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the target of specially organized teaching programs initially started through the Advance trauma life support (ATLS) concept [16–17] followed by more specifically burn oriented programs such as: the American “Advanced Burn Care Life Support Course (ABLS; www.Ameriburn.org)” provided by the American Burn Association and which is also taught outside the US as e. g., in Japan [18] or Sweden. This course is also available on line on the web [19]; or the Australian and New Zeeland “Emergency Management of Severe Burns (EMSB; www.anzba.org. au)” course which also is provided in other countries such as Britain and South Africa [20–21]. The present chapter will therefore rely strongly on these principles as the strategies for the initial care is presented. These are important as they have implications for the success of the whole treatment process and the final outcome. As pointed out the final care of the burn patients is in cases of significant burns undertaken at burn centers and the improved early stabilization and transport care that today can be offered is one of the reasons why modern burn care provides successful results and increased survival. From a teaching perspective modern burn care in western countries may thus be described as most often provided at three locations, firstly, at the scene of the accident or very close by; secondly at a local hospital where also initial stabilization and the start of fluid therapy usually is undertaken and finally the transport to the final care level, a tertiary referral burn unit or center. In densely populated areas direct transport to the burn center is also an often employed alternative. Transport times are then usually in the range of less than 1 hour. The present chapter will review current principles for the care at these first two locations.

Early management

At the accident

The early and immediate care provided to a burn patient may vary depending on many factors most of all related to: the type of injury (thermal, chemical or electric); where the accident has occurred and its relation to different care levels and the available resources. The latter case, being relevant in situations

with large number of injuries, such as in disaster settings or similar circumstances and where other approaches and strategies also will come into play to ascertain good outcome [22]. In far, distant places the care may be started and undertaken by a companion or a bystander, which may also be the case in other settings immediately after the injury. The more organized assessment and care in the very early stage is otherwise most often done, in the western world, by paramedics from an ambulance rescue team or at times from rescue squads comprising personal with higher medical education such as nurses and/or doctors or personal from a rescue groups arriving by e. g., helicopter. At all levels, a similar approach is undertaken based on early trauma rescue principles (ATLS/ABLS). This evaluation/care may mainly be divided into:

primary assessment,

secondary assessment

which is followed by transportation to the next level of care.

The knowledge gained and the treatments undertaken under way needs to be adequately registered and communicated properly to the next level, so that any important findings and interventions made, are properly extended further down in the treatment process.

Most urgently at the site of the fire or accident is to stop the fire process, electricity or chemical exposure and move the patient into a safe area. This may include getting the person out from a trapped situation in e. g., a vehicle. Stopping the fire in e. g., in clothing’s is best done by suffocation of the fire (rolling and adding garments on the burning clothing’s), if not water or other type of fire extinguishers are within reach. Flushing with properly tempered fluid is very good as it not only extinguishes the fire but also cools the wound and thereby reduces the convection of heat and it reduces pain. Be aware of the risk for hypothermia. At this point clothing, jewelry should be removed as they retain heat and may affect blood flow, as the extremities swell (e. g. jewelry/ fingers). Early management also includes, if the exposure is based on chemicals, flushing with significant amounts of water and being aware of the contamination risk for others such as the rescue team, which shall take adequate precautions using gloves and gowns. If the eyes are involved flushing becomes

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even more important prior to having the eyes examined by an ophthalmologist. It is also important to stress that neutralizing agents are contraindicated as they induce heat. In cases of accidents involving electricity, there is also a need to stop the current/ voltage or using an insulator prior to getting into contact with the patient.

At the site of the accident, in the immediate period after the injury, the patient is cared for by regular ATLS/ABLS/EMSB or other well organized trauma algorithms (ABC) and in their relevant order, i. e., A. Airway, B. Breathing, C. Circulation, D. Disability, E. Exposure – each specified in more detail below under primary/secondary assessment. Very important at this site is also to confirm or exclude other injuries that may be more important than the burn itself (see below the details for this under secondary survey). Pain treatment may be important in this setting especially if there is a somewhat longer initial transport. Pain relief is accomplished preferably by i. v., morphine in incremental doses in the larger burns if drugs are at this point available. It is also important to stress that there is an over representation of abuse, psychiatric disorders and criminality among burn injured patients. This may in certain circumstances have implications for the further care procedures. Most importantly at the site of the accident is to be aware of the risk of being infected/contaminated by Hepatitis B and C or HIV, which makes it important for the rescue personal to take appropriate precautions (glasses/glows/gowns).

Wound care at the site of the accident is rather uncomplicated. Burnt textiles may be removed and the patient covered by clean sheets, to reduce the risk of contamination of the wound and also to maintain body temperature. There is no need for ointments or other local treatments at this stage. At times commercially available burn wound coverings may be presented at the site of injury but the potential positive effects of these are yet undocumented why clean sheets may always be preferred.

In the case of isolated burn injuries there is little need to force an uncontrolled early transport unless there is other life threatening illnesses present. It has been suggested in guidelines of the ABA that if transport times are less than an hour – start of fluid treatment is not mandatory. Transport principles for the burn injured to the local hospital vary according to

the local geographic situations, but often airborne transport (helicopter or fixed wing) in Europe is recommended when the transport time exceeds 2 hours or is more than 100 km.

At a local hospital – stabilization prior to transport to the Burn Center

Primary assessment

The primary assessment scheme follows a strict order scheduled according to how urgent the intervention is. It should be done as early as possible and repeatedly controlled during the care of the patient. Some parts may be performed less thorough at e. g., the site of the accident as more is gained by rapid transport to the next care level or there is a risk of hypothermia, e. g. a detailed burn extent determination outside in the cold.

Airway

The airway is immediately assessed, evaluated and dealt with. A compromised airway may be cared for by small means such as bending the neck backwards or pulling the yaw forward. Facial burns or upper airway edema may compromise the airway as time passes from the time of the accident – making intubation necessary. Unconsciousness, very uncommon in the uncomplicated burn setting unless there is a significant carbon monoxide or cyanide exposure, or another injury, may be a reason for a compromised airway and will call for an early intubation. Provide, if possible oxygen at 100% by a non-rebreathing mask to optimize oxygenation and treat possible carbon monoxide/cyanide effects. At this point also evaluate the spine for any concomitant injuries and the need for fixation – not to cause spinal cord injuries.

Breathing

In conjunction to the evaluation of the upper airway the breathing pattern should be assessed and the lungs examined for proper function and especially in the case of circular thoracic burns, as these may compromise breathing mechanics as edema develops in the thoracic wall, which calls for escharotomies (Fig. 1). This may be particularly important in small children as they rely more on auxiliary breathing muscles in their breathing.

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Fig. 1. Escharotomies. The lines indicate the location for escharotomies. Note that it is important that the cut is deep enough to accomplish a tissue release. This needs to be specifically addressed at the areas marked, as it is more difficult to assess the right tissue depth at these locations, i. e., close to the major joints

Circulation

The circulatory status of the patient should be examined. It includes assessing the skin color, sensitivity, peripheral pulses and capillary refill. Heart rate and blood pressure should also be included to confirm adequate organ perfusion. Be aware that heart rate effects needs to be judged cautiously as it may also be affected by other reasons than hypovolemia, such as pain. Blood pressure monitoring when done may bedifficult,beawareoftheriskforfaultyorcompromised measurements by e. g., deep circumferential burns. In cases the peripheral circulation in the extremities is compromised consider early escharotomies (Fig. 1).

Disability

The burn injured patient during “normal” conditions in the acute phase should not have an altered level of consciousness (LOC) even in cases of very severe burns. The LOC should be assessed, e. g., by the Glascow Coma Scale (GCS). If the Level of consciousness (LOC) is altered, suspect other underlying processes such as other trauma, carbon monoxide and/or cyan-

ide intoxication, hypoxia, or other medical conditions such as e. g., stroke or diabetes.

Expose and examine

The patient should be thoroughly examined and in order to do this removal of the clothing is necessary. Be aware of the risk for hypothermia. Jewelry, especially such as rings etc. should be removed due to the risk of compromising extremity (finger) blood flow as tissue edema develops. At this occasion the important assessment of the burn injuries may be performed and evaluated. Important for the outcome is to initiate the fluid therapy, which may also be done at this point and when the extent of the burn injury becomes evident.

Secondary assessment

The complementary second assessment is undertaken rapidly after the first assessment and it is aimed at examining the patient thoroughly from head to toe, mainly in order to rule out other more important injuries that may pose a danger to the patient. One important point is that this examination needs to be undertaken in detail as the burn injury often is the most prominent injury and it may lead to that other injuries may be overlooked.

Other issues to address, at this point is to get a good medical history. This is important from mainly two aspects, firstly, the circumstances around the burn injury as it may help in the determining the prognosis and may indicate the future burn treatment needs. Secondly, to assess the patients present co-morbidities and ongoing medical treatments.

1.Circumstances of the burn. Where and when did it happen – what were the injury mechanisms (scald, flame, chemical or electrical)? Especially the factors, heat level (degrees) and exposure time (seconds) may signal the risk for deep injuries. Indoor accident and risk for inhalation injuries. Are other injury mechanisms present and relevant?

2.Medical history. Previous or associated illnesses (diabetes, hypertension, other heart, lung or kidney disease) – Ongoing medical treatment, alcohol use or other (abuse), allergies. Time for last oral fluid or food intake. The tetanus immunization status, – need for complementary injections?

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Fluid treatment

A corner stone in the treatment of the burn injury is the fluid treatment. Usually i. v., fluid is provided to injuries larger than 15% total burn surface area % (TBSA %) [23–24]. In order to provide fluid treatment intravenously, i. v. lines are needed. These are most commonly applied in the extremities in non-injured tissue, but in cases of massive burns also burned areas may be used. In larger burns getting vascular access may prove difficult and central i. v. lines may be mandatory as may intraosseous, or cutdown strategies in children. The fluid treatment may be initiated early at the scene of the accident, but should not significantlydelaytransportation.Iftransportisplanned for more than 1 hour starting the i. v. fluid is most often recommended. The background for the fluid needs for the burn patients is the rapid fluid loss to the injured tissue that is caused by the negative imbibition pressure, developing in the injured tissues secondary to the thermal injury and that “pulls” the fluid from the vascular space into the surrounding tissues. This effect is at its maximum after approximately two hours. Also a generalized permeability increase in the vascular tree is developing in parallel and that is due to the generalized inflammatory reaction that develops in the body after the burn injury. This effect is added to the effect by the imbibition pressure and they constitute the reason for the fluid needs of the burn injured [25]. The permeability change is claimed to subside at 24 hours and it is therefore most often recommended that the fluid provided are based on crystalloids until this time point [26–28]. In the US fluids are based on lactated Ringer solutions whereas many countries else were do use acetated Ringer. In cases of refractory situations despite extensive fluid volume provided, the addition of colloids and/or vasoactive drugs may be relevant and needed [29–30]. For most injuries this is however uncommon. There are several fluid protocols in use world wide today (Table 1) and the most commonly used is the one first presented by Dr. Baxter in the 60-ties, called the Parkland formula as it was used initially at the Parkland Memorial Hospital in Dallas (Table 2) [31]. This scheme recommends in adults 2–4 ml/kg/TBSA% of crystalloids (ringers solution (lactate/acetate) for the first 24 hours, 50% provided during the first 8 hours and 50% during the

Table 1. Alternative fluid protocols (Modified from Warden GD [32])

Crystalloid based protocols

Parkland	Ringerlactate/acetate 2–4 ml/kg/
	TBSA%; half of the fluid during first 8h
	Children: Ringer lactate/acetate 3–4 ml/
	kg/TBSA% + the regular 24h maintenance
	fluid needs
Modified Brooke	Ringerlactate/acetate 2 ml/kg/TBSA%
Colloid based protocols
Evans	NACl 1 ml/kg/TBSA% +colloid 1 ml/kg/
	TBSA%+ 2 000 ml glucose solution (5%)
Brooke	Ringerlactate/acetate 1.5 ml/kg/TBSA%
	+Colloid 0,5 ml/kg %+ 2 000 ml glucose
	solution (5%).
Slater	Ringerlactate/acetate 2 000 ml/24 +
	fresh frozen plasma 75 ml/kg/24h
Dextran based protocols
Demling	Dextran 40 in NaCl (2 ml/kg/h in 8h) +
	Ringerlactate/acetate in sufficient
	amounts to induce a urine volume of
	30 ml/h + fresh frozen plasma (0,5 ml/
	kg/h from 8–26h post burn)
Hypertonic protocols
Monafo	250 mEq Na/l. Amounts provided to
	induce a urine output of 30 ml/h
Warden	Ringerlactate + 50 mEq Sodium
	bicarbonate (total 180 mEq) during the
	first 8h to induce a urine output of
	30–50 ml/h. Thereafter Ringerlactate
	with the same urinary output goal

following 16 hours. In children the corresponding fluid volume need is larger, that is 3–4 ml/kg/TBSA% and to this the normal 24 hour fluid needs are added (Table 2). It is important to stress that the fluid volume suggested is to be closely adjusted according to endpoints, – that is mainly urine output. In order to maintain perfusion of internal organs the endpoint and goal is for a urine output of 30 ml/h (or 0.5 ml/ kg/h) in adults and 1 ml/kg/h in children. If insufficient urine output, a 30% increase in the fluid volume per hour provided is recommended. Alternatively, if urine output is too large a corresponding decrease is suggested.

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Table 2. The Parkland protocol

Adults

Ringerlactate/acetate 2–4 ml/kg/TBSA%. 50% provided during the first 8h. the remaining fluid during the following 16h.

Children

Ringerlactate/acetate 3–4 ml/kg/TBSA%. 50% provided during the first 8h. the remaining fluid during the following 16h. Normal 24h fluid needs are added to this as glucose solution.

It is important to stress that neither too little fluid nor to large fluid volumes in relation to the needs should be provided as it will lead to less successful results [33]. The needs vary largely between injuries and patients underlining the need for close surveillance and follow up. In general and presently, in cases of less successful fluid resuscitations most often too large fluid volumes have been provided [30]. Too large fluid volumes will lead to deepening of the burn wound and secondary complications from other body compartments such as generalized large edema including cerebral, pulmonary edema and compartment situations, most importantly abdominal compartment syndrome [33]. Especially if using central circulatory endpoints rather than urine output during the first 12–18 hours such risk is higher [34]. Using the parkland formula the patients appear “hypovolemic” as examined by central circulation techniques. e. g., echocardiography in the very early part of the resuscitation period [35–36].

There are situations where larger fluid needs may be present. In general it has been claimed especially for inhalation or electrical injuries and in cases of a delayed start of fluid treatment. In the case of inhalation injuries the data supporting larger fluid needs are older and in newer investigations smaller effects of inhalation injury on the fluid needs have been seen [30]. In electrical injuries the total tissue damage may be larger despite that the skin burn is less extensive. Other instances where larger fluid volumes are called for are in cases of high voltage electrical injuries or crush injures or when myooch hemoglobinemia is present. Under these circumstances an increased diuresis and alkalinisation of the urine is recommended. The diuresis should reach 1–2 ml/kg/h

(adults) and the pH of the urine should be kept alkaline preferably around or above 7. This is accomplished by adding sodium bicarbonate solution to the resuscitation fluids. This strategy should be continued as long as the pigments are present in the urine.

Burn wound evaluation

Most often the first burn wound evaluation is made under the heading “exposure” in the primary survey, at e. g. the accident. A more thorough examination is then made during the second survey. In evaluating the wound it is important to have it adequately exposed and cleaned from debris and blisters, the latter situation calls for good analgesia or is done during general anesthesia. The risk of hypothermia should always be addressed. The wound evaluation is done mainly in two aspects, to determine, the depth and total percent surface area injured (TBSA %). The depth is mainly important as it affects the treatment (surgical excision or not) and the TBSA % is important for the prognosis. TBSA% (including depth) is together with the age of the patient and the prevalence of inhalation injury the most important prognostic factors for the injury. This will govern prognosis and also the fluid treatment.

Burn wound depth

How deep into the skin the injury progresses is dependent on several factors. Firstly, it depends on the thermal energy transferred to the tissue. This depends on the temperature and the exposure time, high temperature and longer exposure times increases the risk for significant injuries. The energy transfer process is further affected by the type of transfer, e. g., convection transfers more energy, and this is counteracted by the ability of the tissue to withstand the temperature (thicker skin – better resistance) or dissipate the heat (higher blood flow reduces the injury). In practice this is exemplified by the lover risk for injuries on the back, in palms and soles with their thicker nature and the higher risk in elderly and children with their generally thinner skin.

Burn wound depth (Fig. 2) has traditionally been divided into three levels according to anatomy, first degree – epidermal injury, second degree – dermal and third degree sub dermal burns. Today a two level

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Fig. 2. Burn wound. Skin anatomy in relation to burn wound depth terminology

nomenclature is used which focuses more on treatment strategies: partial thickness burns (including epidermal and superficial dermal injuries (1st and superficial second degree burn; old nomenclature) and full thickness burns (including deep second degree and sub dermal burns; old nomenclature). Modern care for partial thickness is conservative treatment whereas full thickness burns are surgically excised and transplanted.

A burn involving the epidermis is usually erythematous and very painful but does not contain blisters. It is exemplified by a sunburn. The dead epidermis sloughs of and is replaced by regenerating keratinocytes within 2–3 days. A partial thickness burn wound, is a superficial dermal burn and extends down to the papillary dermis and usually forms blisters. When the blisters are removed the wound is pink, wet and highly sensitive. Blanching is present. These wounds heal within 2 weeks (Fig. 3 A). Deep dermal wounds extend down to the reticular dermis and usually take more than 3 weeks to heal. These wounds also show blistering but the wound underneath has a mottled and white appearance. Blanching, if at all present is slow. Sensitivity to pinprick is reduced and pain is described as discomfort rather

than pain (Fig. 3B). Full thickness wounds involve the entire dermis and extend to the underlying tissue. Appearance is described as charred, leathery and firm. The wound is insensitive to touch and pinprick (Fig. 3C). Deep dermal and full thickness wounds are surgically excised and autologously transplanted.

Burn surface area

The burned body surface area, will as mentioned affect overall prognosis, the resources needed and not least from the practical perspective the immediate fluid treatment. It is therefore mandatory that it is done properly. From a practical perspective the most commonly used technique is based on the rule of nines (Fig. 4). In this setting the body is divided into parts of nine percent (arms and head) or multiples of nine (18%; each leg and each side of the torso/stomach and back) the corresponding chart for children is taking into account the larger size of the head and smaller legs in the smaller children (Fig. 4). If the ambition is to be more detailed the chart of Lund and Browder is generally used [37]. In cases of dispersed injuries it is common to apply the area of the palm and fingers (patient) as an estimate of 1% TBSA% of the injured [37].

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A

B

C

Fig. 3. Burn wound depth assessment (Phostos). A Superficial dermal burn; B Deep dermal burns; C Full thickness burn (distal lower leg)

Other interventions at a referring hospital

When the patient is stabilized at a referring hospital there are other interventions that may be done to progress the care and improve the situation for the patient prior to arrival at the Burn center.

Pain treatment

Pain early after the injury is very variable with patients at times experiencing severe pain where as others have more limited problems [38]. The extent of the pain is in each case difficult to predict in advance. Today most units base their pain treatment strategies on a multimodal pain strategy, which are based on several different principles. For the acute setting most often acetoaminophene (1000 milligram as a single dose and up to 4 grams per day for adults) is used in conjunction, when more significant pain is present, with i. v., administered opioids (e. g. morphine). The latter, are provided in small incremental i. v. doses (1– 2.5 mg), where the needs of the patients is monitored closely and the doses administered accordingly and thereby reducing the risk for a respiratory depression. The i. v. route is important in order to titrate the effect but also not least as it may be a poor uptake in hypoperfused tissue areas (sc. or intramuscularly). Other more advanced pain strategies will be needed and employed during the further care of the patient, at the burn center.

Urinary catheter

Urine output is the main fluid treatment outcome measure. Therefore in order to monitor it, especially in larger burns a urinary catheter needs to be inserted. Modern catheters also have temperature sensors included in the intra bladder portion of the catheter, which at the same time facilitates temperature surveillance. After insertion, urinary content of hemoglobin and myoglobin may be observable in such cases.

Decompression of the stomach

Especially in the larger burns the stress response induces gastric, intestinal ileus and this is also further aggravated by the opioids provided for pain treatment. Therefore gastric decompression is often suggested by a nasogastric tube. Through this, also early enteral nutrition may be started and reducing the

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Fig. 4. Total burn surface area (%). Rule of Nine charts for an adult and a child

need for treatment with antacids for gastric ulcer prophylaxis [39]. The start of the enteral nutrition is made after the airway has been secured in cases of an impeding airway problem.

Temperature control and regulation

In the larger burns maintaining body temperature is mandatory as one of the most important functions of the skin – temperature regulation, is affected by the burn. Also evaporative losses from the wounds generate further heat loss, which may further aggravate the situation. Therefore most often, active warming is needed. Temperature assessment needs to be properly done and one very good technique is to have thermistors in the intra bladder part of the urinary catheter which senses the central body temperature. Good heating equipment includes heating ceilings; warm air mattresses (e. g. Bair Hugger ) or fluid heated mattresses (e. g. Allon ).

Referral to burn center

When the decision to refer the patient to a burn center is made – a physician to physician contact should be taken and the background of the patient and the details of the accident should be properly communicated. Most often many interventions have been made since the accident and thereafter during transport or at the referral hospital. It is therefore important that all these are properly documented and that this documentation is properly communicated and transferred to the burn care physician. Especially the vital parameters, treatment interventions including fluid treatment and urine output should be documented and reported.

Referral criteria for burn center care may vary, but an often used table is that provided by the ABA, which also is applicable for most parts of Europe (e. g. Sweden), and which is close to that recommended by the European Burns Association in 2002 (Alsbjoern et al. www.euroburn.org).

Burn center referral criteria [37]

Second degree burn > 10% (TBSA%)

Third degree burn

Burns that involve the face, hands, feet, genitalia, perineum, and extending over major joints

Chemical Burns

Electrical Burns including lightening injuries

Any burn injury with concomitant trauma in which the burn injuries pose the greatest risk to the patient

Inhalation injury

Patients with pre-existing disease that may com-

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