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Burn Practice Guideline
Burn Practice Guideline
Burn Practice Guideline
Practice
Guideline
Developed by
Texas EMS Trauma & Acute
Care Foundation Trauma Division
Contributors Edited by
Rose Bolenbaucher, M.S.N., RN, TCRN, Trauma Brian Eastridge, M.D., Trauma Medical Director and
Program Education, Trauma Services, University Trauma/Acute-Care Surgeon at University Hospital
Health System, San Antonio in San Antonio
Tracy Cotner-Pouncy, RN, Senior Director, Trauma Brenda Putz, RN, B.S.N., TETAF, Austin
Services, University Health System, San Antonio
Courtney Edwards, M.S.N./M.P.H., RN, Injury Governors EMS and Trauma Advisory Council
Prevention Manager, Parkland Health & Hospital Trauma Systems Committee Trauma Medical
System, Dallas Directors Workgroup
Bonnie Jackson, RN, M.S.N., CCNS, Burn Program Ann Ward, APR, A.Ward Strategic Communications
Manager, U.S. Army Burn Center, U.S. Army
Institute of Surgical Research, San Antonio Military Design by
Medical Center, Fort Sam Houston, Texas Barbara Battista, Graphic Design Services
Wendy McNabb, RN, Director, Trauma and Burn
Photo Credits
Services, University Medical Center, Lubbock
Photographs in this publication are courtesy of
Col. Elizabeth A. Mann-Salinas, Ph.D., RN, FCCM, Task
University Medical Center, Lubbock.
Area Manager, Systems of Care for Complex
Patients, U.S. Army Institute of Surgical Research,
Fort Sam Houston, Texas
Jenny Oliver, B.S.N., RN, Assistant Director of Trauma
Services, University Health System, San Antonio
Brenda Putz, RN, B.S.N., Director, Texas EMS Copyright May 2016 by the Texas EMS
Trauma & Acute Care Foundation Trauma & Acute Care Foundation. Individuals
Kathy Rodgers, RN, M.S.N., CNS, TCRN, CCRN, CEN, may download and print this publication for
Trauma Services Director, CHRISTUS St. Elizabeth use within their organization. Other uses
Hospital, Beaumont including mass copying and distribution of
Sue Vanek, B.S., M.B.A., RN, former Burn Program the copyright publication are prohibited.
Manager, Parkland Regional Burn Center, Parkland
Health and Hospital System, Dallas
2
Contents
Burn Clinical Practice Guideline
Treatment Protocol Considerations................................................................................................ 4
Advanced Trauma Life Support Process/Assessment.............................................................. 5
Airway with C-Spine Protection............................................................................................. 5
Breathing........................................................................................................................................ 5
Circulation...................................................................................................................................... 5
Disability......................................................................................................................................... 5
Exposure......................................................................................................................................... 5
Fluid Resuscitation................................................................................................................................ 5
Determination of Total Body Surface Area......................................................................... 5
Burn Classification....................................................................................................................... 6
Burn History................................................................................................................................... 6
Diagnostics/Basic Laboratory Tests....................................................................................... 6
Special Circumstances......................................................................................................................... 7
Pediatric Considerations........................................................................................................... 8
Geriatric Considerations........................................................................................................... 9
Electrical Injury Considerations.............................................................................................. 9
Chemical Injury Considerations............................................................................................. 9
Circumferential Burns Considerations................................................................................. 9
Additional Considerations for All Types of Burn Patients...........................................10
Wound Care...........................................................................................................................................10
Pain and Anxiety Management............................................................................................10
Burn Center Referral Criteria............................................................................................................11
Psychosocial and Spiritual Support..............................................................................................11
Education Recommendations.........................................................................................................15
Appendices.................................................................................................................................................16
Rule of Nines.........................................................................................................................................17
24-Hour Burn Care Sheet..................................................................................................................18
References...................................................................................................................................................20
3
Burn Clinical Practice Guideline
Treatment of burns is not always straightforward. National 3. Address guidelines systematically and include:
and international guidelines differ from one region to a) ABCDE as in all types of trauma cases,
another. However, all sources agree that managing burn b) Fluid resuscitation,
cases in the first 24 hours is critical and directly correlates c) Wound care,
to morbidity and mortality. d) Pain management,
e) Transfer guidelines, and
To deliver optimal patient care to burn victims, health f ) Psychosocial and spiritual support.
care providers must understand the pathophysiology of
burn injuries, their classification, the appropriate use of Treatment Protocol Considerations
various types of surgical treatment and the latest updates
All trauma cases including patients with burn
in burn science. Some patients may be treated effectively
injuries should be treated by initially following
in the hospital emergency department while others may
the guidelines for Advanced Trauma Life Support to
require hospitalization or stabilization/transfer to a burn
ensure that life-threatening injuries are addressed
center as quickly as possible.
immediately. ABCDs first! The appropriate assessment
and management of burn patients in the first hours
The clinical situation for treating burn cases needs
following injury have resulted in the 96 percent national
clear guidelines to cover all aspects of care during the
survival rate for patients transferred to a verified burn
treatment process. Through a collaboration of Texas
center in 2011, as reported by Advanced Burn Life
verified burn centers and the Texas EMS Trauma & Acute
Support.
Care Foundation (TETAF), this publication was created
to provide clinical practice guidelines for hospitals in
This publication provides information and guidance
Texas for assessing, classifying and treating the patient
in developing policies for treating burn patients.
experiencing a burn injury. Utilization of these guidelines
Information is presented in the order in which
provides the framework to develop burn care policies in
assessment/care should be provided. After addressing
Texas hospitals and ensure consistent, appropriate care
the ABCDs of life support, focus turns to burn injuries.
for burn patients across the state.
Replacing fluid lost from the burns is critical, and an
accurate assessment of the severity and extent of
Publication Objectives
the burns is needed to calculate the amount of fluid
TETAFs goals with this publication include the following:
to provide. Wound care and pain management are
1. Provide resources and references for burn care in Texas addressed next. Many of these activities are occurring
based on nationally accepted standards of care. almost simultaneously, especially if the extent of the
2. Provide guidelines and assistance for the development burn injuries indicates transfer to a burn center is
of policies and ensure consistent practice across Texas for needed. Psychosocial and spiritual support may be
all burn patients. provided throughout the assessment, treatment and
stabilization processes.
4
Advanced Trauma Life Support Assess perfusion status by the following techniques:
a. Pulse check,
Process/Assessment
b. Capillary refill, and
Airway with C-Spine Protection c. Urinary output (see additional parameters in
As in all trauma cases, early recognition of airway the section Determination of Total Body Surface Area,
compromise followed by prompt intervention to ensure below and on page 6).
airway maintenance should be completed. If there is soot
in the mouth, consider early intubation even if the patient Disability
is breathing normally. Follow ATLS guidelines and ensure Detect if there are any manifestations of neurological
the patient has a definitive airway established and continue deficits.
assessments to monitor ventilation. Assessment of the
airway includes: Exposure
a. Removing any burning agent, including chemicals. Evidence-based research supports total exposure of
b. Inspecting for singed nasal, facial and eyebrow hairs. the patient to assess the severity of burns and initiate
c. Looking for burns and edema around the head and neck. treatment.
d. Determining if there are circumferential burns to a. Remove any burning agent, including chemicals.
the chest which may inhibit ventilation and require b. Work toward maintaining a normal temperature by
escharotomy. removing wet dressings and covering with dry, sterile
dressings.
Breathing c. Begin re-warming the patient with blankets and
Determine if the patient is moving air or not. Follow ATLS warmed fluid. Ambient temperature should be from
guidelines. Assessment of breathing includes: 28 to 32C (82 to 90F). The patients core temperature
a. Auscultating breath sounds, must be kept at least above 34C. Increase the room
b. Monitoring rate, depth and work of breathing, and temperature if necessary.
c. Monitoring for dyspnea and stridor. d. Remove all jewelry.
5
The Lund-Browder chart is one of the most accurate
methods to estimate not only the size of the burn area
but also the burn degree in both adult and pediatric burn
patients. This chart is widely used in clinical practice. The
Lund-Browder chart is available in many burn centers and
on the Internet; see the Education Recommendations on
page 15 of this publication for more information.
Burn Classification or Severity Note: The American Burn Association recently has approved the Rule of
A visual assessment should be made to determine the 10, and once it is implemented, will be incorporated in this document.
burns) Complete epithelial damage and damage of n Superficial partial-thickness burns (superficial second
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n Full-thickness burns (third degree); and
n Full-thickness burns involving the underlying fascia,
muscles and bones (fourth degree).
Burn History
Once the ABCDs are completed and fluid resuscitation
has been initiated, attention should be focused on
obtaining information about how the burn injury
occurred. This burn history should include:
n The patients or EMS providers history of the events,
n Time of injury,
n Where the injury occurred including if the patient
source,
n If decontamination occurred,
on the history of burns in a closed area as well as the First Degree Burn
presence of soot in the mouth and nose,
n Presence of facial burns, if applicable,
7
Pediatric Considerations
If the patient is a child, look for signs of abuse.
Specific things to consider include the following:
n Is the pattern of burn consistent with the story?
Accidental Burn
8
Geriatric Considerations Chemical Injury Considerations
Advances in medical care and longevity have resulted in All ERs are required to maintain a reference manual that
an increase in the elderly population, and burn injuries in is updated regularly with chemicals used in their region.
this subset of the population are becoming more prevalent. Every chemical and the appropriate care for an exposure
With patients 65 years of age and older, the risk of mortality should be included in the Material Safety Data Sheet
is increased, so early and aggressive management of (MSDS). This reference should define the appropriate type
burns are needed. Thinner skin, poorer circulation, pre- of emergency care for each chemical in the region that
existing conditions, fewer reserves and higher complication could cause a burn.
rates increase morbidity and mortality. Because of age,
thoughtful consideration should be given to treatment, With chemical burns, it is important to determine that the
such as: patient has undergone decontamination for an appropriate
n Early surgical intervention is recommended. length of time based on the specific recommendations in
n Use care in fluid resuscitation so as not to cause fluid the MSDS, at least 20 minutes or until the burning process
overload. Be aware that it may require more fluid to has stopped. If the burn was caused by a chemical agent,
resuscitate the same burn size than expected to avoid providers should take appropriate precautions to protect
hypovolemia, possibly due to the decreased skin turgor. themselves and the immediate environment from exposure
n Implement aggressive respiratory therapy. Inhalation to the chemical agent.
injury tends to be more prevalent in elderly patients
because they are generally less mobile. Inhalation Circumferential Burns Considerations
injury is a significant predictor of mortality and is an Burns that encircle an extremity, the chest or the abdomen
important comorbidity factor. require special attention. Edema and swelling in the tissue
n Transfer to a burn center is recommended. under the burn may cause the burnt skin which is rigid
n For optimum outcomes, aggressive rehabilitation to act like a tourniquet. In a limb, this can cause ischemia.
is needed. In the chest or abdomen, it can restrict chest expansion
and diaphragm movement and interfere with ventilation.
Electrical Injury Considerations A burn center surgeon should be consulted prior to
When the patients burns were caused by an electrical treatment.
injury, circumstances dictate special care consideration,
including the following: Among the interventions that typically may be
n Assess cardiac rhythm as life-threatening arrhythmias implemented are the following:
may be present. n Checking for pulses; often a doppler scan is needed.
n Assess contact points (it is possible to have more than n Elevating extremities if not contraindicated.
n Be aware that significant underlying tissue and muscle of the burn down to the subcutaneous fat, to release
injury may be present in electrical injuries. If this constricting unyielding burned skin. This may be
happens, muscle fibers and chemicals may be released necessary to restore blood flow. However, this optimally
into the bloodstream, causing electrolyte disturbances. should be performed after appropriate consultation
n Assess for myobloginuria; the presence of these with the burn center surgeon.
muscles fragments in the urine can cause electrolyte
disturbances and kidney failure.
9
Additional Considerations for All Types of Burn Patients Wound Care
Regardless of the patients age or type of burn, these
Initially, the burn must be cooled with cool water, not cold
treatment considerations apply to all burn patients.
and not ice water. Wet dressings put in place in the pre-
n Insert a gastric tube as directed by a physician.
hospital setting must be removed and replaced with sterile,
n Monitor urinary output to assess fluid resuscitation
dry dressings if more than 20 percent of the patients TBSA
by inserting an urinary catheter and monitoring
is affected. Note that wound care is a low priority in the
urine output (UOP) for amount and color, using these
initial care of a severely burned patient unless covering of
guidelines:
the burn with sterile, dry dressing reduces the pain and
Adults UOP goal is 30 cc/hour.
increases the comfort level of the burn injured patient. It
Pediatric UOP goal is 1 cc/kg/hour.
should be noted that wound care should not be attempted
Electrical injuries with myobloginuria UOP goal
until well after the patients airway, breathing and
is 75-100 cc/hour.
circulatory status have been addressed.
n Electrical and inhalation injuries may require
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measured and adjusted to provide relief to the patient,
although careful monitoring of the patients respiratory
status is required.
trauma poses the greater immediate risk, the patient n Feeling hopeless,
being transferred to a burn unit. Physician judgment will n Being concerned about potential changes in lifestyle,
be necessary in such situations and should be in concert appearance, physical limitations, etc., and
with the regional medical control plan and triage n Feeling sad or angry about the loss of property, loved
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Examples of Fluid Resuscitation and
Wound Care Protocols
Fluid resuscitation recommendations vary in verified burn centers in Texas. Facilities in different geographic locations in
Texas should follow the recommendations of their regional tertiary burn center.
12
Burn Unit San Antonio Medical Center UTMB Galveston Blocker Burn Unit
Hotline: 210/916-4141 Hotline: 800/962-3648
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Forms and Tools for Documentation
There are many accessible resources for forms and tools n Documentation of fluid volume should start at point of
that a hospital may use for documentation models. The injury to reinforce the 24-hour flow sheet.
following information is provided as a guideline and should
be considered recommendations only. Resuscitation Phase:
n All burn patients with second- or third-degree burns
guidelines to determine transfer to a burn unit. Having a nasogastric or progastric tube placed.
Rule of Nines chart is recommended; see Appendix A. The n Wound care provided as per recommendations of
Rule of Nines is recommended for initial burn resuscitation receiving burn center.
prior to burn center transfer. The Lund-Browder chart is n Warming efforts documented.
recommended after initial burn care and debridement. n Serial vitals, including a temperature, documented.
Burn Care Sheet patient response during the first 24 hours was
Use a Burn Care Sheet, a tool to travel with the patient appropriate based on:
for the first 24 hours of care. An example is provided as 1. TBSA percentage calculation,
Appendix B. Hospitals also may use one developed by their 2. Fluid resuscitation formula appropriately executed
facilitys team or their RAC. and documented including bolus and maintenance
fluid resuscitation,
Performance Improvement Patient Safety (PIPS) 3. Resuscitation success/failure monitored based on
As with trauma, the care of burn patients should receive hemodynamic status and urinary output, and
a very robust review of standards, protocol utilization, 4. Intake and output documented on 24-hour burn
documentation, fluid resuscitation and outcomes. The burn flow sheet, which traveled with the patient.
review within PIPS must include additional quality filters to
ensure the standard of care is met. Additional Considerations:
n Total length of hospital stay is important for several
Performance Measures by Phases of Care reasons, including burn bed availability, transfer issues
Prehospital Phase: and recognition that in some situations non-burn
n Definitive airway management during resuscitative centers may have to maintain this patient.
phase provided n Unanticipated readmissions.
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Education Recommendations
These resources may assist the hospital in developing specific policies and procedures for treating patients with burn
injuries. In addition, specific educational programs both online and in-person may help clinicians treating burn
patients improve their practice.
Center for Disease Control & Prevention ABLS Provider Course Live A two-day in-person
http://www.cdc.gov/masstrauma/factsheets/public/burns.pdf hands-on course designed to provide the how-to
of emergency care of the burn patient; registration is
http://www.cdc.gov/mmwr/PDF/wk/mm4237.pdf available online.
(occupational burns among restaurant workers)
ABLS Now Convenient online course providing burn
International Society for Burn Injuries injury training and education for busy first responders
http://www.worldburn.org/ and health care providers.
National Rehabilitation Information Center ABLS Handbook The go-to reference guide for
http://www.naric.com comprehensive information on immediate care through
the first 24 hours post burn injury.
Public Domain Files/Resources List
http://docsfiles.com/pdf_burns_care_resources.html Most burn centers offer outreach education. Contact
your local burn center regarding its educational
Wound Care Advisor programs.
http://woundcareadvisor.com/resources/
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Appendices
Appendix A: Rule of Nines Diagram for use in documentation.
Appendix B: 24-Hour Burn Care Sheet Complete documentation that should travel with the patient.
16
infant
Anterior Posterior
Palmar
Method
Patients palm,
including fingers.
Note: The American Burn Association recently has approved the Rule of
10, and once it is implemented, will be incorporated in this document.
17
> 15%
> 15% Trauma BurnTBSA BURN RESUSCITATION
Surface FLOWSHEET Flowsheet
Area Burn Resuscitation
18
> 15 % TBSA BURN REUSCITATION FLOWSHEET
Date 1 REFERRING FACILITY 2
Estimated fluid vol. pt should receive (1) Date: Today's date
(2) Referring Facility: There this form
Pre- 2-4 ml x a (kg) x b (TBSA) = TOTAL
Burn ml/24 hrs (___)
was initiated
Identy# est.wt 24 hr total 2 = (3) Name: Patient's Name
Name DOB or MRN (kg) % TBSA TOTAL ml (___) for 1st 8 hrs (4) Identity/DOB/MRN - self
3 4 5 6 7 explanatory
Date & Time of Injury 8 Burn Center Name: (5) Weight in Kg: Estimated weight
PREBURN "dry weight"
9 10 16
(6)% TBSA: area burned
11 12 13 14 15 17 18
(7) Calculation of individualized RAC
Initial Burn Center Policy: Total fluids
Provider hour calculated for the 1st 24 hrs and the
Initials & from Base 1st 8 hrs
Care Team burn Time Crystalloid Colloid Total UOP Deficit BP Pressors
(8) Date & Time of Injury: Date &
1st time of burn. Not the time pt arrived
2nd to your facility
3rd (9) Provider Initials & Care Team:
4th Initial of provider and name of Care
5th Team i.e., AirLIFE
6th (10) Initial hour from burn: 1st hour
of post-burn i.e., Pt burned 2 hrs
7th
prior arrival, facility will start
8th
charting for pt on the 3rd hour.
Total Fluids: 19
(11) Local Time: time being used by
9th recorder
10th (12) Crystalloid (ml): total of
11th crystalloid volume give over last hour
12th (13) Colloid (ml): total of colloid
13th volume given over the last hour i.e.,
14th Albumin, blood
(14) Total: Total volume (crystalloid
15th
+ colloids) for that hour
16th
(15) UOP: Urine output for last for
17th
last hour
18th
(16) Base Deficit: self explanatory
19th (17) BP: Systolic BP/Diastolic BP
20th (18) Pressors: Vasopressin, Levophed
21st with rate and dose
22nd (19) Total Fluids: 8 hour total of
23rd Crystalloid and Colloid fluid. For Pedi
24th - resuscitation fluids does not
replace maintanence fluid
Total Fluids: 20
requirements for pediatric patients
21
(20) Total Fluids: 24 hour total of
Initials:______ Name/Title:______________________________ Date:_____________
Crystalloid and Colloid Fluid
Initials:______ Name/Title:______________________________ Date:_____________ (21) Initials/Name & Title/Date:
Initials:______ Name/Title:______________________________ Date:_____________ Legible initals and signature of
provider documenting this flowsheet
19
Section 8
References
Advanced Burn Life Support. Parkland Regional Burn Center (2013). Burn Policy
Level 3 and Level 4.
Advanced Trauma Life Support.
San Antonio Medical Center Fluid Resuscitation and
Alfred Health, Burns Management Guidelines, Wound Care Protocols.
http://www.vicburns.org.au/about.html
Sharma, R.K.; Parashar, A.; Special considerations in
American Burn Association Provider Manual 2011, paediatric burn patients, Indian Journal of Plastic Surgery,
http://www.ameriburn.org/verification_guidelines.php 2010 September: 43 (Suppl): pages 43-50. Retrieved from:
www.ijps.org
American College of Surgeons, Committee on Trauma,
Resources for Optimal Care of the Injured Patient (2006). Timothy J. Harnar Burn Center, University Medical Center
Health System, Lubbock, Fluid Resuscitation and Wound
Chung, K.K.; Salinas, J.; Renz, E.M.; Alvarado, R.A.; King, Care Protocols.
B.T.; Barillo, D.J.; Cancio, L.C.; Wolf, S.E.; Blackbourne, L.H.,
Simple derivation of the initial fluid rate for resuscitation of Trauma Nursing Core Course Provider Manual, Sixth
severely burned adult combat casualties: in silico validation Edition.
of the rule of 10, Journal of Trauma, 2010; 69(1): S49-54.
University of Texas Medical Branch Galveston Blocker
Emergency War Surgery Handbook, Chapter 28 Burn Unit Fluid Resuscitation and Wound Care Protocols.
Ennis, J.L.; Chung, K.K.; Renz, E.M.; Barillo, D.J.; Albrecht, U.S. Institute of Surgical Research Clinical Practice
M.C.; Jones, J.A.; Blackbourne, L.H.; Cancio, L.C.; Eastridge, Guidelines Burn Care 2013,
B.J.; Flaherty, S.F.; Dorlac, W.C.; Kelleher, K.S.; Wade, C.E.; http://www.usaisr.amedd.army.mil
Wolf, S.E.; Jenkins, D.H.; Holcomb, J.B.; Joint Theater Trauma
System implementation of burn resuscitation guidelines Ziyad Alharbi, Andrzej Piatkowski, Rolf Dembinski, Sven
improves outcomes in severely burned military casualties, Reckort, Gerrit Grieb, Jens Kauczok, Norbert Pallua;
Journal of Trauma, 2008; 64(2): S146-51; discussion 151-2. Treatment of burns in the first 24 hours: simple and
practical guide by answering 10 questions in a step-by-
First Aid for Burns, Medicine.Net, step form, World Journal of Emergency Surgery, 2012, 7:13.
http://www.medicinenet.com/burns/article.htm Retrieved from:
http://www.wjes.org/content/pdf/1749-7922-7-13.pdf
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