If there is potential that the patient’s airway may deteriorate due to an inhalation injury or oedema subsequent to fluid resuscitation, then intubation prior to retrieval should be discussed with the ARV consultants. Sit the patient up if possible to minimise airway oedema.

Bronchodilators such as salbutamol may be effective in the presence of bronchospasm.
Frequent reassessment of the patient must take place as progressive swelling may cause further airway compromise. In an intubated patient, end-tidal carbon dioxide (ETCO₂) monitoring (if available) should be used to assess respiratory status and adequacy of ventilation.

Always have emergency airway equipment by the bedside.
Consider escharotomy of the chest wall if necessary (see Escharotomy section).

Fluid resuscitation

Effective fluid resuscitation is one of the cornerstones of modern burn care and has contributed significantly to lesser mortality and improved outcomes. Without rapid and effective intervention, hypovolaemia/shock will develop in severe burns cases. Any delay in fluid administration complicates resuscitation and increases mortality.¹⁰
Begin fluid resuscitation with normal saline if the TBSA (for adults) is over 20%. Fluid requirements should be estimated using the Parkland formula and taken from the time of injury.

• 4 mL × TBSA%  × kg = ____mL/24 hours
• ½ total in the first 8 hours post injury
• ½ total in the next 16 hours post injury

Take into account the amount of fluid given since treatment commenced. This formula should be used as a guide; titrate treatment to response and to the desired urine output of 0.5–1 mL/kg/hr.

It is important to maintain an accurate intake and output chart from the early stages of treatment in order to assess the effectiveness of fluid resuscitation. This will also assist retrieval staff with further management during transfer.

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Compartment Syndrome

1. Formation of inelastic, circumferential eschars around burned limbs and the associated extravasation of fluids.
2. Electrical conduction burns leading to muscle and nerve damage and cell death.
3. Systemic inflammation and subsequent volume resuscitation in patients with intravascular volume depletion.

The requirement for an escharotomy and/or fasciotomy usually presents within the first few hours of injury. This procedure may be necessary to relieve pressure if circulation is compromised.

Indicators that a circumferential chest wound may require an escharotomy are where the chest wall movement is decreased or there are signs of any respiratory compromise.
Signs that circulation is compromised and a limb may require a fasciotomy are; loss of circulation as evidenced by decreased capillary return, coolness, pallor, loss of palpable pulses and numbness. Early elevation may prevent the need to perform the procedure.

Prior to performing an escharotomy, discussion with Victorian Burns Service clinicians should always take place.

For detailed instructions on how to perform the above, please refer to the escharotomy guide in the downloadable resources section via the Trauma Victoria website.

Analgesia

Burns are painful due to the thermal injury itself as well as the inflammatory mediator response. IV analgesia administration is the most effective route in burns due to rapid absorption. Morphine is the preferred analgesic drug to manage burns pain in the acute management phase^.3

Analgesia that is administered via the intramuscular, subcutaneous, and oral routes may be unreliably absorbed due to fluid shifts and gastrointestinal stasis. However if IV access is unattainable, then these are optional routes for administration. Intranasal analgesia is often used in the prehospital setting, however the effects of absorption are not clear in the setting of inhalation injury.

Administer analgesia as per local protocols and titrate to effect.

Consider prophylactic antiemetic administration, especially if retrieval and transfer is likely.
 

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Wound care

1. First aid: Immediate cooling of burns with cool running tap water helps to reduce the severity of tissue damage and relieve pain. Burns cooled for 20 minutes show greater re-epithelisation than other time periods. Leave any clothing that is adhered to underlying skin and immediately cool wounds for 20 minutes with continuous running water if possible in partial thickness and superficial burns, not in full thickness burns.
   Patients with a large burn (TBSA > 10%) or children/older people should be observed for hypothermia and in such circumstances cooling should be ceased. In circumstances where running water is not available, apply wet towels or saline soaked gauze to affected areas and change frequently.
    
2. Dress: If the patient is being transferred to the burns service within six hours, cover the wound with plastic cling film. It should be applied longitudinally (to allow for swelling) rather than circumferentially, which may have a tourniquet-like effect.
    

If none is available and/or the patient is unlikely to be transferred to the burns unit within six hours, cover with paraffin gauze / silver or non-adherent dressing. Once dressings are complete, elevate the affected limb if possible to assist in minimising burn wound oedema.¹¹ Place the patient on a burn sheet to absorb any exudate and to allow for minimal adhesion.
It is important to document if the burns have been contaminated at time of injury or during care such as if the patient rolled in dirt at the time of injury or jumped into a dam to cool the burns.

For detailed dressing instructions, refer to the Victorian state burns clinical practice guidelines.

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In-dwelling catheter

A urinary catheter should be inserted and urine output measured hourly. The desired urine output for adults is 0.5–1.0 mL/kg/hr.¹²

A urinalysis should also be performed to check for blood. Discoloured, brown urine in circumferential or electrical injuries may indicate myoglobinuria, a sign of rhabdomyolysis.

Monitoring

Monitoring of the heart rate, respiration rate, blood pressure, temperature and oxygen saturation should take place at 15/60 intervals or less if indicated. Monitor continuously via electronic monitoring if facilities are available. All monitoring should be maintained until the retrieval team arrives.

A baseline ECG should be taken prior to transfer if time permits and facilities exist.

Glasgow Coma Scale

A focused neurological assessment using the GCS should be performed (see table below). This should include a description of the patient’s level of consciousness as well as assessments of pupillary size and reactivity, gross motor function, and sensation. Document the findings and reassess at frequent intervals.
 

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Pathology tests

Pathology tests should be taken for FBC (full blood count), UEC (urea, electrolytes and creatinine) and glucose as well as a blood gases if available. In suspected carbon monoxide poisoning, test for CoHb levels. Consider taking a group and cross-match if the patient is involved in a trauma presentation with a high index of suspicion for further injuries.

X-ray/FAST scan

Consider further diagnostic imaging if available and indicated.

Consider the need for FAST (Focused Assessment with Sonography in Trauma) if available and staff are trained in its use. FAST is used primarily to detect pericardial and intraperitoneal blood and it is more accurate than any physical examination finding for detecting intra-abdominal injury.¹³

In haemodynamically stable patients, FAST can be delayed until the secondary survey and is ideally performed by a second operator while the remainder of the secondary survey is completed.

Naso/orogastric tube (N/OGT)

All patients should be kept nil orally in the initial post-resuscitation phase of injury. In severe burns, enteral feeding will begin upon transfer to the burns service. Discuss the necessity of this with ARV and the burns unit in the early stages of management.

The potential for a base of skull fracture in polytrauma should be considered as a relative contraindication in the decision to insert an NGT. An OGT may be inserted following consultation and under direct visualisation.

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Tetanus immunisation

Tetanus immunisation should be updated if necessary for any burns deeper than superficial-thickness. Tetanus immune globulin should be given to patients who have not received a complete primary immunisation.

Antibiotics

Routine IV antibiotic administration is not recommended in an initial, uncomplicated burn injury as it may facilitate the development of multi-resistant bacteria.¹⁵ There may be some benefit if the wound has been contaminated; discuss with ARV.

Reassess

The importance of frequent reassessment cannot be overemphasised. Patients should be re-evaluated at regular intervals as deterioration in a patient’s clinical condition can be swift. This will be evident in their vital signs and level of consciousness. If in doubt, repeat the primary survey.

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