Prehospital Management, Transportation, and Emergency Care

Introduction

Advances in trauma and burn management over the past three decades have resulted in improved survival and reduced morbidity from major burns. The cost of such care, however, is high; it requires conservation of resources such that only a limited number of burn intensive care units with the capabilities of caring for such labor-intensive patients can be found; hence, regional burn care has evolved. This regionalization has led to the need for effective prehospital management, transportation, and emergency care. Progress in the development of rapid, effective transport systems has resulted in marked improvement in the clinical course and survival for victims of thermal trauma.

For burn victims, there are usually two phases of transport. The first is the entry of the burn patient into the emergency medical system with treatment at the scene and transport to the initial care facility. The second phase is the assessment and stabilization of the patient at the initial care facility and transportation to the burn intensive care unit. With this perspective in mind, this chapter reviews current principles of optimal prehospital management, transportation, and emergency care.

Prehospital Care

Immediate burn care by first responders is important and can vastly alter outcomes, and it can significantly limit burn progression and depth. The goal of prehospital care should be to ease the burning process as well as prevent further complications and secondary injuries from burn shock. Identifying burn patients appropriately for immediate transfer is an important step in reducing the morbidity and mortality. Prior to any specific treatment, a patient must be removed from the source of injury and the burning process stopped. As the patient is removed from the injuring source, care must be taken so that a rescuer does not become another victim. All caregivers should be aware of the possibility that they may be injured by contact with the patient or the patient's clothing. Universal precautions, including wearing gloves, gowns, masks, and protective eye wear, should be used whenever there is likely contact with blood or body fluids. Burning clothing should be removed as soon as possible to prevent further injury. It has been shown that prompt removal of clothing after scald injuries may reduce postburn morbidity. All rings, watches, jewelry, and belts should be removed because they can retain heat and produce a tourniquet-like effect with digital vascular ischemia. If water is readily available, it should be poured directly on the burned area. Early cooling can reduce the depth of the burn and reduce pain, but cooling measures must be used with caution since a significant drop in body temperature may result in hypothermia with ventricular fibrillation or asystole. Cold water treatment over large body surfaces has been shown to trigger clinically relevant hypothermia. Ice or ice packs should never be used because they may cause further injury to the skin or produce hypothermia.

Initial management of chemical burns involves removing saturated clothing, brushing the skin if the agent is a powder, and irrigation with copious amounts of water, taking care not to spread chemical on burns to adjacent unburned areas. Irrigation with water should continue from the scene of the accident through emergency evaluation in the hospital. Efforts to neutralize chemicals are contraindicated due to the additional generation of heat, which would further contribute to tissue damage. A rescuer must be careful not to come in contact with the chemical (i.e., gloves, eye protectors, etc. should be worn).

Removal of a victim from an electrical current is best accomplished by turning off the current and by using a nonconductor to separate the victim from the source.

Onsite Assessment of a Burned Patient

Assessment of a burned patient is divided into primary and secondary surveys. In the primary survey, immediate life-threatening conditions are quickly identified and treated. The primary survey is a rapid, systematic approach to identify life-threatening conditions. The secondary survey is a more thorough head-to-toe evaluation of the patient. Initial management of a burned patient should be the same as for any other trauma patient, with attention directed at airway, breathing, circulation, and cervical spine immobilization.

Primary Assessment

Exposure to heated gases and smoke from the combustion of a variety of materials results in damage to the respiratory tract. Direct heat to the upper airways results in edema formation, which may obstruct the airway. Initially, 100% humidified oxygen should be given to all patients when no obvious signs of respiratory distress are present. Upper airway obstruction may develop rapidly following injury, and the respiratory status must be continually monitored in order to assess the need for airway control and ventilator support. Progressive hoarseness is a sign of impending airway obstruction. Endotracheal intubation should be done early before edema obliterates the anatomy of the area. Intubation should be performed by the most experienced provider.

The patient's chest should be exposed in order to adequately assess ventilatory exchange. Circumferential burns may restrict breathing and chest movement. Airway patency alone does not assure adequate ventilation. After an airway is established, breathing must be assessed in order to ensure adequate chest expansion. Impaired ventilation and poor oxygenation may be due to smoke inhalation or carbon monoxide intoxication. Endotracheal intubation is necessary for unconscious patients, for those in acute respiratory distress, or for patients with burns of the face or neck that may result in edema, which causes obstruction of the airway. The nasal route is the recommended site of intubation. Assisted ventilation with 100% humidified oxygen is required for all intubated patients.

Blood pressure is not the most accurate method of monitoring a patient with a large burn because of the pathophysiologic changes that accompany such an injury. Blood pressure may be difficult to ascertain because of edema in the extremities. A pulse rate may be somewhat more helpful in monitoring the appropriateness of fluid resuscitation.

If a burn victim was in an explosion or deceleration accident, there is the possibility of a spinal cord injury. Appropriate cervical spine stabilization must be accomplished by whatever means necessary, including a cervical collar to keep the head immobilized until the condition can be evaluated.

Secondary Assessment

After completing a primary assessment, a thorough head-to-toe evaluation of the patient is imperative. A careful determination of trauma other than obvious burn wounds should be made. As long as no immediate life-threatening injury or hazard is present, a secondary examination can be performed before moving the patient; precautions such as cervical collars, backboards, and splints should be used. Secondary assessment should examine the patient's past medical history, medications, allergies, and the mechanisms of injury. Any suspicion of nonaccidental injury should lead to immediate admission of a child to the hospital, irrespective of how trivial the burn injury is, and notification of social services.

There should never be a delay in transporting burn victims to an emergency facility due to an inability to establish intravenous (IV) access. If the local/regional emergency medical system (EMS) protocol prescribes that an IV line is started, then that protocol should be followed. The American Burn Association recommends that if a patient is less than 60 min from a hospital, an IV is not essential and can be deferred until a patient is at the hospital. If an IV line is established, Ringer's lactate (LR) solution should be infused at the following rates:

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14 years and older: 500 mL/h
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6–13 years old: 250 mL/h
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5 years and younger: 125 mL/h

Prehospital care of wounds is basic and simple because it requires only protection from the environment with an application of a clean dressing or sheet to cover the involved part. Covering wounds is the first step in diminishing pain. If it is approved for use by local/regional EMS, narcotics may be given for pain, but only intravenously in small doses and only enough to control pain. It has been shown that despite training of medical staff, provision for analgesia for children with burns is lacking and needs further clarification. Intramuscular (IM) or subcutaneous routes should never be used because fluid resuscitation could result in unpredictable patterns of uptake. No topical antimicrobial agents should be applied in the field. The patient should then be wrapped in a clean sheet and blanket to minimize heat loss and to control temperature during transport.

Transport to Hospital Emergency Department

Rapid, uncontrolled transport of a burn victim is not the highest priority, except in cases where other life-threatening conditions coexist. In the majority of accidents involving major burns, ground transportation of victims to a hospital is available and appropriate. Helicopter transport is of greatest use when the distance between an accident and a hospital is 30–150 miles or when a patient's condition warrants. Whatever the mode of transport, it should be of appropriate size and have emergency equipment available as well as trained personnel, such as a nurse, physician, paramedic, or respiratory therapist.

An estimate of burn size and depth assists in making a determination of severity, prognosis, and disposition of a patient. Burn size directly affects fluid resuscitation, nutritional support, and surgical interventions. The size of a burn wound is most frequently estimated by using the rule-of-nines method ( Fig. 7.1 ). The American Burn Association identifies certain injuries as usually requiring a referral to a burn center. Patients with these burns should be treated in a specialized burn facility after initial assessment and treatment at an emergency department. Questions about specific patients should be resolved by consultation with a burn center physician ( Box 7.1 ).

Fig. 7.1, Estimation of burn size using the rule-of-nines.

Box 7.1

From American Burn Association . Advanced Burn Life Supporters Manual. Chicago, IL: American Burn Association; 2011.

Criteria for Transfer of a Burn Patient to a Burn Center

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Second-degree burns >10% total body surface area (TBSA)
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Third-degree burns
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Burns that involve the face, hands, feet, genitalia, perineum, and major joints
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Chemical burns
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Electrical burns including lightning injuries
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Any burn with concomitant trauma in which the burn injuries pose the greatest risk to the patient
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Inhalation injury
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Patients with pre-existing medical disorders that could complicate management, prolong recovery, or affect mortality
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Hospitals without qualified personnel or equipment for the care of critically burned children

Keeping the Patient Warm and Dry

Hypothermia is detrimental to traumatized patients and can be avoided or at least minimized by the use of sheets and blankets. Wet dressings should be avoided.

Pain Control

The degree of pain experienced initially by the burn victim is inversely proportional to the severity of the injury. No medication for pain relief should be given intramuscularly or subcutaneously. For mild pain, acetaminophen 650 mg orally every 4–6 hours may be given. For severe pain, morphine, 1–4 mg intravenously every 2–4 hours, is the drug of choice, although meperidine (Demerol) 10–40 mg by IV push every 2–4 hours may be used. Recommendations for tetanus prophylaxis are based on the patient's immunization history. All patients with burns should receive 0.5 mL of tetanus toxoid. If prior immunization is absent or unclear, or if the last booster was more than 10 years ago, 250 units of tetanus immunoglobulin is also given.

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