Care of Burn Patients

Burn Care Is Complex

There are three distinct phases of care for burn patients: the emergent phase, the hospital phase, and the long-term care phase. 

The emergent, or pre-hospital, phase occurs when the healthcare providers arrive at the scene. 

The hospital phase occurs from the time the patient arrives at the hospital emergency department through their hospital or burn center stay. 

The long-term care phase addresses the care for patients with severe burns after being discharged from the hospital.

The resuscitative phase includes the pre-hospital and hospital phases.

The care of burn patients is complex. These patients have many potential complications and injuries, such as going into burn shock. The care provided in the immediate first few hours after the burn injury is paramount to successful outcomes.

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Pre-hospital Phase (At the Scene)

The pre-hospital phase begins when the health care provider arrives at the scene. In this phase, the provider must:

• Remove the patient from the burn source.
• Evaluate the patient’s airway and determine if there is a need to intubate.
• Address breathing and provide oxygen if needed.
• Address circulation, including removing clothing, starting an IV, and administering IV fluids.
• Perform a quick head-to-toe assessment.
• Obtain patient history.

These steps are discussed further below.

For burn patients, the first priority is to stop the burning process, such as removing a patient from a building on fire.

Stop the Burning Process

The first priority of the healthcare provider when arriving at the scene is to stop the burning process. Because the burn is causing the injury, it needs to be stopped as quickly as possible. However, the way to stop the process depends on the type of burn: thermal, chemical, electrical, or scalding.

Thermal Burns

For a thermal burn, the flames must first be extinguished, which may require smothering them with a blanket or water. Ice should never be used to stop a burn, as it causes significant tissue damage.

Chemical Burns

The first step to stopping a chemical burn is to ensure no chemicals or powders are in contact with the patient. That may require removing the patient’s clothing immediately to eliminate the source of contact. Once the source has been removed, the patient should be doused with water.

When dealing with chemicals or a chemical burn, the provider must wear personal protective equipment (PPE) to avoid coming in contact with the chemical.

Electrical Burns

For an electrical burn, the patient needs to be removed from the electrical source. Any providers on the scene must take precautions to avoid coming in contact with the electrical source themselves.

Scalding Burns

If the patient is scalded by something like hot tar or asphalt, they first need to be removed from the source of the scalding. If clothing is stuck to them, the provider should not attempt to remove it, as skin and tissue could be removed as well.

For a chemical burn, remove the clothing and douse the burn with water.

No matter the type of burn, the first priority of the healthcare provider, prior to assessing the patient or providing other medical intervention, is stopping the burning process.

Assess the Airway

Once the burning process is stopped, it is essential to assess the airway.

Patients with significant facial burns or injuries have the greatest potential for airway edema. Therefore, they should be intubated prophylactically.

Once the patient has been intubated or an oral airway has been put into place, it is essential to address breathing with oxygen.

Address Breathing with Oxygen

For a patient with smoke inhalation, inhalation injury, or evidence of airway edema, 100% humidified oxygen should be administered through the endotracheal (ET) tube or a 100% non-rebreather mask at the scene.

Address Circulation

After assessing the airway and administering oxygen on the scene, circulation must be addressed. Any clothing or jewelry that is restricting the patient from perfusing or breathing needs to be removed.

Large-bore IVs, either 18 or 16 gauge, should be started to administer fluids. The fluid of choice is lactated Ringer.

Perform a Quick Head-to-Toe Assessment

A rapid head-to-toe assessment should be completed to assess for any other life-threatening injuries before arriving at the hospital.

A rapid head-to-toe assessment assesses the patient’s neurological status and any other life-threatening injuries and circumferential burns.

Part of the head-to-toe assessment is to assess the patient’s spine to determine if cervical spine precautions are needed for transport. If the patient fell from a height or has a suspected spinal injury, they will need to be placed on a backboard.

If the patient is suspected of having a spinal injury, narcotic pain medication may be administered through the IV to help manage pain during transport.

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Obtain a Brief History from the Patient

Because the patient will likely be awake and alert at the scene, the provider needs to obtain a brief patient history. Once at the hospital, the patient may be sedated or rushed to surgery, making it difficult for them to communicate with the medical team. 

Questions the provider should ask include:

• What happened?
• What type of burn is it?
• What led to the burn?
• What chemicals were involved?
• What is your medical history?
• Are you allergic to any medications or anything else?
• What medications do you take?
• What diseases do you have that could complicate anesthesia?

Having information on the patient’s history is essential for the continuum of care at the hospital.

Once these steps have been taken, the patient is ready for transport to the hospital.

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Hospital Phase

Upon arrival at the hospital, the patient’s ABCs (airway, breathing, and circulation) will continue to be monitored and assessed.

Airway

Patients who were not intubated at the scene will be further assessed for new stridor, wheezing, and evidence of airway edema. If any of these are present, the patient will need to be intubated.

For patients who were intubated at the scene, an X-ray should be obtained to confirm the placement of the ET tube. The provider must also confirm that the ET tube is well secured, as it could be difficult to reintubate due to edema or inhalation injury should the patient be accidentally extubated.

Care must be taken when securing the ET tube to ensure that it is not secured to any area with a burn injury (such as around the ears) to avoid causing more tissue injury.

Unlike at the scene, the provider at the hospital has access to more equipment to better assess the patient. For example, a fiber optic bronchoscope may be used to further check the patient’s airway and visualize airway injury.

Once the airway is secured, the provider must assess the patient’s breathing.

Breathing

The provider assesses the patient’s breathing by listening to breath sounds, assessing the quality of the patient’s respirations, and examining the sputum (e.g., is it tarry or bloody? Is the patient coughing up soot? Is there soot around the patient’s mouth?).

The provider will also assess for chest wall excursion, examining for evidence of flail chest.

Carboxyhemoglobin (COHb) levels and arterial blood gases (ABGs) will be assessed if there was confirmed or suspected cyanide or carbon monoxide poisoning. If this exposure is present, the patient needs 100% oxygen to reverse these poisonings.

In addition to administering oxygen to assist with breathing, medications, such as albuterol, can be administered to help open the patient’s airways. 

Once the patient’s breathing is assessed, it is important to next address the patient’s circulation.

Circulation

While assessing circulation, the provider needs to estimate the total body surface area that has been burned using the Rule of Nines.

The Rule of Nines estimates the total body surface area affected by burns.

The Rule of Nines is a guide providers use to estimate the total burned body surface area. Patients with a significant percentage of burned surface area will need to be transferred to a burn center for continued care.

A patient should be transferred to a burn center if:

• They have ≥ 20% total body surface area with burns.
• They have full-thickness burns.
• They have burns in certain areas of the body.

Patients who present with these kinds of burns require specialized care at a burn center.

Using the Parkland Formula to Estimate IV Fluid Replacement

Burn patients require significant amounts of fluid because of capillary permeability and extensive fluid loss from the intravascular space. If the fluid is not adequately replaced, they will experience burn shock. The provider uses the Parkland formula to estimate how much fluid the patient needs.

The Parkland formula is:

Fluid requirement=Body surface area burned % × weight kg× 4 mL

Note: the 4 mL variable may vary between healthcare organizations.

For example, if the total burned surface area is 25% and the patient weighs 100 kilograms, the formula is: 25 × 100 × 4 = 10,000. (Note: 25 is used for the percentage, not 0.25.)

IV fluid replacement is crucial for burn patients.

As illustrated in the example above, the Parkland formula will return a large number for fluid replacement (e.g., 10,000 mL). Burn patients require a lot of fluid.

The Parkland formula calculates the total amount of fluid the patient requires in the first 24 hours. Using the example above, the patient requires 10,000 mL (or 10,000 ccs) of fluid replacement. Half of that fluid is administered in the first 16 hours (5,000 mL), and the other half (5,000 mL) is administered over the remaining 8 hours.

Checking if Fluid Replacement is Adequate

Once the fluid replacement is initiated, it is essential to determine if the patient is getting enough. Placing a Foley catheter allows the provider to record urine output and adjust fluid replacement as needed. If urine output is under 30–50 mL per hour, then fluid replacement is not adequate.

Patients who experience burns require special care from the moment the healthcare team arrives at the scene through their hospital stay and long-term recovery. This article outlines the steps the provider needs to take at the scene and upon arrival to the hospital to appropriately assess and care for burn patients.