look down his throat with a laryngeal scope you would not be able to see the chords. He would have died from loss of airway. When in doubt , intubate before transport. If you intubate a patient who does not need it, the tube can always be pulled, but if you fail to intubate a patient who does need it, the patient will die.

Review of the Emergency Care

1. Stop the burning process
2. Stabilize ABC's
3. Observe and treat associate injuries
4. Begin fluid resuscitation
5. Referral Criteria
6. Treatment of Minor Burns

*DISCLAIMER This site is designed as an introduction to thermal injury for emergency medical technicians, medical students and physicians in training. It is not a comprehensive guide to thermal injury. As such the information may not be sufficient to address specific patient problems and these should be handled by physicians familiar with the specific clinical details pertinent to the individual patient. We invite comments from all users of this site.