Understanding Burn Care

Initial care and treatment of burn injuries significantly impacts healing, outcomes, function and appearance. The appropriate treatment for a burn patient depends upon the severity of the burn. For more serious injuries, treatment by a multidisciplinary team at hospital burn centers, with special capabilities, for managing burns is essential.

Smaller or less severe burns still may require specialized treatment. This is due to common complications likely to develop as a result of the burn. Infection, joint contracture impairment, scarring or risk of repeated exposure (especially for fire fighters) all delay and complicate the healing process.

Once someone has been burned, a critical first step is to identify the most appropriate on-scene care. Often this means removing the victim, cooling the burn and addressing the ABCs: airway, breathing and circulation. Factors impacting this include severity and extent of the burn and the most appropriate transport destination.

To maximize positive outcomes, the American Burn Association recommends that burns are best treated at a burn center. Once primary stabilization is achieved and other traumatic injuries have been treated or ruled out, burn-injured patients should be referred to a burn center. Getting a patient to a burn center is key to definitive, long-term care, so it is important to have protocols in place to facilitate transfer to the nearest burn facility. Here are over 120 burn care facilities across the United States; approximately one-half of those are verified burn centers that meet the stringent national requirements set by the ABA and American College of Surgeons. The transporting agency must make every effort to transport burn patients to the closest but also most-qualified burn center available. This transport decision should be assisted by local protocols, knowledge of surrounding facilities and the critical considerations in first stabilizing the patient.

How to Treat a Minor Burn

In general, minor burns are first-degree burns or second-degree burns that are smaller than the size of the patient’s hand. If the area burned is larger than this, or involves functional parts of the body such as feet, face, eye, ears and groin or is located over major joints, more in-depth medical attention is needed. Take the person to the nearest emergency room, family doctor or urgent care clinic to have the burn evaluated. Failure to do so may result in permanent disfigurement or loss of function.

Third degree burns are serious, regardless of size or area of the body that may be involved, and should be evaluated and treated by a qualified healthcare provider. All third-degree burns should be evaluated by a healthcare provider immediately. Burns that meet ABA burn center referral criteria are not minor burns and require specialized medical treatment.

Please note that even a small “minor” burn has the potential to become infected. It is always advisable to seek medical attention as soon as possible. Remember, when in doubt or if you think the individual’s life is in danger, call 911.

Healing

Minor burns that have reddened skin similar to a sunburn, should take 3-5 days to heal. Burns that are 2nd degree or partial thickness should be healed within 10 days. If a burn is taking more than 2 weeks to heal, you should seek treatment with a Burn Care Provider. Healing time approaching 3 weeks is indicative of a deeper burn that can scar if not treated properly. It is important that the burned area is observed for infection while it heals.

Signs of Infection:

• Redness that extends beyond the burned area that can feel warm to touch or swollen
• Change in the drainage to a creamy or colored appearance
• Fever, chills and/or increased pain and swelling in the affected burn limb not relieved by pain medication

As skin begins to heal, it may begin to itch and feel tight, which can be very uncomfortable at times. This is normal and will eventually decrease. Frequent application of lotion can help keep the skin hydrated and minimize the itching. If the itching is too severe, an over-the-counter medication may be helpful in easing the discomfort.

Remember…always follow the directions on the label. The wound should be kept clean with daily dressing changes. Any concern or questions should be directed to a qualified healthcare provider.

Once the burn has healed, it should never be exposed to direct sunlight. Always wear sunscreen outdoors or driving in a car. Re-injuring a healed burn area from sunlight can cause long-lasting skin color changes. Following the above guidelines should promote healing to most minor burns.

EMS Standards for Pre-Hospital Care

1) Safely extricate children and adults (and injured fire fighters) from the burning environment.

2) Remove any clothing, personal protective equipment, or metal accessories that continue to cause heat/burn exposure and/or are in the way of patient management.

3) Remove any prosthesis, rings, necklaces, or other items that are, or may become, constricting bands.

4) Stop the burning process: Cool the burn with running cool (not cold) water for at least 5 minutes. It is essential when applying water to avoid over-cooling the patient. A clear indication that the patient has been over-cooled is if the victim starts to shiver. When this happens STOP the cooling process. Never use ice to cool a burn because this will result in further injury and skin damage to the patient. Most seriously burned patients are conscious and alert during and after the incident causing the burns, and need to be reassured that they are receiving optimal care.

Additional treatment should be consistent with local, regional or state protocols. It is not feasible to cover each and every state/local/county/rural standard of care or protocol. This section should provoke thought and start discussions amongst your leadership to write, adopt and implement a pre-hospital standard of care protocol for your department so that in the event of responding to a burn patient’s needs, including fire fighters with burn injuries, communities will have plans in place to reduce time and increase survivability of patients and staff in an emergency burn situation.

When to Transport to a Burn Center

• Partial thickness burns greater than 10% total body surface area (TBSA).
• Burns that involve the face, hands, feet, genitalia, perineum or major joints.
• Third-degree burns in any age group.
• Electrical burns, including lightning injury.
• Chemical burns.
• Inhalation injury.
• Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery or affect mortality.
• Any patient with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality. In such cases, if the trauma poses the greater immediate risk, the patient may be initially stabilized in a trauma center before being transferred to a burn unit. Physician judgment will be necessary in such situations and should be in concert with the regional medical control plan and triage protocols.
• Burned children in hospitals without qualified personnel or equipment for the care of children.
• Burn injury in patients who will require special social, emotional or rehabilitative intervention.
• Fire fighters sustaining burn injuries.

Some burn centers only accept patients through referral, as such it is important for fire department administrators, government administrators and affiliate leaders to know what burn treatment resources are available in, around or near their jurisdictions so that appropriate care can be received.

Transportation destinations should be based on hospital capabilities, timely access and need for stabilization before transferring to another facility.

Referral and Transfer Criteria for Burn Injuries

Initially, a burn patient may have to gain access to care through an emergency department. Ideally, this emergency department should be a Level I or II Trauma Center. However, access to these facilities may be limited as a result of geography, and the patient may need emergent stabilization beyond the scope and capability of pre-hospital care.

Sample Emergency Department and Initial Treatment Guideline Cards