Page 103 - Journal of Special Operations Medicine - Fall 2015

judicious tube feeding with enteral supplements or pu- times a day after careful initial examination with fluo-
reed high-protein foodstuffs should be initiated and cau- rescein for epithelial (corneal) injury. Ear burns should
tiously advanced to a goal of 25kcal/kg per day plus an be preferably treated with mafenide, because of its bet-
additional 40kcal per each percent TBSA. Overfeeding ter penetration of cartilage compared with silver sulfa-
must be avoided, as it has been found to be deleterious diazene. If no special burn creams are available to care
for ventilator weaning and healing. for a burn casualty, the provider should do what he can
with what is available. Topical antibiotic creams of any
kind and clean, dry cloth coverings are preferable to no
Wound Care
wound care at all.
If evacuation to a burn center will be delayed more
than 12 hours, the provider should consider perform- In addition to minimal supplies carried in general aid
ing initial debridement and wound care, in addition to bags and trauma kits, providers may wish to consider
the steps covered previously. Hypothermia management stocking dedicated burn kits in their aid stations and
remains of paramount importance during this process, evacuation vehicles. Severe burns require a significant
particularly in a field setting. Additionally, pain will amount of dressing materials and a specific, labeled “go
be extreme and the provider will have to balance the kit” is easy for nonmedical personnel to identify. It al-
liberal use of ketamine and/or a narcotic agent with lows more or less capability to be carried as the mission
maintaining the airway. The provider must take every requires. The authors recommend both an acute burn
action possible to ensure a clean environment and to kit and a prolonged field care burn kit (Figure 5) de-
wear personal protective equipment. The wounds are pending on the operational circumstances. The authors'
exposed and gauze is used to remove blisters and de- acute burn kit (Figure 6) contains hydrogel dressings,
vitalized tissue. Scrub brushes soaked in diluted surgi- Fox eye shields, and gauze dressings and wraps for im-
cal antiseptic may then be used to further debride and mediate care in the field and for short evacuation times.
clean the wounds. Chlorhexidine cleanser (e.g., Hibi- The authors’ prolonged field care PFC burn kit (Fig-
6
clens; Molnlycke Health Care; www.molnlycke.com) ure 7) contains an assortment of silver nylon dressings,
is the preferred agent of the USAISR Burn Center, but chlorhexidine scrub brushes, Silvadene, bacitracin topi-
povidone-iodine or even plain soap may be used. Sharp cal ointment, erythromycin ophthalmic ointment, and
debridement of some tissue may be required with scis- gauze wraps. Several commercial options for both types
sors or scalpel. The provider will know living tissue is of kit (e.g., Bound Tree Medical, www.boundtree.com;
present when there is bleeding. Burn areas should be and JBC Corp, www.jbccorp.com) exist or the end user
patted dry after copious irrigation and before placing can build their own.
wound dressings.

Providers may select from either the traditional ap- Figure 5 Acute (left) and prolonged field care (right) burn kits.
plication of burn cream and dry gauze or the newer
silver-impregnated cloth dressings. The primary burn
creams consist of silver sulfadiazine (Silvadene; Pfizer
Inc.; www.pfizer.com/) and mafenide acetate (Sulfamy-
lon; UDL Laboratories; www.mylan.com). Either agent
may be used with either once- or twice-daily dressing
changes, but should not be used on the face. The USAISR
preferred method is mafenide during the day (because
of the pain associated with its use) and silver sulfadia-
zine at night. An alternative is to use silver-impregnated
dressings such as Silverlon (Argentum Medical; www Figure 6 Acute burn kit.
.silverlon.com) or Acticoat (Smith and Nephew; www
.smith-nephew.com) if available. These dressings are
13
soaked in water or saline for application and may be
left in place up to 7 days. Both ease of application and
the increased dressing-change interval are advantages in
the field setting despite their high purchase price. These
may be rinsed and reapplied for use on the same patient.
Burns to the face should be treated with a topical anti-
biotic ointment (e.g., bacitracin) applied four times per
day. Erythromycin or bacitracin ophthalmic ointment
should be applied to the eyelids and globe surface four

Burn Casualties in Prolonged Field Care 91