Burn Priorities of Care: Triage/Treatment/Transfer

Via Christi Regional Burn Center

Sarah Fischer, MSN, RN

Disclosure

I have nothing to disclose…

Objectives

➢ Identify American Burn Association referral criteria

➢ Explain the difference between partial and full

thickness burns

➢ Calculate TBSA using Rule of Nines

➢ Explore the priorities of initial assessment and

management of the burn patient

➢ Describe best practice for patient transport

74 y.o. male – 46% TBSA – flame burnWhat are your greatest concerns?

Is there any other information you want to know?

What is your priority intervention?

Function of the Skin

Superficial Burn – 1st degree

➢ Epidermis only

➢ Pink to red

➢ Painful

➢ No blisters

➢ Heals in 3-5 days

➢ Not included in

calculation %TBSA

Partial Thickness Burn – 2nd degree

➢ Epidermis and part of dermis

➢ Heal without surgical intervention

➢ Blisters• Large or small

• May not appear initially

• Continue to develop

➢ Wet and weepy

➢ Very painful

➢ Blanches

➢ Heals in 7-21 days

Partial Thickness Burn – 2nd degree

Admission

Day 4

Day 11

Full Thickness Burn – 3rd degree

➢ Epidermis, dermis, subcutaneous tissue

➢ Surgical intervention

➢ Insensate

➢ No blanching or capillary refill

➢ Charred, bright red, marbled, leathery,

tan, waxy, or pearly white

➢ Tight, non-elastic

Full Thickness Burn – 3rd degree

Rule of Nines

Primary Assessment: Life and Limb

➢ Airway

• Maintain c-spine precautions

➢ Breathing

➢ Circulation, cardiac status, CPR

➢ Disability, Deformity, Neurological Deficit

➢ Expose, Examine, Environment

• Stop the burning process

• Keep warm and dry

➢ Secondary assessment does not start until all of

these elements are accounted for…

• Including calculated fluid resuscitation

Precedence Over Burns

➢ Airway obstruction

➢ Cardiac arrest

➢ Spinal or head injury

➢ Open chest wounds

➢ Severe abdominal trauma

▪ Burn Center works closely with trauma for

multisystem injuries

▪ Consult with Burn Center physician to

ensure concurrent trauma activation

Primary Assessment - Airway

➢ Positioning

➢ Remove obstructions

➢ Suction

➢ 100% 02 per NRB

➢ Inhalation injury

• Supraglottic vs. Subglottic

➢ Intubate

• Loss of airway in the presence of upper

airway edema is catastrophic

Intubation

➢ Clinical judgment

• Feel free to discuss with Burn Center

➢ Weigh the risks and benefits

• Laryngeal injury, tube misplacement,

stenosis, fistula, swallowing impairment

➢ Err on the side of safety

• Loss of airway in the presence of upper

airway edema is catastrophic

➢ Special considerations for end of life

Intubation

➢ Rapid Sequence Intubation

• By the most experienced person

➢ Route

• Orotracheal vs. nasotracheal

➢ Size of endotracheal tube

• Use standard sizes for age/body type

• Place the largest recommended size possible

➢ Secure the tube

➢ Place NG/OG

Primary Assessment - Airway

Primary Assessment - Airway

Pediatric Considerations

➢ Airway obstructs easily

➢ Avoid hyperextension

➢ Smaller oxygen reservoirs

➢ Limited compensatory

mechanisms

➢ Weaker accessory muscles

➢Intubation

• Be proactive

• Use appropriate size tube

• Cuffed endotracheal tube

• Secure tube

Primary Assessment – Breathing

➢ Assess rate, depth,

lung sounds

➢ Monitor for

circumferential

chest/torso burns

➢ Compromise of chest

wall excursion and

ventilation

Chest Escharotomies

Primary Assessment - Circulation

➢ CPR if indicated

➢ Control hemorrhage

➢ BP and pulse

• Normal pulse: 110-120bpm

• Hypotension: late sign of hypovolemia

• Edema can affect readings

➢ Circumferential burns

➢ Cardiac monitor

Fluid Resuscitation

➢ Two large bore IVs

• Adults > 20% TBSA

• Children > 15% TBSA

➢ Site selection

• Burned vs. unburned

• Peripheral vs. central

• Intraosseous

➢ Lactated Ringers

• D5LR for children < 30kg

Fluid Resuscitation

➢ Initial fluid resuscitation for major burns

• < 5 years old: 125 ml/hour

• 5-14 years old: 250 ml/hour

• > 14 years old: 500 ml/hour

➢ Consider an increased need with

associated trauma and inhalation injury

➢ No boluses or diuretics

➢ Consult with burn physician

• Consensus Formula

• Fluid rates for minor burns

Consensus Formula

➢ Adult thermal and chemical

• 2 ml/kg/TBSA

➢ Pediatric (< 14 years old)

• 3 ml/kg/TBSA

• D5LR for children < 30kg

➢ High voltage injury (any age)

• 4 ml/kg/TBSA

Primary Assessment - Disability

➢ Glascow Coma Scale

➢ Level of consciousness

• Carbon monoxide

• Head injury

• Hypoxia

• Drugs & alcohol

➢ AVPU

➢ Deformity

➢ Disability

Primary Assessment - Environment

➢ Remove clothing, diapers,

jewelry, metal

➢ Stop the burning process

briefly

• Tar

• Chemicals

➢ No ice

➢ Cover with clean, dry sheet

➢ Keep warm

• Avoid hypothermia

• No gel-type blankets or

dressings

History

➢ Mechanism of injury

➢ Associated injuries

➢ Chemical exposure

➢ Substance abuse

➢ Abuse or neglect

➢ Intentional injuries

➢ AMPLET

• Allergies

• Medications

• Past medical history

• Last meal or drink

• Events and

environment

• Tetanus

ABA Referral Criteria

➢ Partial thickness burns > 10%

➢ Face, hands, feet, genitalia, perineum, joints

➢ Full thickness burns, any size

➢ Electrical injury, including lightning

➢ Chemical burns

➢ Inhalation injury

➢ Preexisting medical disorders that could complicate

recovery

➢ Burns with concomitant trauma

➢ Children

➢ Social, emotional, rehab needs

Transport

➢ Monitor vital signs

➢ Assess extremity perfusion

➢ Administer pain medication

➢ Cover burns with clean linens

• Do not apply special dressings

• Saran Wrap

➢ Maintain body temperature

• Hypothermia can be lethal

➢ Documentation

Transport

➢ Physician to physician communication

➢ Referring physician provides:

• Demographic and historical data

• Result of primary and secondary surveys

➢ Receiving physician will give

recommendations for transport

➢ Nurse to nurse communication

➢ Transport by trained personnel

74 y.o. male – 46% TBSA – flame burnWhat are your greatest concerns?

Is there any other information you want to know?

What is your priority intervention?

A: What might make you choose not to intubate?

B: Ventilation becomes difficult. Now what?

C: Where do you place sites? Does a history of CHF change fluid approach?

D: Right radial pulse is absent. Priority interventions?

E: HR is 72bpm. Are you concerned? Interventions?

Secondary: What do you really want to know about history?

Transport: When do you initiate transfer? Communication…

References

➢ American Burn Association. (2016).

Advanced burn life support.

➢ Herndon, D. (2012). Total burn care (4th

ed.). Edinburgh: Saunders Elsevier.

Thank You!

➢ Sarah Fischer, Burn Program Coordinator

• sarah.fischer@ascension.org

• 316-268-5875

➢ Via Christi Regional Burn Center

• 316-268-5388

➢ Via Christi Dispatch

• 1-800-353-3111