Methods: This integrated review was conducted using the methodology suggested by Whittemore & Knafl for Integrated Research Reviews (2005) and Brown (2018) aims to answer the question, “Do clinicians and transport teams estimate TBSA burns appropriately in the prehospital setting in comparison to verified burn centers?” With thermal burns being most burn injuries, it is imperative that the injury is assessed appropriately, and prudent decisions are made when responding to these transport calls. A systematic search of the peer-reviewed literature was completed using the following databases: Cochrane, PubMed, CINAHL Plus, MEDLINE Complete, PubMed, the American Burn Association, and bibliography mining. Key words used in searching were: “prehospital,” and “burn,” and “assessment”. Search criteria was limited to articles published between the years of 2013-2018 for all data bases. A total of sixty-six articles were located and six articles by bibliophagy mining. Contained within the sixty-six articles twenty-four were duplicates and thirty-eight did not meet inclusion criteria. Eleven articles including three level one, one level two, and seven level three met the inclusion criteria appraised using evaluation checklists and the EBR tool (Brown, 2017; Long & Gannaway, 2015). The 2017 National Burn Repository (NBR) reported 212,820 total burn records with the most common burns occurring from fire/flame at forty-one percent and scalding at thirty-five percent ("National Burn Repository 2017 Update," 2017). In the years between 2008-2017 over 67% of reported total burn sizes were less than 10% TBSA ("National Burn Repository 2017 Update," 2017).
Results: Previous studies have shown that in the prehospital setting TBSA burn assessments are often inaccurately done. With the nature of the burn injury, it is important that the patient is transferred to definitive care. Because the burn injured patient is transferred to advanced burn facilities, proper estimation plays a central role in the transfer decision (McCulloh et al., 2018). Patient transfers include many challenges such as, financial cost, delay of care, emotional stress on the patient and family, and usage of additional provider resources (McCulloh et al., 2018). The TBSA not only guides initial fluid resuscitation volumes, but also determines the subsequent need for transfer to specialized burn centers (Goverman et al., 2014). Studies show a consistent trend of overestimation of TBSA burn injuries, in which patients receive significantly more fluids than would be normally required (McCulloh et al., 2018). Insufficient fluid resuscitation my result in tissue ischemia, acute kidney injury, and progression of burn wounds within the zone of stasis to the zone of coagulation (Sadideen, D’Asta, Moiemen, & Wilson, 2016). Inaccurate assessment of TBSA burn percentages and wide variations in fluid resuscitation can increase the risk of complications and death (McCulloh et al., 2018). Overestimation in TBSA percentages often include first degree burns, which then increase the amount of fluids that are given during the initial resuscitation phase (McCulloh et al., 2018). Overestimation of burn size can drive excessive fluid resuscitation which can cause an increased risk of pneumonia, acute respiratory distress syndrome, compartment syndrome, and death (Carter et al., 2017). Tissue edema associated with over resuscitation exacerbates thermal injury and inhibits wound healing (Carter et al., 2017). Patients who have large burns (>20%) are often under-estimated and under-resuscitated while smaller burns are more frequently over-estimated and over-resuscitated (Pham et al., 2018).
Conclusion: Accurate assessment and treatment can expedite transfer and promote improved outcomes in the burn patient population. Referring providers should be able to determine the need for immediate transfer versus outpatient referral of the burn injured patient (Carter et al., 2017). Outreach and training are essential for transport teams, prehospital EMS services, and rural hospital clinicians (Sadideen, D’Asta, Moiemen, & Wilson, 2016). Education for referring providers should emphasize the importance of calculating and recording TBSA to help guide the need for fluid resuscitation (Carter et al., 2017). Since prehospital clinicians usually encounter the burn injured patient first, they are one of the most important keys in helping decrease morbidity, mortality, and permanent disability in the patient. The literature reveals many inaccurate assessments are completed in the prehospital setting, further investigation and studies should be conducted to strengthen the evidence for support of proper education and assessment of the burn injured patient.