ARTICLE IN PRESS

Air Medical Journal ■■ (2018) ■■–■■

Contents lists available at ScienceDirect

Air Medical Journal

j o u r n a l h o m e p a g e : h t t p : / / w w w. a i r m e d i c a l j o u r n a l . c o m /

Critical Care Update

Burn Care: Transfers and Toxins

Mithun R. Suresh, MD, David J. Dries, MSE, MD

Air medical providers are frequently tients should be transferred to a burn center Emergency Department Sample, which
called on to transfer burned patients, par- (Table 1). Many of these criteria relate to the produced a national estimate of 126,742 pa-
ticularly children. Recent literature calls location, mechanism, or severity of the burn. tients. Of this overall estimate, 69,003
standard transfer criteria into question and In addition, there are also criteria that rec- (54.4%) patients met at least 1 of the burn
reveals that children presenting in the emer- ommend the transfer of specific groups of referral criteria, and most of these pa-
gency department who may meet transfer patients, such as children or patients with tients, 57,382 (83.2%), were initially treated
criteria are often discharged. Furthermore, significant comorbidities or rehabilitation at low-volume hospitals, which were
although concern for carbon monoxide and needs. For patients who require transfer, defined as hospitals that admitted less than
cyanide exposure is not new in the setting emergency medical service (EMS) provid- 50 burn patients per year. Interestingly, only
of burn care, recent literature suggests a lack ers will often be needed to transport these a small percentage of the patients who met
of consensus regarding the use of avail- patients. This is particularly important with at least 1 referral criteria and were initial-
able therapies. Here are some recent children because of the unique equipment, ly treated at low-volume hospitals were
comments on these subjects. expertise, and personnel needed to care for transferred (8.2%), but the majority of pa-
these patients. tients (90.1%) were treated and discharged
American College of Surgeons Com- The study by Johnson et al examined pe- from the ED. Some of the factors associ-
mittee on Trauma. Guidelines for trauma diatric burn patients presenting to an ated with transfer in the patients meeting
centers caring for burn patients. In: emergency department (ED) and identi- referral criteria at low-volume hospitals
Rotondo MF, Cribari C, Smith RS (eds). Re- fied factors associated with transfer to were age < 5 years, partial thickness burns
sources for Optimal Care of the Injured another medical facility. The study identi- > 10% total body surface area (TBSA), partial
Patient. Chicago, IL: American College of fied pediatric burn patients in the 2012 thickness burns of the face/head/neck or
Surgeons; 2014:100-106. Nationwide Emergency Department Sample, genitalia, and full-thickness burns. Although
which is a database of discharge data from the destinations of these transferred pa-
Johnson SA, Shi J, Groner JI, et al. Inter- EDs of several hundred hospitals in the tients were not provided in this study,
facility transfer of pediatric burn patients United States. Using weighting variables as- presumably these patients were trans-
from U.S. emergency departments. Burns. sociated with this database, national ferred to regional burn centers because the
2016;42:1413-1422. estimates for ED data were obtained. In patients treated at low-volume hospitals in
2012, a total of 28,363 pediatric burn pa- this study were used as surrogates for
Warner P, Bailey JK, Bowers L, et al. tients were identified in the Nationwide patients treated at hospitals without
Aeromedical pediatric burn transporta-
tion: a six-year review. J Burn Care Res. Table 1
2016;37:e181-e187. Burn Center Referral Criteria

Burn Center Referral Criteria

Kashefi N, Dissanaike S. Use of air
transport for minor burns: is there room Partial-thickness burns of > 10% TBSA
Burns involving face, hands, feet, genitalia, perineum, and major joints
for improvement? J Burn Care Res.
Third-degree burns in any age group
2016;37:e453-e460. Electrical burns, including lightning
Burn injuries can be challenging to Chemical burns
manage, and many hospitals do not have the Inhalation injury
Burn injury with medical disorders that could complicate management
personnel, resources, and expertise to care
Burns and concomitant trauma
for these patients. Consequently, the Amer- Burns in children
ican Burn Association, in conjunction with Burn injury in patients who require special social, emotional, and rehabilitation considerations
the American College of Surgeons Commit- TBSA = total body surface area.
tee on Trauma, has developed referral Modified from Committee on Trauma American College of Surgeons. Resources for Optimal Care of the Injured Patient.
criteria to help providers determine that pa- Chicago, IL: American College of Surgeons; 2014:101.

1067-991X/$36.00
Copyright © 2018 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.amj.2017.12.001
 ARTICLE IN PRESS
2 M.R. Suresh, D.J. Dries / Air Medical Journal ■■ (2018) ■■–■■

significant experience caring for burn in- complications. Moreover, given the specif- described, including overestimation of burn
juries. Consequently, the authors pose the ic findings of this study, nonburn flight team size by referring facilities, lack of experience
question of whether more of the pediatric providers should pay particular attention to and resources to care for pediatric burn pa-
burn patients treated at low-volume hos- resuscitation and temperature control when tients, unfamiliarity with managing less
pitals should be transferred and suggest that transporting burn patients. common etiologies of burns (eg, chemical
this may lead to improved outcomes in Air transport is heavily used in rural and electrical), and concern for airway
these patients. Finally, the authors provide areas or by hospitals that are far from burn compromise and possible inhalation injury.
potential solutions to increase the transfer centers. Although this mode of transport is The authors conceded that all of the pa-
rate, which include improved communica- safe for patients, it should be used judi- tients in the study population met at least
tion between burn centers and transferring ciously. Air transport is expensive, and 1 of the standard referral criteria. Pro-
hospitals along with more detailed refer- insurance companies may only reimburse posed solutions to reduce the rate of air
ral criteria. some of the transport costs. This puts the transport overtriage for minor burn pa-
Unfortunately, the number of active burn patients at risk of having to pay for the tients include other modes of transportation
centers in the United States has declined transport bill out of pocket. Moreover, some (eg, ground ambulance and private
over recent decades, which implies that the patients who are brought to the burn center vehicles), telemedicine, improved commu-
nearest burn center may be a great dis- by air are discharged within 24 hours if their nication between referring facilities and
tance from the transferring hospital. In this injuries are minor. This raises the ques- burn centers, and revised referral criteria.
situation, air transport is often necessary. Air tion of whether air transport was necessary.
transport has been used for decades with Kashefi and Dissanaike examined this and Sheridan RL. Fire-related inhalation
burn patients, and burn flight teams, teams other questions in a recent study. A partic- injury. N Engl J Med. 2016;375:464-469.
of medical providers that specialize in the ular focus of this study was air transport
air transport of burn patients, are often resulting from overtriage, which was Dries DJ, Endorf FW. Inhalation injury:
tasked with transporting these patients. defined as discharge shortly after being epidemiology, pathology, treatment strat-
However, more rapid transport of these pa- brought to the burn center. This can be egies. Scand J Trauma Resusc Emerg Med.
tients is frequently possible with nonburn further defined as primary overtriage, which 2013;21:31.
flight teams. Consequently, it is important is discharge shortly after transport from the
for air medical EMS providers to have some point of injury, or secondary overtriage, Rose JJ, Wang L, Xu Q, et al. Carbon
experience with transporting burn pa- which is discharge shortly after transfer monoxide poisoning: pathogenesis,
tients. The challenges of transporting from another hospital. Both of these phe- management, and future directions of
“standard” critically ill and injured pa- nomena have been observed in patients therapy. Am J Respir Crit Care Med.
tients by air are well-known, but there are with minor burns who are discharged from 2017;195:596-606.
some unique aspects of transporting burn a burn center in less than 24 hours.
patients that all air medical EMS provid- The study population in this triage Dumestre D, Nickerson D. Use of
ers should consider. review consisted of 1,331 patients trans- cyanide antidotes in burn patients with
The recent study by Warner et al exam- ported by air and admitted to a single suspected inhalation injuries in North
ined the outcomes of pediatric burn patients regional burn center between January 2003 America: a cross-sectional survey. J Burn
transported to a single burn center by either and June 2013. There were 256 (19%) pa- Care Res. 2014;35:e112-e117.
a nonburn flight team or a dedicated burn tients in the “overtriaged” group because Inhalation injury results from direct
flight team between January 2007 and they were discharged within 24 hours (in thermal and chemical exposure. The
January 2013. Several outcomes were ex- the first 24 hours, 38 patients died). The rest immune response to this exposure is com-
amined, and there were some differences of the 1,037 (77.9%) patients were assigned bined with systemic effects of inhaled
between the 2 groups. Patients transported to the “accurately triaged” group because toxins, accrual of endobronchial debris, and
by nonburn flight teams were more hypo- they were hospitalized for more than 24 secondary infection. Structure fires gener-
tensive and hypothermic on admission to hours. Comparing the groups, the accurate- ate smoke containing a variety of chemicals,
the burn center than the patients trans- ly triaged patients had a higher mean TBSA products of incomplete combustion, and
ported by burn flight teams (P < .008 and P burned (15% vs. 3.3%, P < .0001), a higher aerosolized debris particles of varying sizes.
< .001, respectively). In addition, there was percentage of patients with partial-thickness Air temperature during fires varies enor-
lower hourly urine output and more vari- burns > 10% TBSA (44.6% vs. 2.3%, P < .0001), mously. Typically, at floor level, air
ability in urine output in patients transported and a higher percentage of patients with temperature can be hundreds of degrees
by nonburn flight teams compared with burn third-degree burns (26% vs. 7%, P < .0001) Fahrenheit. The effect on individuals is
flight teams. Despite these differences, both than the overtriaged patients. Moreover, in complex and unpredictable.
groups had similar complication rates, and the overtriaged group, 236 (92.2%, 17.7% Direct thermal damage is generally con-
neither group had any in-flight deaths. The overall) patients were transferred from other fined to the supraglottic airway except in
authors concluded that transporting pedi- medical facilities, and these patients were rare cases of steam inhalation, such as those
atric burn patients by air is safe, but nonburn classified as “secondary overtriaged.” involving inhalation of pressurized steam in
flight teams that do not have any experi- Given the frequency of air transport engineering spaces. Most injuries below the
ence transporting burned children should overtriage in this study, the authors con- glottis are caused by aerosolized chemi-
consider burn physiology in the child before clude that for patients with minor burns, in cals and incomplete products of combustion.
transport. Burned children are at an in- whom the injury severity and urgency for The type and severity of these injuries are
creased risk for hypoxia, hypothermia, and treatment is low, air transport may not be highly unpredictable depending on the
fluctuations in blood pressure with trans- necessary because the high costs associ- agents released and the particle size inhaled.
port conditions. Therefore, communication ated with this mode of transport may Smaller particles travel to a more distal lo-
between the burn center and flight teams outweigh the benefits and not change the cation in the airways before deposition. The
is imperative to ensure that burn patients management of these patients. Several pos- local effects of these particles include irri-
are stable for transport and to minimize sible reasons for the overtriage rate were tation, mucosal slough, bronchospasm,
 ARTICLE IN PRESS
M.R. Suresh, D.J. Dries / Air Medical Journal ■■ (2018) ■■–■■ 3

increased bronchial blood flow, surfactant baric oxygen therapy are frequently the most The current therapy for CO poisoning is
depletion, and inflammation. difficult to manage in this environment. 100% normobaric oxygen (NBO2) or hyper-
Intense inflammatory responses to in- CO poisoning is ideally diagnosed by the baric oxygen (HBO2) at 2.5 to 3 atm. NBO2
halation injury may occur, which can following clinical triad: 1) symptoms con- and HBO2 remove CO at a faster rate from
generate reactive oxygen species, attract in- sistent with CO poisoning (described the blood by increasing the partial pres-
flammatory cells, and trigger release of previously), 2) a history of recent CO expo- sure of oxygen, which increases the
numerous proinflammatory molecules and sure, and 3) elevated carboxyhemoglobin dissociation rate of CO from hemoglobin.
cytokines. Local pulmonary effects of in- levels. Symptoms associated with CO most NBO2 reduces the elimination half-life of CO
flammation include bronchospasm and commonly include headache, dizziness, from over 200 minutes in room air in some
vasospasm with bronchorrhea, alveolar fatigue, nausea and vomiting, altered men- reports to 74 minutes with NBO2. HBO2 can
flooding, bronchial exudative cast forma- tation, chest pain, and shortness of breath reduce the half-life of CO hemoglobin to 20
tion, and ventilation perfusion mismatching. with later loss of consciousness. Many pa- minutes. However, in actual clinical prac-
Systemic effects lead to a clinically signif- tients are found unconscious or severely ill, tice, the half-life may be higher, up to 42
icant increase in the volume of resuscitation making history unobtainable. The measure- minutes. Hyperbaric oxygen has shown
fluid required in patients with cutaneous ment of carboxyhemoglobin levels in blood a reversal effect on inflammation and mi-
burns in whom significant coincident in- serves as a confirmation of diagnosis due to tochondrial dysfunction induced by CO
halation injury is present. suspected exposure. poisoning. Although several randomized
One of the common toxins seen in smoke Clinical manifestations include critical studies suggest the benefit of HBO2 versus
inhalation is carbon monoxide (CO). This col- illness associated with progressive brain NBO 2 , the overall benefit is not consis-
orless and odorless gas is released during injury and cerebral edema. Characteristics tently demonstrated when meta-analyses
combustion and is rapidly absorbed after in- associated with high short-term mortality are conducted.
halation. CO avidly binds to heme-containing are pH values < 7.20, fire as a source of CO, The American College of Emergency Phy-
moieties such as hemoglobin and enzymes loss of consciousness, high carboxyhemo- sicians acknowledges HBO2 as a therapeutic
of the intramitochondrial cytochrome globin level, and a need for endotracheal option for CO poisoning but does not
system. This binding process results in intubation during hyperbaric oxygen mandate HBO2 use. Experts in HBO2 do rec-
reduced oxygen delivery through the for- therapy. ommend HBO2 use for CO poisoning. HBO2
mation of carboxyhemoglobin and reduced CO poisoning can cause profound car- is recommended by these practitioners for
oxygen use through impaired function of the diovascular effects. Up to one third of all cases of serious acute CO poisoning with
cytochrome cascade. Carboxyhemoglobin patients with moderate to severe CO poi- symptoms including neurologic, cardiovas-
levels of 10% to 20% are associated with soning present with myocardial injury, cular, and metabolic changes.
headache and nausea. Carboxyhemoglobin which may be associated with increased Hydrogen cyanide gas, another impor-
levels of 20% to 30% cause muscle weakness long-term mortality. Higher carboxyhemo- tant toxin associated with inhalation injury,
and impaired cognition, and levels of 30% globin levels are associated with both acute is released from the combustion of synthet-
to 50% are associated with cardiac ischemia and long-term development of myocar- ic polymers and is readily absorbed by
and unconsciousness. Higher levels are often dial ischemia. CO poisoning also increases inhalation. Similar to carboxyhemoglobin,
rapidly lethal. Prehospital treatment with the risk of developing an arrhythmia. The hydrogen cyanide interferes with oxygen use
oxygen may obscure the degree of initial CO inhibition of oxidative phosphorylation and at the cytochrome level and is thought to
exposure as carboxyhemoglobin levels begin reduced cellular “energy” availability alter be a contributor along with anoxia and CO
to normalize when the patient breathes 100% calcium gradients, leading to increased poisoning to early death from acute inha-
oxygen. Resolution of the insult to the cy- calcium sensitivity of myofilaments, in- lation injury. Cyanide intoxication is
tochrome system likely takes longer. creased diastolic intracellular calcium, and characterized by persistent acidosis despite
Another reason for the difficulty in de- a hyperandrogenic state. The most common otherwise successful resuscitation.
tecting CO injury is the similar absorbent electrophysiology disturbance from CO Signs and symptoms of cyanide poison-
spectrum of carboxyhemoglobin and oxy- appears to be the disruption of repolariza- ing are secondary to profound hypoxia and
hemoglobin. Pulse oximeters cannot tion and prolongation of the QT interval. begin less than 1 minute after inhalation.
distinguish between the 2 forms of hemo- Survivors of CO poisoning suffer from These signs include almond-smelling breath,
globin. The partial pressure of oxygen in long-term neurologic sequelae related to tachycardia, and hypertension quickly fol-
arterial blood measure from arterial blood brain injury. Symptoms include impaired lowed by bradycardia and hypotension with
gas reflects the amount of oxygen dissolved memory, cognitive dysfunction, depres- neurologic symptoms, such as headache and
in plasma but does not quantitate hemo- sion, anxiety, and vestibular or motor confusion. Progression to seizures, a de-
globin saturation, the most important deficits. These deficits are evident by 6 creased level of consciousness, coma, severe
determinant of the oxygen-carrying capac- weeks, with studies showing a greater than cardiovascular compromise leading to
ity of the blood. Carboxyhemoglobin levels 40% incidence of depression, anxiety, and cardiac arrest, and, ultimately, death occur
may be measured directly, but this test is cognitive irregularity. Although patients may within minutes to hours. These conse-
frequently not available at the incident scene. improve over many months and even up to quences are avoidable if poisoning is rapidly
The half-life of carboxyhemoglobin is at 1 year, at 6 years after CO poisoning, pa- recognized and treated with an antidote.
least 250 minutes for the victim breathing tients still exhibit a 19% incidence of defined Because of the short half-life of cyanide, no
room air. This is reduced dramatically with cognitive deficits and a 37% incidence of investigations can both confirm poisoning
inhalation of 100% oxygen. Although hy- other neurologic abnormality. In studies of and allow for timely treatment. Lactate
perbaric oxygen will further reduce the half- patients over 30 years after CO poisoning, levels are markers for cyanide toxicity, but
life of carboxyhemoglobin, the hyperbaric intellectual disturbances were found in even these may delay treatment and are
chamber is a difficult environment in which nearly 70% of affected individuals, and neu- more useful to quantify treatment effects
to monitor the patient, perform fluid re- rologic symptoms were found in nearly 50% and determine further management plans.
suscitation, and provide initial wound care. of patients, showing the irreversible nature Therefore, to effectively treat patients with
Patients with the greatest need for hyper- of some neurologic insults. cyanide poisoning, an antidote generally
 ARTICLE IN PRESS
4 M.R. Suresh, D.J. Dries / Air Medical Journal ■■ (2018) ■■–■■

needs to be administered based on a pre- recommended. If the patient does not meet air. This mode of transport is safe, as
sumptive diagnosis. these criteria, antidote administration is seen in the results from a recent study
Pharmacotherapy options for cyanide not recommended. However, 1 study rec- examining pediatric burn patients trans-
toxicity include a standard antidote kit con- ommends immediate administration of 2.5 g ported by nonburn and burn flight
taining amyl nitrate, sodium nitrite, and hydroxocobalamin in the prehospital setting teams. Of note, the patients in this study
sodium thiosulfate or hydroxocobalamin. in which numerous patients are exposed transported by nonburn flight teams
The kit and hydroxocobalamin are the 2 an- to inhalation toxicity and rapid thorough were more likely to be hypotensive and
tidotes currently used in North America. assessment is unavailable. Ideally, arterial hypothermic on arrival to the burn
Nitrites in the antidote kit for methemo- blood gas data and lactate, carboxyhemo- center than the burn flight team pa-
globin bind to and chelate cyanide. Side globin, and cyanide levels should be tients. Consequently, nonburn flight
effects of the kit include interference with obtained in every patient to assist with teams should pay close attention to en-
the oxygen-carrying capacity of hemoglo- overall management and allow diagnosis suring their patients are normotensive
bin, hypotension, and vasodilation leading and data collection for later studies. and normothermic during transport.
to hemodynamic instability. Because some Despite a growing body of supportive • Although air transport of burn patients
of these patients may have coincident CO physiologic data, a recent survey suggests is safe, it needs to be used appropriate-
poisoning, oxygen delivery may be com- the inconsistent use of cyanide antidote ly or else overtriage may occur.
promised. Methemoglobin produced by strategies in patients sustaining inhala- Moreover, for patients with minor burns,
nitrites also complicates oxygen delivery. tion injury. For example, in patients with the costs of air transport may out-
Sodium thiosulfate avoids complications suspicion for significant smoke inhalation, weigh the benefits.
with oxygen transport, but slower onset of the majority of burn directors responding • It is valuable to remember that
action limits its role as the sole antidote for did not test for cyanide on admission. Given conventional pulse oximetry cannot dis-
rapid treatment of cyanide poisoning. In the clinical suspicion of cyanide poison- tinguish between carboxyhemoglobin
contrast, hydroxocobalamin directly binds ing, most responding centers did not and oxyhemoglobin. Similarly, stan-
cyanide to form cyanocobalamin, which is empirically administer an antidote. The dard blood gas data measures only
renally excreted and nontoxic. It does not most commonly available antidote reported dissolved oxygen and again will not
affect oxygen transport and improves he- was hydroxocobalamin followed by the detect carboxyhemoglobin.
modynamic response. cyanide antidote kit. Opinion regarding the • The current therapy for carbon monox-
A growing body of data provides evi- instant administration of hydroxocobala- ide poisoning is 100% normobaric oxygen
dence supporting hydroxocobalamin as the min when inhalation injury is clinically or hyperbaric oxygen. These therapies
preferred cyanide antidote. The effects of suspected was mixed. Thirty-one percent of remove carbon monoxide at a faster rate
this agent are ideal for use in the burn pop- responding burn directors believed hydroxo- from the blood by increasing the partial
ulation with inhalation injury because cobalamin was unlikely to cause harm, pressure of oxygen and increasing the
hydroxocobalamin does not affect the treat- thought it could help significantly, and sup- dissociation rate of carbon monoxide
ment of CO poisoning and does not ported empiric use. Seventeen percent of from hemoglobin.
compromise oxygen delivery. This agent also burn directors believed hydroxocobala- • Although hyperbaric oxygen is a thera-
has the ability to improve hemodynamic min was of no use and did not support its peutic option for carbon monoxide
status in the hypotensive patient. When use, whereas 52% of burn directors respond- poisoning, it is not mandated. Hyper-
used in healthy volunteers and smoke in- ing had varying degrees of confidence in the baric oxygen should be seriously
halation victims, the most common adverse usefulness of this agent. considered for cases of severe carbon
effects are chromaturia and reddening of Of the centers declining to use hydroxo- monoxide intoxication, including loss of
the skin. These changes are self-limited and cobalamin, most believe that this antidote consciousness, ischemic cardiac changes,
asymptomatic but create concern because was unlikely to help patients although it did neurologic deficits, metabolic acidosis, or
of potential interference with clinical ex- not cause harm. These centers frequently a carboxyhemoglobin level > 25%.
amination and photometric-dependent considered hydroxocobalamin to be a waste • Despite an improved safety profile, many
investigation. Less common adverse reac- of money. Other reasons given for avoid- burn centers do not use hydroxocobala-
tions of hydroxocobalamin include rash, ing hydroxocobalamin were the lack of min as empiric therapy in patients
headache, injection site reaction, lympho- experience and information on its risk- exposed to cyanide as part of smoke in-
penia, nausea, pruritus, chest discomfort, benefit ratio. In all, one third of the 90 burn halation. Hydroxocobalamin has an
dysphagia, and allergic reactions. Hydroxo- directors who received surveys provided improved safety and efficacy profile in
cobalamin is typically given in doses of 5 g responses. comparison with the standard cyanide
(70 mg/kg) up to a maximum of 10 g per antidote kit.
patient. The cost of a 5-g vile of this agent Summary Points
is US $800 to $900 with a shelf life of 30
months. The cost of a cyanide antidote kit • A recent study examined pediatric burn Acknowledgments
is closer to US $100 to $200. patients treated at emergency depart- The authors gratefully acknowledge the
Despite the price difference, a recent ments in the United States and found assistance of Ms. Sherry Willett in prepa-
European consensus statement and an that with patients initially presenting to ration of this series for Air Medical Journal.
American recommendation advise 100% hospitals that admit few burn patients
Mithun R. Suresh, MD, is in private practice in Min-
oxygen and supportive measures for smoke and who meet at least 1 American Burn
neapolis, MN, and can be reached at sure0015@
inhalation regardless of hemodynamic Association referral criteria, the large ma- umn.edu.
status. If the patient is hemodynamically jority of these patients are discharged
unstable, acidotic, in cardiac arrest, or has from the emergency department. David J. Dries, MSE, MD, is department head for surgery
at HealthPartners Medical Group and professor or
a decreased Glasgow Coma Score (< 13 Eu- • Hospitals that are located great dis-
surgery and anesthesiology at the University of Min-
ropean and < 8 American), early empiric tances from burn centers may need to nesota in St Paul, MN, and can be reached at
treatment with 5 g hydroxocobalamin is transfer patients with burn injuries by [email protected].