Medical Assessment for Burn Care Patients

 I. Airway

A. Assess for signs of inhalation injury: 

  1. Singed hairs, beard, eyelids, eyelashes, or nasal hairs; 
  2. Peri-oral charcoal; 
  3. Intra-oral charcoal, especially on teeth and gums.

B. Inhalation injury is diagnosed by bronchoscope.
C. Patients with facial and neck burns often develop massive swelling and airway obstruction. Evaluate for respiratory distress and intubate early, before massive swelling impairs ventilation.

II. Breathing

A. If patient is a suspected inhalation injury or is in respiratory distress, he is a candidate for prompt intubation.
B. Nasotracheal tube with a soft, low-pressure cuff is preferred, but oral intubation should be performed in patients with nasal deformation.
C. Emergency surgical airway is rarely indicated. If a surgical airway is necessary, perform a cricothyrotomy.
D. Special Note:     

  1. Patient's level of consciousness is NOT a criterion for intubation. Most severely burned patients are quite awake on presentation to the Emergency Department and, yet, may need to be intubated. Post-burn edema of facial and/or inhalation burns manifests itself early. Establishing an adequate airway is essential. 
  2. An awake patient may be intubated with relative ease if the nose and throat are well anesthetized with Cetacaine and the patient is given sedation as soon as the ET tube is in proper position.

III. Circulation

A. IV 

  1. Two large bore IV's (14-16 gauge angiocath or medicut) are adequate for even the largest body surface burns. IV sites are precious - do not waste them with unnecessary line placement. 
  2. Cutdowns in non-burned areas are permissible but only if absolutely necessary.

B. Fluid Resuscitation

  1. Pre-hospital 
         a. Over age 15: 500 ml/hour Ringers Lactate 
         b. Age 5-15: 250 ml/hour Ringers Lactate 
         c. Under age 5: no fluids     
  2. Emergency Department 
         a. Calculate fluid requirements using the Parkland formula (4 cc/kg body weight/% burned). One-half (1/2) of total should be given in first 8 hours. The remaining amount is divided equally over the next 16 hours. Do not over resuscitate. 
         b. Use Ringers Lactate. Avoid solutions with glucose in them, except in children less than 1 year old. Infants should receive D5LR.

IV. Immediate Therapy

A. Remove all clothing and jewelry.
B. Stop the burning process by cooling the burned area with liberal amounts of normal saline. Then warm the patient.
C. Chemical Burns (personnel must wear appropriate protective clothing during chemical neutralization)

  1. Remove saturated clothing. 
  2. Brush powdered chemicals off the skin. 
  3. Irrigate with copious amount of water. (Irrigation is generally continued until the patient identifies a decrease in pain or burning.)      4. Hydrofluoric acid burns require definitive management. Please consult as soon as possible.

D. Do not cover patients with wet cloths or ice.
E. Nasogastric tube may be indicated if: 

  1. Burns greater than 25% 
  2. Patient intubated 
  3. If nausea or vomiting present: 
         a. Keep patient NPO 
         b. Aspirate contents of stomach

F. An indwelling urinary catheter may be indicated if: 

  1. Burns greater than 20% BSA. 
  2. Perineal burns. 
         a. Check the patency of the indwelling urinary catheter with irrigation after insertion. 
         b. If urine is red or black (hemochromogens), consult with Burn Center.

G. Pain medications:

  1. Use narcotics intravenously. Never intramuscularly. 
  2. Morphine Sulfate is the drug of choice (0.1 mg/kg for children). Monitor respiratory rate after administration. 
  3. Administer only if necessary and document sensorium prior to administration.

H. Give tetanus prophylaxis.
I.  Do not use prophylactic antibiotics.
J. Burn wound care: 

  1. Cover minor burns with dressings dampened with sterile normal saline. Keep the patient warm. 
  2. Patients with a major burn injury should have their wounds covered with a dry clean or sterile sheet. Keep the patient warm. 
  3. Emergency Department escharotomies are rarely indicated. If distal blood flow to the extremities is compromised, consult the burn center physician before attempting escharotomies.

V. History

A. Patient's name, age, and time of burn injury.
B. Etiology of burn injury: 

  1. Scald - nature of scalding agent, i.e., water, grease, etc. 
  2. Flame 
  3. Electrical - determine voltage and mechanism of injury.  
  4. Chemical: 
         a. Name, kind, nature of chemical 
         b. Amount of time flooded with water/saline 
         c. Do not attempt to neutralize the chemical substance
  5. Time of burn (date and hour) 
  6. Where burn occurred: 
         a. Open space (field, etc.) 
         b. Closed space (car, house, etc.)
  7. Pertinent medical history 
  8. Known allergies 
  9. Present medications 
  10. Related injuries

VI. Transfer Procedure

A. Call the John A. Gannon Comprehensive Burn Care Center at MetroHealth Medical Center at (216) 778-4095 and ask for the burn resident. He/she will provide information necessary to transfer and prepare the patient for arrival at the Emergency Department. If emergent transfer is needed, please call Metro Life Flight at (216) 778-5433 or 1-800-233-5433.
B. Patients who are unstable, have inhalation injury, or transferred by ground vehicle should be accompanied by a physician and/or nurse.
C. If possible, someone who knows the patient personally should accompany them to the Comprehensive Burn Care Center. Nearest of kin should be informed of the transfer.
D. Complete Transfer Form and send it with patient, after calling report to nurse in the Comprehensive Burn Care Center.

VII. Final Note

Even though you may wish to transfer a patient immediately, it is important that the patient be medically stable, airway maintained, and shock, if present managed prior to transfer. The Comprehensive Burn Care Center physicians and nursing staff are available to assist you, through consultation, in preparing the patient for a safe transfer. Please call us as early as possible.

Burn Injury Criteria for Burn Center

  1. Partial-thickness burns of greater than 10% of the total body surface area
  2. Burns that involve the face, hands, feet, genitalia, perineum, or major joint
  3. Third degree burns in any age group
  4. Electrical burns, including lightning injury
  5. Chemical burns
  6. Inhalation injury
  7. Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality
  8. Any patients with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality. In such cases, if the trauma poses the greater immediate risk, the patient's condition may be stabilized initially in a trauma center before transfer to a burn center. Physician judgment will be necessary in such situations and should be in concert with the regional medical control plan and triage protocols.
  9. Burned children in hospitals without qualified personnel or equipment for the care of children
  10. Burn injury in patients who will require special social, emotional, or rehabilitative intervention

Questions concerning specific patients can be resolved by consultation with the burn center physician.