THE PRE-HOSPITAL EVALUATION, ASSESSMENT AND RESUSCITATION
OF THE BURNED CHILD AT THE SCENE AND DURING TRANSPORTATION
TO THE HOSPITAL
By
NIRU PRASAD, M.D., F.A.A.P, F.A.C.E.P. Department of Emergency Medicine Henry Ford Hospital, Detroit, Michigan West Bloomfield Center
Department of Ambulatory Pediatrics
St. Joseph Mercy Hospital
Pontiac, Michigan
INTRODUCTION:
1) Epidimology and Prevention
2) Pathophysiology and Classification
a. Anatomy of Skin
b. Depth of Burn
C. Surface Area of Burn Injury
d. Different Kinds of Burn
3) The Diagnostic Findings and Complications of Burns
4) Emergency Medical Service Consideration
5) Initial Assessment and Resuscitation of Burn Victim On Site
6) The Transport
7) Definitive Care
a. The Electric Burn
b. The Caustic Burn
c. Child Abuse
8) Conclusion and Summary
INTRODUCT ION:
Burns are among the most serious and painful injuries that the body can sustain. Thermal injuries are second
only to motor vehicle accidents as the most common cause of accidental death during childhood. The type and
severity of the burn depends upon the mechanism and severity of the energies involved. The source of this
energy may include: heat, scald burn, flame burn, toxic chemical, electricity, and nuclear radiation.
EPIDEMIOLOGY AND PREVENTION:
The most important factors influencing the incidence of thermal injuries are: age, sex, home environment,
economic status. Children younger than five years of age are more susceptible to accidental burn injuries.
Approximately 100,000 children are hospitalized annually for treatment of burns. Burn injuries, if not treated
properly, can also lead to permanent disability and deformity in children and adults. The house fires cause 75
percent of fire-related deaths, and the victims are usually children and the elderly. The fatal injuries sustained
by the victim are usually flame injuries and smoke inhalation. The scald injuries are usually common in infants
and toddlers due to contact with boiling hot liquids. The majority of these victims are infants and toddlers in
kitchens or bathrooms due to poor supervision. By the age of four to six years the frequency of scald injuries
decreases and flame burns become more common due to children playing with matches, cigarettes, and lighters.
The adolescents sustain more injuries during repair of cars, motorcycles, as well as with careless use of
flammable substances, including fireworks. Approximately four to five percent of fatal burn injuries are seen
in battered children. The physical abuse given by the offender is justified as a method of punishment and a
disciplinary measure. The most common method of punishment given to abused children is immersion burn,
leading to scald injuries to extremities, face, and buttock areas. Th electric burn, including household currents,
is more common in toddlers and small children due to contact with extension cords, electric sockets, and hair
dryers. The high-voltage electrical injuries sustained to the mouth and body of children are very serious
injuries, leading to increased mortality and morbidity.
PREVENTION:
The poor environmental and low socioeconomic conditions predisposing to burn victims can be lessened by
proper supervision, social service evaluation, classroom education,, and fire prevention safety precautions.
Children need continuous supervision in the house, particularly kitchens and bathrooms. The hot water should
not exceed 120 degrees F. and all the electric sockets should be capped with protection plugs.
The careless exposure of cooking appliances with overhanging electric cords are potential hazards for infants
and toddlers. The paramedics play a very important role in early resuscitation of burn victims. The decreased
mortality rate in burn victims over the past ten to fifteen years is due to proper fluid resuscitation, adequate
management of the airway, early excision and grafting, prevention of infection and sepsis. The emergency
room physician plays a significant role in early resuscitation and stabilization of burn victims.
PATHOPHYSIOLOGY AND CLASSIFICATION OF BURNS:
The Anatomy of Skin:
The skin being the largest single organ in the body serves three major functions:
1) Protects the body in the environment
2) Regulates the temperature
3) Conducts the nerve impulses to the brain
The skin is divided into two layers: epidermis and dermis. The epidermis is the tough outer
layer of skin. The dermis layer contains hair follicles, sweat glands, sebaceous glands,
blood vessels, and nerve endings. Deeper into the skin are layers of subcutaneous tissue,
muscle, fascia, and bone.
Thermal Burns:
Burns generally are classified as first, second, and third degree burns depending upon the
extent of skin layer involved.
The first degree burn involves the superficial layers of skin and is characterized by redness
of skin without blisters, local pain, and no systemic response. The examples of first
degrees burn are: burn from scalding fluids, exposure to ultraviolet light, or flash burn
secondary to explosions.
The second degree burns are classified as partial and full-thickness burns. The second
degree burn involves epidermis and part of dermis layer with blister formation and are very
painful. Third degree burns extend through the dermis and subcutaneous fat involving
nerve endings, and the burn area becomes dry, discolored, and charred.
Since it becomes very hard for the clinician to estimate the depth of burn on-site, a simple
classification terminology has been used as partial thickness burn involving epidermis or
dermis and full-thickness burn involving epidermis, dermis, and subcutaneous layers. The
extent or amount of body surface involved in the burn is calculated by using the Rule of
Nines formula.
Factors affecting the severity of burns are:
1) The depth of burn. The major burns have partial-thickness involvement of over 25%
in adults and over 15 to 20% in children.
2) The amount of surface area involved is determined by the Rule of Nines. Full-
thickness burns over 10% of the total body surface area are major burns.
3) The involvement of critical areas such as hands, feet, face, or genitalia.
4) The patient's age. The very young or very old are more susceptible to serious
complications.
5) Burns complicated by fractures or major trauma, inhalation injuries, and electric
burns
It is very important for the paramedics to determine the severity and extent of burn area
involved, since this will enable them to make a decision as to which patient will be
transported to a burn unit.
The critical burns are most serious and include:
1) All burns complicated by respiratory distress.
2) Burns complicated by fractures and other injuries.
3) Third degree burns involving more than 10% total body surface area.
4) Third degree burn involving face, hands, feet, or genitalia.
5) Partial-thickness burn involving 25% of body surface.
6) Burns in children with a history of major illness.
The moderate burns are less serious and patients can be transported to nearby hospitals,
such as:
1) Third degree burn involving 2 to 10% of the body surface area.
2) Partial-thickness burns involving 15 to 25% of the body surface area.
3) First degree burn involving major part of body.
In children, any third degree burn or second degree burn of more than 20% of body surface
area is critical.
Since infant's and children's body proportions are different from those of adults, a correct
estimation of percentage of body surface area involved should be made before fluid
resuscitation is done. The Lund and Broder chart gives accurate estimates of a burn surface
area involved in children less than five years of age. A quick assessment may also be
obtained by using the area of palm of the hand (minus fingers and thumb) as one percent of
body surface area involved in infant and child. The rule of nine is helpful in determining the
body surface area involved in patients greater than nine years of age.
If possible, & quick history should be obtained to determine:
1) The mechanism of injury.
2) Length of contact.
3) Estimated heat of the burning object.
4) Whether the victim was in a closed space confinement, enhancing the risk of smoke
inhalation.
5) Any evidence of body trauma suggesting battered child.
With flame or chemical injury the victim can sustain significant pulmonary injury. The
respiratory distress results from direct inhalation of toxic particles or exposure to hot
smoke, acute pulmonary edema or ventilation perfusion mismatch. Always think of carbon
monoxide and cyanide poisoning in individuals sustaining burns in closed spaces. Serious
injuries are sustained while individuals try to escape from source of burn, leading to blunt
trauma to major body organs. The water heater explosions, propane gas explosions, can
throw the victim some distance away resulting in internal injuries and fractures,
myocardial contusion, pneumothorax, flail chest or fracture of long bones. The major
fluid loss from the body leads to hypovolemic shock. The capillary permeability is
markedly increased in the burn patient at the damaged site, resulting in large loss of fluid
from intravascular compartment into extravascular space. The resultant edema, plus loss
of fluid from the wound necessitates large amounts of intravascular fluid resuscitation in
major burn patients. The major physiologic derangement secondary to severe burn
includes:
1) Severe hypovolemia with shock.
2) Lactic acidosis.
3) Renal failure
4) Myoglobinuria due to muscle destruction.
5) Hemoglobinemia
6) Altered level of consciousness due to carbon monoxide exposure or closed head
injury.
7) Reflux ileus in burned child resulting in abdominal distension, vomiting, and
aspiration.
THE PRE-HOSPITAL EVALUATION AND MANAGEMENT OF VICTIM AT SITE:
Management of Thermal Burn:
1) Stop the burning process and prevent further injury. Move the patient away from
burning site. Placing the patient in supine position will minimize the risk for facial
burn, hair ignition and inhalation injuries. Extinguish the fire and remove all the
clothing, jewelry, belt buckles, rings, shoes, etc. because metals retain heat for a
longer duration and cause further tissue damage.
2) Cover the child with sterile sheet or blanket to decrease heat loss and decrease the
risk of infection.
3) For partial-thickness burn, apply cool, wet compress to small areas to control pain.
Do not cover more than ten percent of body surface area with cool compresses at one
time since children are more susceptible to hypothermia than adults.
4) Do not apply ice or break the blisters.
5) Elevate head to 30 degrees if no neck injury is suspected to assist breathing, and
elevate the burned extremity.
6) Assess the airway, breathing, and circulation.
7) Administer high-flow, humidified oxygen.
8) Be prepared to bag mask ventilate the victim and initiate CPR if needed.
The signs and symptoms of inhalation injuries include:
1) Child found in closed, smoke-filled environment.
2) Altered level of consciousness.
3) Singed nasal hair and presence of carbonaceous sputum.
4) Presence of burn and burnt particles around mouth and nose.
5) Sore throat, brassy cough and stridor.
6) Respiratory distress with cyanosis.
Perform a quick primary and secondary survey looking for signs of major life-threatening
injuries and initiate rapid resuscitation. -
1) intubate the child if needed with ET tube one size smaller, since the airway mucosa
swell up with inhalation injury. An early intubation is indicated in severely burned victims with respiratory distress to prevent respiratory failure. Ventilate the child
with humidified oxygen.
2) Start large bore I.V. lines with Ringer's lactate to run
10 cc/kg hour if burn covers more than 15% of the body surface area. If signs of
shock are present, give three bolus of Ringer's lactate 20 cc/kg/hour.
3) Establish contact with baseline station and prepare for transportation.
4) Place cardiac monitor and treat life-threatening rhythm according to ACLS protocol.
5) Rapidly transport the child with major injury to a burn center if available.
The characteristics of burns that should be evaluated at the hospital:
1) Burn greater than 10% body surface area.
2) Burns involving face, hands, genitalia.
3) Electric and chemical burns.
4) Burns with smoke inhalation injuries.
5) Suspected child abuse:
6) Poisonous gas inhalation due to carbon monoxide and cyanide.
For the paramedics, it is important to note that personal safety precautions should be
observed by wearing properly functioning mask system. After the patient has been moved
to an open area, immediately administer 100% oxygen through mask and rapidly transport
the patient after adequate resuscitation.
Management of chemical Burns on Site:
For chemical burns to the eyes:
1) Flush both eyes with large amount of saline or water for 20 minutes.
2) Rapidly check for visual acuity and document.
3) Remove contact lenses if present.
4) Cover eyes with patches.
5) Transport to hospital.
For chemical burns to the skin, the goal of treatment is the same as management of thermal
burn:
1) Removal all the contaminated clothes.
2) Paramedics should protect themselves by using disposable rubber gloves and
goggles.
3) For water soluble chemical, flush the burned area with copious amounts of water.
4) For chemical that are not water soluble, take the following precautions:
a. If a solid substance like lime has been spilled, brush it off completely before
washing. A dry chemical can be activated by contact with water, causing more
tissue damage.
b. Phenol is poorly soluble in water, so remove clothing, flush with water and
apply baby oil or oily substance.
c. sodium metals react to water by burning, so brush it off and apply petroleum
jelly to affected area.
Management of the (Electric) Burn:
The electric burn sustained to the body due to low-voltage current or high-voltage, can
cause severe tissue damage and increased morbidity and mortality. The severity and extent
of tissue damage is determined by the following factors:
1) Tissue resistance of skin and internal body structure.
2) Intensity of current.
3) Type of current, whether alternate current or direct current
4) Pathway of current flow.
5) Frequency and duration of the current.
The resistance of skin plays an important role in passage of current. skin with high
resistance will result in more thermal damage at site, with less tissue penetration. However,
in infants and small children the skin resistance is low due to high skin water content, hence
entrance site of wound may be small; however, there is serious internal organ damage. The
body tissues vary in their electrical resistance capacity from lesser to greater in following
order: Nerves, blood vessels, muscle, skin, tendon, fat, bone. The type of injury sustained
by electric and lightning current include: Direct strike, the most serious type, when direct
current flow is through the victim, such as carrying a golf club or metal during a
thunderstorm. Stride potential refers to current hits the ground, enters through one leg, exits
through the other, after traveling through the body. Flash-over phenomenon - when
lightning injuries to body are facilitated more through wearing wet clothes. Commercial
high-voltage electric current: Direct electric injury such as arc burn or flash burn. The
major organ damage from electric injury includes damage to heart, lungs, kidneys, brain,
abdomen, and musculoskeletal system.
Electric Injury and Clinical Consideration
Organ Involved Clinical Manifestation Treatment
Cardiac Treat according to ACLS protocol Dysrhythmias, asystole
ventricular fibrillation,
PVCs, etc.
Pulmonary Respiratory arrest, acute Pulmonary edema, Protect and maintain adequate
or aspiration syndrome. airway
Kidneys Acute renal failure due Aggressive fluid therapy maintain
to myoglobinuria. urine output lcc/kg/hour
Skin Oral commissure burn with bleeding Treat thermal burn
complications, tongue, dental, thermal burn Tetanus prophylaxis
Plas/Surg follow-up
Abdomen Solid organ damage, ileus or intestine Treat symptomatically
perforation w/surg consultation
Musculoskeletal Compartment syndrome, long bone fractures, Escaratomy,
spine injuries Ortho evaluation
Nervous System Loss of consciousness, paralysis, amnesia, Head injury precautions,
seizures, peripheral neuropathy Treat seizures
Eyes Visual changes, optic neuritis, Ophthalmology follow-up
cataracts
Electrical burns can cause severe tissue damage. Although the surface burn at the point of entry may be very small, the exit wound
may be extensive and deep. (B) A typical small entrance burn wound on the foot.
Treatment of Electric Burn:
1) Protect y6urself. Attempt to disconnect the power source and remove the child from contact.
2) Assess the airway, breathing, circulation, and follow BLS protocol. (Basic Life Support).
3) Place clean dressing over entrance and exit burn sites.
4) For paramedics, administer high-flow oxygen by blow or through mask. Stabilize the victim following
BCLS and ACLS protocol, establish contact with base station and transport the victim to hospital.
Child Abuse and Burn Injury:
The victims of child abuse generally are:
1) Children less than five years of age.
2) Children presenting with burn to back, buttock, and posterior neck area.
3) Circumferential scald burns of hands and feet with clear demarcation and no splash mark.
4) Burns limited to genitalia and buttocks.
A strong clinical suspicion of child abuse needs proper documentation and appropriate action.
Preparing for Transport
Before transport, transfer the patient to a long or short spine board with adequate
immobilization. The paramedics should continue to assume the adequacy of patient's vital
signs through periodic monitoring. The burn area should be properly covered with sterile
sheets. The child should be adequately ventilated with humidified oxygen, I.V. fluids
should be running and cardiac monitor, especially for electric burn, should be in place. En
route to the hospital, carefully monitor vital signs frequently and continue support of
respiratory and circulatory system, including volume replacement.
The author has discussed the epidemiology, pathophysiology, preventive measures, and
clinical management of the burned child on site and during transportation to the hospital.
Since burn injury is the form of accidental trauma with multisystem involvement, a
particular emphasis has been. placed on initial assessment with adequate management of
life-threatening conditions, proper resuscitation, and safe transport of the victim to a burn.
center.
1. Pediatric Emergency Medicine, by Barkin; 1992
2.) Textbook of Pediatric Emergency Medicine, by Gary Fleisher, M.I Stephen Ludwig,
M.D.; second edition, 1988
3. Emergency Care and Transpiration of Sick and Injured, by James D. Heckman,
M.D.; fifth edition, 1992.
4. The Advanced Pediatric Life Support Manual, 1989.
5. Advanced Trauma Life Support Course, 1988.
E. Pediatric Clinic of North America, 1992.
7. Manual of Pediatric Emergencies, by Joseph R. Zanga, 1987.
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