Consensus on the prehospital approach to burns patient management

Prehospital treatment of severely burned patients: a retrospective analysis of patients admitted to the Berlin burn centre

BACKGROUND

Prehospital management of severely burned patients is extremely challenging. It should include adequate analgesia, decision-making on the necessity of prehospital endotracheal intubation and the administration of crystalloid fluids. Guidelines recommend immediate transport to specialised burn centres when certain criteria are met. To date, there is still insufficient knowledge on the characteristics of prehospital emergency treatment. We sought to investigate the current practice and its potential effects on patient outcome.

METHODS

We conducted a single centre, retrospective cohort analysis of severely burned patients (total burned surface area > 20%), admitted to the Berlin burn centre between 2014 and 2019. The relevant data was extracted from Emergency Medical Service reports and digital patient charts for exploratory data analysis. Primary outcome was 28-day-mortality.

RESULTS

Ninety patients (male/female 60/30, with a median age of 52 years [interquartile range, IQR 37-63], median total burned surface area 36% [IQR 25-51] and median body mass index 26.56 kg/m2 [IQR 22.86-30.86] were included. The median time from trauma to ED arrival was 1 h 45 min; within this time, on average 1961 ml of crystalloid fluid (0.48 ml/kg/%TBSA, IQR 0.32-0.86) was administered. Most patients received opioid-based analgesia. Times from trauma to ED arrival were longer for patients who were intubated. Neither excessive fluid treatment (> 1000 ml/h) nor transport times > 2 h was associated with higher mortality. A total of 31 patients (34,4%) died within the hospital stay. Multivariate regression analysis revealed that non-survival was linked to age > 65 years (odds ratio (OR) 3.5, 95% CI: 1.27-9.66), inhalation injury (OR 3.57, 95% CI: 1.36-9.36), burned surface area > 60% (OR 5.14, 95% CI 1.57-16.84) and prehospital intubation (5.38, 95% CI: 1.92-15.92).

CONCLUSION

We showed that severely burned patients frequently received excessive fluid administration prehospitally and that this was not associated with more hemodynamic stability or outcome. In our cohort, patients were frequently intubated prehospitally, which was associated with increased mortality rates. Further research and emergency medical staff training should focus on adequate fluid application and cautious decision-making on the risks and benefits of prehospital intubation.

TRIAL REGISTRATION

German Clinical Trial Registry (ID: DRKS00033516).

Consensus on the treatment of second-degree burn wounds (2024 edition)

Second-degree burns are the most common type of burn in clinical practice and hard to manage. Their treatment requires not only a consideration of the different outcomes that may arise from the dressing changes or surgical therapies themselves but also an evaluation of factors such as the burn site, patient age and burn area. Meanwhile, special attention should be given to the fact that there is no unified standard or specification for the diagnosis, classification, surgical procedure, and infection diagnosis and grading of second-degree burn wounds. This not only poses great challenges to the formulation of clinical treatment plans but also significantly affects the consistency of clinical studies. Moreover, currently, there are relatively few guidelines or expert consensus for the management of second-degree burn wounds, and no comprehensive and systematic guidelines or specifications for the treatment of second-degree burns have been formed. Therefore, we developed the Consensus on the Treatment of Second-Degree Burn Wounds (2024 edition), based on evidence-based medicine and expert opinion. This consensus provides specific recommendations on prehospital first aid, nonsurgical treatment, surgical treatment and infection treatment for second-degree burns. The current consensus generated a total of 58 recommendations, aiming to form a standardized clinical treatment plan.

The Battle of the Titans-Comparing Resuscitation Between Five Major Burn Centers Using the Burn Navigator

The goal of burn resuscitation is to provide the optimal amount of fluid necessary to maintain end-organ perfusion and prevent burn shock. The objective of this analysis was to examine how the Burn Navigator (BN), a clinical decision support tool in burn resuscitation, was utilized across five major burn centers in the United States, using an observational trial of 300 adult patients. Subject demographics, burn characteristics, fluid volumes, urine output, and resuscitation-related complications were examined. Two hundred eighty-five patients were eligible for analysis. There was no difference among the centers on mean age (45.5 ± 16.8 years), body mass index (29.2 ± 6.9), median injury severity score (18 [interquartile range: 9-25]), or total body surface area (TBSA) (34 [25.8-47]). Primary crystalloid infusion volumes at 24 h differed significantly in ml/kg/TBSA (range: 3.1 ± 1.2 to 4.5 ± 1.7). Total fluids, including colloid, drip medications, and enteral fluids, differed among centers in both ml/kg (range: 132.5 ± 61.4 to 201.9 ± 109.9) and ml/kg/TBSA (3.5 ± 1.0 to 5.3 ± 2.0) at 24 h. Post-hoc adjustment using pairwise comparisons resulted in a loss of significance between most of the sites. There was a total of 156 resuscitation-related complications in 92 patients. Experienced burn centers using the BN successfully titrated resuscitation to adhere to 24 h goals. With fluid volumes near the Parkland formula prediction and a low prevalence of complications, the device can be utilized effectively in experienced centers. Further study should examine device utility in other facilities and on the battlefield.

Management of non-severe burn wounds in children and adolescents: optimising outcomes through all stages of the patient journey

Paediatric burn injuries are common, especially in children younger than 5 years, and can lead to poor physical and psychosocial outcomes in the long term. In this Review, we aim to summarise the key factors and interventions before hospital admission and following discharge that can improve the long-term outcomes of paediatric burns. Care can be optimised through first aid treatment, correct initial assessment of burn severity, and appropriate patient referral to a burns centre. Scar prevention or treatment and patient follow-up after discharge are also essential. As most burn injuries in children are comparatively small and readily survivable, this Review does not cover the perioperative management associated with severe burns that require fluid resuscitation, or inhalational injury. Burns disproportionately affect children from low socioeconomic backgrounds and those living in low-income and middle-income countries, with ample evidence to suggest that there remains scope for low-cost interventions to improve care for those patients with the greatest burden of burn injury. Current knowledge gaps and future research directions are discussed.

Expert consensus on the prevention and first-aid management of burns in children

Burns are the second leading cause of unintentional injuries in children and are one of the major causes of disability in children. Timely and effective first-aid management of burns can have a major impact on the prognosis, but there is still a lack of the knowledge on burn management in the general public. With reference to expert opinions and related literature, this consensus summarizes the causes of burns, preventive measures, first-aid methods for common types of burns, and the prevention and treatment of serious complications of burns. It also provides recommendations on the most appropriate pre-hospital treatment. This consensus aims to emphasize the importance of burn prevention, improve the ability of first-aid treatment among witnesses and rescuers, avoid further injury caused by inappropriate treatment, and reduce the mortality and disability rates of burns and the harm to family and society. It can be used as guidance for pre-hospital treatment of childhood burns by first responders, parents, and passers-by.

Prehospital management of burns requiring specialized burn centre evaluation: a single physician-based emergency medical service experience

BACKGROUND

Emergency medical services regularly encounter severe burns. As standards of care are relatively well-established regarding their hospital management, prehospital care is comparatively poorly defined. The aim of this study was to describe burned patients taken care of by our physician-staffed emergency medical service (PEMS).

METHODS

All patients directly transported by our PEMS to our burn centre between January 2008 and December 2017 were retrospectively enrolled. We specifically addressed three "burn-related" variables: prehospital and hospital burn size estimations, type and volume of infusion and pain assessment and management. We divided patients into two groups for comparison: TBSA < 20% and ≥ 20%. We a priori defined clinically acceptable limits of agreement in the small and large burn group to be ±5% and ± 10%, respectively.

RESULTS

We included 86 patients whose median age was 26 years (IQR 12-51). The median prehospital TBSA was 10% (IQR 6-25). The difference between the prehospital and hospital TBSA estimations was outside the limits of agreement at 6.2%. The limits of agreement found in the small and large burn groups were - 5.3, 4.4 and - 10.1, 11, respectively. Crystalloid infusion was reported at a median volume of 0.8 ml/kg/TBSA (IQR 0.3-1.4) during the prehospital phase, which extrapolated over the first 8 h would equal to a median volume of 10.5 ml/kg/TBSA. The median verbal numeric rating scale on scene was 6 (IQR 3-8) and 3 (IQR 2-5) at the hospital (p < 0.001). Systemic analgesia was provided to 61 (71%) patients, predominantly with fentanyl (n = 59; 69%), followed by ketamine (n = 7; 8.1%). The median doses of fentanyl and ketamine were 1.7 mcg/kg (IQR 1-2.6) and 2.1 mg/kg (IQR 0.3-3.2), respectively.

CONCLUSIONS

We found good agreement in burn size estimations. The quantity of crystalloid infused was higher than the recommended amount, suggesting a potential risk for fluid overload. Most patients benefited from a correct systemic analgesia. These results emphasized the need for dedicated guidelines and decision support aids for the prehospital management of burned patients.

Prise en charge du patient brûlé en préhospitalier. Première partie : cas général et inhalation de fumées

Severe burn is a circumstantial pathology, most often accidental but more and more caused by voluntary acts. In the initial phase, the failures encountered are essentially hemodynamic, respiratory and metabolic, placing the emergency physician and the intensivist at the centre of medical care. The role of the pre-hospital physician is essential but often difficult due to the circumstances of intervention. First actions and treatments initiated as well as the evaluation of gravity can favorably modify the prognosis when they are well carried out. In view of this, we will unfold the different stages of pre-hospital care to implement in the event of severe burn.

Burns Centre and fire services: What information can be exchanged to manage the burn patient?

AIM

To describe the experience of using a "Burns Extrication Form" at a regional Burns Centre. Communication between the fire services and burns team previously has been regarded as poor. Significant information is collected by the fire services at the scene and this can aid the management of the patient.

METHODS

The Burns Extrication Form was devised to provide a clear framework of communication between the two services. Information regarding time frames, exposure to heat & smoke, fire loading (potential severity of a fire in a given space by measuring amount of combustible material in confined space), building construction, chemicals involved is passed to the medical team through this form through a National Health Service mailbox. Also, treatment provided by the fire service was documented. All data collected by this form was collated for the purpose of this study. Data ranging from 2014 to 2017 was included in this descriptive study.

RESULTS

The patient journey following contact by fire services shows that out of the 598 persons who were involved in a fire only 92 (15%) attended the Accident and Emergency (A&E) department at the Queen Elizabeth Hospital. Signs of smoke inhalation, singed nose hair and coughing were found in 190 (32%) patients; the fire service administered oxygen to 106 (18%) of these patients although this may have been initiated by Ambulance crews who were on scene prior to the Fire Crew. The remaining 506 (85%) may have not attended A&E at UHB or may have attended another A&E in the West Midlands base on the location of the incident and clinical needs. Of the 92 patients who attended the A&E at UHB 48 (52%) were admitted to the Burns Centre in the hospital. Nine (19%) of these patients had smoke inhalation and three of these patients were managed by intubation. Birmingham North and Black Country North had the highest incidence of burns incidents, 120 and 103 respectively. Whilst, the lowest numbers were found in Birmingham South and Coventry and Solihull with 65 and 61 respectively. Additional results are described in the study.

CONCLUSION

Data provided by the Fire Extrication forms helps us to assess the magnitude of fire-related injury across the West Midlands. The fire services have been shown to provide important first aid as one of the first responders at the scene. Their value in assessing the environment in and patient status helps clinicians further down the patient's journey.

The effectiveness and cost-effectiveness of first aid interventions for burns given to caregivers of children: A systematic review

OBJECTIVES

the effectiveness and cost-effectiveness of burns first-aid educational interventions given to caregivers of children.

METHODS

Systematic review of eligible studies from seven databases, international journals, trials repositories and contacted international experts.

RESULTS

Of 985 potential studies, four met the inclusion criteria. All had high risk of bias and weak global rating. Two studies identified a statistically significant increase in knowledge after of a media campaign. King et al. (41.7% vs 63.2%, p<0.0001), Skinner et al. (59% vs 40%, p=0.004). Skinner et al. also identified fewer admissions (64.4% vs 35.8%, p<0.001) and surgical procedures (25.6% vs 11.4%, p<0.001). Kua et al. identified a significant improvement in caregiver's knowledge (22.9% vs 78.3%, 95% CI 49.2, 61.4) after face-to-face education intervention. Ozyazicioglu et al. evaluated the effect of a first-aid training program and showed a reduction in use of harmful traditional methods for burns in children (29% vs 16.1%, p<0.001). No data on cost-effectiveness was identified.

CONCLUSION

There is a paucity of high quality research in this field and considerable heterogeneity across the included studies. Delivery and content of interventions varied. However, studies showed a positive effect on knowledge. No study evaluated the direct effect of the intervention on first aid administration. High quality clinical trials are needed.

Evidence-based first aid advice for paediatric burns in the United Kingdom

BACKGROUND

Burn and scald injuries are common in children. First aid advice for paediatric burns is offered by a range of health organisations and charities in the UK. Despite this, children still present to emergency departments and burn services having received little or inadequate first aid.

METHOD

A survey was undertaken regarding the content and consistency of the advice given by a cross-section of UK health organisations involved in first aid prevention and education. The advice was subsequently examined to determine if it was evidence-based.

RESULTS

Our study has demonstrated inconsistencies in the content of the first aid advice provided by the 21 organisations included in the study. Seventy-one percent of the information was only available online. The temperature, method and duration of cooling varied substantially, as did the advice recommended for the removal of clothing and jewellery and methods for covering the burn immediately after injury. Results from the literature review concluded the following based on available evidence; cool the burn with running tap water for 20min, remove clothing and jewellery and cover the burn with cling film or a clean non-adhesive dressing.

CONCLUSIONS

This study highlights the lack of consistency between first aid guidance provided by health organisations and charities in the UK.

Review of emergency department wound management in soft tissue trauma - is there a plan?

OBJECTIVE

To assess current acute wound management in English emergency departments.

METHOD

All English emergency departments including minor injury units (n=207) were successfully contacted and a telephone questionnaire was completed. This considered wound treatment policy; management including cleansing, analgesia, dressing selection, suturing, referral patterns, medical photography and antibiotic use.

RESULTS

There was a 100% response. Only 40% of departments had a wound treatment policy. Most had implemented staff training, however the nature and timing of this was variable. Wound cleansing was performed by all departments. Most administered analgesia. Suturing was selectively performed by all departments. There was great diversity regarding dressing selection. The most common reasons for referral to specialist units were the complexity of injury and cosmetically sensitive areas. Photographs were regularly taken in one third of units questioned.

CONCLUSION

This study confirmed an absence of a standard protocol for early soft tissue wound management in the emergency department setting. Key areas that could be improved are dressing simplification, more defined referral criteria and introduction of standardised protocols with structured teaching programmes. We propose a simple approach to management of acute soft tissue wounds that can be applied to most situations.

DECLARATION OF INTEREST

There were no external sources of funding for this study. The authors have no conflicts of interest to declare.

Shaking stress aggravates burn-induced cardiovascular and renal disturbances in a rabbit model

The aim of this study was to address the effects of shaking stress (a.k.a. physical agitation) on burn-induced remote organ injury and to evaluate the application of delayed fluid resuscitation to treat severe burns under shaking conditions. Healthy adult male rabbits, weighing 2.50±0.40 kg, were randomly assigned to the following groups: control group, burn group, and burn+shaking group. One half of burned animals received a 6-h delayed fluid resuscitation and the other half remained untreated. Cardiovascular hemodynamics and functional and pathological changes of the heart and kidney were examined. Compared to normal controls, untreated burned animals showed decreased hemodynamic parameters, increased serum lactic acid, and severe myocardial inflammation. The burn-induced hemodynamic abnormalities and cardiac injury were aggravated by shaking stress. Burn injury led to reduced urine volume, elevated serum creatinine and blood urea nitrogen, and formation of erythrocyte casts in renal tubules. Shaking stimulation worsened the burn-associated functional and pathological changes of the kidney. Fluid resuscitation markedly mitigated cardiac and renal injury in burned animals, and, to a lesser extent, in the presence of shaking stimulation. Shaking stimulation aggravates burn-induced cardiovascular and renal disturbances. Delayed fluid resuscitation attenuates cardiac and renal damages in burn injury under shaking conditions.

Accuracy of burn size assessment prior to arrival in Dutch burn centres and its consequences in children: a nationwide evaluation

BACKGROUND

Total body surface area (TBSA) burned, expressed as percentage is one of the most important aspects of the initial care of a burn victim. It determines whether transfer to a burn centre is necessary as well as the need for, and amount of, intravenous fluid resuscitation. Numerous studies, however, have highlighted inaccuracies in TBSA assessment. Therefore, the differences in burn size estimates between referrers and burn centre's in children and its consequences in terms of transfer and intravenous fluid resuscitation were investigated.

METHODS

This study involved two time periods from January 2002 until March 2004 and January 2007 until August 2008. All referred children admitted to a Dutch Burn centre within 24h post burn were eligible. Data were obtained from patient records retrospectively and in part prospectively.

RESULTS

A total of 323 and 299 children were included in periods 1 and 2, respectively. Referring physicians overestimated burn size with a factor two (mean difference: 6% TBSA ± 5.5). About one in five children was referred to a burn centre without fulfilling the criteria for referral with regard to burn size (assessed by burn specialists) special localisation or inhalation trauma. Proportions of children receiving intravenous fluid resuscitation regardless of indication increased from 33% to 49% (p<0.01). The received volumes tended to be higher than necessary.

CONCLUSIONS

Referring physicians overestimate burn size in children admitted to Dutch burn centres. This has little negative consequences, however, in terms of unindicated transfers to a burn centre or unnecessary fluid resuscitation.

The Alfred pre-hospital fluid formula for major burns

BACKGROUND

The Alfred pre-hospital fluid isotonic crystalloid resuscitation formula for major burns (body weight (kg)×%TBSA burnt=mls in the first 2 h) was adopted by Ambulance Victoria in 2007 for the early and consistent correction of fluid deficit in major burns patients. The aim of this study was to evaluate the associated change in pre-hospital fluid administration.

METHODS

A retrospective explicit chart review of patient records was conducted of all patients with major burns presenting to The Alfred Emergency & Trauma Centre over a 10 year period. Patient demographics, fluid resuscitation and outcomes in the period before the introduction of the new formula were compared to those in the post-introduction period.

RESULTS

There were 126 patients with major burns (≥20% total body surface area burnt) included in the study. The median fluid volume administration pre-hospital after introduction of The Alfred formula was 0.35 (0.22-0.44) mL/kg/%TBSA burnt, which was significantly higher than 0.14 (0.04-0.26) mL/kg/%TBSA administered in the prior period (p=0.013). There was no significant change in physiological endpoints associated with the increased volume. At 24 h, the volume of fluid administered in patients when The Alfred formula was used was 4.9±1.6 mL/kg/%TBSA, which was not significantly higher than the volume administered before 2007 of 4.8±2.2 mL/%TBSA/kg (p=0.802).

DISCUSSION

The Alfred pre-hospital fluid formula has resulted in patients receiving significantly more fluids early, although still below volumes suggested by the Parkland formula. There were no adverse effects of this increased volume detected over the study period. The Alfred pre-hospital fluid formula appears to be safe and more effective in delivering fluid volumes predicted by the current 'gold standard'.

Guidelines for the management of partial-thickness burns in a general hospital or community setting—Recommendations of a European working party

Most partial-thickness burns in Europe and the United States are managed by non-burns specialists who do not treat burns on a regular basis. To achieve better patient outcomes, partial-thickness burns should be properly managed in non-specialist centres and referred to burn units when appropriate. Although some guidelines have been published to assist non-specialists, few have attempted to provide a comprehensive step-by-step guidance emphasising wound-healing principles. A working party of European burn specialists devised a new treatment algorithm to provide clear and current guidance on the management of partial-thickness burns in the general hospital and community setting. Four areas were identified for improvement: diagnosis and referral, wound preparation, wound covering and post-wound care. The guidelines take into account the role of wound dressings, infection and general patient well-being, bearing in mind the different working environments that occur across Europe. They are aimed at improving the overall outcome for community-treated patients within the expanding European Union and reducing the number of preventable late referrals to specialists.

European first aid guidelines

AIM

Our objectives were to determine the most effective, safe, and feasible first aid (FA) techniques and procedures, and to formulate valid recommendations for training. We focussed on emergencies involving few casualties, where emergency medical services or healthcare professionals are not immediately present at the scene, but are available within a short space of time. Due to time and resource constraints, we limited ourselves to safety, emergency removal, psychosocial FA, traumatology, and poisoning. Cardiopulmonary resuscitation (CPR) was not included because guidelines are already available from the European Resuscitation Council (ERC). The FA guidelines are intended to provide guidance to authors of FA handbooks and those responsible for FA programmes. These guidelines, together with the ERC resuscitation guidelines, will be integrated into a European FA Reference Guide and a European FA Manual.

METHODS

To create these guidelines we used an evidence-based guideline development process, based on the methodology of the Scottish Intercollegiate Guidelines Network (SIGN).

RESULTS

The recommendations cover FA for bleeding, wounds, burns, spinal and head trauma, musculoskeletal trauma, and poisoning, as well as safety and psychosocial FA.

CONCLUSIONS

Where good evidence was available, we were able to turn science into practice. Where evidence was lacking, the recommendations were consensus-based. These guidelines provide systematically developed recommendations and justifications for the procedures and techniques that should be included in FA manuals and training programmes.

Educational Opportunities for Experienced Staff

This study evaluates the impact of educational programs, such as Advanced Burn Life Support (ABLS), on the knowledge base of experienced burn nurses. A convenience sample of six clinical experts within a 21-bed southeastern burn center who had never taken ABLS participated. The quantitative findings display a high level of value and an increase in knowledge base. The results of this study suggest that nurses with high levels of experience will have an increase in knowledge and express value in continuing education curricula. Consequently, this study supports the necessity of educational programs for nurses with significant specialized experience.

A comparison of serial halving and the rule of nines as a pre-hospital assessment tool in burns

Following endorsement of serial halving by the Faculty of Pre-Hospital Care of the Royal College of Surgeons of Edinburgh this study aimed to determine whether the technique was comparable to the rule of nines in making initial assessments of body surface area burned. Ten 'casualties' were made up to represent burn victims (range 6-61%). An external panel of six consultants and one specialist registrar in plastic surgery were invited to assess the simulated casualties. They gave individual and a consensus estimate of the burned areas. One hundred and twenty-five members of local emergency services and military paramedical staff were given a brief video and slide presentation describing either the rule of nines or serial halving method of burn area assessment. These techniques were then used to assess the 10 simulated casualties, giving 1250 estimates of burn surface area. The understanding of both techniques appeared adequate in both test groups. Estimates from serial halving and rule of nines groups differed from the assessments of the external panel. No statistical difference was demonstrated between serial halving and the rule of nines as an initial assessment tool when determining disposal. Serial halving has an inherent weakness when assessing certain sizes of burn. The rule of nines requires that the assessor knows and understands the proportionate areas of the body. The mathematics of percentages and fractions appeared to confuse some assessors.

Pre-hospital management of burns by the UK fire service

OBJECTIVE

To determine the current policies and practice of UK fire services for the management of burns patients.

METHODS

Structured telephone questionnaire covering formal policies including patient assessment, oxygen and entonox use, burn assessment and treatment, and paediatric patients and training.

RESULTS

The questionnaire was completed by 74% of the UK Fire Services (n = 46); only 14 had a specific written policy for the management of burns. Most services use "ABC" or "First Aid at Work" principles, although five have no formal guidelines for patient assessment. Oxygen is given by 44 services, all services cool burns with water and/or dressings, and 31 assess burn size. The same protocols are used for both adults and children by 29 brigades, while two brigades use lower oxygen concentrations for children. Only three brigades receive joint training from the fire and ambulance services.

CONCLUSIONS

UK firefighters are in an ideal position to provide early assessment and treatment of burns, but there is currently a wide variation in the fire services' management of these patients. There is a need for clear evidence based national guidelines for all pre-hospital providers to standardise patient care for burns. A suggested protocol is included in this report.

Intravascular hemolysis associated with severe cutaneous burn injuries in five horses

Five horses were evaluated because of severe cutaneous burn injuries following a barn fire. Gross hemolysis and morphologic changes in RBCs consistent with oxidative damage were detected in all of the horses. Of these horses, 4 became azotemic. The overall goals of treatment included wound care, correction of dehydration and provision of diuresis, control of inflammation, pain management, and prophylaxis against sepsis. After treatment, 2 horses survived and were discharged from the hospital. Red blood cell damage and hemolysis following cutaneous burn injury have been investigated in other species and appear to be a result of the release of oxygen radicals from complement-activated neutrophils. Early intervention with aggressive fluid therapy is recommended in the treatment of human burn patients and is likely to be of benefit in horses with burn injuries; a beneficial role of free radical scavengers and xanthine oxidase inhibitors has also been suggested.