Page 101 - Journal of Special Operations Medicine - Fall 2015

of skin integrity equates to precipitous loss of heat. Ac- Burn Progression
tive warming by electrical or chemical means, as well as The provider should anticipate marked clinical deterio-
passive heat retention using blankets, should be applied ration during the first 48 hours after injury. Many casu-
without delay. Commercial devices such as the hypo- alties with isolated burn injuries present initially awake
thermia prevention and management kit (HPMK) rec- and alert; the provider must not be lulled into a false
ommended by the TCCC guidelines are preferred.
sense of security as this honeymoon period is merely
“the calm before the storm.” Burns result in derange-
For wound care, if the burn is less than 20% TBSA, gauze ment of almost all organ systems, among which ARDS
dressings moistened with water or saline may be used as and multiple organ dysfunction syndrome are common.
desired for comfort . However, if the TBSA is more than The provider must be ready to provide aggressive resus-
20%, dry dressings should be used. There are multiple citation measures and close monitoring until transfer of
brands of commercial hydrogel acute-burn dressings care is possible. Burns are dynamic and partial- thickness
and blankets that are sold for both military and civilian burns can progress to full-thickness as some percent-
prehospital use. The Navy recently selected the BurnTec age of the zone of stasis becomes nonviable because
hydrogel dressing (Kikgel Company; www.kikgel.com) of poor perfusion. Burns resulting from gasoline and
to replace the Water-Jel hydrogel dressings (Water-Jel other hydrocarbons tend to convert to deeper injuries
Technologies; www.waterjel.com) previously required in over time because of a derangement of tissue metabo-
Navy and Marine Corps field medical kits. Their use is lism. Frequent reassessment of wound status and TBSA
not indicated outside of WP burns or to extinguish a ca- is necessary and should be performed with each dressing
sualty who is actively on fire. Thermal-burned tissue does change.
not retain heat after injury and the casualty quickly be-
comes hypothermic. The “conductive cooling” advertised Casualties with circumferential full-thickness burns
by these dressings may lead to hypoperfusion of the burn of the extremities are at risk for eschar (burned skin)
wound and systemic hypothermia. They are not used by syndrome. The inelastic burn acts as a tourniquet, pre-
the USAISR Burn Center or other similar facilities.
venting perfusion of affected extremities and impairing
ventilation if the torso is involved. The treatment for
Application of burn creams or silver-impregnated burn this condition is escharotomy, whereby the constricting
dressings is not indicated in the acute phase of burn care. eschar (but not the soft tissues underneath) is incised
Dressings may be secured in place as needed with loose with a scalpel. Usually, little pain associated with the
6
gauze rolls, plastic wraps, self-adherent wraps, or elas- procedure, as full-thickness burns are insensate. Figure
tic bandages. Extreme care should be taken to ensure 4 displays a diagram of where incisions should be made.
bandages are not wrapped too tightly. A primary goal is
to cover the wounds to avoid contamination. With this
goal in mind, providers should appreciate that simply
wrapping a severely burned casualty in a clean sheet or
blanket meets this goal. At no time should wound care
delay or impede transport, other resuscitation measures, Figure 4 Escharotomy sites.
or hypothermia management. 9

Prolonged Field Care
In most recent conflicts, battle casualties have been evac-
uated to a Role 3 level of care within the first few hours
after injury. The preceding portion of this article is ap-
plicable in that setting as well as garrison. It serves as a
review of the latest guidance and practices in burn care.
However, the variable operational environment for Amer-
ican expeditionary forces, particularly Special Operations Resuscitation
Forces (SOF), presents the new challenge of evacuations
potentially being delayed many hours to days. In this After the primary survey and initial burn care are com-
case, providers will reach the “end of the algorithm” and pleted, the provider must anticipate the progression of
continue to care for wounded for far longer. The fol- physiologic derangements due to burn pathophysiology
10
lowing guidance may be used when confronted with this and resuscitation. Proinflammatory mediators result in
situation. The USAISR Burn Center provides 24/7/365 third spacing even in nonburned areas; third spacing will
teleconsultation via burntrauma.consult@us.army.mil or result in a relative intravascular volume depletion and
DSN 312-429-BURN(2876) to deployed providers. potential airway compromise. Prophylactic endotracheal

Burn Casualties in Prolonged Field Care 89