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Discussion

initial burn care in the ER

Had a firefighter come in last night with deep 2nd degree burns on buttocks, one side of upper arm and a hand. First ER doc comes in and says cover with dry, sterile cover, 2nd ER doc comes in and says keep saline soaked gauze on. Next thing I know my tech has this woman swimming in "ice" water. I really didn't know what to do at this point.

Patient liked the ice water, room is packed with family and other firefighters. Most of them have heard the one doctor that said wet dressings. Fortunately she was transferring out to the burn center soon.

I have spent the morning looking up initial burn care on the net and am amazed at the lack of initial care cited, except of course for the airway management part. Which I completely understand and have no problem with.

So whats the latest story. What do we do?

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    First doc was right. Dry, clean dressings and get her to a burn center. She's going straight to the shower when she gets there anyway. (Assuming she's stable enough).

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    Initial dressings are not a big deal. Once they get to a burn unit we are just going to take the dressings off anyway. Just do NOT use ice, this causes further tissue damage to already damaged burned skin.

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    Cover it with something sterile, get baseline labs, and start fluid resuscitation per the Parkland formula.

    I know ER tends to prioritize the active wound, but the burn will be nothing compared to the problems from possible rhabdomyolysis, hyperkalemia, acute kidney failure, lactic acidosis, etc.

    Acting ASAP helps to reduce the severity of those secondary problems that aren't often present until after transfer out of the ER.

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    What I have always been taught is that you want to cool the burn down as soon as possible. Never use ice because it causes further tissue damage. What we do is start off with is apply cool saline soaked dressings to cool the burn down. Then we remove them once the burn is cooled down, dry the patient and then apply our dry sterile dressings. We also keep the patient warm as we can during this entire process. The lower these patients body temp gets the higher the mortality rate.

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    May I make a suggestion for the future? Ask your unit educator (or staff development dept )for additional education on acute burn care. Sounds like there was a lot of confusion around the initial approach until to pt was transferred to the burn unit. The American Burn Association or a course on ABLS may be of help. I have seen a ABLS class on-line but having been able to connect to the link. ALSO...most firefighters have 'funds' to help with taking care of their own and those who take care of them, maybe they could help sponsor a class. Best of luck in being the change in your ED!

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