At our recent Clinical Governance Day (4/5/16) we were honored to have in attendance three experts who have dedicated their careers to the care of the burned patient. A cornucopia of pearls for prehospital and retrieval management were presented. The distillation of the session is included below. Many thanks to Prof. Peter Maitz, Dr. Mark Kol, and Dr. Kar-Soon Lim from Concord Hospital for their enlightening presentations.

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EVALUATION

Do not be distracted by the dramatic nature of the burns. Focus on the standard ABCDE approach to trauma (with burns starting at the E stage).

Use the Rule of 9’s or a reference card for estimating burns. This is an estimate, and does not need to be perfect. A ballpark percentage is all that is expected.

AIRWAY

Traditional risk factors for predicting a need for intubation in burns patients have awful sensitivity and specificity. Patients that were entrapped when burned do have higher risk of airway compromise and deep lung injury.

Expert clinical judgment should guide the need and timing of intubation; however, weigh up the risk of minor morbidity in intubating those that might not need it, compared to the risk of catastrophic airway failure in the few we wait too long to intubate.

Sux is safe to use in the acute setting despite dogmatic concerns of hyperkalemia. I agree with my colleague below about this relevant article from 1967.

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VENTILATION

As severe burns patients are at high risk for developing ARDS and SIRS, a lung protective strategy is recommended (low tidal volumes – 6ml/kg  IBW – with low pressures).

Inappropriate or adverse ventilation (high pressures or volumes) leads to increased risk of ARDS, multi organ dysfunction (MODS), and death.

FLUIDS

Although there is minimal external loss of fluid, these patients will leak massive volumes into the interstitial spaces and develop hypovolemic shock.

Use the Parkland formula to guide fluid resuscitation.

Ideally ongoing fluids should be guided by urine output via an indwelling catheter.

Beware fluid creep (volume above Parkland or adequate urine output). This has no immediate deleterious effect, but can cause severe late complications – compartment syndrome, kidney injury, etc.

COOLING

Cooling of burns should be performed if the patient is seen within three hours of injury. This decreases the size and depth of the burn.

Running tap water for at least 20 minutes is the best method of cooling.

Only use gel products if no running water is available or if the patient’s condition isn’t compatible with the cooling process.

Cooling may have already been completed by bystanders with advice from 000, or by the first arriving crews.

DRESSINGS

Use clean dry sheets or plastic wrap for dressing. If wet dressings are in place at time of evaluation, they should be removed.

Do not delay transport for clever / thorough dressing of the burns.

FASCINOMATA

Severe burns patients have massive release of cytokines and other inflammatory mediators. Burns >25% TBSA yield a body-wide inflammatory response (SIRS).

In circumferential burns, compartment syndrome is uncommonly seen before the 8 hour mark. Be prepared for escharotomy in these patients.

Electrical burns heat tissues with the highest resistance (V=IR). Bones heat up fast and actually cook the surrounding muscles. The subsequent swelling and edema can cause a deep concealed compartment syndrome.

Thoracic ultrasound can be used to look for atelectatic segments and excess lung water.

RESOURCES

Sydney HEMS Major Burns Helicopter Operating Procedure

New South Wales Health Burn Transfer Guidelines

Emergency Management of Severe Burns (EMSB) course – highly recommended!