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On April 28, Patrick Bageant attended an Advanced Burn Life Support (ABLS) class at the Harborview Burn Center in Seattle, Washington He learned a lot in classroom discussion, practice patient assessment scenarios, clinical time, as well as afterclass-discussions of the material The purpose of this presentation is to share some of that knowledge with your ambulance, so that both your EMTs and patients may benefit from the class
A Road Map
This presentation covers the following material:
Initial assessment of the burn patient Appropriate (and inappropriate) intervention guidelines for specific burn scenarios Appropriate (and inappropriate) ALS interventions in burn scenarios Appropriate (and inappropriate) fluid resuscitation guidelines for the burn patient A recap of important points Closing discussion of common but incorrect conceptions regarding burn care
Notice that none of the initial assessment is burnspecific! It is the standard patient care formula
Secondary Survey
Head-to-toe: look carefully for injuries other than the actual burn
Burn injuries are not considered immediate life threats, but they do often accompany traumatic injuries that are life threats!
Assessment Recap:
Burns are not immediately life threatening, but other problems, like MI, diabetic coma, internal bleeding ARE immediate life threats.
Thus, only once you are confident you have found and addressed other conditions, including C-Spine, trauma and underlying emergent medical conditions may you assess the burn.
Do NOT allow your assessment to be distracted by the burn!
(If you are observant enough to notice this only adds up to 99%, you are smart enough to figure out where the other 1% is located!)
Do not apply ice to large burns Initiate fluid resuscitation (more on that later!)
Chemical Burns
What chemical caused the burn? Determine the nature of the exposure immediately Decontamination is required before treatment can begin. Preventing rescuer exposure is the first priority. Consider ordering Haz-mat resources through dispatch All clothing should be cut away, contaminated or otherwise Flush all chemical burns with copious, copious amounts of water. There is no such thing as too much water, but there is such thing as not enough
Airway Burns
Burns to the airway are serious, life-threatening injuries:
As edema develops the airway may close making both intubation and surgical airways impossible. Patients HAVE died in exactly this way Serious blood gas pollution by inhaled products of combustion like carbon monoxide is a common complication. There is NO reliable way to evaluate blood gasses in the field.
Almost all burns to the airway require immediate, aggressive management. Trans-oral intubation is indicated in apnic or chemically sedated patients. Trans-nasal intubation is indicated in non-sedated patients with respirations.
100% oxygen is indicated in all patients with airway burns, REGARDLESS OF PULSE OXIMITRY
Abuse is a common cause of scald burns to children. Obtain a careful history, and document inconsistencies. (Hint: kids do not hold themselves under scalding bathwaterthey try like hell to get out!) Remember: a quiet, submissive child is often an abused child
Lorazepam or benzodiazepines like Ativan may be indicated to calm patients in anxiety-induced hyperventilation. Anxiety is common in burn situations Diuretics are contraindicated in pre-hospital burn care In general, burn-specific care (aside from pain management) is a BLS (or even lower level) affair
Fluid bolus is NOT indicated except in cases of suspected trauma with a systolic pressure of less than 90
Clinical assessment of fluid adequacy can only happen after the fact. That is why fluids are given according to a strict formula, and then adjusted according to urinary output
The formula is:
4 x (pt body weight in kg) x (% of body burned) = cc in first 24 hours Half of this fluid is administered evenly over the first 8 hours. Half is administered evenly over the last 16 hours
It is very, very easy to over resuscitate the patient. Over resuscitation does cause real harm.
It is difficult to over emphasize how easy it is to over resuscitate, and harm, patients. Part of the purpose of the ABLS class is to educate pre hospital providers in exactly this area
Recap
Burns are scary for rescuers But very few burns are immediately life threatening Burn patient assessment should pay attention to medical, traumatic and social conditions
Few alert and oriented people stay in a hot place long enough to be burned. It just is not rational.
But diabetic patients may stay in burning buildings Badly injured patients may stay in burning cars Abused children may stay in burning liquids
Aggressive airway management including aggressive nasal- or oral-tracheal intubation is indicated in patients with airway burns Rule out other, more time-sensitive medical problems before you focus on the burn
Recap
Burns are described in terms of total body area (%) and depth (degree or thickness) Dry, clean, but not necessarily sterile sheets and transport are appropriate treatment for all burns No wet dressings should be applied. No ice should be applied Cleaning should be avoided (except for chemical burns)
Recap
Fluid resuscitation should be initiated as soon as possible, but only according to the strict formula:
4 x (body weight in kg) x (% of body burned) = cc of fluid in first 24 hours Half the fluid is administered evenly in the first 8 hours, half over the next 16
Over-resuscitation is very, very easy. But it causes genuine harm and cannot be undone (diuretics are contraindicated)
Burns should be cooled with ice or open air to take the heat out
False. Except in chemical burns, burning stops when the heat source goes away. (Duh). They do not need to be cooled. In fact, because burn patients cannot control their body temperature, cooling burns can induce dangerous hypothermia
Wet dressings may prevent the dressing from sticking to the wound
False. Wet dressings encourage sticking, and increase hypothermia. Think about the difference between standing in the wind in a dry t-shirt, versus a wet t-shirt. Now imagine your thermoregulation is compromised. Only dry dressings make sense
A Note On Sources
The purpose of this presentation is education and its subsequent enlightening effect, not profit All material for this presentation was shamelessly stolen from the internet and from the ALBS class materials. The architect and messenger of this presentation neither deserves nor claims any credit for the ideas and images presented