EMS World

JAN 2013

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BURN CARE will occur during the hours and weeks following a serious burn. This can be accomplished using pillows. Cover the partial-thickness burn with a clean, dry dressing. The patient should be evaluated by a physician at a hospital. Do not continuously flush partial-thickness burn areas with water unless the source of the burn is chemical. DEEP PARTIAL-THICKNESS, CIRCUMFERENTIAL BURNS Clinically, there is a distinction between partial-thickness and deep partial-thickness burns. However, for purposes of this work, you should focus on the presence of blisters (which characterize partial-thickness burns) and charred or leathery skin (which characterizes full-thickness burns) to differentiate between partial- and full-thickness burns. In areas of the body where there is little or no subcutaneous fatty tissue, burns with partial-thickness characteristics may be more critical and are likely to be a deep partial-thickness burns. All burns that can be described as partialor full-thickness involving the face/ears, hands/feet, and peritoneal/genital area are critical burns. A condition that is particularly lifethreatening is the partial- or full-thickness burn that is circumferential to an extremity or involves significant portions of the chest or abdominal area. With partial- and particularly full-thickness burns, the skin loses its elasticity and contracts. If the burn is circumferential to an extremity or covers a significant portion of the chest or abdomen, the contraction will lead to decreased circulation distal to the injury site. Signs and symptoms include the appearance of a taut or leathery appearance of the impacted tissue, cyanosis or pallor in the area distal to the wound, numbness or a tingling sensation and diminished or loss of pulses. The aforementioned signs and symptoms point to a condition known as compartment syndrome. This is lifethreatening, limb-threatening or both, depending on where the injury is located. For circumferential chest wall burns, as the burn injury begins to manifest, the skin will shrink and impede the inspira- Burn Center Referral Criteria1 Seriously and critically injured burn patients are best managed in burn centers. Most likely to benefit from admission to a burn center are those with:1 1. Partial-thickness burns >10% TBSA; 2. Burns involving the ears, face, hands, feet, genitalia, perineum or major joints; 3. Full-thickness burns; 4. Electrical burns, including lightning injury; 5. Chemical burns; 6. Radiation burns; 7. Inhalation burns; 8. Preexisting medical conditions that could complicate management, prolong recovery or afect mortality, such as end-stage renal disease; 9. Burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality. Evaluate trauma patients first to determine the extent of injury, and, if in doubt, go to the trauma center first; 10. Burn injuries in pediatric patients. Not all burn centers accept pediatric patients. Check with your regional burn center to determine what age limitations it may have and plan accordingly; 11. Need for special social, emotional or rehabilitative interventions. Not all burn centers are colocated with trauma centers. Not all accept patients with, for example, radiation injuries. Call them first, create a relationship and understand their capabilities and limitations. For a list of current burn centers and their contact information, see www. ameriburn.org/BCRDPublic.pdf. Adapted from the American Burn Association's Guidelines for the Operations of Burn Centers, www.ameriburn.org/Chapter14.pdf. tion and expiration. This increased workload on the cardiovascular system can also be life-threatening. Compartment syndrome can only be relieved by escharotomy/fasciotomy. Escharotomy is a surgical incision that cuts through the dead tissue (eschar). Fasciotomy is a surgical incision that cuts into the (subcutaneous fatty) fascia tissue. These terms basically describe the same procedure and are routinely interchanged in managing circumferential burns. The procedure is typically performed by a trained surgeon. Burn Dressings For minor burns, clean, dry dressings are sufficient. Burn-center surgeons generally prefer the same for moderate and severe burns, since anything applied will have to be removed during the debridement process. There are many commercially made burn-specific dressings impregnated with a variety of additives. Commercially made dressings that include some aspect of a silver solution have historically been recommended for situations where the time between injury and admission to a burn center is prolonged. Military personnel have had these dressings applied early in their management in Iraq and Afghanistan and maintained until arriving 72–120 hours later at Brooke Army Medical Center in San Antonio,15,16 where most military personnel with burn injuries are managed. For civilians, when a burn center can be accessed in less than 6 hours, there is no conclusive evidence of benefit to commercially made impregnated dressings. There are other commercially sold dressings reported to have woundhealing properties without silver-based active ingredients. These may aid in healing if you have an extended transport time. However, as with the silverimpregnated dressings, they tend to be expensive, and while the preliminary data for several of these dressings may be promising, there is no conclusive evidence of their added value to a patient whose injury is managed at a burn center in the first few hours. The first recommended purchase specifically for burn care, outside of what is typically found on an ambulance, is lactated Ringer's IV fluid (LR), provided it is on an agency's approved formulary. LR is inexpensive and has a similar composition EMSWORLD.com | JANUARY 2013 49

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