EMERGENCY CARE

1. EMERGENCY CARE

2. CARE AT THE SCENE AIRWAY • Once flames are extinguished, initial attention must be directed to the airway. • Immediate CPR is rarely necessary, except in electrical injuries or in patients with severe carbon monoxide poisoning • CPR should be performed per Advanced Cardiac Life Support (ACLS) guidelines. • Any patient rescued from a burning building or exposed to a smoky fire should be placed on 100% oxygen via a nonrebreather mask if there is any suspicion of smoke inhalation. • If the patient is unconscious or in respiratory distress, endotracheal intubation should be performed by appropriately trained personnel.

3. Other Injuries and Transport • Once an airway is secured, the patient is assessed for other injuries and then transported to the nearest hospital. • Patients should be kept flat and warm and be given nothing by mouth • Place an intravenous line and begin fluid administration with lactated Ringer's (LR) solution at a rate of approximately 1 L/h in the case of a severe burn; • For transport, the patient should be wrapped in a clean sheet and blanket. • Before or during transport, constricting clothing and jewelry should be removed from burned parts, because local swelling begins almost immediately.

4. Emergency Room Care • The primary rule for the emergency physician is to ignore the burn. • As with any form of trauma, the airway, breathing, and circulation protocol (ABC) must be strictly followed FIRST.

5. Emergency Assessment of Inhalation Injury • Inhalation injury should be suspected in anyone with a flame burn, and assumed until proven otherwise • Careful inspection of the mouth and pharynx should be done early. • Hoarseness and expiratory wheezes are signs of potentially serious airway edema or inhalation injury. • Copious mucus production and carbonaceous sputum (i.e., expectorated sputum and not just black flecks in the saliva) • Carboxyhemoglobin levels should be obtained, and elevated levels or any symptoms of CO poisoning are presumptive evidence of associated inhalation injury

6. Resuscitation Goals • Effective fluid resuscitation is one of the cornerstones of modern burn care • Proper fluid resuscitation aims to anticipate and prevent rather than to treat burn shock. • To provide enough fluid replacement to maintain perfusion without causing fluid overload. • Without effective and rapid intervention, hypovolemia/shock will develop if the burns involve > 15% to 20% total body surface area (TBSA)

8. Resuscitation Principles • Adequate resuscitation from burn shock is the single most important therapeutic intervention in burn treatment. • Each patient will react uniquely to burn injury depending on age, depth of burn, concurrent inhalation injury, preexisting comorbidities, and associated injuries. • Lactated Ringer's solution most closely resembles normal body fluids. • Factors that influence fluid requirements during resuscitation besides TBSA burn include burn depth, inhalation injury, associated injuries, age, delay in resuscitation, need for escharotomies/fasciotomies, and use of alcohol or drugs.

9. The Parkland Formula/ Consensus Formula • The Parkland formula has been renamed the Consensus formula because it is the most widely used resuscitation guideline. • The Advanced Burn Life Support curriculum supports the use of the Consensus formula for resuscitation in burn injury. 4 mL/kg per percentage TBSA • kg represents patient weight • percentage TBSA is the size of the burn injury • describes the amount of lactated Ringer's solution required in the first 24 hrs post burn. • Starting from the time of burn injury, half of the fluid is given in the first 8 hrs and the remaining half is given over the next 16 hrs.

10. Other Fluids • There has not been a clinical advantage with colloids. • One study showed a decreased risk of death when albumin was used during resuscitation, but was not statistically significance. • A meta-analysis comparing albumin to crystalloid showed a 2.4-fold increased risk of death with albumin. • Hypertonic saline causes a four-fold increase in renal failure and twice the mortality of patients given lactated Ringer's solution. • FFP should not be used as a volume expander, according to new policies on blood product delivery. • The American Burn Association Practice Guidelines for Burn Shock Resuscitation do not recommend the use of FFP without active bleeding or coagulopathy.

11. Vascular Access/Other Tubes and Catheters • No factor other than airway protection is as critical in the early postburn period as vascular access. • Ideally, obtain peripheral intravenous access away from burned tissues. • If no intravenous access is available, intraosseous catheters may safely be placed in patients of any age. • A patient undergoing resuscitation should have a Foley catheter placed. • Nasogastric tubes should be considered in patients with > 20% TBSA burns, as they will experience gastroparesis and probable emesis.

12. First-line Monitoring Primary modalities for monitoring: • Heart rate • A pulse rate < 110 beats/min in adults usually indicates adequate volume, with rates > 120 beats/min usually indicative of hypovolemia. • Narrowed pulse pressure provides an earlier indication of shock than systolic blood pressure alone. • Urine output • The American Burn Association Practice Guidelines for Burn Shock Resuscitation recommend: • 0.5 mL/kg/hr urine output in adults • 0.5–1.0 mL/kg/hr in children weighing < 30 kg.

13. First-line Monitoring • Blood pressure • Arterial Catheter versus Blood Pressure Cuff • Noninvasive blood pressure measurements by cuff are rendered inaccurate because of the interference of tissue edema and read lower than the actual blood pressure. • An arterial catheter placed in the radial artery is the first choice, followed by the femoral artery.

14. Resuscitation End Points • Many authors feel that urine output and traditional vital signs (heart rate and mean arterial pressure) are too insensitive to ensure appropriate fluid replacement • In adults, arterial blood pressure is relatively insensitive to the adequacy of fluid replacement; pulse rate is more helpful. In older patients, pulse rate becomes less reliable. • Urine output can be taken to reflect organ perfusion; however, urine must be nonglycosuric to be accurate. • Although urine output does not precisely mirror renal blood flow, it remains the most readily accessible and easily monitored index of resuscitation.

15. Tetanus Prophylaxis • Burns are tetanus-prone wounds. • The need for tetanus prophylaxis is determined by the patient's current immunization status. • Previous immunization within 5 years requires no treatment • immunization within 10 years requires a tetanus toxoid booster • unknown immunization status requires hyperimmune serum (i.e., Hyper-Tet).

16. Gastric Decompression • Many burn centers begin enteral feeding on admission to reduce the risk of: • gastric ulceration (Curling's ulcer) • prevent ileus • blunt catabolism. • If patient transport is via air ambulance or is going to take more than a few hours, the safest course is usually to decompress the stomach with a nasogastric tube.

17. Pain Control • During the shock phase of burn care, medications should be given intravenously. • Subcutaneous and intramuscular injections are variably absorbed depending on perfusion and should be avoided. • Pain control is best managed with small intravenous doses of an opiate until analgesia is adequate without inducing hypotension.

18. Care of the Burn Wound • After all other assessments have been completed, attention should be directed to the burn. • If the patient is to be transferred during the first postburn day, which is almost always the case, the burn wounds can be minimally dressed in gauze. • However, the size of the burn should be calculated to establish the proper level of fluid resuscitation, and pulses distal to circumferential deep burns should be monitored. • The patient can be wrapped in a clean sheet and kept warm until arriving at the definitive care center.

19. Escharotomy • Thoracic Escharotomy • The adequacy of respiration must be monitored continuously throughout the resuscitation period. • Early respiratory distress may be due to the compromise of ventilation caused by chest wall inelasticity related to a deep circumferential burn wound • Thoracic escharotomy is seldom required, even with a circumferential chest wall burn. When required, escharotomies are performed bilaterally in the anterior axillary lines.

20. Escharotomy • Escharotomy of the Extremities • Edema formation in the tissues under the tight, unyielding eschar of a circumferential burn on an extremity may produce significant vascular compromise • All jewelry must be removed from the extremities to avoid distal ischemia. • Skin color, sensation, capillary refill, and peripheral pulses must be assessed hourly in any extremity with a circumferential burn

21. ESCHAROTOMY • The occurrence of any of the following signs or symptoms may indicate poor perfusion of a distal extremity warranting escharotomy: • cyanosis • deep tissue pain • progressive paresthesia • progressive decrease or absence of pulses or the sensation of cold extremities. • An ultrasonic flowmeter (Doppler) is a reliable means for assessing arterial blood flow, the need for an escharotomy, and also can be used to assess adequacy of circulation after an escharotomy

22. Locations for Escharotomies • The incisions are placed along the mid-medial and mid-lateral lines of the extremities and the thorax (dashed lines). • The skin is especially tight along major joints, and decompression at these sites must be complete (solid lines). • Neck and digital escharotomies are rarely necessary.