Prehospital Management of Burn Injuries

Abstract

In the last 20 years, large changes in burn care and in the background and logistics around the care for the burn injured have occurred which has implications for how burn care now should be administered and practically performed. Firstly, the incidence of burn injuries has decreased in the Western world and a decrease of about 30% is evident from e.g., since the eighties [1, 2]. In parallel, length of stay in the burn care facilities for the injured has been reduced to about 40% of what it was at that time [3, 4]. Thirdly, the outcome of burns has been significantly improved over the same time period. This may be exemplified by the 50% survival chance that was present for a 45% total burn surface area (TBSA%) burn in a 21-year-old in the late 1970s, which is to be compared to the corresponding 50% survival chance for 80–90% TBSA% burn in the same age patient today [5, 6]. Fourth, patients, with smaller burns, today are to a significant extent treated as outpatients and smaller injuries may have their surgery done as outpatients as well [7–9]. At the same time, an increasing proportion of the patients are in the elderly age groups where the injury poses a larger treat as compared to in younger patients [10, 11]. In this age group, care is to a large extent influenced also by co-morbidities and the possibility to obtain good end results seen especially from the patient perspective [12].

Appendix: Referral and Transport Checklist

1.1 Organization, Logistics, and Communication

Sending hospitals contact recipient hospitals. Responsible physician at dispatch unit decides on transport method in consultation with the doctor on the receiving unit, and always has the medical responsibility for the transportation until this can be handed over to the receiving unit’s medical doctor/specialist.

Those who transport patients should have the right skills for the task and should be used to transport/treat intensive care patients. For intubated or unstable patients, there should be two therapists in the care room and one of them must be specialist anesthetist.

All patient interventions before, during and after the transport should follow the patient, such as referral, list lists, surveillance lists, drug lists, hospital notes.

Other patient actions that are crucial for patient care after reception but not affecting treatment during transportation such as X-ray examination or hospital notes can be faxed to receiving in order not to delay transport. These documents shall, however, always be delivered at the receiving device by the time the patient arrives. X-rays should, if possible, be sent electronically.

Prior to transport, the transport team shall contact a dispatching hospital and receiving hospital and have relevant contact information (phone number/name) available under the entire transportation.

The mobile phone’s benefit is superior to the potential risk of interference electronic equipment. With a plastic surgeon on the receiving unit, the chosen transport method is confirmed and preliminary arrival time communicated. Convey with receiving ICU doctors and discuss possible measures in case of deterioration of the patient’s condition. The transport team shall inform the patient of the condition and assess the patient’s general status before transport.

Examinations that should be carried out before transport:

• Trauma assessment

• Blood gas

• Relevant X-ray examinations

• Blood samples (Hemoglobin/Hct and coagulation)

• B-glucose

• Other relevant studies (possibly including blood grouping and base test)

  • ENT tubes and i.v. lines properly sutured

1.2 Monitoring

The basic principle of monitoring is that it must be at least the same monitoring level as at the sending hospital and should include:

• ECG with arrhythmia monitoring

• Invasive blood pressure measurement (invasive central circulation surveillance)

• Pulse oximetry

• Capnography (if the patient is intubated; controlled against arterial blood gas)

• Temperature measurement (if transport time exceeds 2–4 h, and with larger burns—continuous). For all larger burns, active heating should be secured by thermoregulated fluidized beds

• Diuresis (mL/h)

Treatment targets for all shipments are as follows (unless other target orders are given):

• SpO2 > 92%

• PCO2 4.5–5.5 kPa

• Temperature 37.5 °C

• Diuresis 0.5–1 mL/kg/h

• Blood gas and electrolytes within the normal reference range

Summary Box

The chapter describes the first evaluation and triage of the burn-injured patient and provides algorithms (ABLS/ATLS) for the early examination and stabilization (first 24 h) prior to transport. Based on present guidelines, details are provided in the ABCDE format for patient evaluation and finally especially challenging issues are addressed, together with referral and transport recommendations.