# Burn



## cointosser13 (Aug 19, 2016)

Here's a fun scenario I think you guys might like. 

Its just you (Paramedic) and your partner (EMT) at the station, Engine crew is out and about getting lunch. You have a walk in and someone says "my brother is in my car, he's badly burnt". So you grab up the stretcher and walk up to the car where your patient is lying in the back. First thing you see- patient in his early 20s / approximately 140-160 lbs / 2nd degree burns to his lower abdomen, both arms, neck and face (central facial burns, singed nasal hairs) / 3rd degree burn to his chest and hands. Patient only says "I can't...I can't...". Brother says "he was messing around with a propane tank, I think it exploded because he was smoking". You put him in the back of the ambulance...tell me what YOU would do next. Now I know each of us have different protocols, just imagine you were in a world where your medical director gave you all the power in the world to do anything you wanted to do. What would you do as a provider? 

Vitals: BP- 89/46, P-121 (Sinus Tach), SpO2-99% on room air, ETCO2- 22 . Brother states "I know he's had reactions towards morphine and fentanyl in the past". Also states "he's had multiple surgeries on his knees, no medical history".   

Some key questions: 

Percentage of burn? 
Using the Parkland Formula, how much fluid would you give this patient? 
Dry or wet burn dressing to cover burns? AND why?  
Special type of care you would consider for this patient.


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## SpecialK (Aug 19, 2016)

I would estimate his burns (at a glance) to be about 32.5% using the Rule of Nines.

We do not use "burn dressings" (they are very expensive so not carried) instead we use lots, and lots, of cooling, and glad wrap.  

First of all, have a look in his gob and get him to have a good cough to make sure he doesn't have airway burns.  If he had a burnt oropharynx or coughed up lots of black hack then I would be very worried.  If not, cool him.

Because his posterior is not burnt, I would put him in the shower with a blanket over his back.  I would do it for 10 minutes initially and see how his temperature was.  If it was OK I would do it for another ten minutes.  

Then I would wrap his arms, hands, chest and abdo in glad wrap.  

Put a blanket over his legs and turn the heat up.

Gain IV access, but it's probably going to be in his foot or through an IO.  For pain relief I would give him oral paracetamol, ibuprofen and tramadol in combination, and have him suck on entonox (or MOF) in the shower as appropriate.  If he was still in pain (and I imagine he would be) once we've got him on the bed I'd give him some ketamine, and a decent amount too, 1 mg/kg or more if I had to.  I would give him one litre of fluid as a bolus.

Take him straight to the tertiary burn centre, which fortunately, is quite close to us.  

If his airway was a bit poorer I would be inclined to call for an RSI Officer, 1) for airway and 2) general anaesthetic is going to take away all his feeling of pain.


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## Handsome Robb (Aug 20, 2016)

I agree with the 30-35% TBSA range. 

We don't use the parkland formula as its falling out of favor but to answer your question at 75kg and 35% he'd require 10,500 mL of saline with the first 5,250 mL over the first 8 hours. 

Ketamine, lots and lots of ketamine. If we couldn't control his pain with our pain management dosing I would probably end up intubating him, with more ketamine 2 mg/kg and roc 1 mg/kg. If he's got burns in his mouth or complains of difficulty breathing I'm going to intubate him sooner rather than later. I'd like to see his pressure a bit better before the intubation if possible though. 

Provided the burning process has stopped he'd get dry dressings. If his skin is still hot he needs to be cooled to stop the burning process then dry dressings and be kept warm. 


Sent from my iPhone using Tapatalk


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## StCEMT (Aug 20, 2016)

He sounds to be about 30% burn, parkland hourly amount is a bit under 600mL. 

I am close to a burn center, so I wouldn't have to sit on a long transport time.

Make sure those clothes aren't still burning him, dry dressings and make sure he stays warm because hypothermia. Ketamine...loooots of ketamine. If he seems like he has airway burns, I would rather intubate early instead of screwing with a crappier airway later. I don't think I'd really try to get too fancy with burns. Keep him warm, hydrated, and medicate the **** out of him.


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## cointosser13 (Aug 21, 2016)

I like all of your ideas guys. "Handsome Rob", you told me exactly what I wanted to hear, wanting to intubating him because I mentioned central facial burns, singed nasal hairs. I was also trying to (while it's hard to do it on here) tell you guys that he was actually starting to have difficulty speaking, the pauses while speaking. "StCEMT", nice job on addressing why we should put dry dressings. Of course with a burn such as this he's going to be hypothermic, the ETCO2 also gives it away. Decreased ETCO2 can indicated things like hypothermia, low cardiac output, hypotension and PE. Pain management is a key too. 

By the way... my friend did have a walk in just like this. We called for medevac right away because our medical director doesn't believe in paralytics, and we wanted to intubate the guy right away. Even with all the craziness the raspy voice gave it away.


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## StCEMT (Aug 21, 2016)

How long is your transport time to a burn center where you are?


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## Carlos Danger (Aug 21, 2016)

Just a few pearls I picked up when I worked for a HEMS program that had a contract with a regional burn center:

We agonize too much over how much IVF to give in the very early stages of burn management. In an otherwise healthy patient, its pretty tough to give too much IVF in the first hour or two post-burn. A more measured approach becomes important in later stages, but in the pre-hospital phase with transport times <1 hour, I would advocate for a standard bolus approach, rather than any of the ml/kg/bsa% burned formulas. 

We exaggerate the need for aggressive airway management. If it is clinically indicated, then by all means do it early. But true airway burns are actually pretty uncommon, and burns to the face and singed nasal hairs are actually poor indicators of airway burns.

We exaggerate the degree of opioids that most patients need. Sure, some need lots, but most do not. I've seen more problems caused by EMS being overly aggressive with opioids (HOLY CRAP HE HAS A BURN! THEY HURT LIKE HELL! GIVE HIM ALL THE FENTANYL WE HAVE, NOW!!) than I have with probably anything else. Give them what they need, but just like any other painful condition, a step wise approach is better than a shotgun approach.

Ketamine  - either alone or in conjunction with opioids - may be the best analgesic to use. Not because it is necessarily a more effective analgesic than the opioids, but because these patients are at a high risk for development of opioid induced hyperalgesia with the high doses that are often used early on. It's easier to prevent that than to work around it once it develops.

They get cold really easy, and are much more prone to the complications associated with hypothermia than most other patients are.


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## StCEMT (Aug 21, 2016)

Remi said:


> hyperalgesia


There is my word for the day. Learned something new.


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## Carlos Danger (Aug 21, 2016)

StCEMT said:


> There is my word for the day. Learned something new.



http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2474170

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4021143/


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## cointosser13 (Aug 22, 2016)

StCEMT said:


> How long is your transport time to a burn center where you are?



It's in DC, so about a 2 hour transport. Or ~45 min by air.


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## phideux (Aug 30, 2016)

With the signs of the singed nasal hairs and the trouble speaking, he is going to get a tube now instead of later, a couple of IVs and fluid, dry dressings and a trip to the local trauma center.(our burn center is several hrs away). I am definitely  not spending 20-30 minutes on scene giving him showers and wrapping him in Glad Wrap. If he came to you in a car after the fact, the burning process is probably ended, he needs to get to the ER/Burning Center.


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## johnrsemt (Oct 31, 2016)

Interesting thing I learned a couple of years ago:  if your area still uses the Parkland Formula (or something similar) the fluid you give in the first 8 hours is not 8 hours from when you get to the patient it is 8 hours from the burn.  So if you have a 4 hour time gap between burn and when you see the patient. then give that fluid in the 4 hours left:

In our area it may be hours before someone can get to cell service to call for help.  and an hour or 2 before help arrives


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## TXpeds16 (Oct 31, 2016)

Percentage of burn? 
 ~35%

Using the Parkland Formula, how much fluid would you give this patient? 
70kg @ 35%BSA would be around 5L in the first 8 hours.  Realistically though, in the prehospital setting, he is going to get as much fluid as he needs to get his pressure up.

Dry or wet burn dressing to cover burns? AND why? 
Dry dressing.  With this large of a burn, heat loss is going to be an issue.

Special type of care you would consider for this patient?
Warming will become an issue at some point, whether its with EMS or in the hospital.  If heat loss was an issue while in my care the first thing I would do is warm the box up and put whatever blankets I had on the patient.  Another consideration would be the use of warm IV fluids.

I would be very weary of intubating this patient.  He is already hypotensive, and with the 3rd degree burns on his chest, compliance will be poor.  My guess is he would require higher pressures than normal to ventilate, decreasing preload and C.O. further, possibly leading to cardiovascular collapse.  I think in this case I would probably try a dose of racemic epi, and CPAP if he was struggling to breathe before intubating.  

If intubating became absolutely necessary, initial vent settings I would consider would be either volume control with a low normal Vt(420) and a slightly faster rate, or PC/PS.


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## VFlutter (Oct 31, 2016)

TXpeds16 said:


> Special type of care you would consider for this patient?
> Warming will become an issue at some point, whether its with EMS or in the hospital.  If heat loss was an issue while in my care the first thing I would do is warm the box up and put whatever blankets I had on the patient.  Another consideration would be the use of warm IV fluids.
> 
> I would be very weary of intubating this patient.  He is already hypotensive, and with the 3rd degree burns on his chest, compliance will be poor.  My guess is he would require higher pressures than normal to ventilate, decreasing preload and C.O. further, possibly leading to cardiovascular collapse.  I think in this case I would probably try a dose of racemic epi, and CPAP if he was struggling to breathe before intubating.
> ...



I agree, around 5L warmed LR per concensus formula. 

If he has circumferential burns he will have poor chest excursion regardless if he is intuabted or not so I would not let that deter me. Intubate and escharotomy.


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## Tigger (Oct 31, 2016)

The burn center here wants 500ml/hr for fluid resuscitation in adults. That said, I think I would bolus this patient first and try to get his pressure up a bit, with warmed fluid if all possible

Someone with difficulty speaking should probably be intubated, singed nasal hares and that stuff are not the real concern. Induce with ketamine and maintain sedation with it (Versed seems like a poor choice with that pressure though fent would probably be alright). 

We would fly this patient directly to the burn center, there is no reason to take them elsewhere unless there was some sort of unmanageable airway scenario. Being in the mountains the weather often prevents this, but we can and will drive them down into the city and fly them from the outskirts to the appropriate specialty center.


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## Brandon O (Oct 31, 2016)

Remi said:


> We agonize too much over how much IVF to give in the very early stages of burn management. In an otherwise healthy patient, its pretty tough to give too much IVF in the first hour or two post-burn.



Yet it certainly happens. While EMS probably wasn't at fault when the big burn ends up 15 liters overrescuscitated during the first 24 hours, the 4 liters they give in the field probably didn't help. Some sense for the initial goal volumes (which will be titrated going forward, but mostly via criteria like urine that we don't follow in the field) is helpful to get in the middle of the not enough-too much range.



> We exaggerate the need for aggressive airway management. If it is clinically indicated, then by all means do it early. But true airway burns are actually pretty uncommon, and burns to the face and singed nasal hairs are actually poor indicators of airway burns.



True thermal injury to the lower airways are uncommon, but inhalation injury from other causes (such as direct toxicity from smoke inhalation) is common, and massive fluid resuscitation alone is an indication for intubation (as is, arguably, heavy sedation). It doesn't have to be done in the field as I agree that you often have something of a grace period before the airway really poops out on you, but it should be managed as soon as it safely can be.


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## VentMonkey (Oct 31, 2016)

Decent discussion. Here's a somewhat dated, but thorough care plan for burn patients within the first 48 hours:

http://www.medscape.com/viewarticle/711438


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## VentMonkey (Nov 1, 2016)

cointosser13 said:


> Some key questions:
> Dry or wet burn dressing to cover burns? AND why?


I'm just going to hit on the last couple of questions here since the others have pretty much been driven home. 

Dry dressing, anything over 10% BSA gets dry, and sterile dressing as I have been taught. Hypothermia is very much a reality in this patient population, and their inability to thermoregulate at this point dictates my thought process as well.



cointosser13 said:


> Special type of care you would consider for this patient.


Monitor his airway closely, I don't know that he needs to be intubated right away (unless you were hinting towards "1-2 word sentences" with his reply in your scenario?), though I do like @TXpeds16 angle with the CPAP, and Racemic Epi first.

If I am going to intubate, then yes, Ketamine seems appropriate given his hemodynamic instability. Since this patient will be receiving fluids anyhow (LR), I would like to see what a repeat BP yields, and anything over 90 mmHg systolic, or even a MAP (>) 65 mmHg is enough for me to hit him with even a pinch of Fentanyl and Versed, then reassess from there.

Once intubated, my mode would probably be along the lines of PRVC (Vt-IBW 6-8 ml/ kg; FiO2 1.0; RR 12-14; Peep 5). His airway pressures may be kept at ~35, but monitored closely for any increasing Pplat's/ Ppip's/ inadequate chest excursion. 

Also, something worth mentioning in regards to burn formulas is the time it started beginning in the field. With many burn centers, they like knowing when the patient _first began receiving _fluids. The total volume to be infused may (should) very well include what, and how much was given in the field, again hopefully, LR.

If I am HEMS with a reasonable ETA to the burn center, I don't think I am performing an escharatomy based on his already predisposed, and highly likelihood of risk of infection, but if I am on a ground unit, with an extended ETA, climbing airway pressures, and no relief/ poor chest excursion then I say yes.

P.S. Sorry if my link did not come across in my post above, I'll try and see if I can re-post it.


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## Brandon O (Nov 1, 2016)

VentMonkey said:


> If I am HEMS with a reasonable ETA to the burn center, I don't think I am performing an escharatomy based on his already predisposed, and highly likelihood of risk of infection, but if I am on a ground unit, with an extended ETA, climbing airway pressures, and no relief/ poor chest excursion then I say yes.



No comment on whether this patient (or most) needs field escharotomies -- doesn't sound like much fun to me -- but infection shouldn't be a big concern IMO. The tissue you're incising is coming out.


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## VentMonkey (Nov 1, 2016)

Brandon O said:


> No comment on whether this patient (or most) needs field escharotomies -- doesn't sound like much fun to me -- but infection shouldn't be a big concern IMO. The tissue you're incising is coming out.


Yes, I agree, I have the same sentiment for field chest tubes. 

By field chest tubes I mean actual chest tubes (not "simple" chest tubes) that are seen as a _sterile urgent_ procedure, and not an _emergent procedure_, e.g., surgical cricothyrotomy.


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## Carlos Danger (Nov 1, 2016)

Brandon O said:


> Yet it certainly happens. While EMS probably wasn't at fault when the big burn ends up 15 liters overrescuscitated during the first 24 hours, the 4 liters they give in the field probably didn't help. Some sense for the initial goal volumes (which will be titrated going forward, but mostly via criteria like urine that we don't follow in the field) is helpful to get in the middle of the not enough-too much range.



You'll always be able to find extreme examples of outliers, but I don't think they make a good argument against a simplified approach to IVF administration in these patients. If anything I think they support the need for it. I would advocate something along the lines of 2 liters as fast as reasonably possible and then 1 liter per hour. With transports well over an hour or in certain patients that rate could certainly be adjusted, but I think it makes a nice simple starting point that everyone can understand and be on the same page about and it minimizes the chance of massive over or under resuscitation.

The last HEMS program that I worked for had a contract with a regional burn center that received patients from several surrounding states. We picked up many burn patients from both scenes and hospitals large and small to take them to the burn center. IME, little causes more confusion and miscommunication than how much IVF the patient has gotten and should get. From EMS to the first ED to the burn surgeon's PA to us and then back to the burn surgeon again (who we took med control from for these transports), no one was ever on the same page, and it was very common for these patients to get way too much or way too little IVF. There should be a simpler way.



Brandon O said:


> True thermal injury to the lower airways are uncommon, but inhalation injury from other causes (such as direct toxicity from smoke inhalation) is common, and massive fluid resuscitation alone is an indication for intubation (as is, arguably, heavy sedation). It doesn't have to be done in the field as I agree that you often have something of a grace period before the airway really poops out on you, but it should be managed as soon as it safely can be.



This I think just depends on your basic attitude towards prehospital RSI. Folks who support aggressive RSI in the field will find plenty of ways to justify intubating many of these folks at the scene. Those of us who favor a more measured and conservative approach to prehospital RSI however, feel as though just because a large number of these patients end up intubated eventually does not argue for doing it in the field. When these patients get intibated it is almost always due to systemic edema that develops over the first days and/or because of high narcotic requirements and repeated debridements. Upper or lower airway burns causing early airway edema is actually quite rare, even when the classic signs that we are taught to look for exist.


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## Brandon O (Nov 1, 2016)

Remi said:


> Upper or lower airway burns causing early airway edema is actually quite rare, even when the classic signs that we are taught to look for exist.



Not sure about this. Incidence of inhalation injury (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3653783/figure/F1/):







I agree that:

- It's not always hugely clinical significant
- It doesn't always require intubation (but erring on the side of caution is, I think, probably always appropriate)

And highlight the association with burn severity, meaning I would agree with a conservative approach for smaller burns.

All of this is not necessarily here nor there and I imagine most patients can be intubated at the hospital. I do recall one malpractice/EMTALA case of a non-intubated patient who developed airway compromise during a ground transfer. (Edit: See #9, Smith v Janes.)


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