Page 102 - Journal of Special Operations Medicine - Fall 2015

intubation or cricothyrotomy should be considered for radicals, and ventilator management should include
casualties with a TBSA of more than 40%, even if the lung- protective strategies. Vasopressor agents, primar-
face or neck is not directly injured. These casualties will ily norepinephrine and vasopressin, may be required
have progressive facial, neck, and airway edema from the if shock does not improve with increasing crystalloid
resuscitation alone. All rings, other jewelry, and clothing fluid infusions or if, at 12 hours after injury, fluids are
must be removed, as they may constrict affected limbs. projected to exceed 6mL/kg per TBSA over 24 hours. If
Tape does not stick well to burned or edematous skin, available, albumin solutions and/or freeze-dried plasma
so cotton twill ties (umbilical tape) or sutures should be can be used to decrease fluid requirements after the first
used to secure catheters, tubes, and lines to the body. 8 hours after burn injury. In burn casualties who de-
velop cardiac arrest, pulseless electrical activity is the
Fluid resuscitation must be primarily guided by markers usual presenting rhythm. Providers should know that
of global perfusion, such as urine output (UOP) for re- the cardiac arrest survival rate for burn casualties within
nal function, mentation for neurologic status, capillary the USAISR Burn Center is 25%. Correction of the un-
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refill/peripheral pulses and vital signs, and laboratory derlying cause—often volume deficit—is the most im-
studies, as available. A Foley catheter should be placed portant treatment.
soon after fluid resuscitation begins, with a goal rate of
0.5mL/kg per hour (30–50mL/h for the average adult). The massive fluid resuscitation required to treat burn
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If UOP remains below goal for 2 hours despite fluid re- shock can result in complications. ARDS is a complex
suscitation at the calculated rate, the infusion should be process of noncardiac pulmonary edema. Treatment is
increased by one-third of the present rate. Vital signs, supportive by observing lung-protective strategies. Oc-
peripheral pulses in all extremities, and capillary refill ular compartment syndrome in burns is similar to the
in all digits should be checked at least hourly. Tachycar- typical presentation of retrobulbar hemorrhage, with
dia is almost universal among burn casualties, because a tense globe reflecting increased intraocular pressure.
of hypermetabolism and pain, and does not necessar- Treatment consists of lateral canthotomy and inferior
ily indicate hypovolemia. Capillary refill and noninva- cantholysis. Extremity compartment syndrome can ap-
sive blood pressure become more unreliable as edema pear with or without eschar, and requires escharotomy.
progresses. If invasive arterial-pressure monitoring and Fasciotomy may be required subsequently in very-high-
blood-gas analysis are available, they should be used. volume resuscitations or in the setting of associated
Trending of lactate levels is emerging as a marker of traumatic injury to those affected limbs. Abdominal
global perfusion status and is becoming more readily compartment syndrome results from third spacing into
available in the Role 1 and critical care transport set- the peritoneal cavity, which reduces organ perfusion and
ting using point-of-care laboratory analyzers such as the impedes ventilation. This syndrome should be suspected
i-Stat (Abbott Laboratories; www.abbottpointofcare. in patients undergoing large-volume resuscitations whose
com). Elevated creatinine and blood urea nitrogen levels end-tidal or blood carbon dioxide levels and peak airway
on a basic metabolic profile may indicate prerenal azo- pressures are elevated in the setting of a tense, distended
temia or acute kidney injury. If the holistic assessment abdomen. It has an extremely poor prognosis. Although
leads the provider to believe perfusion is inadequate, the decompressive laparotomy is typically the treatment for
fluid resuscitation rate should be increased by one-third abdominal compartment syndrome, there is a high rate
every hour until improvement is noted. Renal failure of associated mortality in burn patients. Percutaneous
causing anuria prevents UOP from being used to trend drainage may be attempted, but decompressive laparot-
resuscitation. In these cases, end-organ perfusion must omy is a last resort.
be estimated by other means as available, such as blood
pressure, central venous pressure, point-of-care blood- If an intraosseous line was placed during acute resuscita-
gas analysis, and neurologic status. tion, at least two peripheral IV lines should be obtained
before access is made more difficult by edema formation.
Massive volumes of fluid resuscitation may be required Central venous access remains an option to those ex-
in severe burns necessitating positive-pressure ventila- perienced and so equipped. Pain medications and other
tion due to third spacing into the lungs. The head of the agents will be poorly absorbed by the gastrointestinal
bed or stretcher should be elevated 30°. If mechanical tract, so IV administration is preferred. Continuous IV
ventilation is provided, low tidal volumes (6–8mL/kg) infusion of ketamine and/or a narcotic is preferred to IV
should be used to help prevent injury from mechani- “pushes” for consistent pain control. Tetanus prophy-
cal ventilation. Inhalational injuries can result in diffi- laxis should be given as soon as available. In intubated
cult ventilation with high fraction of inspired oxygen patients, a naso- or orogastric tube should be passed
(Fio ) requirements (more than 60%) that may be re- into the stomach and the contents evacuated in the ini-
2
source limiting in the field environment. Prolonged Fio tial phase of care. If evacuation will be delayed more
2
of more than 60% is toxic due to oxygen-generated free than 24 hours and the casualty appears well perfused,

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