A Guide to

Burn Management
For the
First Responder
Burn Center at Westchester Medical Center 2
Contents

Introduction ..................................................................................................................... 5
American Burn Association Referral Criteria ............................................................... 6
Emergent Care of the Burn Patient ............................................................................... 7
Initial Emergency Care.................................................................................................. 7
Care of the Airway ........................................................................................................ 7
Care of Circulation ........................................................................................................ 7
Determine the percentage of total body surface area burn......................................... 8
Rule of Nines ................................................................................................................ 8
Rule of Palms................................................................................................................ 8

Burns
Superficial ..................................................................................................................... 9
Partial Thickness........................................................................................................... 9
Full Thickness ............................................................................................................... 10
Inhalation Injury............................................................................................................. 10

Fluid Resuscitation ......................................................................................................... 11

Worksheet: Calculating Initial Fluid Resuscitation for Adults ........................................ 12
Worksheet: Calculating Initial Fluid Resuscitation for Children..................................... 13
Non-Thermal Burns......................................................................................................... 14
Electrical Burns ............................................................................................................. 14
Chemical Burns............................................................................................................. 14
Eyes .............................................................................................................................. 14
Other Care ....................................................................................................................... 15
Escharotomies .............................................................................................................. 15
Nasogastric Tubes ........................................................................................................ 15
Burn patients are also Trauma Patients........................................................................ 15
Wound Care.................................................................................................................. 15
Isolation......................................................................................................................... 15
Transport....................................................................................................................... 15

Burn Center at Westchester Medical Center 3

Burn Center at Westchester Medical Center 4
Introduction

This guide has been developed as a resource for first responders to assist in the emergent care
of burn victims.

Burn victims often require specialized care and a great deal of attention and resources. We
hope this guide will help you in providing the appropriate resuscitation and care for adult and
pediatric burn victims prior to their transport to the Burn Center at Westchester Medical Center.

If you need additional copies of this resource guide or would like more information, please call
the Burn Center at Westchester Medical Center at (914) 493-8660. We are always available to
help you.

Sincerely,

Karen Buckley, M.D. Nancy Nolan, RN

Assistant Director Assistant Nurse Manager
Burn Center at Westchester Medical Center Burn Center at Westchester Medical Center

Burn Center at Westchester Medical Center 5

American Burn Association Referral Criteria

The following types of patients should be referred to a specialized burn facility after initial
assessment and stabilization at an emergency department.

Second and third degree burns of more than 10% TBSA in patients under 10 or over 50
years old

Second and third degree burns of more than 20% TBSA in all other age group.

Second and third degree burns with serious threat of functional or cosmetic
impairment that involve face, hands, feet, genitalia, perineum, and major joints

Third degree burns of more than 5% TBSA in any age group

Electrical burns including lightning injury

Chemical burns with serious threat of functional or cosmetic impairment

Inhalation injury

Circumferential burns of an extremity and/or the chest

Burned children should be transferred to a hospital with qualified personnel and

equipment

Burns with patterns suspicious for abuse

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Emergent Care of the Burn Patient

Initial Emergency Care:

Stop the burning process
Use C-spine precautions
Apply the basic ABCs of trauma care
Remove all clothing and jewelry

Care of the Airway

Administer 100% high flow, humidified oxygen to all burn patients.
Determine the likelihood of an Inhalation Injury.
Suspect Inhalation Injury if you say yes to any of the following questions:
Was the patient burned in a closed space environment (i.e.: home or car)?
Bums on the face?
Singed nasal hairs and/or eyebrows?
Carbon particles or soot in the mouth?
Hoarseness of the voice?
Stridor or difficulty clearing secretions?
Circumferential neck or chest burn?

IF AN INHALATION INJURY IS SUSPECTED, IMMEDIATE INTUBATION IS INDICATED!

To decrease airway and facial edema, keep the HOB elevated 30 to 90 degrees.

The following are usually done after transfer to a Burn Center. However, if transfer is being
delayed, the following work-up can be done.
1. A direct laygngoscopy can establish whether vocal cord edema exists.
2. Once the patient is intubated, a bronchoscopy will be necessary to determine the
severity of pulmonary insult.

Care of the Circulation

For Healthy Adults with burns greater than 20% Insert 2 large bore IV catheters
For Children, Elderly, or Medically Frail Insert a Foley catheter
Patients with burns greater than 10% (Discard initial urine output)
Infants and Toddlers with smaller burns need a Foley catheter and maintenance IV fluids.
These small patients can decompensate quickly and can die of electrolyte abnormalities, even with very
small burns, so initially hourly urine outputs need to be monitored to ensure that more resuscitation is
not needed.

Due to the increase in capillary permeability, IV fluids must be precisely administered to prevent
shock and avoid fluid overload. Too much fluid can be as harmful as too little.

Burn Center at Westchester Medical Center 7

Determine the % of Total Body Surface Area (TBSA) Burn

In the pre-hospital setting, estimating burn percentage is done by using the Rule of Nines.

The Rule of Nines was recently changes to allow for more precise burn percentage estimation in the
pediatric population.

The Rule of Nines

In an adult, if you look at the chart, most large areas of
the body are either nine percent or twice this, eighteen
percent. If you dont have a chart available, you could
get a good guesstimate with this.

The entire head - 9%

Each arm, forearm and hand - 9%
Each foot, leg, and thigh - 18%
The entire front of the trunk - 18%
The entire back of the trunk - 18%
The genitals - 1%

The Rule of Palms

Using the Rule of Palms, the surface of the palm of the
hand and fingers is about 1% of the body surface area
and is helpful in estimating the area of small burns.

Burn Center at Westchester Medical Center 8

Burns

First degree (superficial): reddened, warm to touch, painful, but skin intact, no blisters.

Second degree (partial thickness): reddened, blistered, moist, painful.

Third degree (full thickness): white, brown, black or red in color, firm, non-blanching, no pain to
touch.

Superficial

Reddened

Uncomfortable

Intact Skin

Partial Thickness Burns

Moist

Reddened

Painful

Blisters common

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Full Thickness Burns

Dry

White, brown, yellow or black

Non-pliable

Minimal pain

Inhalation Injury

History: Flame/Smoke/Enclosed space

Assessment/Findings
Facial Burns

Singed eyebrows, eyelashes, nasal hair

Soot around nose and mouth

Oropharynx inflammation

Carbonaceous sputum

Stridor

Decreased LOC

Rhonchi, wheezing

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Fluid Resuscitation

Once the % burn has been calculated, the Parkland formula (or the Parkland formula for pediatrics) is
used to determine the initial IVF rate:

Adult: 4cc x % burn x weight (kg) = 24 hour estimate

Half given over first eight hours, half given over second sixteen hours

Initial IVF rate= Parkland Estimate for 24 hours

2 8 hr

Pediatrics: 2cc x % burn x wt (kg) +maintenance = 24 hour estimate

Initial Hourly rate is again half this number divided by 8 hours

Maintenance: 0 - 10 kg = 100cc per kg (1,000cc)

11-20 kg= 50ccper kg (500cc)
21+ kg= 20cc per kg
Divide total by 24 to get hourly maintenance (no burn) rate.

Please refer to the worksheet attached to the Burn Diagram for specific instructions with examples on
completing this calculation.

IVF are titrated hourly to maintain precise urine outputs:

Adults = 30cc/hr (or 0.5 cc/kg/hr)
Children= 1 cc/kg/hr (no more than 30 cc/hr)

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WORKSHEET**
Calculating Initial Fluid Resuscitation for Adults

4cc x %TBSA burn (upper limit is 50 %) x Weight (kg) = total fluid needs for 24 hours.

To calculate initial IV fluid rate, follow and fill in the formula below.

4cc x_______% burn x __________weight kg=__________ cc - total fluid needs.

Total fluid needs______________2= _______________need for first eight hours

Then divide by eight to get_____________cc/hr of Lactated Ringers

* This rate is only an estimate, IV fluid rates should be titrated to achieve a urine output of 30 cc/hr.
(or 0.5 cc/kg/hr)
* Please inform MD if urine is red or brown in appearance.

Example: A 92 kg man sustains a*60% TBSA burn.

4cc x 50 % burn x92 kg =18,400 cc total fluid needs for 24 hours.

*(Upper limit = 50%)

Total fluid needs 2 = 9,200 cc (fluid needs for the first eight hours)

9,200 cc 8(hr) = 1,150 cc/hr of Lactated Ringers per hour- start this for the first hour

Titrate the fluids hourly up and down according to the urine output of the hour before

*Goal is to achieve and maintain a urine output of 30 cc/hr.

**Based on the Parkland Formula for Adults

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WORKSHEET**
Calculating Initial Fluid Resuscitation for Children

2cc x_______% TBSA burn x _______ Weight (kg) =___________cc-24 hr fluid estimate

24 hr fluid estimate 2 = ____________ Requirement for first 8 hours

Requirement for eight hours__________ 8(hr) =________cc/hr of Lactated Ringers

*You must add this to the hourly maintenance fluids you would normally calculate for an
unburned child

Maintenance Fluid Needs for 24 hours

0 - 10 kg = 100 cc per kg (1000 cc for first 10 kg)
11-20kg = add 50 cc per kg (500cc for 2nd 10kg)
21 kg and up- add 20 cc per kg

Divide maintenance by 24 to get the hourly maintenance rate and then add this to your Pediatric
Parkland to get the rate for the first hour

Titrate IV to achieve and maintain a urine output = 1cc per Kg (not to exceed 30 cc/hr) Inform MD
if urine is red or brown in appearance. For children it is important to monitor serum glucose
levels.

Example: A 23 kg child sustains a 72 % burn.

2cc x 50% TBSA burn (stop at 50% for 72 % burn) x 23 (Weight) kg= 2,300 cc/24 hr fluid estimate.

(24 hr. Fluid estimate) 2,300 2 = 1,150 cc for 8 hrs

1,150 8 = 143.7 ~ 144 cc/hr of Lactated Ringers in addition to the maintenance rate

Maintenance Fluid Needs:

0 - 10 kg = 100 cc per kg (1000 cc for the 1rst 10 kg)
11 - 20 kg = 50 cc per kg (+500 cc for the 2nd 10 kg
Above 20 kg= 20 cc per kg (+60 cc for the 3kg over 20)
Total Maintenance is 1,560 cc in 24 hours = This is 65 cc/hr

Pediatric Parkland Plus Maintenance= 144 cc + 65 cc = 209 cc/hr for the first hour

Titrate IV hourly up and down according to the previous hours urine output

*Goal is to achieve and maintain a urine output = 1cc/kg (but not to exceed 30 cc/hr- take note for
children >30 kg)
** Based on Parkland Formula for Pediatrics--1/2 of the Parkland formula plus
calculated maintenance needs

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Non-Thermal Burns

Electrical Burns
Approximately 1,000 people in the U.S. die each year as a result of electrical contact. Contributing
factors include 1) Type of current-alternating or direct; 2) Voltage-high or low; 3) Duration of contact
and 4) Path of current through body

High-risk groups
Children Agricultural workers Utility workers Fisherman Golfers

Types of Current
Alternating Current (A/C) Direct Current
Voltage may be high or low Most commonly used in the industrial
A/C current causes tetanic spasms that environment
"freeze" the victim to the electrical source Usually produces a single spasm that tends
increasing the duration of contact to "throw " the victim away from the source-
Potential for concurrent injury is high
Electrical injury categories
True electrical injury - current enters and exits the body
Arc burn - current jumps or arcs between two surfaces-frequently over a joint
Flame burn - ignition of clothing

Management
Stop the injury - interrupt the current
Remove the patient from the circuit after the electricity has been turned off
Extinguish any secondary clothing fire
Apply the basic ABCs
Assess the injury - assess the cardiac status and monitor for arrhythmias
Remove potentially constrictive jewelry
Keep patient warm and transfer

Chemical Burns
Depth of burn dependent on the type of chemical, concentration, physical properties and duration of
contact.
For a dry alkali, such as lime, brush the powder off first.
For almost all substances, start immediate and continuous lavage with water or normal saline.
Dont try to neutralize an acid with and alkali, or vice versa, as this will cause an exothermic
reaction, and a thermal burn on top of the chemical burn
Hydrofluoric acid burns are treated with calcium gluconate gel, followed by s.q. injections if
pain persists

Eyes
If contact with chemical has occurred, irrigate with NS for 20 minutes and obtain an
ophthalmology consult. If there is question of thermal burns to the eyes, obtain an
ophthalmology consult.

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Other Care

Escharotomies
If an extremity has a circumferential full thickness burn, escharotomies may be needed. They
must be done as soon as possible if you cant get a Doppler pulse, or if the extremity feels very hard,
or if you no longer get good capillary refill distally in areas that are unburned, or only partial thickness.

Nasogastric Tubes
NG tubes should be placed in patients with total body surface area burns of 20% or more or if the
patient is experiencing nausea and vomiting. Keep the patient NPO.

Burn Patients are also Trauma Patients

Assess patient for associated trauma such as foreign bodies (explosion), fractures, spinal
injuries, soft tissue damage or head trauma ( burns alone do not alter consciousness).
Obtain a full patient history including events of the accident.
All pain medications (1st choice is morphine) are to be given IV only!
Administer Tetanus Toxoid as indicated.

Obtain the Following Laboratory Studies:

Hemoglobin/Hematocrit
Chem 7 with serum osmolarity.
PT/PTT
Carboxyhemoglobin
Urine lytes, osmolarity, myoglobin
ABG

Wound Care
Please refrain from debriding wounds, applying topical creams or ointments. Never apply ice. Once
wounds are assessed, wrap patient in sterile drape sheets to protect the wounds and blankets to
keep patient warm. Burn patients can quickly develop hypothermia.

Isolation
Please make sure that all staff entering the room as well as family members and friends of the
patient wear appropriate isolation apparel. When wounds are exposed wear hats, masks, sterile
gowns and sterile gloves. When patient is covered wear yellow barrier gowns and gloves.

Transport
Once the patient has been cleared of or treated for associated trauma, preparation for transfer to the
Burn Center should be initiated via. Westchester Medical Center Transfer Center 1 (866) 468-6962.

Please report all information to the Transfer Center, who will then put you in
contact with a physician.

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