Life-Saving Training Blog

When there is a residential house fire, in many cases if the family that lives there is lucky, they escape without injury while the house burns down. If they were unlucky one or more family member is seriously burned or dead. All this is very sad, mostly preventable and has everything to do proper response and proper burn care. Read on to learn more about the advances made in burn care and burn treatment over the last several years.

Burn Care: A Brief History

On May 4, 1973 the National Commission on Fire Prevention and Control transmitted their final report of their 2-year project entitled, “America Burning” to President Nixon. At that time there were approximately 6,200 National fire deaths yearly and an estimated 100,000 injuries.

Many changes have been implemented in the past five decades to prevent fires and reduce injuries and deaths, according to the U.S. Fire Administration. Let’s look at the last 10 years:

• In 2012, there were 3,146 National Fire Deaths (a 10% rate per million population).
• In 2021, there were 4,316 National Fire Deaths (a 13% rate per million population). This includes 63.8% males and 36.2% females.
• The 10-year trend from 2012 to 2021 included:
  • The fire death rate (per million population) increased by 17.9%.
  • The 0–4 year-old children fire deaths decreased by 17.7%.
  • The 5-9 year-old children fire deaths increased by 7.8%.
  • The 10-14 year-old children fire deaths increased by 16,8%.
  • The 65-74 year-old adult fire deaths increased by 35.8%.

Burn Injury Basics

Burns are diffuse soft-tissue injuries created by destructive energy transfer via radiation, thermal, or electrical energy. Significant injury can also be caused by chemical substances. All this causes destruction of the skin which is the body’s barrier to the outside environment. In 2021, there were 14,700 estimated burn injuries (61.4% males and 38.6% females).

Let’s focus on thermal burns which are very common. When heat absorbed by the skin exceeds the tissue’s ability to dissipate the heat a thermal burn occurs. Heat energy can be transmitted in a variety of ways causing these thermal burns:

• Flame burns are caused by flames touching the skin and made worse when the clothing is caught on fire.
• Scald burns are caused by hot liquids spilling on the patient. Common with children near a pot on the front kitchen stove burners.
• Contact burns are produced by touching a hot item.
• Steam burns are caused by direct exposure to hot steam exhaust.
• Flash burns are electrothermal injuries cause by the arching of an electrical current.

The depth of the burn is important to assess and described as:

• Superficial burns involve only the epidermis layer of the skin and produces a very red, painful skin. Formerly called a first-degree burn. (eg; sun burn)
• Partial-thickness burns involves the epidermis and portions of the dermis layers of the skin. They are characterized by pain and blistering.
• Full-thickness burns extend through the epidermis and dermis layers of the skin into the subcutaneous tissues. Formerly called a third-degree burn. These burns require skin grafts.

The total body surface area (TBSA) of the burn is calculated using the rule of nines, the rule of palm, or the Lund-Browder chart. Most practitioners advocate counting only the areas of partial- and full-thickness burns. Many area treatment and transportation protocols take into consideration the TBSA percentage.

Treatment of a burn focuses on salvaging as much of the injured tissue as possible by improving perfusion and eliminating the secondary changes that turn damaged tissue into dead tissue. Hypovolemia, or loss of fluids such as blood or water, is a significant problem that must be dealt with promptly. Cases of circumferential extremity burns can have a “tourniquet effect” on the extremity if not managed in the hospital promptly. In its worst presentation, a burn around the entire chest can make it difficult for the patient to move the chest wall to breathe. These situations may require an escharotomy, which is a surgical cut through the eschar or leathery covering of the burn injury to allow for swelling and minimize the potential for developing compartment syndrome, on arrival at the hospital.

Prehospital Management of The Burn Patient

The typical EMR/EMT Level Burn Patient Protocol involves:

• Stop the burning – Here is where the “Stop, Drop, and Roll” comes in! This step is usually done with water and may involve flushing with copious amounts of water/saline for >20 minutes if the burn is a chemical burn.
• Assess and manage ABCs and get some vital signs.
• Assess for the potentially lethal respiratory burn and consider potential for CO inhalation. Provide oxygen therapy as needed.
• Remove constricting objects distal to the burn (ie; rings, watch, bracelet) as they could become tourniquets as the limb swells.
• Cover the burn with a dry sterile dressing. If < 10% TBSA some regions may allow specialized sterile moist dressings. If >10% TBSA use a dry sterile dressing or burn sheet.
• Transport destination should prefer taking the patient to the nearest trauma center if there is trauma associated with the burn injury. Otherwise consider direct transport to a burn center in consult with medical control.

Advanced EMTs and Paramedics should begin aggressive fluid resuscitation per their protocols and in consult with medical control. Monitor closely for hypothermia, hypovolemia, and the effects of airway swelling!

Any New Burn Care Guidelines?

Not really…

The International Liaison Committee on Resuscitation (ILCOR)’s First Aid Task Force has had the cool water for first aid for a thermal burn on their radar for years. As of 2022, the thermal burn cooling treatment recommendations state: “We recommend the immediate active cooling of thermal burns with running water as a first aid intervention for adults and children (strong recommendation, very low–certainty evidence). Because no difference in outcomes could be demonstrated with the different cooling durations studied, a specific duration of cooling cannot be recommended. Young children with thermal burns being actively cooled with running water should be monitored for signs of hypothermia.”

As far as burn dressings, ILCOR tackled this in 2015 and made the following treatment recommendations: “It is common for first aid providers to cover a burn with a dressing after it has been cooled; however, based on limited data, there is no evidence that a wet dressing compared with a dry dressing is beneficial for care of a burn. One study showed no benefit for a topical penetrating antibacterial versus petrolatum gauze or for a topical nonpenetrating antibacterial versus dry dressing. After cooling of a burn, it may be reasonable to loosely cover the burn with a sterile, dry dressing (Class IIb).”

The American Burn Association (ABA) does have 2022 Clinical Practice Guidelines but they are focused on “early” rehabilitation and mobilization interventions in critically ill burn patients. Early is defined as an intensive care unit (ICU) setting during the first 14 days and not focused on prehospital care.

Burn Center & Prehospital Referral Criteria

In the United States there are approximately 128 self-designated burn care facilities. The ABA and American College of Surgeons (ACS) developed a joint review program to verify burn centers. They do not designate as that is done by most States (similar to the Trauma Center level designation process).

Based on a ABA Burn Repository review the burn centers have a survival rate of 96.8% with 68% of the burn patients male and 32% of the burn patients female. The cause of admission was: 43% Fire/Flame, 34% Scald, 9% Contact, 4% Electrical, 3% Chemical and 7% Other. The place of occurrence for the burn injury was identified as: 73% Home, 8% Occupational, 5% Street/Highway, 5% Recreational/Sport, and 9% Other.

According to the ABA, the criteria for transport or transfer of an Adult/Pediatric burn patient to a burn center includes:

• Partial thickness > 10% total body surface area (TBSA).
• Face, hands, feet, genitalia, perineum, or major joints.
• Full thickness in any age group.
• Electrical burns, including lightning.
• Chemical burns.
• Inhalation injury.
• Burns with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality.
• Burns and trauma (ie; fractures) in which the burn poses the greatest risk of morbidity or mortality. If the trauma poses the greater immediate risk the patient may be initially stabilized in the trauma center before being transferred to the burn center. (This is a physician judgement call in concert with regional medical control plan and triage protocols).
• Burned children in hospitals without qualified personnel or equipment for the care of children.
• Burn injury in patients who will require special social, emotional, or rehabilitative intervention.

Of course, always follow your Regional Protocols for treatment, triage, and transport of the burn patient.

Burn Prevention Tips

With so many burn injuries occurring in the home be observant for teachable moments when visiting patient’s homes. Be the example in your neighborhood and share your knowledge with your friends and family. Here are a few tips to share:

• Install smoke alarms in every bedroom on every level of the home.
• Keep space heaters away from anything that could burn by creating a 3-foot safety zone.
• Do not overload outlets with more items plugged in than the socket can handle.
• Keep lighters and matches away from children. Child-resistant lighters are not child-proof!
• Only use gasoline outdoors and store in cool, well-ventilated areas out of reach of children.
• Do not store flammables near electrical chargers.
• If you have a live Christmas tree keep it watered and once it is getting dry remove it from inside your house. Never leave the lights on the tree for an extended period of time or overnight.

How to Make Sure You’re Up to Date on Burn Treatment

It is always a good time to review basic burn assessment and management since we do not go on these calls every day. Prevention does work as well as some very useful legislation has been helpful (ie: children’s sleepwear, stricter building codes, smoke alarms, CO monitors) in fighting the problem identified in the landmark report America Burning. However, the public education involved in prevention is an ongoing effort of all emergency services responders which never ends.

• Review your regional burn protocols.
• Inspect your headquarters and homes for fire hazards, working fire extinguishers, fresh batteries in the smoke/CO monitors.
• Makes sure the ambulance is appropriately stocked for burn calls and replace those burn sheets that fall apart in your hands when opened!
• Perhaps invite a representative from the burn center to give an in-service and answer questions about the current state of burn care in your region.

As always, be careful out there, stay safe and remember the scene is never safe!

About the Author:

Bob Elling, MPA, Paramedic (retired) – has been a career paramedic, educator, author, and EMS advocate since 1975. He was a paramedic with the Town of Colonie EMS Department, Albany Times Union Center, and Whiteface Mountain Medical Services. He was also an Albany Medical Center Clinical Instructor assigned to the Hudson Valley Community College Paramedic Program. Bob has served as National/Regional Faculty for the AHA and involved in many successful life-saving legislative campaigns with the You’re the Cure Network. He also served as paramedic and lieutenant for New York City EMS, a paramedic program director, and the associate director of New York State EMS Bureau. He has authored hundreds of articles, videos, and textbooks to prepare EMS providers for their career. Bob is the ECSI Medical Editor for the CPR and First Aid Series, Co-Author of EVOS, and Co-Lead Editor of Nancy Caroline’s Emergency Care in the Streets.