Initial assessment and stabilization In Burn (Burn Guidelines)

Initial assessment and stabilization In Burn (Burn Guidelines)
Step 1
Thermally injured patients should be evaluated using a systematic approach that first seeks to identify the greatest threat(s) to life.

Considerations step 1
The initial evaluation of burn patients should be performed using a systematic approach such as those described in the course materials of Advanced Burn Life Support (ABLS) and Emergency Management of Severe Burns (EMSB) [36,37]. These approaches involve methodical evaluation of burn patients using a primary and a secondary survey, with a subsequent definitive care plan that addresses consultation and transport. Improved physician response has been demonstrated following implementation of a similar standardized and systematic approach to trauma patients [38–40].

Primary survey
Immediate evaluation for each burn patient starts with the primary survey [36,41], which comprises the following steps.
·        Airway management    
·        Breathing and ventilation    
·        Circulation and cardiac status    
·        Disability, neurologic deficit and gross deformity    
·        Exposure (completely disrobe the patient, examine for associated injuries and maintain a warm environment)

Airway management
Protecting the airway of a thermally injured patient is an utmost priority (see also, Smoke Inhalation Injury, page 11). Circumstances surrounding the patient’s injury can be indicative of the potential for inhalation injury and airway compromise.  Early intubation is indicated in patients with symptomatic inhalation injury, or any thermal injury to the face, mouth or oropharynx that threatens airway patency [42]. Fires in an enclosed space or fires that involve use of accelerants or other chemicals predispose patients to inhalation injury.
Airway injury includes:
(1)  supraglottic injury, which typically results in edema from direct thermal insult, and
(2)  subglottic injury with parenchymal injury due to involvement of toxic gases or soot [43].
Clinical findings that warrant further evaluation for airway compromise include singed facial hair, carbonaceous sputum, soot in or around the mouth, hoarseness, stridor, increased work of breathing, and inability to tolerate secretions [40,42]. Upper airway obstruction occurs in 20–33% of hospitalized thermally injured patients with inhalation injury [43]. Management of airway compromise can include a jaw-thrust maneuver, chin lift, oral airway device, endotracheal intubation, or a surgical airway solution; the most experienced clinician in airway management should secure a definitive airway.

Breathing and ventilation
Once the airway is secure, breathing assessment follows (see also, Smoke Inhalation Injury, page 11). The initial responder should auscultate bilateral breath sounds and determine respiratory rate and depth of respiration to evaluate the patient’s ability to adequately ventilate and oxygenate, thus assessing the status of the lungs, chest wall and diaphragm. Specific to burns, identification of circumferential burns of the trunk or neck that may impair respirations is indicated at this time as well, and treatment is the performance of a rapid bedside escharotomy [42].

Circulation and cardiac status
Upon presentation, patients with major burns should be placed on a cardiac monitor and a continuous pulse oximeter, and should undergo blood pressure evaluation (see also, Burn Shock Resuscitation, page 16; and Escharotomy and Fasciotomy in Burn Care, page 18). Blood pressure, heart rate and clinical assessment of unburned skin color are parameters utilized to assess circulatory status. Due to increased catecholamine response following a thermal injury, 100–120 heart beats per minute is considered within normal limits; [36] a higher heart rate should raise suspicion for hypovolemia, other trauma and inadequate pain management. Peripheral, central and intraosseous routes are available for access and may safely be placed through burned tissue if necessary [41].
Fluid management based on weight and burn size should be addressed once further assessment of burns has been established [44,45]. Administration of fluid boluses is unnecessary unless hypotension or other signs of hypovolemia are present. Bolus administration leads to further exacerbation of edema formation and should be avoided unless indicated.
An intact gastrointestinal tract can serve as a conduit for fluid resuscitation. A significant number of burn patients who undergo oral resuscitation for large burns experience vomiting.  Enteral resuscitation is an option if resources are limited; however, oral resuscitation is more feasible for burns smaller than 30% TBSA [44].  Complete circulatory assessment requires evaluation of perfusion of all extremities, paying particular attention to any circumferentially burned extremities. Compromised perfusion can be secondary to the formation of a tourniquet effect by the non-expandable eschar. Vascular compromise must be identified and treated prior to loss of distal pulses, which is a late finding. If compromised, escharotomy is indicated. This procedure should be performed by a qualified surgeon to reestablish adequate perfusion.

Disability, deficit and deformity
Patients who have sustained a thermal injury often present without altered mental status. However, the possibility of associated injury, substance use, hypoxia, inhalation injury or a pre-existing condition should always be addressed as part of the history of the event. Patient mental status can be easily evaluated via the Glasgow Coma Scale (GCS), which utilizes verbal, motor and eye measurements to establish a baseline mental status on trauma patients [42].

Providing adequate environmental control is key for this subset of patients as they have lost their ability to thermoregulate.  The patient must be completely exposed to assess for injury and to remove any contaminants that might prolong contact with chemicals or heat sources. Removing clothing early in the evaluation process stops the burning process; all diapers, jewelry, contact lenses, and other accessories should be removed to prevent a tourniquet effect [42]. A warmed environment and readily available clean blankets can prevent or limit hypothermia during the examination process. Thermal injuries can be cooled with cool, not cold, water for approximately 3–5 min [36]. Ice and cold water should be avoided, as they cause hypothermia, can thus complicate long-term burn management by further conversion of the burn, and may lead to coagulopathy, cardiac arrhythmias and death [42]. Pediatric patients are particularly susceptible to hypothermia and will need increased active warming efforts [41].

Secondary survey
Thorough examination for non-burn related life-threatening injuries occurs at the secondary survey and is prioritized prior to addressing thermal injury. Indicated imaging, laboratory analyses and adjunctive measures such as urethral catheters, nasogastric tubes, etc. should be completed at this time. Once these steps are complete, a thorough assessment of thermal injury may ensue.

Balance of benefits and harms
This systematic process, as first described for the initial evaluation and treatment of trauma patients, encourages a simplified and methodical approach to identify those injuries most likely to cause death in the first 24 h after burn. This approach emphasizes a pragmatic process for rapidly and accurately diagnosing potentially life-threatening problems, focusing on the precise magnitude of the severity of injury, without inefficient expenditure of time and resources. For example, it is more important to conclude that the patient has smoke inhalation injury and needs to be intubated rather than waiting for analysis of carbon monoxide levels by blood gas analysis.  The risk is that some patients may be treated excessively out of proportion to the true severity of their injuries.  For example, some patients may be intubated but would otherwise recover without airway protection and ventilator support, and some patients with 30% TBSA burns can be resuscitated orally without excessive intravenous fluids.  However, the converse hazard is that critical injuries will be underappreciated, resulting in loss of airway patency, or respiratory or circulatory failure.

Values and preferences
In resource-limited settings (RLS) there is no established universal protocol for evaluation of thermally injured patients, yet it is estimated that over 95% of fatal fire-related burns occur in low-and middle-income countries (LMIC) [46]. Despite the widespread occurrence of thermal injury in these settings, one third to one half of those injured do not seek treatment at a facility; a lack of centers of excellence also limits management [46]. In RLS, therefore, it is important to provide training and education to health care workers at basic level facilities to reduce the incidence of unnecessary deaths from inadequately treated burns [47].

Two significant barriers exist when implementing a standardized assessment for burn patients: cost and the ability to disseminate information. In RLS, allocation of funding may be better prioritized for resources more desperately needed for patient care. The ability to disseminate this information is difficult.  In resource-abundant countries, courses are offered on a fairly regular basis, and telecommunication and podcasting courses are also options. In these settings, the administrative decision to pursue further education in the initial assessment of burn patients would be a necessary focus for quality improvement.

Step  2
Evaluation of burn should estimate total body surface area (TBSA) utilizing a standardized method and delineate characteristics that require immediate attention from a designated burn center.

Considerations step 2
Although the full extent of the thermal injury is assessed in precise detail during the secondary survey, an estimate of burn size and depth is needed during the primary survey to understand requirements for circulatory support. Patients in the extremes of age should be given special attention as their skin is thin and more susceptible to more extensive injury from lesser thermal insults [42].
Determining the extent of burn is commonly estimated using the Rule of Nines [48]. This rule is based on the concept of dividing the adult body area into anatomic regions, which are represented by nine percent, or a multiple of nine, to calculate the TBSA. If only a portion of an anatomic region is burned, then further evaluation to determine the exact percentage burned is necessary. In infants and children, burn size is modified secondary to the disproportionate body surface area of the head and lower extremities and this is accounted for using the Lund-Browder chart [49]. Using the size of the patient’s palm, including the fingers, can act as an approximation as one percent TBSA and can be used as a guideline for estimating burn size [50]. Computerized methods have evolved and demonstrate high correlation and reproducibility that also facilitates the use of telemedicine [51].
Once  the primary and secondary surveys have ensured stabilization  of the thermally injured patient, transfer to a facility  capable of providing the care necessary to support a burn  patient is initiated if indicated. Patients who should be referred  to a higher level of care for burns include those with partial  thickness (second degree) burns greater than 10% TBSA;  those with burns of the face, hands, feet, genitals, perineum,  or across major joints; and those with full thickness (third  degree) burns of any size [52].

Balance of benefits and harms
Larger burns require increased resuscitation due to systemic effects,  thus emphasizing the importance of being able to accurately  and efficiently estimate burn size. It is also clear that  burn patients have improved outcomes if treated in a facility  capable of providing an advanced level of burn care [47].  Therefore, it is important to accurately identify those patients  with burns severe enough to merit transfer so that outcomes  will be optimized. However, transfer to burn centers can  cause significant strain on patients and their support systems.  Patients may become isolated secondary to transfer. If  patients are fortunate enough to have family accompany them,  financial and emotional strain are still contributing factors  to the status of both the patient and their support system.

Values and preferences
Hospitalized patients in RLS often rely on family members for assistance  during their hospitalization, for example to provide meals.  Families play an integral part of care for hospitalized patients  in this setting and transfer to distant locations could jeopardize  the quality of care for some patients.

Implementing standardized education regarding burn size measurement  is a costly undertaking and requires commitment  by hospitals and ministries of health. In addition, transport  costs for patients would be significant, as the number  of burn centers worldwide is small and is even smaller in  settings with limited resources. However, the cost of inadequate  care is reflected in loss of life or function, placing greater  burdens on families and communities. Future development  of applications (apps) for smartphones may provide a cost-effective  alternative for practitioners in RLS.

Appropriate resuscitation should be initiated promptly and tailored  based on patient parameters to avoid over- and under resuscitation.

Considerations Step 3
Patients sustaining burns greater than 20% TBSA demonstrate an  increased capillary permeability that results in decreased intravascular  volume, particularly in the first 24 h following injury  [53]. Resuscitation is aimed at providing adequate perfusion  while using the smallest allotment of fluid possible to  avoid over-resuscitation and its sequelae.
Both  over- and under-resuscitation are physiologically detrimental  to the thermally injured patient. Over-resuscitation  can result in compartment syndrome of the extremities and  abdomen as well as acute respiratory distress, while under-resuscitation  can further perpetuate burn shock and lead  to organ failure [44,53]. Resuscitation can be given orally or  via intravenous fluid. Patients with burns of less than 30% TBSA  are candidates for oral resuscitation; however, early oral intake  can be used to offset intravenous resuscitation volume requirements  for patients with larger burns [44].
Multiple  resuscitation formulas are utilized to guide burn resuscitation  and include, but are not limited to, the Parkland and  modified Brooke formulas. Recommendations for use of lactated  Ringer’s solution with all these formulas range from 2 to  4 mL/kg/% burn over a 24-hour period [53]. All the formulas guide  resuscitation with the goal of titrating fluids to obtain a urine  output of 0.3–0.5 mL/kg/h in adults and 1.0 mL/kg/h in children  [44,53]. Resuscitation formulas serve merely as a guide  and patients are resuscitated based on their physiologic needs,  not solely from numbers dictated by a formula. Formula  instructions further recommend that pediatric patients  require more fluid for burns comparable to those of adults  due to the increase in body surface area-to-weight ratio [44].  Maintenance fluids, including a source of glucose, should be  added to pediatric patient resuscitation fluid as hepatic glycogen  stores will be depleted after 12–14 h of fasting [44].
Certain  subtypes of patients, including those with inhalation injuries,  electrical burns and delayed resuscitation, have been shown  to demonstrate additional fluid needs [54]. Delayed resuscitation  further propagates the complications of under resuscitation;  the importance of early initiation of tailored resuscitation  is thus emphasized.

Balance of benefits and harms
Evidence consistently demonstrates that patients suffering significant  (>20%) burn size incur a systemic response to their injury  that leads to a state of burn shock. The benefit of early resuscitation  initiation is paramount and aids in prevention of hypo perfusion,  renal failure and death. Nonetheless, continuation of unchecked fluid resuscitation can lead to catastrophic  complications, such as airway compromise, edema of extremities  leading to a tourniquet effect requiring escharotomy,  and abdominal compartment syndrome leading to multiple  organ failure requiring exploratory laparotomy and pulmonary  complications.

Values and preferences
Facilities in RLS may only have the option of oral resuscitation because  intravenous resuscitation fluid may be limited. However,  intravenous resuscitation is a reliable approach to decrease  hypoperfusion and has the additional advantage of not  requiring patient cooperation or gastrointestinal tolerance to  be effective.

Administration of intravenous resuscitation in RLS can be limited  by access to medical facilities capable of aggressive fluid  resuscitation. Peripheral or central intravenous or intraosseous  access may be limited for similar reasons. Resource-abundant  settings typically initiate ongoing evaluation  and management of patients with large burns in an intensive  care unit with monitors, invasive devices such as urethral  and central venous catheters, and a low ratio of patients  to nursing staff. Overcoming the cost of aggressive resuscitation  in RLS is daunting. Oral resuscitation could be implemented  when tolerated by patients to aid in offsetting cost.

Tetanus immunization status should be evaluated and addressed if  indicated.
Considerations Step 4
Burn wounds can harbor bacteria and are particularly known to  be tetanus prone. Vaccination for Clostridium tetani was first established  in 1897 and has since evolved to include a tetanus toxoid  (TT) and is used widely [55]. The US Centers for Disease Control  and Prevention (CDC) have established recommendations  for routine vaccination that includes three doses of TT and  booster dosing every subsequent decade. Patients who are current  with vaccination status require no further treatment. Burn  patients with unknown or inadequate vaccination status should  receive TT in addition to tetanus immune globulin
(TIG). Intravenous immune globulin may be used as an alternative  if TIG is unavailable [55].

Balance of benefits and harms
There is great benefit to administration of TT and TIG in the acute  management of a burn. Prevention of a life-threatening tetanus  infection is easily achieved with vaccination. Minimal risk  accompanies vaccination and the benefit-to-harm ratio is heavily  weighted toward the benefit.

Values and preferences
Vaccinations have gained widespread acceptance. However, recent  concerns regarding complications following administration  have caused numerous parents to opt out of vaccinating  their children. Respectfully informing patients and their families  of the potential risk of tetanus infection following a thermal  injury and recommending appropriate intervention is key.  Additionally, some regions of the world such as Nigeria and  Pakistan are experiencing significant social resistance to vaccinations  [56].

Although tetanus vaccination in the US ranges from US$14.20– 42.61,  global programs for childhood immunization have brought  the price even in RLS to $0.20 [55,57]. Basic health care providers  throughout the world, even in RLS, should have access  to TT; TIG may be more expensive and less available. Again,  to ensure the avoidance of unnecessary tetanus infections  complicating burns, emphasis must be placed on adequate  vaccination for all.
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