Annals of the MBC - vol. 2 - n' 2 - June 1989

TRANSPORTATION OF BURN PATIENTS

Marichy J., Vaudelin Th., Marin-Laflltche I., Gueugniaud P.-Y., Bouchard C1.

Centre de Brûlés, Hôpital Edouard Herriot, Lyon, France

SUMMARY. It is nowadays well known that an appropriately instituted first aid and medical transport can be important in minimizing the morbidity and the mortality from bum injury. In a recent study we analysed the mortality rate in relation with the transportation of the burned patients admitted to our Bum Centre. Despite the fact that around 60% of the burned patients have a medical transport, the mortality rate remains high (30%) when the patient is admitted between the fourth hour and the twenty-fourth hour after trauma. This fact emphasizes the need to conduct an educational programme not only for the non-medical population but above all for medical and paramedical teams.

In 1979, one year after the Los Alfaques disaster, Arthurson and Banuelos reported in their analysis a higher survival rate in the patients transported to Barcelona than in the patients transported to Valencia (Fig. 1). There were no significant difterences between the two groups of patients transported to Barcelona and Valencia with regards to the patients' age and the seriousness of their bums. The only difference was that the patients taken to Barcelona received adequate medical treatment during their transportation, unlike most of the patients taken to Valencia.
The conclusions of many authors concerning the transportation of burned patients emphasize appropriate management and medical treatment during their transportation, in order to minimize post-injury morbidity and mortality.
In this retrospective study we analyse the mortality rate in relation to the transportation of the patients admitted to our Bum Centre.

1. Population

1. The mean age of these patients was 23.4 years (5 to 95). The mean mortality rate was 12.3%. The mortality rate increased in correlation with the patient's age and the seriousness of the bum. In the case of inhalation injury, the mortality rate reached 50% of the patients.
2. Almost 50% of the patients were referred by the hospital situated closest to the accident. 30% came straight to the Bum Centre. 20% were referred by a general physician or a paramedic.

Fig. 1

2. Mode of transportation

1. Almost 60% of the burned patients received medical treatment during their transportation. Initial transportation was provided by S.A.M.U. or the Fire Service (2 1 %) and secondary transportation by S.A.M.U. (31%) or private ambulance (16.7%).
2. The most serious burned patients were transported by S.A.M.U.; the mean B.S.A. was 29.3% (+ 26) for initial transportation and 34.1% (+ 23) for secondary transportation. Minor bum patients were transported by the Fire Service (9.7% + 11), private ambulance (19.1% + 18) or private motles (7.6% + 7.8).

The mortality rate was lower in the initial transportation group than in the secondary transportation group (20.3% vs. 26.7%). It was nil in the private modes group. In eflect, the mean seriousness of the burn was more important in the secondary transportation group.
We observed a low mortality rate when the patient was admitted before the fourth hour or after the second day post-injury; inside this range the mortality rate is high (max. 30%). The time of admission post-injury is important as already emphasized by Hamit in 1981. The haemodynamic instability is certainly the main cause of the high mortality rate in these patients (Fig. 2).

a) Haemodynamic status

At admission, 1304 patients were considered as having a good haemodynamic status (arterial pressure greater than 1Omm/Hg, diuresis greater than lml/hr., central venous pressure greater than 0, no vasoconstriction); 4.1% of the patients died (Fig. 3).
81 patients had an instable haemodynamic status, and 59 died (72.8%).
Fluid resuscitation was in course before admission in 850 patients. 291 of these received an inadequate and insufficient fluid resuscitation. The mortality rate was 54.9%. When the fluid resuscitation was adapted for the other 559 patients, the mortality rate was 9%.
740 patients had no intravenous route, and 2% of these died.
We considered fluid resuscitation to be adapted when an intravenous line was secured and an electrolyte solution started in adult patients with burns over 20% and in children with burns over 10%; the IV should run according to Parkland's formula or Evans' formula (Fig. 4).

b) Pulmonary function

Amongst the population having no clinical sign of inhalation injury (1471 patients), there were 116 fatalities due to the seriousness of the burns and septic complications (7.9%). Nevertheless, in this population it is possible that some patients had an inhalation injury without any clinical sign.

Early complication of inhalation injury appeared in 119 patients; 80 of these died (67.2%). In a more recent study on 582 patients admitted to our Bum Centre from January 1984 and December 1985, the mortality rate of these patients was lower (50%) (Fig. 5).

Despite the fact that information about the ill-regulated function of the burned patient is widespread, 24 patients were hypothermic at their admission, and 14 died (58%). Their rectal temperature was below 35' (Fig. 6).

d) Neurological signs

The neurological status was classified according to the Glascow score, ranging from 15 (normal) to 0 (coma). The mortality rate was low for patients having a Glascow score of 15 (3.5%), compared to patients with a score below 10 (66.7%) or under anaesthesia (51.9%) (Fig. 7).

Fig. 2 Fig. 3

Fig. 4 Fig. 5

5. Discussion

Two identified phases of transportation of burn patients are the initial transfer from the scene of the accident to the nearest hospital and the referral of the burn patient from this hospital to the regional bum centre. In both cases, an adequate transportation must be planned according to instituted rules:

A) Management of the burn patient before transportation

1. Referral to the nearest burn centre raises many important questions prior to instituting the transfer. The referring physician must obtain the baseline vital signs including blood pressure, pulse, respiratory rate, temperature and neurologic status before transportation to ensure that the patient is properly prepared. Associated trauma must be indicated.
2. A secured intravenous line is necessary. The initial fluid resuscitation must be adapted to Parkland's formula (4ec/kg/%burn/24hr. of crystalloids). At this time, colloids are not indicated because they can dangerously increase interstitial oedema.
3. The insertion of a nasogastric tube is important to avoid aspiration from vomiting, especially during air transport.
4. In suspected inhalation injury an endotracheal tube is required to maintain an adequate airway and oxygenation.
5. Maintenance of core temperature is mandatory, as the risk of hypothermia is high, especially in patients with extensive burns. In addition to sterile sheets, many layers of blankets may be necessary when it is impossible to increase the environmental temperature.

B) Local treatment

1. Topical application must be avoided before admission to the burn centre.
2. The patient should be covered with a clean sheet and/or a "life-cover".
3. Chemical burn or nuclear contamination must be copiously irrigated before transportation (30' least).
4. The use of a cool solution may be helpful reducing the pain of burn injury but should instituted cautiously because of the risk hypothermia.

Fig. 6 Fig. 7

6. Conclusions

All these rules are well known by the Bum Centres but are sometimes neglected by physicians and/or paramedics working in a general hospital or even in the hospital where the Burn Centre is located. In the majority of cases, a single call to the specialist may solve a delicate problem.
This study stresses the fact that in fire disasters well-trained personnel can supplement health professionals to ensure an efficient and safe transport, which is an important factor in minimizing morbidity and mortality from bum injury.

RESUME. La prise en charge précoce du brûlé est un élément capital pour sa survie. L'évolution parallèle des techniques de réanimation et la structuration des organisations publiques (S.A.M.U.) et privées de transport devraient contribuer à diminuer les taux de morbidité et de mortalité des brûlés. Dans une étude rétrospective portant sur 1532 brûlés hospitalisés entre 1978 et 1983 au Centre de Brûlés de l'Hôpital Edouard Herriot, nous avons analysé le taux de mortalité en fonction des conditions de transport des patients et de la précocité de celui-ci. Les résultats indiquent que des efforts d'information auprès des équipes médicales et paramédicales sont encore nécessaires pour améliorer la prise en charge initiale du brûlé.