TY - JOUR
AU - Stockinger, Zsolt T
AB - Abstract Management of wartime burn casualties can be very challenging. Burns frequently occur in the setting of other blunt and penetrating injuries. This clinical practice guideline provides a manual for burn injury assessment, resuscitation, wound care, and specific scenarios including chemical and electrical injuries in the deployed or austere setting. The clinical practice guideline also reviews considerations for the definitive care of local national patients, including pediatric patients, who are unable to be evacuated from theater. Medical providers are encouraged to contact the US Army Institute of Surgical Research (USAISR) Burn Center when caring for a burn casualty in the deployed setting. Burn, burn injury, burn trauma, casualty care, burn flight, Burn Navigator INTRODUCTION The goal of this clinical practice guideline (CPG) is to provide practical recommendations for care of burn casualties in a deployed setting. U.S. service members are stabilized and then evacuated out of theater for definitive care at the U.S. Army Institute of Surgical Research (USAISR) Burn Center at Fort Sam Houston, TX, USA; the USAISR is the only burn center in the DoD. Local national patients, often children, may be present for care at military medical facilities with no possibility of definitive care beyond that provided in theater. If caring for a burn casualty in a deployed environment or any theater of operations, contact the USAISR Burn Center as soon as possible at: − DSN 312-429-2876 (BURN) − Commercial (210) 916-2876 or (210) 222-2876 − Email to burntrauma.consult.army@mail.mil Early consultation will facilitate coordination of care to include possible activation of the Burn Flight Team for U.S. service members. Inability to contact the Burn Center should not delay evacuation.1 Optimal treatment of burn patients can consume enormous personnel and logistical resources. Despite the best efforts of providers at each level of care, the mortality for burn casualties who cannot be evacuated out of theater is significantly higher than that experienced in Continental U.S. facilities. These and other factors must be considered in the deployed environment. Review of Chapter 26: Burn Trauma in the 2013 Emergency War Surgery manual is also recommended.2 POINT OF INJURY In the field, interrupt the burning process, and address any life threatening bleeding, airway compromise, or tension pneumothorax; do not let the burn distract from care of life threatening injuries. TCCC guidelines still apply to the burn victim; however, burn injuries can be distracting but they rarely are imminently life threatening, so address hemorrhage and airway issues according to TCCC guideline. Brush off dry chemicals then rinse off dirt and any other contaminants with clean water. Once a survey of injuries is possible, do so and then cover the patient with blankets to prevent hypothermia. Evacuate the casualty as soon as possible, preferably to a facility capable of providing initial burn care including escharotomy and transfusion if necessary. INITIAL BURN SURVEY Perform primary and secondary trauma surveys. Avoid becoming distracted by the appearance of burned tissues. Assess and protect the airway. Immediate intubation may not be necessary in less severe burn casualties, thereby allowing time to complete the primary survey. Indications for endotracheal intubation include a comatose patient, symptomatic inhalation injury, deep facial burns, and burns over 40% total body surface area (TBSA). Edema after burn injury causes most supraglottic airway devices to be inadequate. Use a large-bore endotracheal tube (ETT), especially if inhalation injury is suspected. Size 8 ETT or larger is preferred for adults to facilitate pulmonary toilet including bronchoscopy, and decrease the risk of airway occlusion due to casts comprised of blood, mucus and debris. Secure ETT with cotton umbilical ties; standard adhesive ETT holders do not work around burned skin. Consider securing ETT with stainless steel wire or suture secured around pre-molar teeth prior to long-range transport, particularly in patients with extensive facial burns. Frequently reassess position of the ETT during acute resuscitation as edema waxes and wanes. Keep the patient warm as burns increase evaporative and convective heat loss. In patients who can be transferred quickly to an appropriate facility, use only loose, dry dressings as all dressings will be removed upon arrival at the next facility. For major burns, do not debride blisters until the patient has reached an appropriate level of surgical care. ACUTE RESUSCITATION OF ADULT BURN PATIENTS Calculate the patient’s initial burn size using the Rule of Nines as outlined on the JTS Burn Resuscitation form available on the JTS website. When wounds are cleaned, calculate using the Lund-Browder chart. Superficial (1st degree) burn is NOT included in the calculation of TBSA used for fluid resuscitation. Superficial burns (1st degree) appear red, do not blister, and blanch readily. Partial thickness burns (2nd degree) are moist and sensate, blister, and blanch. Full thickness burns (3rd degree) appear leathery, dry, non-blanching, are insensate, and often contain thrombosed vessels. Use the JTS Burn Resuscitation Worksheet found in the JTS Burn Care CPG to assist initiation of fluid resuscitation; it is imperative that this flowsheet be initiated at the first level of care and follows the patient through the care continuum in order to appropriately manage their fluid resuscitation and prevent the morbidities that develop from both over and under-resuscitation. For adults, initiate intravenous (IV) fluid resuscitation using the Rule of 10 (10 mL/h × %TBSA) for patients with burns of 20% TBSA or greater.3 The Rule of 10 applies to patients weighing between 40 and 80 kg. For patients weighing more than 80 kg, add 100 mL/h to IV fluid rate for each 10 kg > 80 kg. Lactated Ringer’s (LR), plasma-lyte, or other isotonic solution is the preferred resuscitation fluid for burns without other major injuries; other solutions (normal saline) should be used with caution as electrolyte imbalance may result. For resuscitation of patients with other serious trauma, including use of blood products, please refer to the Damage Control Resuscitation CPG found on the JTS website.4 In the absence of overt hypotension (mean arterial pressure (MAP) < 55), avoid fluid boluses in burn patients since it contributes to edema. Instead, adjust the hourly rate of IV fluids to maintain adequate organ perfusion, as reflected by urine output (UOP).5 Place a bladder catheter (i.e.: Foley catheter) to monitor urine output on an hourly basis; ideally a catheter with a calibrated urometer should be used, but these are not always readily available in the deployed environment. Monitor UOP closely and decrease or increase isotonic fluid infusion rate by approximately 20–25% per hour to maintain a UOP of 30-50 mL/h. Every attempt should be made to minimize fluid administration while maintaining organ perfusion. If UOP > 50 mL/h, then decrease the fluid rate by 20–25% for the next hour and reassess. Over-resuscitation can lead to many life threatening complications in the burn patient – so close monitoring of UO and end organ perfusion is imperative. Both under- and over-resuscitation can result in serious morbidity and even mortality; patients who receive over 250 mL/kg in the first 24 hours are at increased risk for severe complications including acute respiratory distress syndrome and compartment syndromes. Hour-to-hour fluid management is critical, particularly during the first 24 hours. Use the Burn Resuscitation Flow Sheet attached to the JTS Burn Care CPG to record both fluid intake and UOP. The flow sheet should be transferred with the patient and NOT restarted at each echelon of care, to ensure accurate recording of total volume resuscitation since injury, to avoid over resuscitation. At 8–12 hours post-burn, if the hourly IV fluid rate exceeds 1000 mL/h or if the projected 24 hours total fluid volume approaches 250 mL/kg, initiate 5% albumin infusion (Table I) for adult patients. Continue the 5% albumin infusion until the 48-hour mark. Fresh frozen plasma may be substituted. Table I. Hourly infusion rates for 5% albumin for adults 5% Albumin Infusion (mL/h) . 30–49% TBSA . 50–69% TBSA . 70–100% TBSA . <70 kg 30 70 110 70–90 kg 40 80 140 >90 kg 50 90 160 5% Albumin Infusion (mL/h) . 30–49% TBSA . 50–69% TBSA . 70–100% TBSA . <70 kg 30 70 110 70–90 kg 40 80 140 >90 kg 50 90 160 Open in new tab Table I. Hourly infusion rates for 5% albumin for adults 5% Albumin Infusion (mL/h) . 30–49% TBSA . 50–69% TBSA . 70–100% TBSA . <70 kg 30 70 110 70–90 kg 40 80 140 >90 kg 50 90 160 5% Albumin Infusion (mL/h) . 30–49% TBSA . 50–69% TBSA . 70–100% TBSA . <70 kg 30 70 110 70–90 kg 40 80 140 >90 kg 50 90 160 Open in new tab If possible, measure bladder pressures every 4 hours in intubated patients with >20% TBSA burns.6 Sustained pressure >12 mmHg suggests early intra-abdominal hypertension and adjuncts such as colloid fluid should be considered. If the pressure is >20 mmHg, the patient should be paralyzed and the bladder pressure re-measured. Persistent bladder pressures >20 mmHg may indicate abdominal compartment syndrome (See Abdominal Compartment Syndrome below). Combat casualties with burns often present with multi-system injury, to include inhalation injury, hemorrhage, and soft tissue trauma. Associated injuries may increase fluid needs above and beyond standard burn formula predictions. After the first 24–48 hours, completion of resuscitation is marked by stabilizing hemodynamic parameters and reduction of IV fluid to a maintenance rate. Management of Persistent Oliguria And Hypotension Clinically significant hypotension must be correlated with UOP. Adequate end organ perfusion as estimated by UOP 30-50 mL/h generally requires a MAP >55 mmHg. Persistent oliguria and hypotension should trigger an assessment of the patient’s hemodynamic status and intravascular volume. Monitor intravascular fluid status using all available technologies. Consider early use of 5% albumin as discussed above as an adjunct. Reassess for a possible missed injury or ongoing bleeding. When available, monitor central venous pressure (CVP); goal CVP is 6–8 mmHg. If CVP is low, increase IV fluid rate. If CVP is at goal but hypotension (MAP < 55 mmHg) persists, use vasopressin 0.04 Units/min (do not titrate) followed by norepinephrine (titrate 2-20 mcg/min) if needed. Epinephrine and phenylephrine may be used as additional vasopressors in severe shock. If intravascular volume appears adequate (CVP at goal), STOP increasing IV fluid rate even if oliguria persists. Consider this patient hemodynamically optimized and that the oliguria likely results from an established renal insult. Expect and tolerate some degree of renal dysfunction in large burns. Continued increases in IV fluid administration, despite optimal hemodynamic parameters, will only result in “resuscitation morbidity,” that is often times more detrimental than renal failure. If the patient exhibits catecholamine-resistant shock, consider the following diagnoses: − Missed injury and/or ongoing blood loss. − Acidemia. If pH < 7.20, adjust ventilator settings to target PCO2 30–35 mmHg. If, despite optimal ventilation, pH remains <7.2, consider administration of sodium bicarbonate or THAM (tris-hydroxymethyl aminomethane). − Adrenal insufficiency is extremely rare in the burn patient and all other causes of hypotension must be ruled out; however, if suspected then start hydrocortisone. 100 mg IV every 8 hours. Rapid sequence intubation with etomidate may increase risk of adrenal insufficiency.7 − Hypocalcemia. Maintain ionized calcium > 1.1 mmol/L. SPECIAL CONSIDERATIONS Antimicrobial Prophylaxis Prophylactic IV antibiotics are not indicated for burn injury in the absence of infection. Penetrating wounds or open fractures should be treated with antibiotics according to current guidelines. See Wound Care section for discussion of topical antimicrobials. Administer tetanus prophylaxis as for any trauma patient. If wound infection is diagnosed clinically, direct empiric therapy against gram positive and gram negative bacteria. Narrow antibiotics based on known susceptibilities. If these data are unavailable, a good starting point is broad coverage with vancomycin for gram positive organisms and a carbapenem or 4th generation cephalosporin for gram negative organisms. Inhalation Injury Inhalation injury occurs secondary to smoke of chemical exposures and is exacerbated by retained carbonaceous particles (soot) and chemicals. Clinical signs include progressive voice changes, soot about the mouth and nares, hypoxia, and shortness of breath. If available, use bronchoscopic lavage to remove debris. Be judicious, as excessive irrigation may transport irritants to uninjured lung. Serial bronchoscopy may be required to remove large debris or casts. Patients diagnosed with inhalation injury should receive aerosolized unfractionated heparin 5000 units per ETT every 4 hours; heparin must be mixed with albuterol since heparin causes bronchospasm. Populations at risk for carbon monoxide (CO) toxicity include those exposed in enclosed spaces to fires, engines, and cooking stoves. Symptoms of CO toxicity include confusion, stupor, coma, seizures, and cardiac ischemia. Administer 100% oxygen and measure CO-hemoglobin levels via co-oximetry if available. Hyperbaric oxygen therapy may further reduce the CO-hemoglobin half-life but this therapy is cumbersome and not available while deployed. Every burn patient should be placed on supplemental oxygen until CO exposure can be ruled out. Cyanide is encountered in fires and industrial processes. Early effects include dizziness, headache, nausea, and anxiety. High-dose exposure causes rapid onset of coma, seizure, respiratory depression, hypotension, and tachycardia. Lactic acidosis >8 mmol/L is common. Administer 100% oxygen via mechanical ventilation. Hydroxocobalamin, Cyanokit TM, is the preferred antidote; infuse 5 g IV over 7 minutes. It may be infused over 2–5 minutes in cases of cardiac arrest or severe hypotension, and may be repeated if no clinical improvement.8 Cyanokit TM should be available at every Role 3 hospital and Role 2 hospitals as well if there is a high risk of managing burn casualties. Hydrogen fluoride (HF) is a byproduct of standard fire suppression systems. Exposure to HF may result in rapidly progressive or fatal respiratory failure despite minimal external evidence of injury. Symptoms include shortness of breath, cough, or hypoxia; there must be a high level of suspicion for HF inhalation.9 Treatment is supportive. If hypocalcemia is present, administer nebulized calcium gluconate (1.5 mL of 10% calcium gluconate in 4.5 mL water) q4hr until normalization of serum calcium levels. In the absence of significant burns, consider steroids if symptoms do not improve. Bronchopneumonia can develop within a week. Refer to Inhalation Injury and Toxic Industrial Chemical Exposure CPG for additional information.4 Ophthalmic Injury Every patient with facial burns should have a thorough eye exam. If available, consult an ophthalmologist for all patients with facial burns or corneal injury verified by Wood’s lamp exam. Eye exams should be done early, before facial edema sets in. If no injury exists, lubricate the eyes of intubated patients every 2 hours with lacrilube. If a corneal injury is identified, use a Fox shield to cover the eyes and apply ophthalmic erythromycin ointment at least every 2 hours. If an open globe is suspected, DO NOT place topicals, but cover the eye with a Fox eye shield. Lines and Tubes Sew and/or staple all venous and arterial catheters in place as tape does not adhere to burned skin. Do not circumferentially tape lines around extremities; this may cause limb ischemia as extremities swell during resuscitation. Gastrointestinal Prophylaxis Burn patients are prone to nausea, vomiting, and stress ulceration. Place oro-gastric or naso-gastric tube in intubated patients for gastric decompression and later enteral nutrition. Secure gastric tubes with umbilical ties. Administer IV proton pump inhibitor or similar agent to all patients with >20% TBSA burn injury. Circumferential Burns Escharotomy is normally performed in the setting of a circumferential full thickness burn to the torso or extremities. If the burn is superficial or not circumferential and extremity pulses are absent, rule out hypovolemia, hypotension, or occult bleeding. The requirement for extremity escharotomy or fasciotomy usually presents in the first few hours following injury. If the need for either procedure has not been identified within the first 48 hours, then circulation is likely to remain adequate without surgery. Elevation of burned extremities 30–45° is required to decrease edema and improve circulation. A patient who required extremity escharotomy or fasciotomy at a lower echelon of care should be reassessed upon arrival. Extension of incision(s) may be required to restore circulation. For any circumferential extremity (including fingers) burn, hourly monitoring is essentially. The extremity should be elevated as high as feasible. Palpable radial pulses do not exclude digital compartment syndrome and digital pulses must be checked by using the Doppler to assess the palmar arch and digital arteries for hand and digit burns. In general, palpable pulses of the radial, dorsalis pedis and posterior tibial are sufficient as long as there are no burns distal to these pulses. Absent Doppler signals or pulses that are diminishing on hourly exams should prompt immediate consultation with a burn surgeon and strong consideration of surgical decompression with escharotomies. Escharotomy is performed by incising full thickness burns into the subcutaneous fat. Patients will require analgesia and sedation. Extend escharotomy incisions the entire length of the circumferential portion of full thickness burn. Carry incisions across involved joints. Control bleeding with electrocautery. Thoracic escharotomy incisions should extend from the neck, across the mid-clavicle, and down the anterior axillary line. (See Figure 1.) Connect each side with an incision across the upper abdomen. In the upper extremities, place the hand in the anatomic position (palm facing forward) and make an incision in the mid radial or mid ulnar line, carrying the incision up the arm. If both hand and arm are burned, continue the incision across the mid ulnar or mid radial wrist and onto the hand. Lower extremity escharotomy incisions are placed in the mid-lateral and/or mid-medial line extending from the ankle to the hip (Fig. 1). FIGURE 1. Open in new tabDownload slide Escharotomy incisions. Dashed lines indicate the preferred sites for escharotomy incisions. Bold lines indicate the importance of extending the incision over involved major joints. Incisions are made through the burned skin into the underlying subcutaneous fat using a scalpel or electrocautery. For a thoracic escharotomy, begin incision in the midclavicular lines. Continue the incision along the anterior axillary lines down to the level of the costal margin. Extend the incision across the epigastrium as needed. For an extremity escharotomy, make the incision through the eschar along the midmedial or midlateral join line. Reprinted from Figure 26.2-1 Emergency War Surgery; Fourth United States Revision; 2013 FIGURE 1. Open in new tabDownload slide Escharotomy incisions. Dashed lines indicate the preferred sites for escharotomy incisions. Bold lines indicate the importance of extending the incision over involved major joints. Incisions are made through the burned skin into the underlying subcutaneous fat using a scalpel or electrocautery. For a thoracic escharotomy, begin incision in the midclavicular lines. Continue the incision along the anterior axillary lines down to the level of the costal margin. Extend the incision across the epigastrium as needed. For an extremity escharotomy, make the incision through the eschar along the midmedial or midlateral join line. Reprinted from Figure 26.2-1 Emergency War Surgery; Fourth United States Revision; 2013 Consider fasciotomy in the operating room (OR) if pulses remain undetectable after escharotomy. Continue hourly exams to ensure adequate perfusion following interventions. Optimal fluid resuscitation and prompt escharotomy usually mitigates the need for fasciotomy. Due to the frequency of extremity injuries seen among combat casualties, fasciotomies on burned extremities may be required for those with delayed revascularization, hemorrhage requiring massive resuscitation, and crush injuries. If long-range aeromedical evacuation is imminent, and there is concern that delayed compartment syndrome could go unrecognized, consider delaying evacuation, provided the patient’s overall condition will allow it. Following the patient with serial exams and/or compartment pressures in a facility where fasciotomies can be performed quickly, is reasonable. Evacuation can proceed once the clinical exam and/or compartment pressures have stabilized or once fasciotomies have been performed. Abdominal Compartment Syndrome Massive fluid replacement (>250 mL/kg within 24 hours) is a risk factor for abdominal compartment syndrome, a clinical diagnosis which includes increased bladder pressure, increased airway pressure, oliguria, and hypotension. Bladder pressure >20 mmHg in the setting of this syndrome in burn patients warrants early consideration of therapeutic paracentesis which may provide partial relief of elevated intra-abdominal pressure related to fluid sequestration. The decision to pursue decompressive laparotomy must factor in the significant risk of morbidity and mortality from the procedure in patients with extensive burns or burns to the abdominal wall. If decompressive laparotomy is required, perform a standard celiotomy followed by temporary abdominal closure. use a Bogotá bag or similar sterile plastic material sewn to the skin edges.10,11 Chemical Burns Expose body surfaces, brush off dry chemicals, and copiously irrigate with clean water. Large volume (>20L) serial irrigations may be needed to thoroughly cleanse the skin of residual agents. Do not attempt to neutralize any chemicals on the skin. Use personal protective equipment to minimize exposure of medical personnel to chemical agents. Resuscitation strategy and goals for patients with chemical burns are the same as for thermal injuries. White phosphorous fragments ignite when exposed to air, and will appear as smoking tissues. Clothing may contain white phosphorous residue and should be removed. Fragments imbedded in the skin and soft tissue should be irrigated out if possible or kept covered with soaking wet saline dressings or hydrogels. Urgently retrieve deeply imbedded fragments in the OR. Monitor calcium levels very closely and treat hypocalcemia with IV replacement. Refer to Inhalation Injury and Toxic Industrial Chemical Exposure CPG for additional information.5 Electrical Injury First responders should remove the patient from the electricity source while avoiding injury themselves. In cases of cardiac arrest, follow advanced cardiac life support (ACLS) protocol and provide hemodynamic monitoring if spontaneous circulation returns. Small skin contact points (cutaneous burns) can hide extensive soft tissue damage. Observe the patient closely for clinical signs of compartment syndrome (see Circumferential Burns for discussion of fasciotomy). Tissue that is obviously necrotic must be surgically debrided. Compartment syndrome and muscle injury may lead to rhabdomyolysis, causing pigmenturia and renal injury. Pigmenturia typically presents as red-brown urine. In patients with pigmenturia, fluid resuscitation requirements are much higher than those predicted for a similar-sized thermal burn. IV crystalloid infusion should be adjusted to maintain UOP 75–100 mL/h in adults. If pigmenturia does not clear after several hours of resuscitation consider IV infusion of mannitol (12.5 g/L in LR) and/or sodium bicarbonate (150 mEq/L in D5W). Closely monitor the intravascular volume status of patients receiving mannitol (an osmotic diuretic). Wound Care Whenever possible, debride (remove sloughed skin and blisters with scrub brushes or gauze) burn wounds in the OR, thereby providing a clean, warm environment to examine wounds and place sterile dressings. Use chlorhexidine gluconate or similar antiseptic cleanser. Definitive removal of burn eschar (sharp/surgical excision) will be performed after stabilization and transport to the USAISR Burn Center. Shave and debride the face, covering wounds with a topical polymicrobial ointment, such as bacitracin, QID and PRN. It is imperative that facial burns do not dry out. Ear burns are prone to chondritis which usually requires the cartilage to be debrided; apply Sulfamylon (mafenide acetate) cream BID and cover with Xeroform or Adaptic to prevent from desiccating. Pressure necrosis will cause ischemic injury to cartilage; careful placement of ETT ties is important and should not put pressure on the ears. Wrap burns on scalp, trunk, neck, and extremities in sterile gauze soaked with a 5% solution of Sulfamylon. Apply the solution QID and as needed to keep dressings lightly moist. Alternatively, dress burns with silver-impregnated nylon, covered with sterile gauze and moistened with sterile water. Silver-impregnated dressings may be left in place for extended periods of time (up to 7 days) which is advantageous in the deployed setting. Avoid over-wetting dressings to avoid macerating tissues. In patients who cannot be safely evacuated for burn excision, consider using silver sulfadiazine cream alternated BID with Sulfamylon cream to provide antimicrobial penetration of thick burn eschar as a bridge to surgical care. Guidelines for Patients Who Cannot Be Evacuated from Theater Care provided in theater is not envisioned to be definitive care. Definitive care for U.S. service members is provided at the USAISR Burn Center. Coalition forces progress along the evacuation chain in order to return to their home nation health care facilities. Unfortunately, the care available to local national patients may fail to compare to the definitive care available for U.S. and coalition forces. Care decisions are to be made in the context of the available continuum of care for the patient in their nation of origin. Take into consideration inhalation injury, medical co-morbidities, and extremes of age, which can increase mortality. For patients with extensive burns with less than half of the burn being full thickness, initiate resuscitation and allow burn depth to declare itself. Actual burn depth can be difficult to determine at initial presentation. After approximately 48–72 hours, reassess the patient to more accurately estimate the percentage of full thickness burn. Burn injuries may initially appear survivable, but graft loss, infections, or conversion of donor site(s) to full thickness wounds themselves may transform a potentially survivable injury into a fatal one. Be aware of this possibility and the potential change to an expectant category. The transition from aggressive care to comfort care is a difficult decision, especially when the team has worked exhaustively to maximize survival. The attending surgeon should elicit objective input from medical colleagues, nurses, and facility leadership in making this decision. For patients with extensive burns, proceed with resuscitation and plan for excision and grafting within a week to maximize survival. Skin substitutes such as allograft (deceased donor skin) and biologic dressings such as xenograft (pig skin) are not readily available outside CONUS. The extent of burn excision should be guided by the amount of autograft (split thickness donor skin) available. Do not excise wounds if autograft sites are not available. If patients arrive with open burn wounds, surgically excise to a healthy wound bed and apply NPWD until granulation tissue is noted. Meshing of split thickness skin grafts will maximize available donor skin. Meshing grafts wider than 3:1 is not recommended. Utilize dilute epinephrine solution (1:1,000,000 concentration) to minimize blood loss at excision and donor sites. To control raw surface area bleeding apply non-adherent telfa layer, followed by gauze soaked in the dilute epinepherine solution. Prior to harvesting donor skin, infiltrate subcutaneous tissue with the solution by clysis. Take the patient to the OR for staged excisions and grafting of full thickness burns. Complete the excision within one week of injury. Consider using NPWD over fresh autograft with intervening non-adherent layer (e.g., Dermanet) and leave in place for 3–5 days. Following NPWD removal, use Sulfamylon (5% solution) moistened gauze dressings for approximately 5–7 days. When graft interstices close, transition to a topical polymicrobial ointment. Whenever resources are available, perform extensive dressing changes in the OR (not ICU or ward), especially early in the treatment process while wounds remain open. This allows for optimal pain control (with airway protection as needed), facilitates wound examination, and provides a clean, warm environment. Gram negative bacterial and fungal colonization followed by infection is associated with a high rate of graft loss and increases mortality. Liberal use of dilute Dakin’s solution (1/4 strength or 0.125%) to cleanse colonized burn wounds is recommended. Delay grafting procedures until colonization and infection are controlled. Once the grafts are healed, continue to keep the patient clean, using showers when available. Early ambulation and physical therapy, with range of motion of all affected joints, is critical to the long-term functional outcome in burn patients. Early and continuous nutrition is vital to wound healing. Even patients who are able to eat may need supplementation to meet calorie goals. Consult a nutritionist when available. Use a nasoenteric feeding tube to provide a high protein, low fat enteral formula and administer a daily multivitamin. Added Considerations for Pediatric Burn Patients Deployed surgical teams frequently provide initial care for injured local national children. Burn care for children generally follows adult recommendations, with a few modifications. The small airway of a child can quickly be compromised by modest mucosal edema. Carefully secure the ETT and provide adequate sedation to prevent unplanned extubation. Peripheral or intraosseous vascular access may suffice initially, but central venous access is more reliable during formal burn resuscitation; catheters should be sewn in place. Children with burns under 15% TBSA usually do not need a calculated resuscitation. They can be given 1.5× calculated maintenance rate and have diapers weighed for UOP. If they can eat, they should be allowed access to bottle feeds. Some of these children can be supported enterally, with nasoenteric infusions of World Health Organization (WHO) resuscitation formula (1 L clean water, 8 tsp sugar, ½ tsp salt, and ½ tsp baking soda).10 Children with burns over 15% TBSA usually require a calculated resuscitation. Place a bladder catheter (size 6 Fr for infants and 8 Fr for most small children). The Modified Brooke formula (3 mL/kg/%TBSA LR or other isotonic fluid divided over 24 hours, with one-half given during the first 8 hours) is a reasonable starting point. This only provides a starting point for resuscitation, which must be adjusted based on UOP and other indicators of organ perfusion. Goal UOP for children is 0.5–1 mL/kg/h. Decrease or increase the isotonic fluid rate by approximately 20–25% per hour to maintain UOP at 0.5–1 mL/kg/h. Very young children do not have adequate glycogen stores to sustain themselves during resuscitation. Administer a maintenance rate of D5LR to children weighing <20 kg. Utilize the 4-2-1 rule: 4 ml/kg for the first 10 kg + 2 mL/kg 2nd 10 kg + 1 mL/kg over 20 kg. This maintenance rate is in addition to the isotonic infusion, and is not titrated. In children with burns >30% TBSA, early administration of colloid may reduce overall resuscitation volume. If needed, initiate 5% albumin at the child’s calculated maintenance rate (use the 4-2-1 rule) and subtract this from the isotonic fluid rate; the albumin rate is maintained while the isotonic fluid is adjusted based on UOP. Monitor resuscitation in children, like adults, based on physical examination, input and output measurements, and analysis of laboratory data. The well-resuscitated child should have alert sensorium, palpable pulses, and warm distal extremities; urine should be glucose-negative. Monitor electrolytes every 8 hours during the first 72 hours to pick up hypo- and hypernatremia and hypocalcemia. Replace calcium to maintain iCa >1.1. Cellulitis is the most common infectious complication and usually presents within 5 days of injury. Prophylactic antibiotics do not diminish this risk. Most anti-streptococcal antibiotics are successful in eradicating infection. Initial parenteral administration is advised for most children presenting with fever or systemic toxicity. Nutrition is critical for pediatric burn patients. Naso-gastric feeding may begin immediately at a low rate in hemodynamically stable patients. Start with a standard pediatric enteral formula (e.g., Pediasure) targeting 30–35 kcal/kg/d and 2 g/kg/d of protein. Children may rapidly develop tolerance to analgesics and sedatives; dose escalation is commonly required. Ketamine is a useful procedural adjunct. Propofol may also be used for procedural sedation but should not be used for long-term sedation in children. When burned at a young age, many children will develop disabling contractures. These are often very amenable to correction which may be performed in theater with adequate staff and resources. Seek early consultation from the USAISR Burn Center (DSN 312-429-2876 (BURN); Commercial (210) 916-2876 or (210) 222-2876; email burntrauma.consult.army@mail.mil). Opportunities for pediatric surgical care provided by non-governmental organizations may be considered on a case-by-case basis and require the coordinated efforts of all involved. CONCLUSION Deployed medical providers should anticipate burn casualties during wartime. Interventions during acute resuscitation should seek to optimize organ perfusion while avoiding the sequelae of over-resuscitation. Definitive burn care for patients encountered in the deployed environment will depend on the continuum of care for which they are eligible. This CPG provides a framework to optimize care for these patients. 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This work is written by (a) US Government employee(s) and is in the public domain in the US. Published by Oxford University Press on behalf of Association of Military Surgeons of the United States 2018.
TI - Burn Casualty Care in the Deployed Setting
JF - Military Medicine
DO - 10.1093/milmed/usy076
DA - 2018-09-01
UR - https://www.deepdyve.com/lp/oxford-university-press/burn-casualty-care-in-the-deployed-setting-xJz2y7MRNN
SP - 161
EP - 167
VL - 183
IS - suppl_2
DP - DeepDyve
ER -