June 25, 2019
Jeff Clawson, M.D.
In one of your review comments from the first draft Release Burn of CDE 78b -- Protocol 7: Burns/Explosions, you indicated that there was a missed difference between things that were essential in burn center care that did not have, or require, the same urgency or care in the prehospital (dispatch and scene evaluation/care) setting. I was unaware of this, so can you explain how to better understand and describe this difference so we get it right in the lesson?
“Each year in the United States, burn injuries result in more than 500,000 hospital emergency department visits and approximately 50,000 acute admissions. Most burn injuries are relatively minor, and patients are discharged following outpatient treatment at the initial medical facility. Of the patients who require hospitalization, approximately 20,000 are admitted directly or by referral to hospitals with specialized multidisciplinary programs dedicated to the treatment of burn injuries.”
American Burn Association: RESOURCES FOR OPTIMAL CARE OF THE INJURED PATIENT (2014)
CHAPTER 14 – Guidelines for Trauma Centers Caring for Burn Patients
These are the Burn Centers.
Not so well known is the significant difference in what constitutes important things in caring for burn patients by responders in the prehospital setting vs. what the Burn Center does. While significant burns to the face, hands, feet, genitalia, perineum, and major joints are said to require Burn Center care, this does not mean that our care for these types of burns in the field is any different, or more urgent, for these particular burns vs. other burns. Most prehospital care for burns is supportive and compassionate and includes cooling, flushing, pain medications, fluid replacement for large (> 25%) burns and/or prolonged transports, and trying to keep the burned area relatively clean. Also, preventive measures for hypothermia (especially in children) should be considered. COLD transport is generally recommended.
The main exception is airway involvement usually paired with facial burns or burns incurred within enclosed spaces. That said, perhaps the single most important prehospital area of clinical attention is the consideration of airway burns and the effectiveness of breathing. Significant airway involvement is quite uncommon in the vast majority of burns—even those to the face. There is a higher level of response and care (ALS) as shown by having CHARLIE codes for “Difficulty breathing” and “SIGNIFICANT FACIAL burns,” and DELTA codes for “DIFFICULTY SPEAKING BETWEEN BREATHS” and various decreased levels of consciousness.
The issues of special care (even Burn Center admission) involving significant burns to the face, hands, feet, genitalia, perineum, and major joints, is based on the Burn Center’s ability to preserve physical functionality that is closely related to reducing the ravages of scarring. Surgical intervention, including grafting, is paired with burn healing and infection-preventing processes, followed by rehabilitative and emotional care, which is based on the burn injury severity, disfigurement, and/or loss of functionality aspects of the patient’s overall condition.
In essence, most things done specific to Burn Center care are simply not done, nor can be done, in the prehospital window of basic supportive care provided by emergency dispatchers and responders.