Page 107 - Journal of Special Operations Medicine - Winter 2016

300mL/h, increase IV rate by 0.25 × 300 = ■ Minimum: Triage patient to more rapid evacu-
75mL/h. New rate is 375mL/h.) ation if extremity is edematous and you are
• If UO too high, decrease IV rate by 25%. unable to palpate distal pulses. Elevate burned
■ Better: Capture urine in premade or improvised extremities above heart level and have patient
graduated cylinder exercise or provide passive range of motion
• Collect all spontaneously voided urine (PROM) to burned extremities to mobilize
hourly and carefully measure; >180mL every edema. Provide pain control to enable PROM.
6 hours is adequate for adults.
• A Nalgene (Thermo Fisher Scientific Inc., ◆ Pain Management:
®
http://www.nalgene.com/) water bottle is an Refer to Analgesia and Sedation CPG.
example of an improvised graduated cylinder. ➤ Burns can be painful and can cause hypovolemia.
■ Minimum: use other measures Thus, frequent, smaller doses of an IV opioid or
• If unable to measure UO, adjust IV rate to ketamine are preferred.
maintain HR less than 140, palpable periph- ■ In hypovolemic burn patients, ketamine can be
eral pulses, good capillary refill, intact men- used for severe pain or for painful procedures,
tal status. but less than the full anesthetic dose is safer
• Measure the BP and consider treating hypo- (e.g., 0.1–0.2mg/kg IV push, assess response
tension, but remember: BP does not decrease and redose ketamine as needed every 5–10
until relatively late in burn shock, because minutes).
of catecholamine release. On the other hand, ■ For prolonged care of burn patients, a ket-
BP may be inaccurate (artificially low) in amine infusion may provide more consistent
burned extremities. analgesia and help conserve supplies of analge-
sic medications.
Note: Electric injury ■ Burn wound care is extremely painful. Ensure
• Patients with high-voltage electric injury an adequate supply of analgesic agents is avail-
causing muscle damage and gross pigment in able before starting wound cleaning, debride-
the urine (and similar patients, such as rhab- ment, escharotomy, or dressing change. Refer
domyolysis or crush injury) have a higher to Analgesia and Sedation CPG or obtain tele-
target UO of 70–100mL/h in adults. See PFC medicine advice for adequate dosing of proce-
Crush CPG. dural analgesia for burn care.
• If this does not cause gradual clearing of the ■ Consider administering an oral or IV benzo-
pigment (urine turns lighter on three or four diazepine for anxiety (common with repeated
hourly checks), the patient likely needs urgent painful wound care).
surgery for decompression/debridement.
◆ Infection:
◆ Extremity Burns: Burn wounds are easily infected.
Burned extremities are vulnerable to injury from ➤ Goal: Prevent burn wound infection through
postburn swelling. wound care. If evacuation to higher level of care
➤ Goal: Prevent and manage swelling (edema) of is anticipated within 24 hours, simply cover burns
burned extremities to prevent long-term damage. with clean, dry gauze and leave intact blisters in
■ Best: Elevate burned extremities above heart place. Always avoid wet dressings, because of the
level. Encourage patient to exercise burned ex- risk of hypothermia. If evacuation is not antici-
tremities to decrease edema. Monitor peripheral pated for more than 24 hours, and time, medica-
pulses on all burned extremities hourly, using tion, and human resources permit, provide wound
a Doppler flowmeter if available. Perform es- care as soon as possible after the injury (within
charotomies of circumferential burns to restore the first 24 hours). If resources are not available
blood flow (Appendix A). Anticipate blood loss initially, provide wound care as soon as possible.
and prepare for blood transfusion. ■ Best: Clean wounds and debride loose dead
Obtain teleconsultation. skin by scrubbing gently with gauze and
chlorhexidine gluconate solution (e.g., Hibi-
■ Better: Consider doing escharotomies for cir- clens, Möl nylcke Health Care, http://www.
cumferential full thickness (3rd degree) burns of hibiclens.com/) in clean water; apply topical
an extremity if extremity is edematous, you are antimicrobial cream (silver sulfadiazine [Sil-
unable to palpate distal pulses, and evacuation vadene, Pfizer Inc., http://www.pfizer.com/] or
will be delayed. Anticipate blood loss and pre- mafenide acetate [Sulfamylon, Mylan, http://
pare for blood transfusion. www.mylan.com/]), followed by gauze dress-
Obtain teleconsultation. ing. Repeat daily.

PFC Guideline: Burn Management 91