BBA Resources

Pre-hospital Approach to Burns Patient Management

1. S.A.F.E approach: as for all pre-hospital emergencies.

  • Shout/call for help
  • Assess the scene
  • Free from danger
  • Evaluate the casualty

References

  1. Scene approach, assessment and safety. In Greaves I, Porter K, eds. Pre-hospital Medicine. The principles and practice of immediate care, pp 273-9. London: Arnold, 1999.
  2. National Association of Emergency Medical Technicians. Pre-hospital Trauma Life Support Manual 1994. 1994.
  3. Basic Life Support. In Greaves I HTPK, ed. Emergency Care A Textbook for Paramedics, pp 17-26. WB Saunders, 1997.
  4. IHCD. Ambulance Service Paramedic Training. 3. 1994. Bristol. Ref Type: Serial (Book,Monograph)
  5. IHCD. Ambulance Service Basic Training. 1991. Bristol. Ref Type: Serial (Book,Monograph)

   
  2. Stop the burning process (for example: stop, drop and roll); remove the burning source.

  • Remove all burnt/burning clothing (unless stuck to the patient), jewellery (bring bagged clothing to hospital for examination)
  • Chemicals – need longer period of irrigation and specific information about the chemical concerned should be obtained.

   
3. Cool the burn wound

  • Ambulance control despatch system will advise the 999 caller to cool the burn area for up to 10 minutes
  • If this has been done, Pre-hospital carers should cool for another 10 minutes during package and transfer
  • Water should not be ice cold o If the burn area is small
     (< 5%) 
    then a cold wet towel can be placed on the burn area, on top of the clingfilm dressing but before wrapping up the whole patient to maintain body warmth beneath the blankets.
  • Be aware of the risk of hypothermia, especially in children and the elderly
  • Cool the burn wound but warm the patient

References

  • Nguyen NL, Gun RT, Sparnon AL, Ryan P. The importance of immediate cooling—a case series of childhood burns in Vietnam. Burns 2002; 28:173-6.
  • Nguyen NL, Gun RT, Sparnon AL, Ryan P. The importance of initial management: a case series of childhood burns in Vietnam. Burns 2002; 28:167-72.
  • Allison K. The UK pre-hospital management of burn patients: current practice and the need for a standard approach. Burns 2002;28:135-42.
  • Jandera V, Hudson DA, de Wet PM, Innes PM, Rode H. Cooling the burn wound: evaluation of different modalites. Burns 2000;26:265-70.
  • Sawada Y, Urushidate S, Yotsuyanagi T, Ishita K. Is prolonged and excessive cooling of a scalded wound effective? Burns 1997;23:55-8.
  • Lawrence JC. First-aid measures for the treatment of burns and scalds. J.Wound.Care 1996;5:319-22.
  • Hodson AH. Treating burns by initial cooling. J R.Soc.Med 1992;85:121.
  • Latarjet J. [Immediate cooling with water: emergency treatment of burns]. Pediatrie.(Bucur.) 1990;45:237-9.
  • Lawrence JC. British Burn Association recommended first aid for burns and scalds. Burns Incl.Therm.Inj. 1987;13:153.
  • Clayton MC,.Solem LD. No ice, no butter. Advice on management of burns for primary care physicians. Postgrad.Med. 1995;97:151-60, 165.
  • Demling RH, Mazess RB, Wolberg W. The effect of immediate and delayed cold immersion on burn edema formation and resorption. J.Trauma 1979;19:56-60.
  • Kravitz H. Letter: Cooling as first aid for burns. Pediatrics 1974;53:766.
  • Kravitz H. First-aid therapy for burns—cool it: need to instruct laymen. Clin.Pediatr.(Phila) 1970;9:695-7.
  • Australian and New Zealand Burn Association. Emergency Management of Severe Burns Course Manual. 1996.
  • First Aid Manual, the authorised manual of St John Ambulance, St Andrew’s Ambulance Association and the British Red Cross. London: Dorling Kindersley, 1997.
  • Judkins K.C. Thermal Injury. In Greaves I, Porter K, eds. Pre-Hospital Medicine The Principles and Practice of Immediate Care, pp 375-87. London: Arnold, 1999.
  • Burns. In Greaves I HTPK, ed. Emergency Care A Textbook for Paramedics, pp 270-8. WB Saunders, 1997.
  • Raine TJ, Heggers JP, Robson MC, London MD, Johns L. Cooling the burn wound to maintain microcirculation. J Trauma 1981;21:394-7.
  • Jelenko C, III, Jennings WD, Jr., O’Kelley WR, III, Byrd HC. Threshold burning effects on distant microcirculation: Presence of a passively transferrable, nondialyzable arteriolar constrictor substance in blood of burned patients. Am.Surg. 1974;40:388-91.
  • Jelenko C, III, Jennings WD, Jr., O’Kelley WR, III, Byrd HC. Threshold burning effects on distant microcirculation. II. The relationship of area burnt to microvascular size. Arch.Surg. 1973;106:317-9.
  • Jelenko C, III, Jennings WD, Jr., O’Kelley WR, III, Byrd HC. Threshold burning effects on distant microcirculation. I. Preliminary observations. Arch.Surg. 1971;102 :617-25.
  • King T.C,.Price P.B. Surface Cooling Following Extensive Burns. JAMA 1963;183:677.
  • Ofeigsson O.J. Water Cooling: first aid treatment of of scalds and burns. Surgery 1965;57:391.
  • Cooke M.W, Morrell R, Wilson S, Bridge P, Edwards S, Allan T.F et al. Does criteria based dispatch of 999 calls adequately detect the critically ill and injured? Pre-hospital Immediate Care 1999;3:191-5.
  • Childs C. Temperature regulation in burned patients. Journal of Intensive Care 1994;131-4.



4. Dressings

  • Cover burnt area with Clingfilm
  • Be aware of possible constricting effect of wrapping!
  • Wrap the patient up in blankets or duvet (Cool the burn wound but warm the patient)
  • In chemical burns after irrigation / cooling. Clingfilm theoretically may worsen chemical burn effect, irrigate   thoroughly until pain or burning has decreased. Go for wet dressings only but beware of powder injuries,  which may be worsened with water. Bring data sheet on likely chemical if available with the patient to hospital.

References

  1. Allison K. The UK pre-hospital management of burn patients: current practice and the need for a standard approach. Burns 2002;28:135-42.
  2. O’Rourke G, Hanley K, Dowling J, Murphy A, Bury G. The use of basic life support kits in general practice. Ir.Med J 1999;92:399-400.
  3. Kinsella J,.Booth MG. Pain relief in burns: James Laing memorial essay 1990. Burns 1991;17:391-5.
  4. Vartak AM, Keswani MH, Patil AR, Savitri S, Fernandes SB. Cellophane—a dressing for split-thickness skin graft donor sites. Burns 1991;17:239-42.
  5. Queen D, Evans JH, Gaylor JD, Courtney JM, Reid WH. Burn wound dressings—a review. Burns Incl.Therm.Inj. 1987;13:218-28.
  6. Coats TJ, Edwards C, Newton R, Staun E. The effect of gel burns dressings on skin temperature. Emerg.Med J 2002;19:224-5.
  7. Treharne LJ, Kay AR. The initial management of acute burns. J R.Army Med Corps 2001;147:198-205.
  8. Cole RP, Shakespeare PG, Chissell HG, Jones SG. Thermographic assessment of burns using a nonpermeable membrane as wound covering. Burns 1991;17:117-22.
  9.    
    5. Assessment and management of immediately or imminently life threatening problems:

        A.c.B.C (Airway with cervical spine stabilisation, breathing, circulation)

    • Patient may have other injuries co-existent with their burn injury
    • O2 high flow non-rebreath mask (15 litres/min). (Not necessary for small burns without any suspected     inhalation injury)

    References

    • 19. Australian and New Zealand Burn Association. Emergency Management of Severe Burns Course Manual. 1996.
    • 38. American College of Surgeons. Injuries due to burns and cold. In ACS committee on trauma, ed. Advanced Trauma Life Support for Doctors (ATLS), pp 273-88. Chicago: 1997.
    • 39. Hodgetts T, McNeil I, Cooke M. The Pre-Hospital Emergency Management Master. London: BMJ, 1995.

       
    6. Assessment of burn severity

    • Time of burn injury o In order to estimate the size of burned area, use the Wallace rule of Nines or the ‘half burnt/half not’ approach
    • Mechanism of Injury (flame {clothes or patient caught fire}, flash burn, scald, electrical, chemical)
    • Burn within confined space = possible inhalation injury
    • In children and elderly, always be mindful of potential Non Accidental Injury. Keep good records and keep the clothing.

    References

    • 40. Ashworth HL, Cubison TC, Gilbert PM, Sim KM. Treatment before transfer: the patient with burns. Emerg.Med J 2001;18:349-51.
    • 41. McGugan EA, Paterson B, Nichol N, Klaassen B. Re: Accuracy of burn size estimation and subsequent fluid resuscitation prior to arrival at the Yorkshire Regional Burns Unit. A three year retrospective study. Burns 2000;26:415-6.
    • 42. Collis N, Smith G, Fenton OM. Accuracy of burn size estimation and subsequent fluid resuscitation prior to arrival at the Yorkshire Regional Burns Unit. A three year retrospective study. Burns 1999;25:345-51.
    • 43. Hammond JS,.Ward CG. Transfers from emergency room to burn center: errors in burn size estimate. J Trauma 1987;27:1161-5.

    7. Cannulation and intravenous fluids

    • Cannulate for titrated opiate / opioid analgesia
    • Do not allow cannulation procedures to unnecessarily extend the on scene time.
    • Limited attempts to cannulate the patient (2 attempts only)
    • Fluid replacement (0.9% normal saline or Hartmann’s solution) can be commenced if the patient is     cannulated.
    • Fluid replacement must be started for burns > 25% T.B.S.A and / or if time to hospital is more than 1 hour     from time of injury. (1000 ml for adult, 500 ml for child 10-15years, 250 ml 5-10years, no fluids for under 5’s)
    • Fluid therapy should ideally be warmed

    References

    • 44. Henry S,.Scalea TM. Resuscitation in the new millennium. Surg.Clin.North Am. 1999;79 :1259-67, viii.
    • 45. Myers C. Fluid resuscitation. Eur.J Emerg.Med. 1997;4:224-32.
    • 46. Warden GD. Burn shock resuscitation. World J Surg. 1992;16:16-23.
    •   47. Dalton A.M. Pre-hospital intravenous fluid replacement in trauma: an outmoded concept? Journal of Royal Society of Medicine 1995;April:213-6.
    •  

    8. Analgesia

    • Is best accomplished by cooling and covering initially
    • Intravenous opiate / opioid, titrated to effect in adults with anti-emetic.
    • Intranasal diamorphine is an option to be considered/adopted in children
    • Entonox should only be used when above options unavailable (difficult to administer, varying efficacy and     decreased oxygen delivery)

    References

    • 8. Allison K. The UK pre-hospital management of burn patients: current practice and the need for a standard approach. Burns 2002;28:135-42.
    • 12. Hodson AH. Treating burns by initial cooling. J R.Soc.Med 1992;85:121.
    • 35. Coats TJ, Edwards C, Newton R, Staun E. The effect of gel burns dressings on skin temperature. Emerg.Med J 2002;19:224-5.
    • 48. Kendall JM, Reeves BC, Latter VS. Multicentre randomised controlled trial of nasal diamorphine for analgesia in children and teenagers with clinical fractures. BMJ 2001;322:261-5.
    • 49. Chambers JA,.Guly HR. Prehospital intravenous nalbuphine administered by paramedics. Resuscitation 1994;27:153-8.
    • 50. Phillips GD. First aid in disasters. Med J Aust. 1980;2:420-4.
    • 51. Wilson JA, Kendall JM, Cornelius P. Intranasal diamorphine for paediatric analgesia: assessment of safety and efficacy. J Accid.Emerg.Med 1997;14:70-2.
    •  

    9. Transport

    • Information to A&E as per national standard (age, gender, incident, ABC problems, relevant treatment, ETA)
    • All treatment should be carried out with the aim of reducing on-scene times and delivering the patient to the     appropriate treatment centre.
    • Initial transport to the nearest appropriate A&E department. Unless local protocols allow direct transfer to     burns facility
    • References
      • 52. Cummings G,.O’Keefe G. Scene disposition and mode of transport following rural trauma: a prospective cohort study comparing patient costs. J Emerg.Med 2000;18:349-54.
      • 53. Baack BR, Smoot EC, III, Kucan JO, Riseman L, Noak JF. Helicopter transport of the patient with acute burns. J Burn Care Rehabil. 1991;12:229-33.
      • 54. Novak J,.Tury P. [Inter-hospital transportation of burned patients]. Magy.Traumatol.Orthop.Helyreallito.Seb. 1991;34:43-8.
      •   55. National Burn Care Review. National Burn Care Review Report. Dunn, K. W. 2001. Ref Type: Report
      • 56. Palmer J.H,.Sutherland A.B. Problems associated with transfer of patients to a regional burns unit. Injury 1987;18:250-7.
      • 57. Marichy J, Chahir N, Peres-Tassart C, Abeguile R. [Prehospital management of burns]. Pathol.Biol.(Paris) 2002;50:74-81.
      • 58. Nakae H,.Wada H. Characteristics of burn patients transported by ambulance to treatment facilities in Akita Prefecture, Japan. Burns 2002;28:73-9.
      • 59. Slater H, O’Mara MS, Goldfarb IW. Helicopter transportation of burn patients. Burns 2002;28:70-2.
      • 60. De Wing MD, Curry T, Stephenson E, Palmieri T, Greenhalgh DG. Cost-effective use of helicopters for the transportation of patients with burn injuries. J Burn Care Rehabil. 2000;21:

      The guidance in this consensus document has been agreed between the BBA
      and the Pre-hospital Committee of the RCS of Edinburgh.

      August 2002
      For review in 2004