The patient with burns presents a difficult challenge to most health personnel. Apart from the severity of the injury, there is the distress to patient and relatives to manage, as well as the uncertainty of their personal, employment and financial future. In addition to these factors, the surgical maxim that the trauma patient who is seen, assessed and treated early by skilled personnel heals more quickly than the delayed patient is true for the burn victim, as well as the trauma patient.
The emergency management of severe burns (EMSB) is a one-day didactic and interactive course essential for any medical professional exposed to the burnt patient in either the prehospital, hospital or emergency context. This course is based on the principle that timely emergency assessment, resuscitation and transfer provide the best chance of recovery in patients with burns. The aim of the course is to provide sufficient factual information, guidelines and protocols regarding the initial management of the patient with severe burns to enable medical, nursing and emergency practitioners to deal competently and confidently with this problem. It is designed to be a stand-alone course but it can also be taught in conjunction with ATLS.
Epidemiology
In the UK, approximately 250 000 people are burnt each year. Of these, 175 000 attend accident and emergency departments, and 13 000 of these are admitted to hospital. Some 1000 patients have severe enough burns to warrant formal fluid resuscitation; half of these are children under 12 years. In an average year, 300 burn deaths occur. These UK figures are representative of most of the developed countries, although some, such as the US, have a higher incidence.
Burns are also a major problem in the developing world. Over two million burn injuries are thought to occur each year in India (population 500 million), but this may be a substantial underestimate. Mortality in the developing world is much higher than in the developed world. For example, Nepal has approximately 1700 burn deaths a year for a population of 20 million, giving a death rate 17 times that of the UK. Most burns are due to flame injuries. Burns due to scalds are the second most common.
The most infrequent burns are those caused by electrocution and chemical injuries. The type of burns suffered is related to the type of patient injured. It is therefore useful to break down burn aetiology by patient groups as this reveals the varying causes of injury. In most groups, there is a male predominance. The only exception is in elderly people, among whom more women are injured because of the preponderance of women in that population.
Children aged up to 4 years comprise 20% of all patients with burn injuries. Most injuries (70%) are scalds due to children spilling hot liquids or being exposed to hot bathing water. These mechanisms can lead to large area burns. Because of changes in the design and material of night clothing, flame burns are less common than they were. Boys are more likely to be injured, a reflection of the behavioural differences between boys and girls. Ten percent of burns happen to children between the ages of 5 and 14. Teenagers are often injured from illicit activities involving accelerants, such as petrol, or electrocution.
Most burns (> 60%) occur in patients’ aged 15-64. These are mainly due to flame burns, and up to a third are due to work related incidents. Some 10% of burns occur in people aged over 65. Various effects of ageing (such as immobility, slowed reactions, and decreased dexterity) mean elderly people are at risk from scalds, contact burns, and flame burns. Burn victims’ health is often compromised by some other factor, such as alcoholism, epilepsy, or long-term psychiatric or medical illness. All such problems need to be addressed when managing patients in order to speed recovery and prevent repetition of injury.
EMSB course
The one-day course is run in various centres across the UK throughout the calendar year and incorporates the following components:
Course manual
This contains the complete syllabus of the course and is sent to students beforehand. It is expected that the manual is read twice before the course and a study guide is provided to assist with learning. The manual provides all the information required to both pass the course and provide the healthcare provider a good grounding in the practical aspects of managing acute burns. The manual begins with chapters on the aetiology, epidemiology and burn physiology and then progresses to dealing with inhalational injury, burn wound assessment, management, and burns shock and fluid resuscitation. Special burns such as chemical and electrical burns as well as paediatric burns are covered. The burns referral pathway and guidelines and the outpatient management of burns completes the topics covered.
Formal lectures
These take place at the start of the course, in the morning and reinforce the reading in the manual as well as providing a broader view than the written text, highlighting the relevant and key learning points. The lectures are didactic in nature. There are opportunities for questions, but the bulk of discussions will occur later in the course, or at any point with a free instructor throughout the day.
Skills stations
Important practical aspects of the course are taught in these stations in greater depth with candidates given the possibility to practice the skills. The areas covered are as follows:
Interactive discussion groups
Small group teaching sessions take place addressing the various issues of managing, treating and resuscitating different types of burns and burn patients. Candidates are able to use their own clinical experience and expand on topics to help their understanding. Role-playing making referrals, and discussing the treatment of different types of burns, chemical, industrial, thermal and electrical and the multiply injured trauma patient form the cornerstone of the group.
Simulated burns cases
Volunteers are placed in a moulage to simulate clinical cases of burns to give the candidate practical experience of managing a severe burn. In this section the prior learning is consolidated and applied making it clinically relevant. The cases involve ‘real’ subjects and either course facilitators or volunteers pose as patients and are treated accordingly, similar to an ATLS moulage.
Examination and clinical test
At the end of the day, a multiple choice exam is taken and a clinical case via a simulated moulage is examined. These will test both the candidates’ knowledge and the effectiveness of the teaching. The clinical scenario is made as life-like as possible with live models and make up designed to replicate differing depth of burns and potential associated injuries. A time limit is placed on the candidate for the scenario. In the time frame, the candidate must score as many points as possible following the structured algorithm as taught in the course.
The scores from the moulage and the written test are collated and candidates are informed on the day as to whether they have passed or failed. Failure of the course requires the candidate to re-sit the examinations on a separate occasion. Candidates who have shown a good attitude, aptitude and have scored highly on the written test are invited to train as instructors at a later date.
Course details
The EMSB course is run by the British Burns Association, a non-profit making charitable organisation with a mandate to promote and disseminate knowledge in the treatment and prevention of burns. The one-day course is run at different venues throughout the country at regular intervals all year round. For those personnel in the military a special two-day course is run covering the same territory as the normal course, but in addition there are military specific modules on the second day. The course fee is £100.
Conclusion
The emergency management of severe burns is an enjoyable and informative course, which is a necessity for any medical professional that regularly sees acute burns.