Here’s a list I’ve had for a while but not published: obvious, less obvious, and utterly surprising reasons your alive patient might be pale. References within. Detailed reference list coming soon.
Image above – a person with vitiligo (Source: Adobe Stock)
Drugs – Amiodarone can cause a ‘bluish-grey’ skin discoloration (Douglas et al, 2013: 44)
Vitiligo (segmental and non-segmental) due to the lack of melanin, causes ‘pale patches of skin’ (Douglas et al, 2013: 46); non-segmental vitiligo ‘is thought to be an autoimmune condition’ (NHS – Vitiligo)
Earlier this year I had the pleasure of speaking with a patient with Functional Neurological Disorder (FND). Ailsa reached out to the College of Paramedics after experiencing an unsettling mixture of treatment by healthcare professionals in a variety of settings. She hopes to encourage healthcare clinicians to learn more about her condition, a functional neurological disorder. Our understanding of this group of conditions is currently being reshaped, so I agree it is another area in which we must stay up-to-date.
The publication of this post on Article 999 comes at a timely moment as just two days ago I read here that a study published in Epilepsy and Behaviour has documented MRI changes in patients with functional seizures. This furthers the point that what science and medicine thought it knew about this – and perhaps other conditions – while not fiction, is also not yet fact.
Members of the College of Paramedics can read the published article in last month’s issue of Paramedic INSIGHT or online here.
If you, like me, struggle to understand the action potential, here is a great video from UBC Medicine, which explains the concept with dominoes. Check it out below.
Content warning: This video may contain sensitive content.
This video demonstrates the assessment and management of burns, using equipment that is recommended within the locality at the time of production. Remember to check your local, current guidelines before putting anything into practice. Produced by HCPs and students.
This video demonstrates use of burn gel wraps, which may no longer be used in your ambulance Trust. Please check your local guidelines regarding this. According to the British Burn Association:
Burn gel wraps may be used to provide analgesia, but only after adequate cooling has occurred as they do not actively remove heat from the wound
Varley et al (2014)
Remember to follow good IPC in real life.
The transcript below has been slightly edited, with titles added, to make it easier to read.
You must read the full disclaimer at www.article999.co.uk/disclaimer and check your local guidelines before putting into practice any of our content.
BURNS: The practical stuff
This video contains content some might find sensitive.
Treatment
With all assessments and interventions, use an aseptic technique, especially because ‘burns are prone to infection’
Purcell, 2003: 217
Airway
The patient’s airway might worsen. Here’s why:
‘A burned patient may have a patent airway on the initial evaluation. […] In the time that follows, the face, as well as the airway, will likely swell.’
NAEMT, 2016: 411
… So, consider HEMS for RSI.
Breathing
The patient’s breathing might worsen. Here’s why:
Is there a chest wall burn?
‘Burns constrict the chest wall similarly to having several leather belts progressively tightening around the patient’s chest. As time progresses, the patient cannot move the chest wall to breathe.’
NAEMT, 2016: 412
So, consider HEMS and ventilatory support where needed.
Other considerations:
Inhaled toxins ‘can produce asphyxiation’
NAEMT, 2016: 412
If: – LOC in a fire with ‘heavy smoke’ – trapped patient in a fire consider O2
El-Helbawy & Ghareeb, 2011
Circulation
Swelling might get worse. Here’s what to do about it:
‘Distal limb perfusion may be critically reduced’; ‘Burned extremities should be elevated during transport to reduce the degree of swelling in the affected limb’
NAEMT, 2016: 412
A complication of swelling:
Fluid loss occurs from swelling and evaporation
NAEMT, 2016: 416
Giving Fluids – Pros and Cons
Consider IV fluids, especially if the burn is >10% of the body (AACE, 2016: 265-266). Keep watching for info on how to determine this.
Give fluids with caution. Too much -> ‘cardiac failure, […] infectious complications, acute respiratory distress syndrome, and even death’.
Too little -> ‘hypovolemic shock, organ failure’
(NICE, 2016)
Judicious fluid management of children with severe burn injury can improve the respiratory outcome measures of these children
Duran and Sheridan, 2016
Cannulating – Essentials
When cannulating, ‘placement through the burn is appropriate [only] if no alternative sites are available’
NAEMT, 2016: 412
What about heat?
Patients with burns are not able to maintain their own body heat
NAEMT, 2016: 413
…So, give blankets
ECGs
ECGs are required for electrical burns (AACE, 2016: 265) but consider them for all burns as ‘cardiac dysrhythmias’ result from the release of ‘muscle potassium’ (NAEMT, 2016: 418) and studies have shown disturbances in the cardiac functions of in-hospital burn patients (Jeschke et al, 2008).
Disability
Do your BMs
Hyperglycemia may occur in burns patients and has a higher risk of ‘morbidity and mortality in critically ill patients’ (Wolfe et al, 1979; Mecott et al, 2010).
Pain management in children
In children, ‘a multi-modal approach to pain and sedation can improve the neurological status of severely burned children’
Duran and Sheridan, 2016
Expose/Examine
Cooling the burn:
Cool with a wet compress
Purcell, 2003: 217
‘Cooling gels such as Burnshield are often used by paramedics. These are useful in cooling the burn and relieving pain in the initial stages.’ *
Be aware of the risk of ‘heat loss’
Hudspith and Rayatt, 2004
*This guidance is changing. Check your local guidance first, and consider the use of cling-film after running water.
Documentation during examination:
Assess and document:
‘Burn depth & features’ (Purcell, 2003: 217)
Other considerations:
Anticipate Swelling. Take off jewelry. Be aware that these and clothing ‘retain residual heat’ (NAEMT, 2016: 413).
Cooling – more details
Irrigate early to cool and prevent further burning.
Chemical burns: 15 mins min (AACE, 2016: 265)
All burns: Max 20 mins (AACE, 2016: 266)
This is most effective ‘within 20 minutes of the injury’ (Hudspith and Rayatt, 2004).
Don’t use ice cold water as ‘intense vasoconstriction can cause burn progression’ (Hudspith and Rayatt, 2004).
When using cling film
Discard ‘the first few centimetres’ to be aseptic
‘lay this on the wound rather than wrapping the burn’ to anticipate swelling
(Hudspith and Rayatt, 2004)
Consider using wet dressings instead in chemical burns (Allison and Porter, 2004)
Estimating total burns
Consider the use of tools to estimate the total body percentage of the burns (NICE, 2016; Mersey Burns, 2013).
Transport
Using those tools [such as Mersey Burns] will help determine the right treatment centre for the patient and the treatment priority.
Time critical features:
major abcd problems
airway burns
history of hot air or gas inhalation
respiratory distress
burns that completely encircle the chest, neck, or limb
significant facial burns
burns >10% total body area
‘presence of other major injuries’
(AACE, 2016: 266)
References
Association of Chief Ambulance Executives (AACE), 2016. UK Ambulance Services Clinical Practice Guidelines. Bridgwater: Class Professional Publishing
Allison, K. and Porter, K. 2004. Consensus on the prehospital approach to pain management. Emergency Medicine Journal. 21 (1), pp. 112-114
Duran, C. and Sheridan, R.L. 2016. Current Concepts in the Medical Management of the Pediatric Burn Patient. Current Trauma Reports. 2 (4), pp. 202-209
El-Helbawy, R.H. and Ghareeb, F.M. 2011. Inhalation injury as a prognostic factor for mortality in burns patients. Annals of Burns and Fire Disasters. 24 (2), pp.82-88
Hudspith, J. and Rayatt, S. 2004. First aid and treatment of minor burns. BMJ. 328 (7454), pp. 1487-1489
Jeschke, M.G. et al. 2008. Pathophysiologic response to severe burn injury. Anals of surgery. 126, pp. 37-51
National Association of Emergency Medical Technicians (NAEMT). 2016. PHTLS. Prehospital Trauma Life Support, 8th Edition. Burlington: Jones and Bartlett Learning.
NICE, 2016. Mersey Burns for calculating fluid resuscitation volume when managing burns. Available at: https://www.nice.org.uk/advice/mib58/chapter/summary (Accessed 06/04/19)
Purcell, D. 2003. Minor Injuries. A Clinical Guide. Edinburgh. Elsevier.
St Helens and Knowsley Teaching Hospitals NHS Trust, 2013. Mersey Burns. Available at: https://merseyburns.com (Accessed 06/04/19)
*Stiles, K. and Goodwin, N. 2018. British Burn Association: First Aid Clinical Practice Guidelines. Available Online: https://www.britishburnassociation.org/wp-content/uploads/2017/06/BBA-First-Aid-Guideline-24.9.18.pdf (Accessed 29/03/21)
*Varley, A. et al. 2014. British Burn Association: First Aid Position Statement. Available Online: https://www.nbt.nhs.uk/sites/default/files/attachments/British%20Burn%20Association%20First%20Aid%20Position%20Statement.pdf (Accessed 29/03/21)
Wolfe, R.R. et al. 1979. Glucose metabolism in severely burned patients. Metabolism. 28 (10), pp. 1031-1039
