Consensus on the pre-hospital approach to burns patient management
Introduction
In the United Kingdom (UK), burns patients account for approximately 175 000 emergency department attendances and 15 000 hospital admissions each year.44 Consequently the first aid and pre-hospital care for this large group of patients is of great importance and yet in the authors’ experience, simple things are often not done very well.
In 1998 a national survey revealed 58% of UK ambulance services had no specific treatment policy for burns patients.1 Pre-hospital carers often feel out of their depth in caring for burns patients, particularly children and there is a lack of teaching and simple, evidence-based guidelines.
The Faculty of Pre-Hospital Care set out to improve the information available concerning immediate care of the burns patient in simple, unambiguous guidelines, so that any carer (including first-aider, ambulance person, nurse or doctor) could administer safe, appropriate care. The process to achieve consensus over these guidelines has taken time and the advice and ratification by all groups that look after burns patients from the point of their injury through to definitive care has been painstakingly followed (Table 1, Table 2).
It is hoped that the guidelines, although basic, can form the basis for current pre-hospital care and that they may be updated as new evidence or arrangements for burns patients are made within the UK (Table 3).
Section snippets
SAFE approach
For all pre-hospital emergencies, this acronym can be used to remind the carer of the first priorities in patient care.
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Shout or call for help.
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Assess the scene for dangers to rescuer or patient.
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Free from danger.
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Evaluate the casualty.18., 19., 24., 25., 43.
Stop the burning process
The burning process should be stopped/extinguished and the patient should be removed from the burning source. All burnt clothing should be removed (unless it is stuck to the patient) together with any jewellery, which may become constrictive. All items of clothing should be brought in a plastic bag to the hospital for examination. For patients with chemical burns, they may need a longer period of irrigation under tap water and specific information about the chemical concerned should be obtained.
Cool the burn wound
There is often confusion over this process and how long it should last for. It is suggested that the ambulance service despatch system will advise the ‘999’ caller to cool the burn area for up to 10 min. Cool running tap water is sufficient and ice cold water should not be used. If this has been done, pre-hospital carers should cool for another 10 min during package and transfer. If the burn area is small (<5%) then a cold wet towel can be placed on the burn area, on top of the Clingfilm™
Dressings
Dressings are important to help the patient’s pain control and to keep the burnt area clean. The burnt area should be covered with a cellophane type wrap Clingfilm™ remembering the possible constricting effect of wrapping; smaller pieces are perhaps better than circumferential sheet. The patient should be wrapped up in blankets or a duvet.
In chemical burns the affected area should be irrigated thoroughly until pain or burning has decreased and only wet dressings should be used. There may be a
Assessment and management of immediately or imminently life threatening problems: AcBC (airway with cervical spine stabilisation, breathing, circulation)
It should be remembered that the patient may have other injuries co-existent with their burn injury. These should be suspected, diagnosed and treated as with any other pre-hospital emergency. The patient should have high flow oxygen delivered via a non-rebreath mask (15 l/min). If a patient has an isolated burn injury that is small, and when no inhalation injury is suspected, oxygen may not be necessary.2., 4., 22.
Assessment of burn severity
In order to estimate the size of the patient’s burned area, use the Wallace Rule of Nines or serial halving (“half burnt/half not” approach: Is burn >1/2 of patients total body surface area (TBSA); if it is not, is it 1/4–1/2 or <1/4). This latter technique although new, is effective in burn size estimation in pre-hospital care. Other important features of the burn injury to define are:
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Time of burn injury.
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Mechanism of injury (flame {clothes or patient caught fire}, flash burn, scald,
Cannulation and intravenous fluids
The emphasis for patient cannulation should be for the administration of titrated opiate/opioid analgesia. It is important that cannulation procedures do not unnecessarily extend the on scene time. Access should be limited to two attempts only and should generally be undertaken in transit. The intraosseous route may be necessary in children.
Fluid replacement with 0.9% normal saline or Hartmann’s solution can be commenced if the patient is cannulated, but must be started for burns >1/4 TBSA
Analgesia
Analgesia is best accomplished by cooling and then covering the burned area. Intravenous opiate/opioid can be titrated to make the adult patient more comfortable and should be accompanied by an anti-emetic. In children intranasal diamorphine is an option that may be considered. Entonox should only be used when these options are unavailable as it may be difficult to administer, has varying efficacy and decreases the oxygen delivery.1., 6., 9., 23., 31., 51., 60.
Transport
All treatment should be carried out with the aim of reducing on-scene times and delivering the patient to the appropriate treatment centre. This should be the nearest appropriate accident and emergency department (A&E), unless local protocols allow direct transfer to a burns facility.
Communication with A&E should give the standard information (age, gender, incident, ABC problems, relevant treatment, ETA).5., 13., 15., 39., 42., 44., 47., 50., 56.
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