United States Naval Flight Surgeon Handbook
2nd Edition 1998

Burn Management

References:

• Pruitt, BA, Jr.: The burn patient: I. Initial care, II. Late care and complications of thermal injury. Current Problems in Surgery. April-May 1979;16:4 and 5.

• Martyn, JAJ: Acute management of the burned patient. Philadelphia: Saunders, 1990.

• Munster, AM: Burn Care for the House Officer. Baltimore: Williams and Wilkins, 1980.

• Committee on Trauma, American College of Surgeons: Advanced Trauma Life Support. Chicago: 1993.

Point of Contact:

U.S. Army Institute for Surgical Research (ISR)
Brooke Army Medical Center
DSN: 429-2876/2604/0501
Com: (210) 916-2876/2604/0501 or 1-800-222-BURN

Message Address: CDR USAISR FT SAM HOUSTON TX

First Aid at Scene:

1. Stop the burning process and remove the patient to a safe area.
   

2. Place patient in a supine position and initiate CPR if indicated. The same general principles of cardiopulmonary resuscitation apply, and are a priority.
   

3. Cover patient (clean sheet &/or "space blanket").
   

4. If 30 min. to ER, start large bore (16 ga.) IV with Lactated Ringer's solution (LR).
   

5. Oxygen; intubate if necessary. Carbon monoxide poisoning is the most frequent cause of death in the first hours after a fire.

Notes:

• Rapidly remove burning clothing.
  

• Electrical burns: Ensure patient is clear of electrical source prior to rescue.
  

• Chemical burns: Remove soaked clothing, and irrigate with copious amounts of water ASAP.
  

• Ensure that the patient and the medical team are completely clear of the fire area for their protection and to avoid interference in fire fighting efforts.

ER/Medical Department Treatment:

1. Re-assess ABC's of BLS. FLUID RESUSCITATION is of great concern.
   

2. Oxygen, NG tube & foley for all serious burns. Intubation if indicated.
   

3. Assess extent and severity of burns. (Rule of 9's or mapping; patients hand = 1% body surface).
   

4. IV analgesics titrated to reduce pain to tolerable levels during initial cleaning and debridement.
   

5. Gently clean and debride wounds; cover wounds with Silvadene or Sulfamylon. Keep patient warm; clean and re-cover wounds daily.
   

6. Evaluate the eyes using fluorescein.

Special Situations

1. Electrical Burns:

• Cutaneous lesions may be misleadingly small (tip of the iceberg) in the face of serious deep tissue damage.
  

• Watch for myoglobinuria and treat promptly. Give 25 grams of mannitol IV and add 12.5 grams (1 amp) to subsequent liters of fluid. Alkalinization of the urine with sodium bicarb will increase excretion (1 amp in a liter of LR). Use of any diuretic makes urine output an invalid estimator of circulatory status.
  

• May cause tetanic contractions leading to fractures of the vertebrae and falls may lead to other injuries.
  

• May impair circulation; monitor pulses closely. Escharotomy, as with any circumferential burn may be needed. However, a fasciotomy maybe required due to deep muscle injury.

2.Chemical Burns:

• Alkali powder (lime): brush the powder from the skin before lavage is begun.
  

• Phenol: instead of lavage and in any case after lavage as well, the skin should be washed with a solvent such as polyethylene glycol, propylene glycol (anti-freeze), or glycerol to remove residual phenol.
  

• White phosphorous: must be kept moist to prevent ignition of the retained phosphorous particles. Wash the involved area with an 0.5% or 1.0% solution of copper sulfate. This will cause the formation of a blue-black film of cupric phosphide on the surface of the retained particles. Debride the particles and keep them moist or you will have another fire.

3.Closed Space Fires:

• May have inhalation injuries. Look for facial burns, singed nasal hair or eyebrows, oropharyngeal burns, carbonaceous sputum, hoarseness and stridor, etc.
  

• Intubate early for inhalation injuries.
  

• Evaluate for carbon monoxide and toxic gas inhalation. Don't forget re-evaluation for delayed effects.

Fluid Resuscitation:

First 24 hours post-burn:

• 2-4 ml of LR / kg body weight / % body surface burned.
  

• infuse 1/2 calculated dose within first 8 hours post-burn; second half over next 16 hours.
  

• adjust IV rate to maintain urine output at 30-50 ml/hr in adults.
  

• make decreasing adjustments of IV rate gradually (10% increments q 1hr).
  

• use of diuretics make urine output an invalid measure of circulatory status.

Second 24 hours:

• 5% albumin in LR @ 0.5 ml / kg / %burn (200 cc of salt-poor albumin placed in 800 cc of LR).

PLUS:

• D5W (or 1/4 Normal saline (1/4 NS) primarily for children) to yield same hourly infusion rate as the first 24 hours.

• Adjust D5W or the 1/4 NS rate, not the 5% albumin soln., in order to maintain urine output 30-50 ml/hr.

General Considerations:

1. ALL medications must be given IV during the resuscitation because of the dramatic changes in capillary permeability. Otherwise, the patient can receive an overdose when fluid mobilization occurs.
   

2. Sodium shifts can cause serious hyponatremia. The rate of fall of serum sodium levels is very important, especially in young patients. Serum sodium must be carefully monitored when giving large volumes of IV fluids.
   

3. Transfusion is indicated for hematocrit under 30. Packed RBC's are preferred.
   

4. Insulin infusion may be instituted for serum glucose over 200mg%.
   

5. Histamine (H2) blockers and antacids should be used to keep the gastric pH at7.0.

Aeromedical Evacuation:

1. Patient must be accompanied by a physician or nurse.
   

2. 2 IV lines, sewn in place; NG tube; foley. (Balloons filled with water, not air).
   

3. Intubate if airway is a concern.
   

4. Chest X-ray to evaluate placement of lines and tubes, and rule out pneumothorax. Insert a chest tube if indicated.
   

5. Apply Silvadene to burns, and cover patient with "space blanket".
   

6. Cardiac monitor & ACLS meds.
   

7. Notify the Burn Center if a ventilator is required.

• NOTE: Foley & ET tube cuffs should be filled with WATER not air.

Criteria for Burn Center Referral:

• Burns over 25% body surface area (BSA).
  

• Partial thickness (second degree) burns over 20% BSA.
  

• Full thickness (third degree) burns over 10% BSA.
  

• Burns involving face, hands, eyes, feet, or perineum.
  

• Burns associated with significant fractures or other major trauma.
  

• High voltage electrical burns.
  

• Inhalation injury.
  

• Pre-existing disease.
  

• Very young and very old.

United States Naval Flight Surgeon Handbook: 2nd Edition 1998

The Society of U.S. Naval Flight Surgeons