CE Article: Interfacility Transport of the Burn-Injured Patient, Part 1

Objectives

Upon conclusion of this course, students will be able to:

• Recite criteria outlined by the American College of Surgeons Committee on Trauma and the American Burn Association (ABA) that dictate the types of burn injuries that should be referred to a verified burn center;
• Explain the community need for specialized resources and systems to safely transfer patients with critical burn injuries to the proper level of care;
• Develop a protocol to address transport of critical burn patients from a local hospital to a regional burn center;
• Detail the list of necessary and recommended supplies for ground and air transfer of the critical burn-injured patient.

Where burn care is immediately available, a local protocol should be developed to address transport from emergency scenes directly to the burn center. However, due to geography or distance, that is not the case for many communities. This article was created as a guide for agencies that must transport patients from a local hospital to a regional burn center.

This review will be presented in two sections. The first will provide an overview and cover the referral process and equipment that may be needed. Part 2 will examine initial patient contact, assessment/evaluation, legal considerations, transport options, and appropriate destinations. 

Background

Patients with serious burn injuries are typically managed in verified burn centers. However, while there are 5,198 hospitals in the United States, only 132 include burn centers.^1,2 Most burn injuries are initially managed by EMS and first seen at a community or general hospital. Patients who meet transfer criteria are typically moved by either ground or air to a verified burn center to obtain optimal care.³ (Currently there are 132 self-identified burn centers in the United States. Of those 72 have met or exceeded the American Burn Association verification standards. The nonverified burn centers are typically smaller and may lack the comprehensive resources to meet the standards. Nevertheless, burn care is specialized, and the best care for a patient with a burn injury is at a burn center.)  

The evidence shows that with appropriate training, expertise, and equipment, patients with burn trauma can be safely and efficiently transferred by ambulance over long distances to a burn center.⁴ The involvement of EMS in the transport of these patients is critical, as the greatest risks for complications include airway failure and loss of or inability to attain intravenous access.⁵ Literature also suggests more training is needed to help first responders and community hospitals triage patients with burn injuries to optimize the transport of patients by air.^6–8  

Criteria for Burn Center Referral

According to the American College of Surgeons Committee on Trauma and the American Burn Association (ABA), burn injuries that should be referred to a burn center include:

1. Partial-thickness burns of greater than 10% of the total body surface area (TBSA);
2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints;
3. Third-degree (full-thickness) burns in any age group;
4. Electrical burns, including lightning injury;
5. Chemical burns;
6. Inhalation injury;
7. Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality;
8. Any patients with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality. In such cases, if the trauma poses the greater immediate risk, the patient’s condition may be stabilized initially in a trauma center before transfer to a burn center. Physician judgment will be necessary for such situations and should be in concert with the regional medical control plan and triage protocols;
9. Burned children in hospitals without qualified personnel or equipment for the care of children;
10. Burn injury in patients who will require special social, emotional, or rehabilitative intervention.

If the patient meets any of the above criteria, they are best managed at a verified burn center. If in doubt, contact the burn center for consultation. 

Transfer Notification, Equipment, and Other Preparations  

Based on the information provided by the transferring hospital, obtain the equipment and supplies needed to support the patient during the transfer. It may also be necessary to add staffing to the ambulance for specialty care such as ventilator management, or simply a second (or third) person who can assist with care during the transfer. Critical care paramedics, certified flight paramedics, and flight nurses have undergone additional training and will have the equipment and resources needed. Most 9-1-1 paramedic providers will require additional resources, technical support, and trained personnel.

Consider the ambulance available (size, air vs. ground) and total time required to the destination. Does the vehicle have sufficient fuel or a refueling strategy to complete the transfer? Other equipment that may be needed during a transfer includes: 

Ventilator—Patients who are on a hospital-based ventilator typically have additional settings beyond rate and volume. Where available, a transport ventilator with someone who is credentialed in its use is indicated. 

Cardiac monitor—Depending on the volume replacement and time lapse from the initial burn until transfer, electrolyte imbalances may have begun, which can lead to ECG changes. Imbalances can include hypo- and hyperkalemia and hypo- and hypercalcemia; ECG changes may include ventricular dysrhythmias, tall and peaked T-waves, the presence of a U-wave, or wide and bizarre QRS complexes. Patients with electrical burns are also susceptible to cardiac dysrhythmias and should be monitored throughout the transfer.⁹ Treat dysrhythmias caused by electrical shock the same as those associated with cardiac events. 

End-tidal carbon dioxide (EtCO₂) monitor—Patients with burn injuries should be evaluated for potential respiratory injuries to include inhalation injury as well as circumferential burns around or across the chest that limit the depth and quality of respiration. 

Oxygen saturation (SpO₂) monitor—For many of the same reasons identified in EtCO₂, SpO₂ can be compromised, particularly with inhalation injuries. 

Noninvasive blood pressure monitor—Depending on the injury location, monitoring the blood pressure may require alternatives to the traditional upper arm. Frequent blood pressure monitoring is vital given the quantity and quality of pain medication that may be indicated for the patient with a burn injury. 

Intravenous pumps—Data suggests inconsistent and dangerous overuse and underuse of IV fluids with the management of critical burn injuries. The use of IV pumps can aid a steady and consistent infusion of fluids. 

Additional IV fluids—Patients with critical burn injuries may need multiple liters of IV fluids due to the nature of the body’s response to the injury. This includes interstitial fluid shift that leads to cellular depletion. The fluid that leaves the cell has a similar composition to the complex electrolyte solution found in lactated Ringer’s (potassium chloride, calcium chloride, sodium chloride, and sodium lactate). If LR is unavailable, 0.9% sodium chloride (NaCl) solution is not ideal but an acceptable substitute. 

Sufficient pain medication—Pain medication is administered until the pain is relieved or other medication administration endpoints are reached. The most commonly used pain medication is morphine sulfate (MS),¹⁰ which is administered in 2-mg increments until the pain is relieved or side effects such as hypotension, respiratory depression, or nausea appear. Mathematically, a sufficient amount of MS is not always routinely stocked on ambulances for long transports in this scenario. As an example, a three-hour transport may need as much as 72 mg of MS.

Alternative pain medication—Depending on how long the patient has remained at the transferring hospital, they may have already reached endpoints for the use of MS or other pain medications. A multimodal pain management approach may have been implemented and should also be considered, such as other narcotics, benzodiazepines, or an array of medications that may include IV acetaminophen. 

Ketamine may also be selected when strong analgesic and sedative effects are warranted and there is a desire to reduce opiate requirements.^10–13 Ketamine has become more common in EMS, with a third of paramedics currently using it under protocol.^10,11 Ketamine’s most common indication is followed by sedation for intubation or agitation. It has been shown to demonstrate better analgesia compared to MS and reduce secondary hyperalgesia and windup pain.¹³ Ketamine can be intravenously dosed at 0.5–2 mg/kg/hr or 0.1–0.35 mg/kg IV one time to treat moderate to severe pain. Alternatively, it can be administered at 10 mg intranasally every 90 seconds up to a total dose of 50 mg.¹⁴  

Supplemental medications—Medications known as phenothiazine antiemetics should be readily available, given the amount of pain management medication that may be used. Antiemetics include Zofran, Compazine, and Phenergan (rely on your local protocol). Narcan should also be available, given the tenuous balance of managing pain while not substantially suppressing critical life functions. 

Tympanic membrane thermometer—The integumentary system (skin, hair, nails) is the largest system of the body. Significant damage to the skin can lead to hypothermia. This is a commonly overlooked problem with patients who have serious burn injuries. Increased mortality has been noted in patients with 20%–39% TBSA burns, as well as patients with 40% or more TBSA burns who arrive at the hospital by EMS with a core temperature 97.7°F (36.5°C) or below.¹⁵ Hypothermia is more pronounced in older patients and pediatric patients. The patient’s temperature must be monitored, and the air temperature in the ambulance patient care area should be maintained between 85°F–100°F (29.4°C–37.8°C) and adjusted to keep the patient normothermic. 

Equipment to treat hypothermia—Previous literature has demonstrated that up to 42% of patients suffering burn injury are hypothermic on arrival at the hospital. The first treatment of hypothermia is to reduce further heat loss by transferring the patient to a warm ambulance and removing cold or wet clothing. Equipment to conserve body heat, such as reflective blankets, is essential. Consider equipment to aid in rewarming, such as fluid warmers or warmed forced-air delivery devices, depending on the transportation time and climate hazards of a region.^15,16 The equipment to maintain normothermia or treat hypothermia may include a fluid warmer. 

Oxygen—The distance traveled for a burn center transfer may be farther than the typical referral hospital. Having sufficient humidified oxygen for the duration is essential. The typical M oxygen cylinder, when full and pressurized at 3,450 PSI, will yield 3,000 liters. A nonrebreather mask that needs 10 lpm will use a fully pressurized M cylinder in five hours. Other large cylinders used in fixed systems include H and K cylinders. Both can be pressurized to 4,500 PSI and when full can store up to 6,900 liters. Seldom does an ambulance routinely maintain a full cylinder on board. Verify what is available and, if needed, obtain additional oxygen before the transfer. 

Additional equipment that may be utilized depending on availability and patient need includes:

12-lead cardiac monitor—This may be needed for a patient with an electrical injury or metabolic induced dysrhythmias. 

i-STAT or similar testing/monitor device—This device, with the appropriate cartridges, can provide point-of-care testing of arterial blood gas, electrolytes, complete blood count, and other common lab tests that may be indicated depending on the length of transport and personnel credentialed to use the device. 

Conclusion

The geography to be covered and resources available when transporting a burn patient interfacility, including transport vehicles, vary significantly from community to community. This guide was developed to help ensure the needs of the burn-injured patient are met based on current science. Nevertheless, EMS clinicians should always rely on local protocol and medical control should there be uncertainty or variance in treatment practices.  

Sidebar: Needed Equipment

• Ventilator
• Cardiac monitor
• EtCO₂  monitor
• O₂ sat monitor
• NIBPM
• IV pumps
• Lactated Ringer’s solution
• Pain medications
• Supplemental medications (phenothiazine antiemetics) 
• Tympanic membrane thermometer
• Oxygen

Recommended Equipment

• 12-lead cardiac monitor
• i-STAT or similar testing device
• Fluid warmer

References

1. American Hospital Association. Fast Facts on U.S. Hospitals 2020, www.aha.org/statistics/fast-facts-us-hospitals. 

2. American Burn Association. Burn Center Regional Map, https://ameriburn.org/public-resources/burn-center-regional-map/. 

3. Klein MB, Kramer CB, Nelson J, et al. Geographic access to burn center hospitals. JAMA, 2009; 302(16): 1,774–81. 

4. Hick JL. Right care, right place, right time. Regional systems of care are the best way to ensure patients with emergent conditions have the best outcomes. Minnesota Medicine, 2015; 98(5): 32–3. 

5. Klein MB, Nathens AB, Emerson D, et al. An analysis of the long-distance transport of burn patients to a regional burn center. J Burn Care Res, 2007; 28(1): 49–55. 

6. Ahmed A, Van Heukelom P, Harland K, et al. Characterizing demographics, injury severity, and intubation status for patients transported by air or ground ambulance to a rural burn center. J Burn Care Res, 2014; 35(3): e151–8. 

7. Vercruysse GA, Friese RS, Khalil M, et al. Overuse of helicopter transport in the minimally injured: A health care system problem that should be corrected. J Trauma Acute Care Surg, 2015; 78(3): 510–5. 

8. Roman J, Shank W, Demirjian J, et al. Overutilization of Helicopter Transport in Smaller Burns—A Healthcare System Problem That Should Be Corrected. J Burn Care Res, 2020 Jan 30; 41(1): 15–22. 

9. Sun CF, Lv XX, Li YJ, et al. Epidemiological studies of electrical injuries in Shaanxi province of China: a retrospective report of 383 cases. Burns, 2012 Jun; 38(4): 568–72. 

10. Griggs C, Goverman J, Bittner EA, Levi B. Sedation and Pain Management in Burn Patients. Clinics Plastic Surg, 2017; 44(3): 535–40. 

11. Buckland DM, Crowe RP, Cash RE, et al. Ketamine in the Prehospital Environment: A National Survey of Paramedics in the United States. Prehosp Disaster Med, 2018; 33(1): 23–8. 

12. Zorumski CF, Izumi Y, Mennerick S. Ketamine: NMDA Receptors and Beyond. J Neurosci, 2016; 36(44): 11,158–64. 

13. Edrich T, Friedrich AD, Eltzschig HK, Felbinger TW. Ketamine for long-term sedation and analgesia of a burn patient. Anesth Analg, 2004; 99(3): 893–5, table of contents. 

14. Epocrates, www.epocrates.com/mobile/iphone/essentials. 

15. Weaver MD, Rittenberger JC, Patterson PD, et al. Risk factors for hypothermia in EMS-treated burn patients. Prehosp Emerg Care, 2014; 18(3): 335–41. 

16. Du Pont B, Dickinson E. Identifying and Managing Accidental Hypothermia. J Emerg Med Serv, 2017; 42(11). 

Randy D. Kearns, DHA, MSA, FACHE, FRSPH, CEM, is an assistant professor in the College of Business Administration at the University of New Orleans and a retired clinical assistant professor from the School of Medicine at the University of North Carolina. 

Christopher K. Craig, DMSc, MMS, PA-C, is assistant professor of surgery and senior physician assistant for trauma/burn services and disaster and prehospital services at Wake Forest University.

Eugene Elliott, MPH, MPA, MS, NRP, is a program analyst for the Department of Health and Human Services, program director for public safety and emergency management at Pamlico Community College, a staff paramedic for the CarolinaEast Health System, and adjunct EMS faculty at Anna Maria College.

Charles Burnell, MD, FACEP, is chief medical officer for the Acadian Companies.

Jeffrey E. Carter, MD, FACS, is associate professor of surgery at the Louisiana State University Health Science Center New Orleans and medical director of the University Medical Center Burn Center, New Orleans.