Wildland Firefighting: When the Firefighter is the Patient
Wildland Firefighter Demographics This document is intended to be used by the wildland firefighter line medic to: use as a means of burn identification and first aid management of minor burns identify a clear trigger point where a firefighter’s wound is significant enough that they must be pulled off of the line and sent to the hospital identify patient management considerations for the burned firefighter in transport to the nearest facility identify consultation and transfer considerations to the Burn Center from the nearest facility In accordance with the National Wildfire Coordinating Group (NWCG), specific standards will be used when any firefighter sustains burn injuries, regardless of agency jurisdiction. The following is a summary of these standards. After on-site medical response, initial medical stabilization, and evaluation are completed; the agency administrator or designee having jurisdiction for the incident and/or firefighter representative (e.g. Crew Boss, Medical Unit Leader, Compensations for Injury Specialist, etc.) should coordinate with the attending physician to ensure that a firefighter whose injuries meet American Burn Association criteria is immediately referred to the nearest regional burn center. The decision to refer the firefighter to a regional burn center is made directly by the attending physician or may be requested of the physician by the agency administrator or designee having jurisdiction and/or firefighter representative. The agency administrator or designee for the incident will coordinate with the employee’s home unit to identify a Workers Compensation liaison to assist the injured employee with the workers compensation claims and procedures. Workers Compensation benefits may be denied in the event that the attending physician does not agree to refer the firefighter to a regional burn center. During these rate events, close consultation must occur between the attending physician, the firefighter, the agency administrator or designee and/or firefighter representative, and the firefighter’s physician to assure the best possible care for the burn injuries is provided.
Refer to the Incident Medical Plan (ICS-206), NWCG “Clinical Treatment Guidelines for Wildland Fire Medical Units” (PMS 551), and NWCG “Standards for Burn Injuries” (NWCG#12-2008) for additional information on reporting, treatment, and transportation of the injured firefighter.
Burn Identification & First Aid First Degree Burns (Superficial) •
Only damages the outermost layer of the skin, the epidermis
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Usually heals in a few days
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Appears pink, painful
Firefighters with first degree/superficial burns on 10% of their skin or greater should be pulled from the line and taken to a hospital.
Second Degree Burns (Partial Thickness)
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Destroys the epidermis
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Appears red, swollen, and blistered
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Usually heals in 2 weeks
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Can extend into the dermis (deep partial thickness burn)
Firefighters with second degree/partial thickness burns 1% (the size of their palm) or greater should be pulled from the line and taken to a hospital.
Treatment for 1st and 2nd degree burns: 1) Stop the burning process with cool water if the injury just occurred. ***DO NOT use ice to cool as this can reduce blood flow to the damaged tissue & deepen the injury. ***DO NOT repeat the cooling process (this process will be complete in approx. 5 minutes) ***STOP cooling if the patient begins to shiver. 2) For minor 1st degree burns apply a moisturizing cream or lotion but make sure it does not contain alcohol, dyes, or perfumes. 3) For minor 2nd degree burns apply an antibiotic ointment to cover the area of the burn. 4) Cover with a band aid or other protective dressing. 5) Ensure the patient drinks plenty of fluids to avoid dehydration.
DON’T •
Do not break blisters.
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Do not apply butter or other home remedies because they can trap heat or cause infection and make the wound worse.
Third Degree Burns (Full Thickness)
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Affects all layers of skin
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Patient feels no pain, or no increase in pain when pressure is applied to wound
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Will not blanch
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May appear tough & leathery
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Can be very dry in appearance
Firefighters with third degree/full thickness burns of ANY SIZE should be pulled from the line and taken to a hospital
Burn Patient Management- Primary Survey Rescue/Remove the Victim from Heat Source •
PROTECT YOURSELF!
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Smother the flames
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Remove smoldering clothing
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Fire Extinguisher
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Water (if no alternative)
Airway •
Maintain airway & constantly reassess
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Administer O2 @ 100%
Inhalation Injury •
Suspect if an enclosed space, fumes, smoke, stridor, hoarse or raspy voice, carbonaceous sputum, singed facial/nasal hairs, swelling, etc.
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Consider cyanide, carbon monoxide poisoning
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Hyperbaric Treatment is not necessary.
Hydroxycobalamin/Cyanokit •
Cyanide Sources from house fires include combustion of carbon /nitrogen compounds-polyurethane foam, plastic cups, wool, silk
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Cyanide blocks electron transfer chain in mitochondria.
Symptoms: -Cherry red skin or retina -Confusion, ataxia, convulsions, coma -Tachypnea followed by apnea •
Hydroxycobalamin combines with cyanide to form Vitamin B-12.
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Causes flushing, mild hypertension, rash, & bradycardia.
Breathing •
Listen to verify breath sounds in each lung
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Assess adequacy of rate and depth of respiration
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Circumferential full thickness burns of the trunk may impair ventilation and should be closely monitored
***Escharotomy can usually wait until arrival to the Burn Center
Circulation •
BURNS DO NOT BLEED! (If there is bleeding, identify & treat the cause.)
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Evaluate BP, pulse rate, skin color, peripheral pulses
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Obtain two large bore catheters into veins under unburned skin if possible
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Preferred fluid is Lactated Ringers (Use Normal Saline if LR is not stocked on your truck.)
ABLS Fluid Recommendations Initial Pre-Hospital Fluid Management is determined by patient age ≤ 5 yrs.
125ml LR/hour
6-13 yrs.
250ml LR/hour
≥ 14 yrs.
500ml LR/hour
(After patient arrives to the ED and the foley is placed, fluids are fine tuned.)
Disability •
A burn patient is typically alert and oriented to begin with. If your patient is not, look for reasons why! -CO Poisoning
-Substance abuse
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Pre-existing condition (seizure)
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Assess patient using AVPU method
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Identify any gross deformity/serious associated injuries
-Hypoxia
Exposure/Environmental Control •
Remove all clothing, jewelry, metal, diapers, shoes
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Log roll patient to remove clothing from back, check for burns & associated injuries.
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KEEP WARM- cover the patient with dry sheets & warm blankets, warm ambulance/environment
Burn Patient Management- Secondary Survey •
Complete History
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Obtain weight if possible
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Complete head to toe examination of the patient
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Fine tuning of fluids based on ABLS 2010 Resuscitation formulas
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Assess extremity perfusion
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Continue to assess ventilation
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Pain management using IV route (Burn Center providers use Fentanyl and Versed for pain and anxiety management)
Rule of Nines
• Carefully Calculate % TBSA (after ABCDE & secondary survey)
No Wound Care Needed •
Simply cover patients with clean, dry sheets and a warm blanket
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Do not use wet dressings, creams, or gels
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Burn Center providers need to assess wounds in a timely fashion, removal of dressing and ointments delays assessment
Transport •
Transfer to the nearest hospital per agency protocol to stabilize and rule out trauma
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Detailed report with SAMPLE history for hand off of care and paperwork
Arrival at Nearest Medical Facility •
Insertion of lines/tubes
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After thorough evaluation, ER staff completes steps for consultation and probable transfer to the Burn Center
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Calculate fluid rates for transfer using latest ABLS guidelines
American Burn Association Consultation & Referral Criteria
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2nd degree burns > 10 %
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burns to face, hands, feet, perineum, major joints
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3rd degree burns
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electrical burns
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inhalation injury
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chemical burns
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pediatric burns—Children’s Hospital
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burns with associated trauma
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burns accompanied by pre-existing medical conditions
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burns with special social, emotional, or rehabilitation needs
Adult Fluid Resuscitation Adults (> 14 years old)
2 ml LR x TBSA x kg
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Give ½ in first 8 hours of injury and remainder over next 16 hours.
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Adjust rate to maintain urinary output at 0.5 ml per kg per hour or 30-50 ml/hr
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If urine out of target range for two consecutive hours increase or decrease fluids by 1/3
Pediatric Fluid Resuscitation Infants and children (< 14 years old, < 40 kg ) 3 ml LR x kg x % TBSA •
Give ½ in first 8 hrs of injury & remainder over next 16 hrs
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Infants < 10 kg (22 lbs) use D5LR as resuscitation fluid
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Adjust rate to maintain urinary output at 1ml per kg per hour
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If urine out of target range for two consecutive hours increase or decrease fluids by 1/3
Electrical Injury Fluid Resuscitation 4 ml LR x kg x TBSA burn •
Maintain urinary output at 75-100 ml/hour
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May need to increase urine output to 1-1.5 ml per kg per hour to clear urine pigments
UCH Burn Center Transfer Checklist University of Colorado Hospital: Burn/Trauma ICU Burn Center Transfer Checklist and Data Sheet th
12605 E. 16 Ave. Aurora, CO 80045 Telephone: (720) 848-7583 Fax: (720) 848-7308 To transfer a patient, please call our access center at 720-848-2828 ***If capable, you can upload pictures of burn injuries using our secure image uploader on at www.uch.edu/burn. Thank you for referring this patient to University of Colorado Hospital. It is our goal to provide you and your patient with the very best service possible. We hope you will find this checklist user-friendly and helpful in the transfer process. Please feel free to contact us at any time, day or night. To assist us in providing feedback and increasing communication, please begin by providing contact information below. Date: ____________________ Referring Facility ______________________________________Referring Physician____________________________________ Mailing Address: ____________________________________________________________________________________________ Telephone: _____________________ Fax: _____________________ Email: ___________________________________________
Burn Specific Interventions/Needs Is there an inhalation injury? o If there is any question, GET an ABG Administer oxygen Get a patient weight ___________kg Size the Burn (See diagram below)__________% Calculate IV fluid rate using 2010 ABA consensus formula (See tool ) Keep patient warm o Use warm IV fluids (LR) @ 40oC o Heat the room/transfer vehicle o only expose necessary areas Place IV lines through burn if no alternative PLACE FOLEY o Urine Output is your key indicator of adequate resuscitation Tetanus given today/prior ___________ No wound care needed: cover with clean, dry linens Rule out and manage other injuries/trauma Elevate burned extremities Are there circumferential burns that may need escharotomies? (Most escharotomies can wait until arrival to the Burn Center.) LABS: ABG with CO, CBC, BMP, Blood Alcohol, Creatinine, Lytes, Urine Toxicology, Lactate
Fluid Resuscitation Guideline Patient Weight: __________kg % TBSA Burn: __________ Time of injury: __________ %TBSA___________ x weight (kg) ___________x 2ml= ___________ml over 24 hrs (½ to be given in first 8 hours, ½ to be given over the next 16 hours) *Preferred IVF is Ringers Lactate* For children, use 3ml. (Infants < 10 kg (22 lbs) use D5LR for fluid.) For electrical injuries, use 4ml in the formula. Rate at which fluid started: ___________ml/h Time at which fluid started: ___________ Total fluids given at time of transfer ___________L Total Urine output at time of transfer __________
Important Data Needed To Ensure Quality Of Care:
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Name of Patient: _______________________________________
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DOB/ Age: ____________________________________________
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Mechanism of Injury: _____________________________________________
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Allergies: ______________________________________________
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Current Meds: __________________________________________
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Next of Kin: ___________________________________________
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Next of Kin Contact Information: ______________________________________________________
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Past Medical History:___________________________________________________________________________________ ____________________________________________________________________________________________________
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Past Surgical History: ___________________________________________________________________________________ _____________________________________________________________________________________________________
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Photos uploaded at www.uch.edu/burn? Yes______ No______
Medical Providers can upload photos during patient consultation & transfer to www.uch.edu/burn.
