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Emergency Management of Severe Burns

Manual

Article · February 2012

DOI: 10.12968/jpar.2012.4.2.114

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Career Development
Emergency management of
severe burns
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T he patient with burns presents a difficult
challenge to most health personnel. Apart
from the severity of the injury, there is the
distress to patient and relatives to manage, as well
as the uncertainty of their personal, employment
and financial future. In addition to these factors, the
surgical maxim that the trauma patient who is seen,
assessed and treated early by skilled personnel heals
more quickly than the delayed patient is true for the
burn victim, as well as the trauma patient.
The EMSB is a one-day didactic and interactive
course essential for any medical professional exposed
to the burnt patient in either the prehospital, hospital
or emergency context. This course is based on
the principle that timely emergency assessment,
resuscitation and transfer provide the best chance of
recovery in patients with burns.
The aim of the course is to provide sufficient factual
information, guidelines and protocols regarding the
initial management of the patient with severe burns to
enable medical, nursing and emergency practitioners
to deal competently and confidently with this
problem. It is designed to be a stand-alone course but
it can also be taught in conjunction with ATLS.
Epidemiology
In the UK, approximately 250 000 people are burnt
each year. Of these, 175 000 attend accident and
emergency departments, and 13 000 of these are
admitted to hospital. Some 1000 patients have severe
enough burns to warrant formal fluid resuscitation;
half of these are children under 12 years. In an
average year, 300 burn deaths occur. These UK figures
are representative of most of the developed world
countries, although some, such as the US, have a
higher incidence.
Burns are also a major problem in the developing
world. Over two million burn injuries are thought to
occur each year in India (population 500 million),
but this may be a substantial underestimate.
Mortality in the developing world is much higher
than in the developed world. For example, Nepal
has approximately 1700 burn deaths a year for a
population of 20 million, giving a death rate 17 times
that of Britain. Most burns are due to flame injuries.
Burns due to scalds are the second most common.
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The most infrequent burns are those caused by
electrocution and chemical injuries. The type of burns
suffered is related to the type of patient injured. It
is therefore useful to break down burn aetiology by
patient groups as this reveals the varying causes of
injury. In most groups, there is a male predominance.
The only exception is in elderly people, among
whom more women are injured because of the
preponderance of women in that population.
Children aged up to 4 years comprise 20% of all
patients with burn injuries. Most injuries (70%) are
scalds due to children spilling hot liquids or being
exposed to hot bathing water. These mechanisms can
lead to large area burns. Because of changes in the
design and material of night clothing, flame burns are
less common than they were. Boys are more likely to
be injured, a reflection of the behavioural differences
between boys and girls. 10% of burns happen to
children between the ages of 5 and 14. Teenagers
are often injured from illicit activities involving
accelerants, such as petrol, or electrocution.
Most burns (> 60%) occur in patients’ aged 15–64.
These are mainly due to flame burns, and up to a
third are due to work related incidents.
Some 10% of burns occur in people aged over
65. Various effects of ageing (such as immobility,
slowed reactions, and decreased dexterity) mean
elderly people are at risk from scalds, contact
burns, and flame burns. Burn victims’ health is
often compromized by some other factor, such as
alcoholism, epilepsy, or chronic psychiatric or medical
illness. All such problems need to be addressed when
managing patients in order to speed recovery and
prevent repetition of injury.
EMSB course
The one-day course is run in various centres
across the UK throughout the calendar year and
incorporates the following components.
Course manual
This contains the complete syllabus of the course
and is sent to students beforehand. It is expected
that the manual is read twice before the course and a
study guide is provided to assist with learning.
The manual provides all the information required
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to both pass the course and provide the healthcare
provider a good grounding in the practical aspects
of managing acute burns. The manual begins
with chapters on the aetiology, epidemiology and
burn physiology and then progresses to dealing
with inhalational injury, burn wound assessment,
management, and burns shock and fluid resuscitation.
Special burns such as chemical and electrical burns
as well as paediatric burns are covered. The burns
referral pathway and guidelines and the outpatient
management of burns completes the topics covered.
Formal lectures
These take place at the start of the course, in the
morning and reinforce the reading in the manual as
well as providing a broader view than the written
text, highlighting the relevant and key learning
points. The lectures are didactic in nature. There
are opportunities for questions, but the bulk of
discussions will occur later in the course, or at any
point with a free instructor throughout the day.
Skills stations
Important practical aspects of the course are taught
in these stations in greater depth with candidates
given the possibility to practice the skills. The areas
covered are as follows:
Burn area and fluid resuscitation: in this station,
candidates are given real life cases and scenarios
and have to calculate the burn area and fluid
requirements. This includes not just the total fluid
required but also the rate of administration for both
paediatric and adult cases.
Documentation and transfer: the importance of
documentation is highlighted and taken into greater
depth, not just of the burn and the patient, but also
the documentation required before transfer to a
burns unit for treatment.
Escharotomy: the indications, placement of incisions
and technique of escharotomies are discussed and
reinforced here as well as potential sequelae.
Burn wound assessment: using pictures and clinical
signs different types of burns are assessed for their
extent. While nothing is as good as seeing the
burns in person, pictorial evidence increases the
knowledge base of the candidate, and provides
skills for recognizing different types of burn.
Airway management—here the differences
between upper airways (above the larynx) and
lower airways management are discussed. Practical
management of the airway is practiced ranging
from simple airway maneuvers to intubation.
Interactive discussion groups
Small group teaching sessions take place addressing
the various issues of managing, treating and
resuscitating different types of burns and burn
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Career Development
patients. Candidates are able to use their own clinical
experience and expand on topics to help their
understanding. Role playing making referrals, and
discussing the treatment of different types of burns,
chemical, industrial, thermal and electrical and the
multiply injured trauma patient form the cornerstone
of the group.
Simulated burns cases
Volunteers are placed in a moulage to simulate
clinical cases of burns to give the candidate practical
experience of managing a severe burn. In this section
the prior learning is consolidated and applied making
it clinically relevant. The cases involve ‘real’ subjects
and either course facilitators or volunteers pose as
patients and are treated accordingly, similar to an
ATLS moulage.
Examination and clinical test
At the end of the day, a multiple choice exam is
taken and a clinical case via a simulated moulage
is examined. These will test both your knowledge
and the effectiveness of our teaching. The clinical
scenario is made as life-like as possible with live
models and make up designed to replicate differing
depth of burns and potential associated injuries.
A time limit is placed on the candidate for the
scenario. In the time frame, the candidate must score
as many points as possible following the structured
algorithm as taught in the course.
The scores from the moulage and the written test
are collated and candidates are informed on the day
as to whether they have passed or failed. Failure
of the course requires the candidate to re-sit the
examinations on a separate occasion.
Candidates who have shown a good attitude,
aptitude and have scored highly on the written test
are invited to train as instructors at a later date.
Course details
The EMSB course is run by the British Burns
Association, a non-profit making charitable
organisation with a mandate to promote and
disseminate knowledge in the treatment and
prevention of burns. The one-day course is run at
different venues throughout the country at regular
intervals all year round. For those personnel in the
military a special 2-day course is run covering the
same territory as the normal course, but in addition
there are military specific modules on the second
day. The course fee is £100.
Conclusion
The emergency management of severe burns is
an enjoyable and informative course, which is a
necessity for any medical professional that regularly
sees acute burns.
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