Page 103 - Journal of Special Operations Medicine - Winter 2016

Management of Burn Wounds Under Prolonged Field Care

Leopoldo C. Cancio, MD; Doug Powell, MD; Britton Adams, NREMT-P, ATP;
Kenneth Bull, MD; Alexander Keller, MD; Jennifer Gurney, MD; Jeremy Pamplin, MD;
Stacy Shackelford, MD; Sean Keenan, MD

his Role 1, prolonged field care (PFC) guideline is in- ■ Patients with smoke inhalation injury may
Ttended to be used after Tactical Combat Casualty Care present with a range of symptoms in terms of
(TCCC) Guidelines, when evacuation to higher level of severity.
care is not immediately possible. A provider of PFC must ■ Patients with severely symptomatic smoke inha-
first and foremost be an expert in TCCC. This Clinical lation injury (e.g., respiratory distress, stridor)
Practice Guideline (CPG) is meant to provide medical pro- require immediate definitive airway (cuffed tube
fessionals who encounter burns in austere environments in trachea) because they are at risk of immediate
with evidence-based guidance. Recommendations follow airway loss. Oxygenate and ventilate.
a “best,” “better,” “minimum” format that provides al- ■ All patients with burns covering >40% TBSA
ternate or improvised methods when optimal hospital op- should be intubated because total-body swelling
tions are unavailable. A more comprehensive guideline for will tend to obstruct the airway. Patients with
burn care is available in the Joint Theater Trauma System facial burns around the mouth may require in-
Clinical Practice Guideline (JTS CPG) for Burn Care at tubation (Figure 1).
http://www.usaisr.amedd.army.mil/cpgs.html.
Figure 1 Severe facial burns with airway secured.

Burns covering >20% of the total body surface
area (TBSA), or those with smoke inhalation in-
jury (and airway or breathing problems), are life
threatening. Burns that affect vision, decrease
hand function, or cause severe pain can take the
warfighter out of action.

Hypothermia risk is high in burn patients. Antici-
pate that all burn casualties will become hypother-
mic and take immediate measures to prevent it by
covering patient. Aggressively rewarm if tempera-
ture falls below 36°C (96.8°F).

Telemedicine: Management of burns is com- • Best: Rapid-sequence intubation by skilled
plex. Also, burns are highly visual and a lot can provider, followed by continuous sedation
be communicated via pictures or video. Establish and airway maintenance, supplemental oxy-
telemedicine consult as soon as possible. gen, portable ventilator.
• Better: Cricothyroidotomy followed by con-
US Army Institute of Surgical Research tinuous sedation and airway maintenance,
(USAISR) Burn Center supplemental oxygen via an oxygen concen-
DSN 312-429-2876 (429-BURN) trator, portable ventilator.
Commercial (210) 916-2876 or (210) 222-2876 • Minimum: Cricothyroidotomy, ketamine,
E-mail to burntrauma.consult.army@mail.mil ambu bag with positive end-expiratory pres-
sure (PEEP) valve.
Notes:
◆ Airway management: • Patients with mild symptoms of smoke inha-
➤ Goal: Avoid airway obstruction due to inhalation lation injury (e.g., some cough, no respira-
injury or burn-induced swelling. tory distress) can be observed.

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