Nearly 75% of all scalding burns in children are preventable. By understanding the high-risk situations for fires and burns and taking steps to make your home safer, you can help protect your child from fire and burn injuries or death.

The focus for prehospital treatment for burns includes:

EMT

• Halt the burning process
• Protect the airway
• Prevent further potential disability
• Maintain homeostasis (treat for shock)

Paramedic

• Control airway with advanced adjuncts if needed
• Administer high flow O2, BVM if needed
• Establish IV x2 if possible for severe burns, don't insert IV in burnt tissue if possible, (consider IO)
• Providing pain control, per MCP.

In addition to managing a patient’s ABC’s, prehospital management and initial assessment should involve extinguishing active flames, removing smoldering clothing and jewelry, covering the burned area with clean, dry dressings, and applying cold (not iced) wet compresses only to small injuries. Significant burns (>10% of total body surface area [TBSA]) should not be covered with cold compresses as this could induce hypothermia. Burns in general place patients at risk for hypothermia. To decrease this risk one should turn the heat up in the ambulance or apply extra blankets. If blisters are present, do not unroof them. Simply cover them with a sterile dressing as mentioned above.

After initial and secondary surveys, the prehospital provider should determine the severity and extent of the burn. Determining severity of a burn is based on four criteria: depth of injury, percentage of body surface area involved, location of burn, and association with other injuries. The depth of injury is classified as 1st-degree, 2nd-degree (partial-thickness burn), or 3rd-degree (full-thickness burn)(Table 1). Estimating the percentage of body surface area involved differs between adult and pediatric patients as the body surface area of the head and neck is much larger in children. The Lund and Browder chart is the most common way to estimate TBSA in children (Figure 1). If this resource is unavailable, one may use the palm of the individual to estimate 1% of the TBSA. Burns affecting 10 percent of a child’s body are considered major and require hospitalization at a burn center if available.

Fluid resuscitation is a crucial aspect of pediatric burn care in the prehospital setting as children are at higher risk of dehydration due to a lower circulating blood volume and increased insensible losses. Oral rehydration is possible in the case of smaller burns, but IV/ IO fluid resuscitation should be initiated for children with burns >10% TBSA. For these children, initial management should consist of a 20cc/kg fluid bolus of crystalloid fluid (normal saline or lactated ringers). Following this, the Prehospital Advanced Burn Life Support (ABLS) recommends starting an age-based maintenance fluid infusion rate until more specific volume requirements are determined.

• 125cc/hr for patients younger than five years of age
• 250cc/hr for patients between five and 15 years of age
• 500cc/hr for patients older than 15 years of age

Formulas are available to calculate specific volume requirements in addition to maintenance fluids in children such as the Cincinnati and Parkland depending on a child’s age. However some require a patient’s total BSA in m2 (Table 2). Another important consideration in pediatric burn care is adequate pain control. Pediatric patients may be treated with IV or IN analgesia such as fentanyl or morphine. Fentanyl is preferred for patients with possible circulatory compromise. One to 2mcg/kg/dose of IV/IN fentanyl repeated at 30-60 minute intervals or frequent 0.1mg/kg/dose of IV morphine is appropriate with careful monitoring of respiratory status.

Effective September 1, 2020 a new collaboration between Primary Children's Hospital (PCH) and the University of Utah Health's Burn Center started. PCH will now take any pediatric patient FROM THE SCENE with burn +/- trauma. Burn injury in itself is a trauma. These patients will be coming to PCH first for a trauma evaluation. This will include children for whom EMS has concerns of significant inhalational injury. The trauma team will work with a burn team to run the initial resuscitation at PCH and, depending on other trauma-related injuries and potential need for ECMO, the child will either be kept at PCH or transferred to the Burn Unit after stabilization.

References:

Arbuthnot, M., Garcia, A. Early resuscitation and management of severe pediatric burns. Seminars in Pediatric Surgery 2019; 28(1): 73-78

Scorched Skin: A Guide to Prehospital Burn Management. David Hostler, PhD, NREMT-P, DMT-A. https://www.jems.com/2015/04/06/scorched-skin-a-guide-to-prehospital-burn-management/

Antoon, A. (2020) ‘Burn Injuries” Kliegman, R., et al. Nelson Textbook of Pediatrics. 21st ed. Philadelphia, PA: Elsevier; .614-623

When you encounter a patient with burns it is very tempting to add a preventive antibiotic, especially when the blisters have ruptured or the burns are severe. One thing to remember is that burns are NOT a dirty wound and do not need prophylactic antibiotics. The only exception to this is if it is an old burn that is now infected.

Follow the protocols for pain management to make the patient more comfortable, but realize that burns are extremely painful. Achieving a pain score of zero is impossible. The goal with pain management in these types of patients is to take the edge off. Non-pharmacologic interventions such as distraction, gentle handling, extremities being elevated to around heart level to diminish pain, all work great. Dressing the wound can help relieve pain and calm nerve endings exposed to the air by the burn.

Occlusive ointments are also very good to apply to the burns. The two creams/ointments most recommended by burn specialists are silver sulfadiazine and bacitracin ointment. Caution should be used with both of them for different reasons. Silver sulfadiazine should not be used in patients with a sulfa allergy and bacitracin should not be used on more than 30% of the body surface area because there is limited data showing it can be nephrotoxic (harmful to the kidneys).

Coronavirus Avoidance, a few things teachers can learn from healthcare workers

Utah EMSC put together a training toolbox for teachers entitled Coronavirus Avoidance, a few things teachers can learn from healthcare workers. The toolbox includes posters and signage

https://drive.google.com/drive/folders/1cJbzPOc-D0B-PI1fK-HTJUvaxG_lCAns?usp=sharing

Covid-19 Trackers

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Johns Hopkins Global tracker (mobile)

Utah Department of Health

tdickson@utah.gov