4. TRAUMA EMERGENCIES

4.2 BURNS / INHALATION INJURIES

A burn injury is caused by an interaction between energy (thermal, chemical, electrical* or radiation*) and biological matter. Thermal burns (flames, scolds, contact with hot substances or objects, including steam) account for the majority of burns. Chemical burns are caused by acids, alkalis and organic compounds (phenols, creosote, and petroleum products) commonly found in industrial and household environments.

Burn severity should be assessed and classified by degree. The first-degree burn involves only the upper layers of the epidermis and dermis. The second-degree burn penetrates slightly deeper and produces blistering of the skin. First- and second- degree burns are considered partial thickness burns. Third-degree or full thickness burns penetrate the entire dermis. These burns may involve injury to blood vessels, nerves, muscle tissue, bone, or internal organs. Burn surface area should be assessed by the rule of nines.

Inhalation injury and fire toxicology (Carbon Monoxide, Hydrogen Chloride, Phosgene, Nitrogen Dioxide, Ammonia, Cyanide, Sulfur Dioxide, Methane, and Argon) frequently accompany burn injuries. This is especially true if injury occurred in a closed space and/or patient presents with facial burns, singed nasal hairs, beard or mustache, sooty or bloody sputum, difficulty breathing, or brassy cough. The signs and symptoms of inhalation injuries may not be noted until several hours after inhalation.

* NOTE: see specific protocols

ASSESSMENT / TREATMENT PRIORITIES

1. Assure scene safety, including safety for the patient(s) and rescuer(s). Call appropriate public service agencies FIRE/RESCUE/HAZMAT for assistance if needed. Take appropriate personal protective measures against airborne dust or toxic fumes and any other potential chemical agents.

2. Maintain universal blood and body fluid precautions.

3. Maintain an open airway and assist ventilations as needed. Assume spinal and other potential traumatic injuries when appropriate and treat accordingly.

4. Administer high flow oxygen by non-rebreather mask or bag valve mask as determined by patient's condition (humidified oxygen is recommended).

5. Early endotracheal intubation must be considered for all patients with suspected inhalation injuries and/or present in respiratory distress.

6. Determine patient's hemodynamic stability and symptoms. Continually assess Level of Consciousness, ABCs and Vital Signs.

7. Treat all life threatening conditions as they become identified.

8. Obtain appropriate history related to event ( determine mechanism and time of exposure, assess patient for evidence of inhalation injury including potential for toxic inhalation exposure) Obtain Past Medical History, Medications, Drug Allergies, Substance abuse.

9. Appropriately manage all Thermal/Chemical burns.

10. If suspect severe Carbon Monoxide Poisoning, consider appropriate Point-of-Entry as defined by Regional capabilities, i.e., Burn Center and/or Hyperbaric chamber availability.

 

TREATMENT

BASIC PROCEDURES

1. Assure scene safety, including safety for the patient(s) and rescuer(s). Call appropriate public service agencies FIRE/RESCUE/HAZMAT for assistance if needed. Take appropriate personal protective measures against airborne dust or toxic fumes and any other potential chemical agents.

2. Maintain universal blood and body fluid precautions.

3. Maintain an open airway and assist ventilations as needed. Assume spinal and other potential traumatic injuries when appropriate and treat accordingly.

4. Administer high flow oxygen by non-rebreather mask or bag valve mask as determined by patient's condition (humidified oxygen is recommended).

5. Treat all life threatening conditions as they become identified.

6 Appropriately manage all Thermal/Chemical burns.

a. THERMAL

b. CHEMICAL

7. Activate ALS intercept if deemed necessary and if available.

8. Initiate transport as soon as possible with or without ALS.

9. Notify receiving hospital.** If suspect severe Carbon Monoxide Poisoning, consider appropriate Point-of-Entry as defined by Regional capabilities, i.e., Burn Center and/or Hyperbaric chamber availability.

INTERMEDIATE PROCEDURES

1. Assure scene safety, including safety for the patient(s) and rescuer(s). Call appropriate public service agencies FIRE/RESCUE/HAZMAT for assistance if needed. Take appropriate personal protective measures against airborne dust or toxic fumes and any other potential chemical agents.

2. Maintain universal blood and body fluid precautions.

3. Maintain an open airway and assist ventilations as needed. Assume spinal and other potential traumatic injuries when appropriate and treat accordingly.

4. Administer high flow oxygen by non-rebreather mask or bag valve mask as determined by patient's condition (humidified oxygen is recommended).

5. Treat all life threatening conditions as they become identified.

6. ALS STANDING ORDERS

a. Provide advanced airway management, if indicated.

b. Initiate IV Normal Saline. If suspected hypovolemia, administer 250 cc-500 cc fluid bolus and titrate to patient's hemodynamic status.

7. Appropriately manage all Thermal/Chemical burns.

a. THERMAL

b. CHEMICAL

8. Activate Paramedic intercept, if deemed necessary and if available.

9. Contact MEDICAL CONTROL. Medical Control may order:

10. Initiate transport as soon as possible with or without Paramedics.

11. Notify receiving hospital.** If suspect severe Carbon Monoxide Poisoning, consider appropriate Point-of-Entry as defined by Regional capabilities, i.e., Burn Center and/or Hyperbaric chamber availability.

PARAMEDIC PROCEDURES

1. Assure scene safety, including safety for the patient(s) and rescuer(s). Call appropriate public service agencies FIRE/RESCUE/HAZMAT for assistance if needed. Take appropriate personal protective measures against airborne dust or toxic fumes and any other potential chemical agents.

2. Maintain universal blood and body fluid precautions.

3. Maintain an open airway and assist ventilations as needed. Assume spinal and other potential traumatic injuries when appropriate and treat accordingly.

4. Administer high flow oxygen by non-rebreather mask or bag valve mask as determined by patient's condition (humidified oxygen is recommended).

5. Treat all life threatening conditions as they become identified.

6. ALS STANDING ORDERS

a. Provide advanced airway management, if indicated.

b. Cardiac monitor/ Dysrhythmia recognition. Manage according to protocol.

c. Initiate IV Normal Saline. If suspected hypovolemia, administer 250 cc - 500 cc fluid bolus and titrate to patient's hemodynamic status.

7. Appropriately manage all Thermal/Chemical burns.

a. THERMAL

b. CHEMICAL

8. Contact MEDICAL CONTROL. Medical Control may order:

9. Initiate transport as soon as possible.

10. Notify receiving hospital.** If suspect severe Carbon Monoxide Poisoning, consider appropriate Point-of-Entry as defined by Regional capabilities, i.e., Burn Center and/or Hyperbaric chamber availability.

** Many EMS systems will develop point of entry protocols to determine which patients need transport to specialized burn centers. According to the Committee on Trauma of the American College of Surgeons (ACS) and the American Burn Association (ABA), burn injuries usually requiring referral to a burn center include the following guidelines:

1. Second- and third-degree burns that in combination cover more than ten percent (10%) of the body surface area in patients under ten (10) or over fifty (50) years of age.

2. Second- and third-degree burns that in combination cover more than twenty percent (20%) of the body surface area of patients in the other age groups.

3. Second- and third-degree burns that involve the face, hands, feet, genitalia, or erineum or those that involve skin overlying major joints.

4. Third-degree burns over more than five percent (5%) body surface area in any age group.

5. Significant electrical burns, including lightning injury.

6. Significant chemical burns.

7. Inhalation injury.

8. Burn injury in patients with preexisting illnesses that could complicate management, prolong recovery, or affect mortality.

9. Burns in any patient in whom concomitant trauma poses an increased risk of morbidity or mortality and who may be initially treated in a trauma center until stable before transfer to a burn center.

10. Burns in children seen in hospitals without qualified personnel or equipment for their care should be transferred to a burn center with these capabilities.

11. Burn injuries in patients who require special social and emotional or long-term rehabilitation support, including cases involving suspected child abuse and neglect.

 

 

 

AMERICAN BURN ASSOCIATION CATEGORIZATION OF BURNS

MAJOR BURN

MODERATE BURN

MINOR BURN

No electrical burns, inhalation injury, severe preexisting medical problems, or complications






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