7-18
on wound care.)
Primary:
- Stop the burning process. Decontaminate chemical burns at the scene. Remove any hot synthetic
clothing. For patients with tar burns, immerse the injured areas in cold water until the hot tar has
cooled down. - Protect the C-spine. Cervical injury is common following high-speed motor vehicle accidents, explosions,
high-voltage electrical injury or falls/jumps. - Airway. Secure the airway. Prophylactically intubate patients with mild symptoms of airway obstruction
(swelling of the face, upper airway or larynx) or smoke inhalation injury, and before a prolonged
aeromedical or ground evacuation. See Procedure: Intabate a Patient - Breathing. Give 100% O 2 by non-rebreather mask for burn, shock or carbon monoxide poisoning.
Intubated patients can be bag-ventilated for prolonged periods (up to 12 hours) during evacuation. - Circulation. IV circulatory support: insert 2 large-bore cannulas through (in order of preference):
unburned skin, eschar, cut-down or intraosseous cannula. Start Lactated Ringer’s (LR) at 500 cc/hr
for adults or 250 cc/hr for children age 5-15. Do not give an initial fluid bolus (contraindicated in burn
patients), unless the patient has low blood pressure or major mechanical trauma (i.e., bleeding). Secure
the lines with suture: tape does not stick well to burned skin. This IV fluid rate will need to be adjusted
based on burn size and weight (see paragraph 8 below). Insert Foley catheter to monitor fluid output. - Disability. Neurological exam and treat neuro injuries. Even patients with massive injuries should
initially be alert, unless they have received drugs, have sustained a head injury, are in shock, or have
ingested a toxic substance (carbon monoxide, drugs, alcohol). - Exposure and environment. Keep the patient warm by all available means (aluminum combat casualty
blanket, warm IV fluids, sleeping bag, etc.). Burn patients lose heat through the damaged skin, and
severe hypothermia can result if the environment is not kept hot. Cool only the smallest burns. Never
soak a burn patient in wet linens unless he also has heat stroke. Monitor core temperature at least
hourly if possible. - Fluid Resuscitation. Carefully measure burn size and preburn weight, and estimate fluid resuscitation
needs according to the formula below (see Notes). - Do a careful secondary survey. Remove all the clothing, roll the patient to inspect the back, and remove
all jewelry (especially rings, since fingers can swell causing damage beneath rings). Examine the corneas
with fluorescein and Wood’s lamp, looking for corneal defects in all patients with facial burns and
those who complain of eye problems. Treat corneal abrasions with ophthalmic antibiotics such as
erythromycin and gentamicin. Look for non-thermal trauma. Burns can make it more difficult to detect
spinal or extremity fractures, or intraabdominal injury. A diagnostic peritoneal lavage can be done through
burned skin. Check the tympanic membranes for rupture in blast injuries.
10.Open fractures in burn patients are at high risk for developing osteomyelitis. Immobilize the fracture
with splints. A plaster cast can be used over a burn, but should be immediately bivalved to permit
wound care and to allow for post-burn swelling. Definitive care is external fixation.
11.Use frequent, low-dose IV narcotics (e.g., morphine, fentanyl, methadone) for pain control. Avoid IM
narcotics. IV ketamine is useful for painful procedures. Give Phenergan 25 mg IV, IM, or po to potentiate
the effects of narcotics and treat nausea.
12.Place a nasogastric tube to prevent gastric ileus, vomiting and aspiration. To prevent stress ulceration
of the stomach and duodenum, give 30 cc of magnesium- or aluminum-containing antacids q 2 hrs,
preferably via nasogastric tube. Clamp the tube for 30 minutes after each dose, or give an IV H 2 -blocker
such as cimetidine.
13.Immunize against tetanus as needed.
14.If the patient will be evacuated within 24 hrs of injury, then no specific wound care of the burn is
needed. Otherwise, cleanse the burns with an antimicrobial solution and daily shower. (Use normal saline
or similar to cleanse the face.) In general, do not debride small (< 2 cm diameter) blisters if they are
intact, but unroof them if they rupture, lie across major joints, or are large. If the burns are in the scalp,
shave the hair. Apply an antimicrobial burn cream such as silver sulfadiazine (Silvadene, Flamazine,
etc.) or mafenide acetate (Sulfamylon) bid. Following application, the wounds can be left open, but in
the field it is best to cover the wounds with sterile gauze dressings or clean linen. IV ketamine or
narcotics are useful for pain control during dressing changes. Alternate topical treatment: apply