Burn injuries in the Advanced Trauma Life Support method is the same as other kinds of trauma with certain very important details.*
The ABCs need to be followed in burn patients. However, burn injuries can lead to rapid airway compromise so A includes evaluation for intubation. B includes breathing and stop the burning. And C involves fluid replacement based on the extent of burns and the adequacy of urine output.
Airway
“Although the larynx protects the subglottic airway from direct thermal injury, the airway is extremely susceptible as a consequence of exposure to heat. Clinical indications of inhalation injury include :
- Face and/or neck burns
- Singeing of the eyebrows and nasal vibrissae
- Carbon deposits in the mouth and/or nose and carbonaceous sputum
- Acute inflammatory changes in the oropharynx, including erythema
- Hoarseness
- History of impaired mentation and/or confinement in a burning environment
- Explosion with burns to head and torso
- Carboxyhemoglobin level greater than 10% in a patient who was involved in a fire
“Any of the above findings suggests an inhalation injury and the need for intubation. Transfer to a burn center is indicated if there is an inhalation injury, but if the transport time is prolonged, intubation should be performed prior to transport. Stridor occurs late and is an indication for immediate endotracheal intubation. Circumferenatial burns of the neck can lead to swelling of the tissues around the airway: therefore, early intubation is also indicated for these injuries.”
Breathing and Stop the Burning Process
“All clothing should be removed to stop the burning process; however, do not peel off adherent clothing. Synthetic fabrics can ignite, burn rapidly at high temperatures, and melt into hot residue that continues to burn the patient. any clothing that was burned by chemicals should be removed carefully. Dry chemical powder should be brushed from the wound, with the individual caring for the patient avoiding direct contact with the chemical. The involved body surface areas should be rinsed with copious amounts of warm tap water. The patient then should be covered with warm, clean, dry linens to prevent hypothermia.”
Every burn patient needs supplemental oxygen with or without entubation.
“Always assume carbon monoxide (CO) exposure in patients who were burned in enclosed areas. The diagnosis of carbon monoxide poisoning is made primarily from a history of exposure and by direct measurement of carboxyhemoglobin (HbCO).”
“Therefore, any patient in whom CO exposure could have occurred, should receive high-flow oxygen via a non-rebreathing mask.
It is critical to realize that a normal PaO2 does not rule out dangerous carbon monoxide blood levels. That is why you must directly measure the carboxyhemoglobin level.
Circulation
It can be difficult to evaluate circulating blood volme in patents with severe burns. Also they may have suffered other injuries that contribute to hypovolemic shock.
Shock is treated according to ATLS resuscitation principles.
“Any patient with burns over more than 20% of the body surface requires fluid resuscitation. After establishing airway patency and identifying and treating immediately life-threatening injuries, intravenous access must be established. Large-caliber (at least 16-gauge) intravenous lines should be introduced immediately in a peripheral vein. If the extent of the burn precludes placement of a catheter in unburned skin, the IV should be placed through the burned skin into an accessible vein.”
“Blood pressure measurements can be difficult to obtain and may be unreliable in patients with severe burn injuries, but monitoring hourly urine output can reliably assess circulating blood volume in the absence of osmotic diuresis (e.g., glyccosuria). Therefore, an indwelling urinary catheter should be inserted.”
“The initial fluid rate for burn patients is based on seeral well-known formulas:Patients with burns require 2 to 4 mLof Ringer’s lactate solution per kilogram of body weight per percentage BSA of deep partial-thickness and full-thickness burns during the first 24 hours to maintain an adequate circulating blood volume and provide adequate renal perfusion. The calculated fluid volume is initiated in the following manner: one half of the total fluid is providedin the first 8 hours after the burn injury. . . . . The remaining one-half of the total fluid is administered during the subsequent 16 hours.”
But the actual fluid rates are adjusted based on the patient’s urine output.
The preferred fluid is Ringer’s lactate. “In very small children (i.e., <10 kg), it may be necessary to add glucose to their IV fluids to avoid hypoglycemia.”
ECG monitoring should be initiated in all burn patients because cardiac arrythmias “may be the first sign of hypoxia and electrolyte or acid-base abnormalities.”
“Persistent acidemia may be caused by cyanide poisoning. Consultation with a burn center or poison control center should occur if this diagnosis is suspected. Cyanide is a naturally occurring toxin that may be inhaled in a confined space fire.”
Criteria For Transfer to a Burn Center
“The American Burn Association has identified the following types of burn injuries that typically require referral to a burn:
- Partial-thickness and full-thickness burns on greater than 10% of the BSA in any patient.
- Partial-thickness and full-thickness burns involving the face, eyes, ears, hands, feet, genitalia, and perineum, as well as those that involve skin overlying mjaor joints.
- Full-thickness burns of any size in any age group.
- Significant electrical burns, including lightning injury (significant electrical burns, including lightning injury (significant volumes of tissue beneath the surface can be injured and result in acute renal failure and other complications)
- Significant chemical burns
- Inhalation injury
- Burn injury in patients with preexisting illness that could complicate treatment, prolong recovery, or affect mortality
- Any patient with a burn injury who has concomitant trauma poses an increased risk of morbidity or mortality, and may be treated initially in a trauma center until stable before being transferred to a burn center
- Children with burn injuries who are seen in hospitals without qualified personnel or equipment to manage their care should be transferred to a burn center with these capabilities
- Burn injury in patients who will require special social and emotional or long-term rehabilitative support, including cases involving suspected maltreatment and neglect.
- *The Advanced Trauma Life Support Course Manual, American College of Surgeons, 2012. pp. 230-241.
