POINT OF INJURY

1. In the field, INTERRUPT THE BURNING PROCESS and address any life-threatening bleeding, airway compromise, or tension pneumothorax in accordance with Tactical Combat Casualty Care (TCCC) guidelines. Burn casualties may have additional traumatic injuries which are more life-threatening in the short term and require immediate attention.
2. Rinse off dirt and any contaminating chemicals, including hydrocarbon fuels, with clean water. Dry chemicals should be brushed off before irrigation. Once a survey of injuries is performed, cover the patient with blankets to prevent hypothermia.
3. Evacuate the casualty as soon as possible. Tactical considerations and distance may require prolonged casualty care in which resuscitation is begun under pre-hospital conditions.

INITIAL BURN SURVEY

All burn victims are trauma patients first and should be treated and initially evaluated according to TCCC/ATLS guidelines. Perform primary and secondary surveys as for any trauma patient. Below are some examples of burn severity.

Figure 1. Examples of Burns

Acute injuries found in the primary and secondary survey should be addressed in accordance with standard trauma protocols. In evaluating a patient for non-burn trauma, avoid becoming distracted by the burns.

Perform a rapid airway assessment and obtain a definitive airway if needed. Immediate intubation may not be necessary in less severely burned casualties, thereby allowing time to complete the primary survey and prepare for controlled intubation.

Indications for endotracheal intubation include coma or depressed mental status with Glasgow Coma Scale (GCS) <8, symptomatic inhalation injury, deep facial or neck burns, and burns of ≥ 40% TBSA.

NOTE: Edema after burns or inhalation injury causes supraglottic airway devices such as laryngeal mask airways to be ineffective.

- Use a large-bore endotracheal tube (ETT), especially if inhalation injury is suspected. Size 8 ETT or larger is preferred for adults. The larger ETT facilitates subsequent bronchoscopy and pulmonary toilet and decreases the risk of later airway occlusion due to casts comprised of blood, mucus, and debris.

Secure ETT

- Use cotton umbilical ties around the neck but ensure it does not cut into the corner of the mouth.
- Consider use of stainless-steel wire secured around a pre-molar tooth prior to long-range transport, particularly in patients with extensive facial burns.
- Frequently reassess position of the ETT during the acute resuscitation period as edema waxes and wanes.
- Avoid use of adhesive tape to secure ETTs, as this is not a safe method in burn patients. Tape does not stick well to burn patients. Do not use tape to secure an ETT.

Keep the patient warm. Burns increase insensible heat loss. Burn casualties with injuries >20% TBSA are at high risk of hypothermia.

NOTE: Do not debride blisters until the patient has reached a facility with emergency medical or surgical capability. Cover burns with loose, dry gauze or a clean sheet.