Burns
Hey students! š„ Welcome to one of the most critical lessons in paramedicine - understanding and managing burn injuries. Burns are among the most challenging emergencies you'll encounter as a paramedic, requiring quick assessment, immediate intervention, and careful decision-making about patient care and transport. By the end of this lesson, you'll understand how to classify burns, assess their severity, manage airway complications, implement fluid resuscitation protocols, and determine when specialized burn center care is needed. Let's dive into this life-saving knowledge that could make the difference between recovery and tragedy for your patients!
Understanding Burn Classifications and Assessment š„
Gone are the days of simply calling burns "first, second, and third degree" - modern burn medicine uses more precise terminology that better guides treatment decisions. As a paramedic, you need to understand these classifications because they directly impact your treatment protocols.
Superficial burns (formerly first-degree) affect only the epidermis, the outermost layer of skin. Think of a mild sunburn - the skin appears red, is painful to touch, but doesn't blister. These burns typically heal within 3-7 days without scarring and don't require fluid resuscitation. While uncomfortable, they're rarely life-threatening unless they cover massive areas of the body.
Superficial partial-thickness burns (formerly superficial second-degree) extend into the upper dermis. These burns are characterized by red, wet-appearing skin with blisters that form within hours of injury. They're extremely painful because nerve endings remain intact. A classic example is accidentally grabbing a hot pan - the immediate blistering and intense pain are hallmarks of this burn type.
Deep partial-thickness burns (formerly deep second-degree) penetrate deeper into the dermis, potentially destroying hair follicles and sweat glands. These burns may appear white or cherry red, feel less painful due to nerve damage, and take weeks to heal with potential scarring. Picture someone's clothing catching fire briefly - the areas where fabric burned against skin often result in these deeper injuries.
Full-thickness burns (formerly third-degree) destroy all layers of skin and may extend into subcutaneous tissue, muscle, or bone. Paradoxically, these burns are often painless because all nerve endings are destroyed. The skin appears leathery, white, brown, or charred. A person trapped in a house fire who suffers prolonged exposure to flames typically sustains these devastating injuries.
The Rule of Nines remains your primary tool for estimating total body surface area (TBSA) burned. Each arm represents 9%, each leg 18%, the front and back torso each 18%, the head 9%, and the genitals 1%. For children, adjust these percentages - their heads are proportionally larger (18%) and legs smaller (14% each). Remember, only partial and full-thickness burns count toward TBSA calculations for fluid resuscitation purposes.
Airway Management in Burn Patients š«
Airway complications represent the most immediate threat to burn patients, and recognizing inhalation injury can mean the difference between life and death. Inhalation injuries occur in approximately 20% of burn patients admitted to hospitals, but this percentage is much higher in enclosed space fires.
Upper airway injuries result from inhaling superheated gases and steam. Signs include singed nasal hairs, soot around the mouth and nose, hoarse voice, stridor, and swelling of the face and neck. These patients can deteriorate rapidly as airway edema progresses. If you suspect upper airway involvement, secure the airway early - waiting for obvious distress may be too late.
Lower airway injuries occur when patients inhale toxic chemicals and particulates from burning materials. Carbon monoxide poisoning is common, presenting with headache, confusion, and cherry-red skin (though this classic sign appears in less than 5% of cases). Hydrogen cyanide poisoning from burning plastics and synthetic materials causes similar symptoms but progresses more rapidly.
Circumferential neck burns can create external compression as the burned tissue swells and contracts. These burns may require emergency escharotomy (surgical release of burned tissue) to prevent airway compromise.
Your assessment must include asking about the fire environment - was the patient in an enclosed space? What materials were burning? How long was exposure? A patient rescued from a basement fire involving furniture and electronics faces much higher risk than someone with flash burns from a gas grill in an open area.
Fluid Resuscitation Principles š§
Burn shock develops when capillary permeability increases dramatically, causing massive fluid shifts from intravascular to interstitial spaces. This process begins immediately after injury and peaks at 6-8 hours post-burn. Understanding fluid resuscitation principles is crucial because under-resuscitation leads to organ failure while over-resuscitation causes compartment syndrome and pulmonary edema.
The Parkland Formula remains the gold standard for initial fluid calculations: 4 mL Ć weight in kg Ć %TBSA burned = total fluid needed in first 24 hours. Give half this volume in the first 8 hours (calculated from time of injury, not arrival time), and the remaining half over the next 16 hours. For example, a 70kg patient with 30% TBSA burns needs 8,400 mL total - 4,200 mL in the first 8 hours and 4,200 mL over the following 16 hours.
However, the Parkland Formula provides only a starting point. Fluid resuscitation requires constant monitoring and adjustment based on urine output (goal: 0.5-1.0 mL/kg/hour in adults), blood pressure, heart rate, and mental status. Some patients need significantly more or less fluid than the formula suggests.
Lactated Ringer's solution is the preferred crystalloid because its electrolyte composition closely matches extracellular fluid. Avoid normal saline for large-volume resuscitation as it can cause hyperchloremic acidosis. Colloids like albumin aren't recommended in the first 24 hours because increased capillary permeability allows them to leak into tissues, potentially worsening edema.
Children require modified approaches - they need fluid resuscitation for burns exceeding 10-15% TBSA compared to 20% in adults. Their formula uses 3 mL/kg/%TBSA rather than 4 mL/kg/%TBSA, plus maintenance fluids calculated separately.
Specialized Burn Care Referral Criteria š
Not every burn patient needs a specialized burn center, but knowing referral criteria can save lives and prevent unnecessary complications. The American Burn Association has established clear guidelines that every paramedic should memorize.
Automatic burn center referrals include any patient with burns involving the face, hands, feet, genitalia, perineum, or major joints. These areas require specialized care to preserve function and appearance. A seemingly small burn on someone's palm could permanently disable their hand without expert treatment.
Age-based criteria recognize that very young and older patients tolerate burns poorly. Refer any patient under 10 or over 50 years old with partial or full-thickness burns exceeding 10% TBSA. A 5-year-old with 12% burns from hot bathwater needs burn center care, while a healthy 25-year-old with similar injuries might be managed at a trauma center.
Percentage-based referrals include partial-thickness burns exceeding 10% TBSA in patients aged 10-50, or any full-thickness burn exceeding 5% TBSA regardless of age. These thresholds reflect the body's limited ability to handle extensive tissue damage and fluid losses.
Special circumstances requiring burn center care include electrical burns (including lightning), chemical burns, inhalation injuries, burns with concurrent trauma where burn injury poses the greatest risk, and patients with pre-existing conditions that could complicate recovery.
Circumferential burns of extremities or chest require immediate attention regardless of other factors. These burns can act like tourniquets as they swell and contract, cutting off circulation or restricting breathing. Emergency escharotomy may be needed during transport.
Consider transport time and resources when making referral decisions. A patient who meets burn center criteria but lives 4 hours from the nearest facility might receive better initial care at a closer trauma center, with transfer arranged once stabilized.
Conclusion
Burn management represents one of paramedicine's greatest challenges, requiring rapid assessment, aggressive intervention, and careful decision-making about definitive care. Remember that burn severity depends not just on size but on depth, location, patient age, and associated injuries. Airway management takes absolute priority - secure airways early when inhalation injury is suspected. Fluid resuscitation using the Parkland Formula provides your starting point, but tailor treatment to individual patient responses. Finally, know your referral criteria cold - getting the right patient to the right facility at the right time can mean the difference between full recovery and lifelong disability. Master these principles, students, and you'll be prepared to handle one of emergency medicine's most complex challenges! š
Study Notes
ā¢ Burn Classifications: Superficial (epidermis only), superficial partial-thickness (upper dermis), deep partial-thickness (deep dermis), full-thickness (all skin layers)
ā¢ Rule of Nines: Head 9%, each arm 9%, each leg 18%, front torso 18%, back torso 18%, genitals 1%
ā¢ Parkland Formula: 4 mL Ć weight (kg) Ć %TBSA = 24-hour fluid requirement; give half in first 8 hours
ā¢ Fluid Resuscitation Threshold: Adults >20% TBSA, children >10-15% TBSA
ā¢ Airway Priority: Secure early if inhalation injury suspected - don't wait for obvious distress
ā¢ Inhalation Injury Signs: Singed nasal hairs, facial burns, hoarse voice, stridor, soot around mouth/nose
ā¢ Automatic Burn Center Referrals: Face, hands, feet, genitals, perineum, major joints, circumferential burns
ā¢ Age-Based Referrals: <10 or >50 years old with >10% partial/full-thickness burns
ā¢ Percentage Referrals: >10% partial-thickness (ages 10-50), >5% full-thickness (any age)
ā¢ Preferred IV Fluid: Lactated Ringer's solution for burn resuscitation
ā¢ Urine Output Goal: 0.5-1.0 mL/kg/hour in adults during resuscitation
ā¢ Only Count: Partial and full-thickness burns for TBSA and fluid calculations