Page 98 - Journal of Special Operations Medicine - Fall 2015

Care of the Burn Casualty

in the Prolonged Field Care Environment

Nicholas M. Studer, MD, EMT-P; Ian R. Driscoll, MD;
Ivonne M. Daly, MD, FACS; John C. Graybill, MD

ABSTRACT

Burns are frequently encountered on the modern battle- weapons (e.g., the Molotov cocktail) have been used in
field, with 5%–20% of combat casualties expected to the recent conflicts in Southwest Asia or exist in the ar-
sustain some burn injury. Addressing immediate life- senals of potential adversaries. 1
threatening conditions in accordance with the MARCH
protocol (massive hemorrhage, airway, respirations, The skin provides an essential role in fluid balance, ther-
circulation, hypothermia/head injury) remains the top moregulation, and protection against microorganisms.
priority for burn casualties. Stopping the burning pro- Burns disrupt these functions while generating a severe
cess, total burn surface area (TBSA) calculation, fluid inflammatory and hypermetabolic state that can lead to
resuscitation, covering the wounds, and hypothermia multiple organ failure. Inhalational injury, damage to
4
management are the next steps. If transport to defini- the lining of the respiratory tract, occurs after exposure
tive care is delayed and the prolonged field care stage is to smoke and is frequently seen in casualties trapped in
entered, the provider must be prepared to provide for confined spaces or vehicles.
the complex resuscitation and wound care needs of a
critically ill burn casualty.
Classification of Burns
Keywords: burn injury; inhalation injury; Tactical Combat Providers must have thorough knowledge of the skin
Casualty Care; prolonged field care; Silverlon; Water-Jel; and subcutaneous tissues as an organ system to under-
Burntec stand the nature of burn injury. The common classifica-
tion of first-, second-, and third-degree burns has now
been replaced with more anatomically descriptive terms:
superficial, superficial partial thickness (Figure 1A),
Introduction
deep partial thickness (Figure 1B), and full thickness
Casualties with burn injury are considered among the (Figure 1C). Superficial burns consist of damage to the
most difficult to care for. Historically, 5%–20% of com- epidermis only, and although extremely painful, they are
bat casualties will present with burns. Five percent of neither life threatening nor permanently scarring. Super-
1
combat wounded in the Iraq campaign had burn inju- ficial partial thickness burns involve only the upper pap-
ries. Certain populations, specifically armored vehicle illary dermis and are characterized by extreme pain and
2
and naval vessel crewmen, are at higher risk. Burns may blistering. These are often wet with exudate and have
also result from non-battle injuries sustained while de- brisk capillary refill. Deep partial thickness involves the
ployed or in garrison. Burning of human waste was a lower reticular dermis and presents with decreased pain
common mechanism during the recent conflicts. De- due to nerve ending damage. Deep partial- thickness
3
ployed personnel have been estimated to be exposed burns are generally drier, with diminished exudate com-
to twice the risk of suffering burn injury compared to pared with superficial partial thickness burns, and have
the civilian population in the United States. Burns are delayed capillary refill. Full-thickness burns have a whit-
common injuries resulting from terrorist bombings of ish, wax-like, leather, or charred appearance. They are
both military and civilian populations. While there are generally insensate due to complete destruction of nerve
many etiologies of burn injuries, including chemicals, endings and dry from lack of perfusion.
radiation, and electric current, thermal burn injury is
the most common and is the focus of this article. Blast Jackson’s theory of thermal wounds describes the dis-
injuries are often accompanied by thermal burns. Flame tribution of full-thickness burns (Figure 2). This theory
weapons such as napalm, white phosphorus (WP), ther- provides an explanation for the goals of resuscitation and
mobaric/fuel-air explosives, and improvised incendiary wound care, as well as why casualties with full-thickness

86