Advances in trauma and burn management over the past three decades have resulted in improved survival and reduced morbidity from major burns. The cost of such care, however, is high; it requires conservation of resources such that only a limited number of burn intensive care units (ICUs) with the capabilities of caring for such labor-intensive patients can be found; hence, regional burn care has evolved. This regionalization has led to the need for effective prehospital management, transportation, and emergency care. Progress in the development of rapid, effective transport systems has resulted in marked improvement in the clinical course and survival for victims of thermal trauma.

For burn victims, there are usually two phases of transport. The first is the entry of the burn patient into the emergency medical system with treatment at the scene and transport to the initial care facility. The second phase is the assessment and stabilization of the patient at the initial care facility and transportation to the burn ICU. With this perspective in mind, this chapter reviews current principles of optimal prehospital management, transportation, and emergency care.

Immediate burn care by first responders is important: it can vastly alter outcomes and significantly limit burn progression and depth. The goal of prehospital care should be to ease the burning process and prevent further complications and secondary injuries from burn shock. Identifying burn patients appropriately for immediate transfer is an important step in reducing morbidity and mortality. Before any specific treatment, a patient must be removed from the source of injury and the burning process stopped. As the patient is removed from the injuring source, care must be taken so that a rescuer does not become another victim. All caregivers should be aware of the possibility that they may be injured by contact with the patient or the patient’s clothing. Universal precautions, including wearing gloves, gowns, masks, and protective eyewear, should be used whenever contact with blood or body fluids is likely. Burning clothing should be removed as soon as possible to prevent further injury. It has been shown that prompt removal of clothing after scald injuries may reduce postburn morbidity. All rings, watches, jewelry, and belts should be removed because they can retain heat and produce a tourniquet-like effect with digital vascular ischemia. If water is readily available, it should be poured directly on the burned area during the first 5 minutes maximum to avoid hypothermia. Early cooling can reduce the depth of the burn and reduce pain, but cooling measures must be used with caution because a significant drop in body temperature may result in hypothermia with ventricular fibrillation or asystole. Cold water treatment over large body surfaces has been shown to trigger clinically relevant hypothermia. Ice or ice packs should never be used because they may cause further injury to the skin or produce hypothermia.

Initial management of chemical burns involves removing saturated clothing, brushing the skin if the agent is a powder, and irrigating with copious amounts of water, taking care not to spread the chemical on burns to adjacent unburned areas. Irrigation with water should continue from the scene of the accident through emergency evaluation in the hospital until achieving a normal skin pH level (5.4–5.9). Efforts to neutralize chemicals are contraindicated because of the additional generation of heat, which would further contribute to tissue damage. A rescuer must be careful not to come in contact with the chemical.

The initial management of patients who suffer an electrical injury includes confirming that the scene is safe from electrical current, which must be turned off from its source.

Initial assessment of a burned patient is divided into primary and secondary survey. In the primary survey, immediate life-threatening conditions are quickly identified and treated. The primary survey is a rapid, systematic approach to identify life-threatening conditions. The secondary survey is a more thorough, head-to-toe evaluation of the patient. Initial management of a burned patient should be the same as for any other trauma patient, with attention directed at the ABCDE, as follows:

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  A: Securing the A irway and Cervical Spine Protection

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  B: B reathing and Ventilation

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  C: C irculation and C ardiac Status

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  D: D isability, Neurologic D eficit, and Gross D eformity

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  E: E xposure and E nvironmental Control

Rapid, uncontrolled transport of a burn victim is not the highest priority, except in cases where other life-threatening conditions coexist. In most accidents involving major burns, ground transportation of victims to a hospital is available and appropriate. Helicopter transport is of greatest use when the distance between an accident and a hospital is 30 to 150 miles or when a patient’s condition warrants. Whatever the mode of transport, it should be of appropriate size and have emergency equipment available, as well as trained personnel, such as a nurse, physician, paramedic, or respiratory therapist.

An estimate of burn size and depth assists in making a determination of severity, prognosis, and disposition of a patient, and it should be done after the primary survey is completed. Burn size directly affects fluid resuscitation, nutritional support, and surgical interventions. The size of a burn wound is most frequently estimated by using the rule of nines method ( Fig. 6.1 ). The American Burn Association identifies certain injuries as usually requiring a referral to a burn center. Patients with these burns should be treated in a specialized burn facility after initial assessment and treatment at an emergency department. Questions about specific patients should be resolved by consultation with a burn-center physician ( Box 6.1 ). ^,

Estimation of burn size using the rule of nines.

(From American Burn Association. Advanced Burn Life Support Providers Manual . Chicago, IL: American Burn Association; 2022.)

The appearance of burned skin is rather obvious and has the potential to mask or cover any other potential injuries that the burn patient could have. The burn patient is a trauma patient with burns and should be promptly and effectively evaluated to include other potential injuries. It is important to establish effective communication between the transferring unit and the receiving center. The American Burn Association has referral guidelines that identify those patients needing to be transferred to a burn center. ^,

Once the need to transfer the patient is identified, the transferring process begins. The doctor-to-doctor referral process starts with the initial care facility. Available phone numbers and doctor information should be available to centers, and the center should promptly call and ask for all the information needed for the transfer.

The referring physician should give a brief and concise history of the event that includes the time of injury and all resuscitation efforts attempted before the call. The ABCDEs of trauma resuscitation should be discussed and the most current vital signs and physical examination findings should be presented. The accepting facility should then fill out an intake form that details all the information. Understanding the patient’s status is essential for a successful and uneventful transfer. It is imperative that physicians participate in the process by adding to the already available information gathered by other personnel.

Transferring a patient without the needed information can potentially lead to bad outcomes and/or unnecessary expense. For example, a burn patient with an underlying anoxic brain injury could be transferred to a burn center when instead the diagnosis of brain death could have been made at the initial care facility.

Physicians can access patient information utilizing different technologies. Although a doctor-to-doctor phone call is preferred by many, today’s technology allows patient data to be transferred, including pictures and laboratory results and any other clinical information needed to further assess the patient’s needs. Although some physicians still prefer the immediacy of the telephone, secure electronic messaging tools are beginning to supplement phone calls and beepers to facilitate communication among physicians. ^,

The primary purpose of any transport team is not to bring a patient to an ICU but to bring that level of care to the patient as soon as possible. Therefore the critical time involved in a transport scenario is the time it takes to get the team to the patient. The time involved in transporting a patient back to a burn center becomes secondary. Communication and teamwork are vital to an effective transport system.

When transportation is required from a referring facility to a specialized burn center, a patient can be well stabilized before being moved. Initially, the referring facility should be informed that all patient referrals require physician-to-physician discussion. Pertinent information needed includes patient demographic data, time, date, cause and extent of burn injury, weight and height, baseline vital signs, neurologic status, laboratory data, respiratory status, medical and surgical history, and allergies.

The referring hospital is informed of specific treatment protocols regarding patient management before transfer. To ensure patient stability, the following guidelines are offered:

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  Establish two IV sites, preferably in an unburned upper extremity, and secure IV tubes with sutures.

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  Insert a Foley catheter and monitor for acceptable urine output (0.5 mL/kg/h for adults; 1 mL/kg/h for children).

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  Insert a nasogastric tube and ensure that the patient takes nothing by mouth.

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  Maintain body temperature between 38°C and 39°C (taken rectally).

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  For burns less than 24 hours old, only use lactated Ringer’s (LR) solution. The staff physician will advise on the infusion rate, which is calculated based on the percentage of total body surface area burned.

After physician-to-physician contact and collection of all pertinent information, the physicians will make recommendations regarding an appropriate mode of transportation. The options are based on distance to a referring unit, patient complexity, and comprehensiveness of medical care required. Options include:

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  Full medical ICU transport with a complete team consisting of a physician, a nurse, and a respiratory therapist from the burn facility

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  Medical intensive care transport via fixed wing aircraft or helicopter with a team from the referring facility

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  Private plane with medical personnel to attend patient

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  Commercial airline

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  Private ground ambulance

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  Transport van with appropriate personnel

Transport team composition

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