EMT STANDING ORDERS:

• Routine Patient Care. (Scene Safety and BSI)
• Remove the Patient from the source of hazard if safe.
• Call for AEMT/Paramedic intercept. & Assisst AEMT/Paramedic in patient care.
• Assess for evidence of smoke inhalation or burns; soot around mouth or nostrils, singed hair, carbonaceous sputum.
• If the patient has respiratory difficulty, altered level of consciousness and /or hemodynamic compromise, see Airway Management Protocol - Adult or Airway Management Protocol - Pediatric and Smoke Inhalation/Carbon Monoxide Poisoning Protocol - Adult or Smoke Inhalation/Carbon Monoxide Poisoning Protocol - Pediatric.

Thermal:

• Stop burning process with water or normal saline
• Cut/remove non-adherent clothing and jewellery. Do not remove skin or tissue.
• To protect from infection, cover burns with clean dry sterile dressing or sheets.
• Keep patient warm and prevent hypothermia due to large thermal injuries.

Chemical:

• Identify agent(s) and consider HAZMAT intervention, if indicated. See Hazardous Material Exposure Protocol (1 Hazardous Materials).
• Consider contacting Oman Poison Control Center at 24560019.
• Decontaminate the patient as appropriate.
  • Brush off dry powders if present, before washing.
  • Scrape viscous material off with a rigid device, e.g., a tongue depressor.
  • Flush with copious amounts of clean water or sterile saline for 10 - 15 minutes, unless contraindicated by type of chemical agent (e.g., sodium, potassium or dry lime and/or phenols).

Electrical/Lightning:

• Ensure your own safety; disconnect the power source.
• For MCI associated with lightning, cardiac arrest patients should receive first priority.
• Consider spinal motion restriction for burns due to electric flow across the body.
• In events of multiple casualties involved in electrocution "revers" triage should be performed.

Assess Extent of Burn:

• Determine extent of the burn using the Rule of Nines (see next page).
• Determine the depth of injury.
• Do not include 1^st degree burns in burn surface area (BSA) percentage.

AEMT/PARAMEDIC Standing Order - ADULT:

• Establish IV access.
• Transport time less than 1 hour:
• Administer warm 0.9% NaCl/LR at 500 mL/Hour.
• Transport time greater than 1 hour and 2 ^nd or 3 ^rd degree burns involving ≥ 20% BSA:

Burn Area X Pt. Wt. in Kg / 4 = # mL/hour, over the first 8 hours 0.9% NaCl/LR IV.

Example: 20% burned area, patient weighs 70kg. 20x70 = 1400/4 = 350 mL/h

Pain Control

• If a partial thickness burn, 2 ^end degree is < 10% body surface area:
  • Apply room-temperature water or room-temperature wet towels to burned area for a maximum of 15 minutes. Prolonged cooling may result in hypothermia.
  • For patients in severe pain and blood pressure at least 100mmHg consider Morphine sulphate 2 - 5 mg slow IV/IO push to maximum dosage of 10mg.
  • Reassess every 3-5 minutes after administration of morphine sulphate.
  • Never Administer IM Pain Injections to a burn patient.

ADVANCED EMT STANDING ORDERS - PEDIATRIC

• Establish IV access.
• Transport time less than 1 hour:
  • 5 - 15 years of age: 250 mL/hr 0.9% NaCl/LR.
  • 2 - 5 years of age: 125 mL/hr 0.9% NaCl/LR.
  • Less than 2 years of age: 100 mL/hr 0.9% NaCl/LR.
• Transport time greater than 1 hour and 2nd or 3rd degree burns involving ≥15% body surface area:
  • Burn Area x Pt. Wt. in Kg / 4 = # mL/hour x first 8 hours 0.9% NaCl/LR IV.

Example: 20% burned area, patient weighs 30 kg. 20x30 = 600/4 = 150 mL/hr.

An IO device can be inserted through burned skin as long as the underlying bone has not been compromised.

PARAMEDIC STANDING ORDERS Refer to:

• Airway Management Protocol - Adult or Airway Management Protocol - Pediatric.
• Pain Management Protocol - Adult & Pediatric.

To Add the Rule of Nine Diagram

Expert burn center opinion recommends limiting prehospital IV fluids based on concerns for fluid overload and development of compartment syndrome. In cases where burn patients are in shock, IV fluid administration should be based on use of the Shock Protocol - Adult or Shock Protocol - Pediatric.

PEARLS:

• Apnea may last longer than asystole in lightning injuries. Provide ventilatory support.
• Electrocution/lightning burns can occur anywhere along the path a current travel through the body. Evident surface burns may only comprise a small portion of the overall burn injury, and an injury’s full extent may not be immediately apparent.
• Chemical burns: If 0.9% NaCl or sterile water is not readily available, do not delay; use tap water for flushing the affected area. Flush the area as soon as possible with the cleanest readily available water using copious amounts of water.