Page 100 - Journal of Special Operations Medicine - Fall 2015

Fully expose the casualty and remove any garment not body typically develop burn shock and require admit-
removed during the primary survey. In the acute phase, tance to an intensive care unit for close airway, hemody-
there is no need to debride burn wounds. Copious clean namic, and urine output monitoring during the ongoing
water (sterile or electrolyte-containing solutions are not resuscitation. Third, in cases where TBSA is more than
required) should be used to quickly irrigate the wounds 20%, all dressings must not be dry, to prevent excessive
to cleanse the affected area of dirt, gasoline or other evaporative heat loss from water-moistened dressings.
liquid contaminants, and other foreign matter. Brief Finally, mortality correlates with increasing TBSA.
transport times cannot be assumed on the battlefield; ir-
rigation as close to point of injury as possible will there- After estimating the TBSA, adequate vascular access must
fore reduce the risk for infection and chemical injury. be obtained if not done so already. Large-bore (18 gauge
However, management of the patient’s core body tem- or larger) peripheral intravenous (IV) lines are preferred.
perature remains paramount. Known chemical and WP When possible, place IV catheters in nonburned areas.
burns require special care and extensive irrigation. IV lines should be secured with wraps if placed through
burned skin, as tape generally does not stick well. If ocu-
A rapid calculation of total burn surface area (TBSA) in- lar involvement is suspected (e.g., facial burns), apply
clusive of all partial-thickness and full-thickness burns is Fox eye shields to both eyes and secure in place with a
important to guiding further therapy. Superficial burns circumferential gauze wrap. Prophylactic antibiotic us-
do not compromise the physiologic function of the skin age (combat pill pack or injectable) is not indicated for
and, therefore, are not included in this calculation. Sev- burns alone with no penetrating injuries present. Multi-
eral formulas exist, including the Lund and Browder modal pain management with ketamine and/or narcotic
chart, the Rule of Nines, and the Rule of Palms. The agents should be provided in accordance with the TCCC
Lund and Browder chart lists burn surface area per body guidelines. The intramuscular route of administration
area and is considered to give the most accurate total; it should not be used in casualties with burns, because of
can be printed, laminated, and placed inside field medi- poor or variable absorption due to third-spacing of fluid.
cal sets (Figure 3). The Rule of Nines is similar to the
Lund and Browder chart, but is a less accurate estimate; Fluid resuscitation should be initiated with a warmed iso-
it is included on the injury diagram of the TCCC Card. tonic crystalloid such as Plasma-Lyte (Baxter International
The Rule of Palms is useful for smaller burns and pro- Inc.; www.baxter.com) or lactated Ringer’s solution us-
vides a quick visual estimation of the burned surface by ing the US Army Institute of Surgical Research (USAISR)
assuming the palm of the hand of the burned individual Rule of Tens. This formula recommends 10mL/h multi-
equals 1% of their TBSA. The importance of the TBSA plied times the TBSA for casualties weighing between
calculation is fourfold. First, TBSA is used to estimate 40kg and 80kg. For every 10kg over 80kg, add 100mL/h.
the amount of fluid to be given during resuscitation. Other formulas, such as the Parkland formula, are not
Second, patients with burns covering more than 20% of recommended for military use, because of concerns of
over-resuscitation. The adverse outcomes associated with
8
over-resuscitation are discussed under Resuscitation in
this article. The TCCC guidelines indicate that Hextend
(BioTime Inc.; www.biotimeinc.com) may be used for the
first 1,000mL of fluid resuscitation if crystalloid is not
available, but should be used with caution and replaced
with crystalloids or albumin as soon as possible, because
of its recent correlation with potential kidney injury.
Figure 3 Lund and
Browder chart. Hemodynamic status should be maintained with a sys-
tolic blood pressure of at least 90mm Hg and capillary
refill less than 2 seconds. Tachycardia is an unreliable
indicator of volume status in burn casualties, because
of pain and the inflammatory response. In general,
fluid boluses should be avoided in favor of increasing
the fluid infusion rate. In casualties experiencing burn-
shock pathophysiology, bolus administration primar-
ily results in rapid extravasation into the “third space”
without significant clinical improvement.

Hypothermia management is of even greater impor-
tance with burns than in other trauma casualties. Loss

88 Journal of Special Operations Medicine Volume 15, Edition 3/Fall 2015