I HATE fire standbys - Hate em. I know some people love them and that's great if you are one of those people - we need people like you. I, however, hate them.
"P2, respond to the area of 123 Main St. for the structure fire."
Worst words out of a dispatcher's mouth. We called en route and headed over to the area.
"P2, be advised, fire has 1 victim, unresponsive. Go direct to command."
We arrived just as they pulled her out. They placed her directly on our stretcher and quickly loaded her into the ambulance. We immediately cranked up the heat inside.
She was about 40-50 years old and unresponsive. She had obvious burns to her anterior chest, upper extremities up to her shoulders, and the left side of her neck. She had nasal singing and soot around her face, mouth, and in the back of her throat with some swelling to her face around the area where the neck burn ended. She was breathing around 30 breaths per minute with wheezing and stridor. She had strong, rapid radial pulses around 130 and her sat was 88%. She was sick.
This patient was involved in an apartment fire. While I didn't know this at the time, the fire started in her apartment, on the couch she was sleeping on. It was ultimately determined that she fell asleep while smoking a cigarette which then lit the couch on fire which resulted in thermal burns to her chest, upper extremities, and neck, as well as a pretty significant inhalational injury.
This patient had three immediate life threats: 1) Her inhalational injury, and 2) and 3) her inevitable cyanide and carbon monoxide toxicity. The burns themselves are a distracting injury.
Are burns deadly? Yes, of course, but not immediately (generally). Threats to the ABCs are immediately dangerous, however. There are a couple of important concepts in these patients right off the bat... Always assume they fell down the stairs trying to escape and swallowed a bunch of chemicals in the process. That is to say, these patients are trauma patients first, tox patients second, and burn patients third. So until her life threats are taken care of, I don't care what her burn percentage and all that is.
So, does this patient need to be intubated?
Yes. She has obvious indications for intubation. She is unresponsive, not protecting her airway, with soot on her face/in her mouth, and has stridor. She needs a tube.
But let's say it was less obvious, what are some indications for airway management in burn patients?
Generally, intubation should be considered for patients displaying one or more of the Denver criteria: Full thickness facial burns, stridor, respiratory distress, swelling on laryngoscopy, upper airway trauma, altered mentation, hypoxia/hypercarbia, hemodynamic instability, singed facial hair and suspected smoke inhalation.
None of these criteria are perfect, however. We still overestimate the number of patients who actually need to be intubated and over-intubate patients with burns. Part of me thinks "better safe than sorry," which is true to some extent, while the other side of me considers that intubation, ventilation, etc. is not a harmless thing... It'd be a shame for that burn patient to survive their injuries only to succumb to ventilator-associated pneumonia later on... I guess, despite this, when in doubt, it's still probably safer to err on the side of intubation until more definitive research comes out.
Fortunately, in this case, it was obvious. So we get to work... We placed her on a NRB mask and an NC, both at 15 lpm for pre-oxygenation, and then got a full set of vitals and an IV. Side note on IVs - avoid burned areas, yes, but if needed, you can place an IV through the burn. That is fine.
She ended up being normotensive, which was nice, and hypoxic, which we assumed. We knew this was going to be a potentially challenging tube so we did a double setup with a cric kit open and at the ready. It was actually my partner's turn for the tube, so he set up for that while I pushed the meds (ketamine and rocuronium) and readied the cric. My partner, being an absolute rockstar, got the tube on the first shot!
So with that out of the way, we could start to focus on other things. We completed our secondary survey (which was largely unremarkable) and focused on the burns.
Now, I don't want to waste a bunch of time going over burns, depth of burns, etc. All of that is important, yes, but takes too much time and is easily searchable information. Here is the gist on major burns: We care about the percent total body surface area burned (%TBSA) with partial thickness (second-degree) and full thickness (third-degree) burns. Superficial (first-degree) burns don't matter today.
For adults - I am not going to talk about pedi burns today, so assume going forward that I am only talking about adults - there are two popular ways to calculate %TBSA burned: The Rule of Nines and the Lund and Browder diagrams. Use whichever one your agency uses... The Rule of Nines tends to be more popular pre-hospital for ease of use/memorization while the Lund and Browder diagrams tend to be more accurate - but both have limitations.
In fact, all of this has limitations... We are REALLY bad at estimating both burn depth and %TBSA burned. Don't be discouraged, however: 1) There are some fair reasons for this and 2) EDs suck just as bad.
This patient is covered in soot, scorched clothes, carpet, dirt, etc. She has combinations of first-degree, second-degree, and third-degree burns. These all lead into each other and, at the time of injury, can look VERY similar. The official numbers will be calculated later, when the patient is settled, fluffed up, cleaned, debrided, etc. Our goal is ballpark. You want to be as close as possible, don't get me wrong, but understand that there is a good chance you will overestimate the number compared to the burn unit later that night - it happens. The number we care about is 20%. 20% is generally the cut-off for fluid resuscitation.
Her %TBSA burned ended up being 33% - but let's be real, we called it 40%. She obviously needed to go to a burn center, but we didn't have one where I was working at the time, so we brought her to the level I trauma center.
En route, we covered her burns with dry, sterile dressings, initiated fluid resuscitation, kept her on 100% O2, and gave her hydroxocobalamin. Let's talk about each of those for a minute.
This one is a classic NREMT question: Dry vs wet dressings. In big burns, the answer is ALWAYS dry, sterile dressings. Wet dressings run the risk of hypothermia and hypothermia is very bad. These patients lost a big chunk of their thermoregulatory ability with this burn. So the answer is dry dressings. We want to keep the burn covered for several reasons including infectious control and pain management.
So now here comes the fluid part. There are several formulas for fluid resuscitation in burn patients... The Parkland is by far the most well-known. The parkland formula is [4 mL x %TBSA x kg]. The first half is given over the first 8 hours and the rest over the next 16. The jam with Parkland is that it tends to be too much fluid... So then the Brooke formula came out. The Brooke formula is the same concept, except it's [2 mL x %TBSA x kg]. But that may under-resuscitate the patient, particularly in larger burns. So then the ABA came out with the consensus formula, which is just a combination of the two... [2-4 mL x %TBSA x kg]. Then there is the rule of 10s... For adults 40-80 kg: [%TBSA x 10 mL = initial fluid rate in mL/hr]. If the patient is >80 kg, you simply add an extra 100 mL/hr to the total for every 10 kg >80 kg. Then there is the really simplified version, which is actually the one used in my protocols at the time, which is 500 mL/hr as a flat rate, assuming the burn is >20% TBSA.
To put in perspective how different each of these formulas can be, here they are for this patient (assuming the initial 40% estimation at roughly 75 kg).
Parkland: 750 mL/hr
Brooke: 375 mL/hr
Consensus: 375-750 mL/hr
Rule of 10s: 400 mL/hr
Straight dosing: 500 mL/hr
Now, here is a common misunderstanding... The hospital doesn't actually follow through with these... Ever. They don't actually get 750 mL/hr for exactly 8 hours and then the rest over the next 16 hours... The whole purpose of these formulas is to give a rough guess on how many mL/hr they should initially recieve until they produce some urine... At that point whatever that rate is, say 750 mL, is adjusted up or down by 20-25% to maintain a urine output of at least 0.5 mL/kg/hr. This is why it probably doesn't matter too much... the big take-home point: Give some amount of fluid, but not too much. The burn center I regularly transport to specifically likes the 500 mL/hr rule and has both EMS and outside hospitals just start there to avoid over-resuscitation.
Now, this is already a super long post... So I am going to be lazy and just send you all to a previous post I wrote regarding CN and CO poisoning in burn patients. I'll copy/paste it in the comments below! Don't forget to check it out. That is why the 100% O2 and the hydroxocobalamin are important! Again, these patients are tox patients until proven otherwise.
With that said, we got her to the hospital pretty quickly (<10 min transport time), and she was cared for in the ED for about 1-2 hours before she was ultimately flown to a burn center for further care. Unfortunately, she died on hospital day 10 after facing several complications, with the family ultimately placing her comfort measures.
So there ya have it - burns in a <2000 word post.
Obviously, this is a SUPER broad, yet important topic and you should by all means read more about it. We have entire videos on the website dedicated to burns, CO poisoning, CN poisoning, etc. and if you aren't a member, no worries, there are a lot of interesting books, YouTube videos, etc. you can find.
What are your experiences with burn patients? Have you ever treated one? Do you like fire standbys? What is wrong with you? What questions do you have about burn patients? Ask below!
Until next time, thanks for reading!
-Dean Stockley
References:
Badulak JH, Schurr M, Sauaia A, Ivashchenko A, & Peltz E. Defining the criteria for intubation of the patient with thermal burns. Burns. 2018. May;44(3):531-538. doi: 10.1016/j.burns.2018.02.016. Epub 2018 Mar 13. PMID: 29548862. https://pubmed.ncbi.nlm.nih.gov/29548862/
Boehm D & Menke H. A History of Fluid Management-From "One Size Fits All" to an Individualized Fluid Therapy in Burn Resuscitation. Medicina (Kaunas). 2021. Feb 23;57(2):187. doi: 10.3390/medicina57020187. PMID: 33672128; PMCID: PMC7926800. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7926800/
Concannon E, Damkat Thomas L, Kerr L, et al. Review of Indications for Endotracheal Intubation in Burn Patients with Suspected Inhalational Injury. European Burn Journal. 2023; 4(2):163-172. doi: 10.3390/ebj4020014. https://www.mdpi.com/2673-1991/4/2/14
Rice Jr, PL & Orgill DP. Emergency care of moderate and severe thermal burns in adults. UpToDate, 2022.
Romanowski KS, Palmieri TL, Sen S, Greenhalgh DG. More Than One-Third of Intubations in Patients Transferred to Burn Centers are Unnecessary: Proposed Guidelines for Appropriate Intubation of the Burn Patient. J Burn Care Res. 2016 Sep-Oct;37(5):e409-14. doi: 10.1097/BCR.0000000000000288. PMID: 26284640. https://pubmed.ncbi.nlm.nih.gov/26284640/
Wooding D. Grey's Anatomy Case Review: Don't Get Burned. CanadiEM. March 2021. https://canadiem.org/greys-anatomy-case-review-dont-get.../
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