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. 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. Soldiers and Marines have had these dressings applied early in their management in Iraq and Afghanistan and maintained until arriving 72— 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 wound-healing properties without silver-based active ingredients. These may aid in healing if you have an extended transport time.
However, as with the silver-impregnated 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. LR is inexpensive and has a similar composition to the fluid being lost during burn injury.
For agencies with caches of supplies for atypical medical disasters, impregnated dressings offer great value. While it may be cost-prohibitive to stock supplies on each ambulance for single burn patients, in an MCI, where having multiple patients with burn injuries could extend the times between injury and definitive treatment, impregnated dressings could be used more effectively.
For EMS agencies not within 6 hours of a burn center, impregnated dressings may also be of benefit. Consult your local medical director and the regional burn center regarding the best dressing to be purchased and stocked on ambulances and in MCI response caches.
Morphine sulfate MS is an excellent medication for managing burn-injured patients. An alternative is fentanyl Sublimaze , given at 50—75 mcg IV, then 25 mcg until either a maximum dose of mcg is reached or clinical improvement is noted. Always follow your local protocol for pain management. The total drug used with these medications can be different for burn-injured patients. While MS typically has an endpoint of 10 mg, it is not unusual for critical burn patients to receive 30 or 40 mg in the first 24 hours following injury.
This is an important consideration when transferring patients over long distances to regional burn centers.
You may need additional medication for such transfers. Antiemetic medications such as ondansetron Zofran or promethazine Phenergan may be needed as well because MS and other pain medications can lead to gastrointestinal discomfort and vomiting.
Follow your local protocol in use of these medications. The most effective means of administering pain medications is through an existing IV. If an IV cannot be secured, IO access is sufficient, provided is consistent with local protocol and your scope of practice. Intramuscular injections are generally contraindicated for burn-injured patients. For serious or critical burn injuries, the quality and quantity of absorption for an IM injection is unpredictable, and multiple IM-administered doses can be dangerous.
While there are other methods of administering pain medication, for the burn-injured patient, the preferred routes are IV and IO. Any other means of administration should be based on your protocols with the guidance of your medical director. Minor and superficial burns generally do not involve EMS outside of aid stations at mass gatherings, and superficial burns for otherwise-healthy patients with no concomitant injuries or medical conditions generally are not seen at hospitals.
These should be evaluated by a physician at a hospital. Serious burns also encompass inhalation burns, even with no obvious sign of thermal injury involving the dermis, and small. Other critical burns include steam inhalation burns, electrical shocks with contact points or lightning injuries, significant chemical burns and burns from radiation sources.
Patients who present with time-sensitive injuries and illnesses such as trauma, STEMI, stroke and burns rely upon EMS providers who are educated and equipped to manage acute events outside the hospital. These patients have their best outcomes when triage and transport guidelines identify the best location for their care, which may not be in the same community. Just as traumatically injured patients have their best outcomes at specialized trauma centers, burn-injured patients fare better at burn centers.
EMS destination plans and protocols should reflect hospitals where such appropriate specialty services are available. Care of the burn-injured patient can be quite challenging. While this article incorporates a best practices approach to burn-injured patients, rely on your local protocol to guide your practice.
American Burn Association. The effectiveness of regionalized burn care: an analysis of 6, burn admissions in North Carolina from to J Am Coll Surg, Apr; 4 : — Examining national burn care policies—is the Israeli burn care alignment based on national data? J Burn Care Res, Jul; 33 4 : —7. Takanishi DM Jr. Trauma system development: crisis at our doorstep. Hawaii Med J, Jun; 65 6 : —4.
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Federal Emergency Management Agency. Randy D. Charles B. James H. Preston B. Bruce A. The most common mistake made by clinicians is including first-degree burns in the total body surface area of injury TBSA when assessing the percentage of burn. Making an error when estimating the TBSA will create a cascade impacting fluid resuscitation.
This could also contribute to overtriage, leading to an incorrect and typically less convenient and more costly destination choice. For most clinicians, their last burn injury education was a 45—minute lecture during a trauma program where the day included a focus on large-bore venous access and significant fluid resuscitation.
While it is important to ensure that what caused the burn is not continuing to burn the patient, it is contraindicated to soak or continuously irrigate your patient with sterile or clean water.
While it can aid in pain management, it can also plunge the patient into hypothermia. Once you can touch the skin around the burn and it is not hot, no additional fluid should be used. Many EMS systems have only one intravenous solution from which to choose: normal saline. If the only fluid available is normal saline, use it until LR is available, but understand it is less than ideal and could create complications if used in excess.
A later addition was impregnated dressings with cooling properties. 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. Preexisting medical conditions that could complicate management, prolong recovery or affect mortality, such as end-stage renal disease;. 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;.
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;. 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. While burn injury is commonly associated with trauma and the two share many similarities, they should not be confused. Patients with penetrating or blunt force trauma can exsanguinate or suffer other grave consequences even when the most optimal care is provided.
The definitive solution for such patients is rapid movement to a trauma center and the care of a trauma surgeon. A burn injury, properly managed in the prehospital and community hospital setting, is far less likely to cause grave consequences over the same period of time. As noted in military experience, burn-injured patients have good outcomes over much larger intervals from initial injury to arrival at a burn center.
While this is not a reason to delay the transfer of burn-injured patients, it is critical to note where trauma is suspected in addition to the burn injury. For optimal care, burn-injured patients are best managed at burn centers that have trauma services as well. The basic approach is to rely on the Rule of Nines to determine the extent of injury.
For partial areas, either estimate percentages of percentages e. Sign in. EMS World Expo. Current Issue. Issue Archives. After excluding the retracted studies, HES was associated with higher mortality rates, more prevalent renal failure, and higher requirements for renal replacement therapy.
Hence, both were excluded from the present review. The Cochrane review 68 of , updated in , included 42 studies with good methodological quality, in which HES was compared with any other fluid therapy for hypovolaemia treatment. A significant increase in renal failure and renal replacement therapy was observed in the HES group. Burn patients were not excluded, but a separate analysis in this population was not provided. The aim was to calculate the total volume infused within the first 72 h and determine the safety profile.
No differences were found in the mortality rate, volume administered, or renal damage between the groups Table 4. Colloid studies in major burns. Concerning natural colloids, fresh frozen plasma has classically been used as a plasma expander, but the high associated cost and risk of disease transmission have limited its use mainly to coagulation disorders 77 Table 4.
A larger volume was needed in the crystalloid alone group, and there was a greater increase in intra-abdominal pressure. In addition, a correlation was found between the amount of liquid infused and intra-abdominal pressure.
These findings are consistent with those reported by Ivy and colleagues, 78 who described intra-abdominal hypertension and abdominal compartment syndrome in major burns. Nonetheless, the sample size was small; hence, larger studies are needed to evaluate the efficacy of fresh frozen plasma in preventing compartment syndrome. The use of albumin for fluid resuscitation in critically ill patients has been questioned since , when the Cochrane 79 review concluded that albumin may be associated with higher mortality.
The Surviving Sepsis Campaign, 85 published in , recommends albumin in patients unresponsive to crystalloid resuscitation, with a 2C level of evidence.
However, burn patients are generally excluded from these studies or are not analysed as a subgroup. We retrieved four relatively recent studies specific to these patients. In , Cooper and colleagues 38 carried out a multicentre randomized clinical trial with 42 burn patients comparing fluid resuscitation with RL vs RL plus albumin. The BSA and inhalation injuries were more severe in the albumin group.
Although the differences between arms were not significant in themselves, the expected mortality was In the intention-to-treat analysis, there were no significant differences between the groups for the primary outcome, lowest MODS from day 0 to day 14, or mortality at day 28, but the authors mentioned that their study was underpowered for both these outcomes. On multivariate analysis, albumin administration was found to be a protective factor for mortality.
An observational retrospective—prospective study published by Park and colleagues 41 in compared burn patients treated with RL and a synthetic colloid vs those treated with albumin. Mortality, days on mechanical ventilation, mechanical ventilation-associated pneumonia, and laparotomy for abdominal compartment syndrome were significantly lower in the albumin group.
The study was limited partly by its prospective—retrospective design. No randomization or blinding was specified, implying a high risk of bias.
The latest study published on albumin in burn resuscitation was a meta-analysis carried out by Navickis and colleagues 86 in , including randomized and non-randomized clinical trials.
After exclusion of two studies with a high risk of bias, albumin was found to be associated with a lower incidence of compartment syndrome and lower mortality. After concluding this review and in agreement with the opinions of others, 70 , 87 we believe it is reasonable to say that the studies motivating the HES alert, which did not include burn patients, may not have been an entirely appropriate basis for the warning in this population.
The small number of studies investigating colloids in burn patients do not reflect an increase in acute kidney injury or mortality. Furthermore, none of the HES studies prompting the alert was done with balanced HES, and chloride is known to be associated with renal injury. Both albumin and plasma could be a good option for burn patients, although the available data on plasma use are limited.
Multicentre studies focused on colloid use should be carried out in this specific population. Suboptimal fluid resuscitation in burn patients leads to greater burn depth and extension of the shock period, which usually takes place in the first 24—48 h. According to the results of goal-directed therapy studies, the amount of fluid given in the first 24 h should be somewhat higher that that estimated by the Parkland formula.
Major burn resuscitation should ideally be performed according to goal-directed therapy with thermodilution methods because they are less invasive than PAC and have been well validated in burns. The initial resuscitation fluid should be a balanced crystalloid. Colloids seem inappropriate during the first hours because of the patient's increased capillary permeability.
Ringer's acetate seems to protect the electrolytic balance in large replacements, and it may be the crystalloid of choice for initial resuscitation in burn patients. Although there are reports of poorer outcomes in septic patients with the use of HES, the current scientific evidence does not suffice to support a specific contraindication for HES use in burn patients.
As was the practice in many burn units, we formerly used HES after the first 24 h when it was needed and we did not have the impression that outcomes were worse in our patients, but this is a subjective evaluation.
Gelatins have not shown superiority over crystalloids in their expansion capacity, and their safety is still uncertain. Hypertonic solutions, albumin, and plasma have been associated with lower volume requirements for initial resuscitation, lower intra-abdominal pressure, and a lower incidence of compartment syndrome; hence, these solutions could have a place in burn resuscitation, but additional evidence is needed to support their use.
Multicentre randomized controlled trials on fluid resuscitation in major burns are still needed to define the best fluid therapy in this population. Data are lacking on the optimal end points for TTD, the difference between initial resuscitation with Ringer's lactate or Ringer's acetate, the proper timing to initiate colloids, and the comparative performance of the different natural and synthetic colloids in burn patients. Wrote the manuscript and approved the final manuscript: P.
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Fluid resuscitation, burn percentage, and physiologic age. J Trauma ; 19 : — 5. Greenhalgh DG. Burns ; 36 : — Schwartz SI. Supportive therapy in burn care. Consensus summary on fluid resuscitation. J Trauma ; 19 : — 7. Shires G. J Trauma ; 19 11 Suppl : — 3. Saffle JIL. J Burn Care Res ; 28 : — Fluid resuscitation in adults with severe burns at risk of secondary abdominal compartment syndrome—an evidence based systematic review. Burns ; 35 : — Early fluid resuscitation improves outcomes in severely burned children.
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Sao Paulo Med J ; : — Baxter CR. Types causes of burns encountered in cohort in this study in percentages. Pre- and post-sodium levels are presented in Figure 3. Overall, there was a statistically significant decrease in sodium levels post-resuscitation. Thirty patients had hypokalaemia at the time of admission The num- ber reduced to 16 patients by the end of resuscitation period Four patients were admitted with initial hyperkalaemia 3.
Pre- and post-potassium levels are presented in Figure 4. No patients had hypochloraemia in this study. However, 39 patients had hy- perchloremia Out of 82 patients assessed available data for albumin level, 23 patients had hypoalbuminaemia at the time of admission The number markedly increased to 79 patients by the end of the resuscitation period None of the patients had hyperalbuminaemia in our study.
We assessed total protein in blood in 81 patients with available data. While the initial reading of patients showed that 33 of them had hypoproteinaemia No patients had hyperprotinaemia in our study. Figure 5 and Figure 6 summarize the levels found on admission and post-resuscitation for albumin and total protein, respectively. Figure 3. Pre- and post-sodium levels using two-tailed paired t-test. Figure 4. Pre- and post-potassium levels using two-tailed paired t-test.
Figure 5. This study is the first in GCC and MENA regions, to the best of our knowledge, that demonstrates that management of burn patients in the shock phase with. Figure 6. There is a limited number of up to date literature directly investigating the effect of resuscitation of burn patients with lactated ringers LR in terms of electrolytes balance. These amounts reflect those found in blood, except for sodium, and would prevent hyperchloremic acidodsis in our study chloride levels were maintained as well as ensure patients remain in the normal potassium level range.
These solutions, however, fail to control sodium levels in such patients and are usually associated with hyponatremia. On the other hand, studies in animal models show that addition of sodium containing mixtures such as sodium pyruvate, and sodium butyrate improve hemodynamic stability and organ functions in burn patients [24] [25]. Therefore, it would be important to see if these effects would be achieved by modifying the current recommended solutions such that they contain more sodium.
The original Parkland formula as was introduced by Baxter in recommended the use of colloids in the second 24 hours post burn [3] [27]. On his review paper of different formulas, Greenhalgh mentioned that this recommendation is not usually followed [28]. Blumetti et al. Still, the use of colloids albumin and dextran during the initial resuscitation period is controversial. Additionally, from our experience, deaths that may occur at a later stage may be due to complications such as septic shock and hence albumin may need to be reconsidered for these patients in burn shock phase.
It follows that a significant number of our patients may have been at risk of passing away even though none actually expired in the burn shock phase. Furthermore, it is clear in our study that the progressive decline in albumin and protein levels was dramatic and occurred in the entire co- hort and all other subgroups analyzed. Consequently, we believe that albumin in addition to current recommended crystalloids may be important for these burn patients although this may need to be confirmed in controlled studies.
Our study is stand-alone to the best of our knowledge in this area of practice which gave a close zoom in at the baseline and post-resuscitation levels of electrolytes, albumin and proteins following RL.
Our data consist of a cohort admitted at the major burn unit in the Emirate of Abu Dhabi. Unfortunately, we did not have a comparator arm to contrast the levels with patients who receive albumin in the burn shock phase. This is an important limitation in our study which other groups has to overcome by performing controlled investigations. For the sake of comparison, contrast our post-resuscitation mean of albumin of Lack of clarity as to the optimal fluids to use enabled us to have these different cohorts and hence made it possible to demonstrate the great differences in effect they have on post-resuscitation electrolytes and proteins levels.
Nevertheless, we suggest that other centers attempt at replicating our findings and possibly include a reference arm. It is noteworthy, that larger subgroups were more likely to have significant re- ductions in sodium and protein levels. They were also more likely to show a be- neficial effect of RL on normalization of potassium levels.
If we remember that sample size was again a factor that ruled albumin out of the acute management of burn patients, it may be prudent that we conduct larger multicenter studies to finally weigh albumin back in the management of burn patients during the burn shock phase in the future. These patients may be at risk for significant reductions in albumin and protein levels which put them at an increased risk of death. We recommend using the original Parkland Formula and hence to start colloids after the first 12 - 24 hours period after crystalloid administration.
Hyponatremia correction by adding more sodium, possibly using normal saline or sodium supplementation, may be beneficial. Future studies are needed to replicate our findings and to finally come to an end of the old chapter on albumin in burn patients.
The authors thank Dr. They all confirm that they have done this piece in their work time and received no fun- ding from any source. Burns, 35, World Journal of Surgery, 29, Journal of Emergencies, Trauma, and Shock, 4, German Medical Science, 9, Nursing Clinics of North America, 32, In: Herndon, D. Surgery Gynecology and Obstetrics, 79, The New England Journal of Medicine, , Burns, 26, BMJ, , Pediatric Emergency Care, 13,
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