Page 104 - Journal of Special Operations Medicine - Winter 2016

• Burns or explosions in a closed space are as-
sociated with higher risk of inhalation injury Note: Significant over- or underestimation of
than burns occurring in open areas. burn wound size (by more than 10%) may lead to
• Supraglottic airway (e.g., laryngeal mask significant morbidity. Underestimation may lead to
airway [LMA], King LT [Ambu, http://www under-resuscitation and organ failure (i.e., renal
.ambuusa.com/], or Combitube [Medtronic failure, shock); overestimation may lead to resusci-
Minimally Invasive Therapies, http://www tation morbidity (i.e., respiratory failure, compart-
.medtronic.com/covidien]) is not appropri- ment syndromes).
ate because edema will continue to increase • “1st degree” (superficial) burns look like a
over 48 hours and these tubes do not over- mild-moderate sunburn. They appear red,
come vocal-cord edema. blanch readily, do not blister, and hurt when
• Endotracheal tube must be secured circum- touched. Do NOT include these wounds in the
ferentially around the neck using cotton ties estimation of TBSA used for fluid resuscitation
or similar. Tape does not stick to the face (Figure 2).
well enough in burn patients. • “2nd degree” (partial thickness) burns are
• Place nasogastric (or orogastric) tube to de- moist, blister, blanch, and hurt. Include these
compress stomach in intubated patients. wounds in the TBSA estimation (Figure 3).
• Perform frequent endotracheal suction of in- • “3rd degree” (full thickness) burns appear
tubated patients to ensure tube patency and leathery, dry, nonblanching, do not hurt, and
remove mucus/debris (approximately once often contain thrombosed vessels that are vis-
an hour or more frequently if oxygen satura- ible. Include these wounds in the TBSA estima-
tion [SpO ] drops). tion (Figure 4).
2
• If there is evidence of inhalation injury, use
3–5mL of endotracheal saline to facilitate
suctioning and prevent tube insipation and ■ Best: When wounds are cleaned/debrided, re-
obstruction.
• Monitoring end-tidal CO is an important calculate TBSA using the Lund-Browder chart
2
(Appendix B).
capability for all intubated patients. A ris- ■ Better: Same as minimum.
ing end-tidal CO could indicate clogging of ■ Minimum: For small wounds, calculate the size
2
endotracheal tube or poor ventilation from of the wound by using the patient’s hand size
another cause (e.g., bronchospasm, tight es- (including fingers) to represent a 1% TBSA.
char across chest).
• Use PEEP on all intubated patients. For larger wounds, calculate the patient’s ini-
tial burn size using the Rule of Nines (Appen-
• Perform a surgical escharotomy of the chest dix C).
for tight, circumferential, full-thickness
burns that impair breathing. Incision goes ◆ Fluid Resuscitation:
through the full thickness of the burn and ➤ Goal: Over the first 24–48 hours postburn,
into the fat (Appendix A). Expect some pain plasma is lost into the burned and unburned tis-
and bleeding.
• Use bronchodilators (e.g., albuterol inhaler) sues, causing hypovolemic shock (when burn size
is >20%). The goal of burn-shock resuscitation
for intubated patients with inhalation injury, is to replace these ongoing losses while avoiding
if available.
over-resuscitation.
Ventilator management of burn patients can be ■ Best: Isotonic crystalloids (e.g., lactated Ring-
complicated and evolve as pulmonary conditions change er’s, Plasma-Lyte IV [Baxter, http://www.baxter
due to volume overload/edema and acute respiratory .com/]);
distress syndrome (ARDS). Telemedicine consultation • Start intravenous (IV) or intraosseous (IO)
with skilled providers is recommended. administration IMMEDIATELY
• IV/IO can be placed through burned skin if
◆ Assess Burn Size: necessary.
➤ Goal: Accurately identify burn wound size to • NO bolus (unless hypotensive, in which case,
identify appropriate fluid resuscitation needs. bolus only until palpable pulses are restored)
• Initial IV rate 500mL/h; start while complet-
Estimating burn wound size may be difficult. En- ing initial assessment
gage remote specialty consultants early. If possible, send • Adults: measure burn size (TBSA) and multi-
pictures of wounds that have been cleaned and debrided. ply by 10. This is now your IV fluid rate. For

88 Journal of Special Operations Medicine Volume 16, Edition 4/Winter 2016