EMT Burn Management: Part 3

Treatment Guidelines For The Burn Patient

You’ve taken an educated guess on burn depth, calculated the burn area and classified the burns severity. With those priorities out of the way we can start treating the victim. (Yes, I’m taking some creative literary licence here, since assessment and treatment tend to occur in tandem.)

There are things we tend to do well and things we tend to do poorly in prehospital burn management. Here are some “do and don’t” type guidelines to direct your burn treatment.

Always consider the possibility of non - accidental trauma in pediatric burns.

Always consider the possibility of non – accidental trauma in pediatric burns.

Do:

Assess the heck out of the Airway.

  • Inhalation burns are easy to miss if you’re not paying attention. Burn victims have a tendency to gasp when they are burned. You need to look really close at that airway. Shine a light on the patients facial hairs (yes women have them also) and look for singed or missing patches. Look up their nose and in their mouth for evidence of burns.
  • Listen to the lungs and auscultate over the trachea. Reassess frequently. Only time will tell for certain if there is damage to the lower airway or lungs. Until then, you need to reassess frequently and don’t get caught behind the eight ball trying to manage an airway that goes down hill due to unrecognized burns.

Stop the Burning Process 

  • Flush the burn. The purpose of using liquids on the burn are is to stop the burning process. This might be a change from what you learned in your EMT class. Current burn guidelines do not recommend “cooling” the burn. The act of cooling burn tissue does not seem to promote better healing. It does contribute to hypothermia, which is a larger problem. One of the most overlooked elements of our burn treatment is:

Keep the Patient Warm

  • Burn patients loose heat at a tremendous rate. We need to cool the burn not the patient. Burn centers anticipate that critical burn patients will be hypothermic on arrival. We don’t tend to disappoint them. Crank up the heater until you sweat.
  •  One of the biggest things we do to contribute to burn patient hypothermia is cooling the burn too aggressively either by soaking the patient or soaking the dressings and bandages and leaving them in place. Instead of soaking, we want to:

Apply Dry, Sterile Dressings to The Burn

  • That’s right. The days of wrapping a burn in dressings and then pouring saline over them are over. In the long run this creates more complication that benefit. keep those dressings dry and sterile. Then move on to something more beneficial like:

Give IV Fluids

  • Burns displace a tremendous amount of fluid. You will find that it is difficult to give too much fluid to the moderate or severely burned patient. One good Guideline is 2-4cc of fluid X Kg. of body weight X percentage of TBSA burned = total fluid for the first 8 hours of treatment. While you’re working that out, open the line up and give some fluid. 500 – 1000ccs is a good starting point for patients over 15 years of age.

Consider ALS

  • For potential advanced airway interventions and pain control.

Create a semi-sterile field

  • That’s what those burn sheets are for. Open them up and avoid unnecessarily contaminating burn wounds.

A Few Big Don’ts:

  • Don’t pull stuck clothing off the burn. Removing clothing is OK but things sticking to the wound can wait for debridement at the facility.
  • Don’t put Silvadene, ointments, Salves, Tiger Balm or anything else on the wound unless specifically indicated by your protocols. Every family member seems to know some magic burn cure from grandma or the Internet. Kindly try to intercept them before they contaminate the wound further with their good intentions.
  • Don’t let the patient get cold.
  • Don’t neglect the airway. (Have I hit this one enough yet?)
  • don’t forget that patients who cannot speak can probably still hear and understand you.

Burns can be complex and emotional calls. As caregivers they present unique and fascinating challenges. In the future I’m sure I’ll come back around and discuss in more detail special considerations like burns in pediatrics and the elderly, non-accidental trauma, electrocution, chemical burns and other unique burn scenarios.

Treating your burn patient can be relatively smooth sailing if you fall back onto the guidelines presented here. Establish the depth and extent of the burn, identify any moderate or severe burn indicators and treat the burns, and the patient appropriately. Thanks for coming along on the journey. I hope your next burn call goes smoothly.

Also See:

Part 1: An EMT Guide To Burn Assessment and Treatment

Part 2: Burn Assessment and Treatment – Making the Call

Comments

  1. Wow Steve,
    That was so helpful! I want to thank you for putting this up. This is actually for research, for a book I’m working on, but this is also very helpful information. Never know when you might be put into a situation like this, right? Well, anyway, thanks again!
    -Kokoro

  2. Steve Whitehead says:

    You’re welcome Kokoro. I’m glad it was helpful. Send me an e-mail when your book is done. I’d love to see it.

    Steve

  3. It could be a while…but alright, sounds good! ^^
    Could I ask you something about burns?

    Kokoro

  4. thank you so much! you really helped me with a project I have to do on burns! this site got me an A. 🙂

  5. hector says:

    I think you need to clarify your information. Cool running water for 20-30mins immediately after the burn event is the international standard for first aid care. This has been adopted by all the major burns organisations. Once this is completed wounds then need to be covered with clingfilm as a first choice (not with hydrogel type dressings – particularly in large surface area burns). Hydrogel dressings are suitable in the absence of water but only for the initial cooling. Emphasis on warming the patient begins at the burn scene. Cool the burn (only for 20-30mins at the beginning), then warm the patient. Note: if cooling hasn’t been done at the scene it still needs to be done even if this means you cool the pt in the mabulance en-route to hospital using running water (1st choice), wetted dressings (2nd choice) or hydrogel dressings (3rd Choice).
    ABC’s and ALS are always the first priorities however especially inhalational burn injuries.

  6. Steve Whitehead says:

    @Swe You’re welcome. Glad I could help.

    @Hector Thanks for your contribution. I always appreciate readers adding to the article. I’m a bit confused about your request for me to clarify. It sounds like everything you mentioned matches my burn treatment recommendations perfectly. On which points did you think I was short on detail or inaccurate?

  7. Thanks Steve. The issue of cooling en-route to hospital needs clarification as the jury is still out. The big (presumed) worry is hypothermia but there are a few studies that contradict this. eg Singer 2010, Lonnecker 2001 . Aside from Mx time critical issues, prehospital can improve its contribution to accelerated wound healing by cooling using running water – but just for the 20-30mins. This may overlap into the trip to hosp if it hasn’t been done at scene. If it has been done then dry dressings as you point out are the way to go. There is no reason not to stay at scene to cool minor burns in adults <10% unless there are TC/other issues. This doesn't apply to paeds unless burns are superficial and <5% TBSA. The guys really need to focus on infection as well. Frequent glove changes, face mask in car, avoid cross contamination of the wound -if you touch the wounds chnage your gloves etc. Cheers

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