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Subsequently, specific guidelines on the care of burns in PFC this treatment in the event of burn injury as accessible as a
situations have been published. These guidelines explicitly tourniquet. The use of these oral rehydration packets could be
42
state that IV resuscitation with isotonic fluids is the best op- discussed and taught before deploying as a part of basic life
tion. However, the maximum burn size recommended for en- saver fundamentals taught throughout the military. Another
teral resuscitation is less than 30%TBSA, as is the maximum consideration in these scenarios (as well as mass casualty care)
rate of 300 to 500mL/h infusion through an NG tube. Im- is the cost of resuscitation fluids (Figure 2). In addition, these
portantly, these recommendations include that plain water is solutions require no specialized equipment or machinery that
ineffective and may be dangerous, leading to side-effects like would further increase cost. As opposed to pumps, poles, and
hyponatremia. As such, both of the published guidelines men- needles, the only other object needed for enteral fluids would
tioned give instructions on how to make a homemade ORS be a cup, bottle, or canteen. In short, oral rehydration pack-
using potable water and sugar, salt, and baking soda or even ets are a low cost yet very effective way to ensure that the
mixing different proportions of commonly available IV solu- Servicemembers down range can receive timely treatment for
tions. Similar formulas with different starting points have been burn injuries.
given elsewhere, which also mentioned that if a weighing scale
is not available, ORS should be prepared to have a similar Conclusion
taste as that of tears. This and other guidelines also mention
45
specific drinks to avoid such as high–sugar content drinks and While prospective randomized trials for enteral resuscitation
coffee or other diuretic drinks. are long overdue, the use of the gut for hydration/resuscitation
of the moderately burned patient is feasible in resource-poor
Last, one distinct possibility that has been suggested is the po- settings. Guidelines indicate that burns of up to 40% TBSA
tential for enteral resuscitation through slow infusion through may be successfully treated in this manner. Furthermore, liter-
the rectum (proctoclysis), which has previously been used in ature suggests that this strategy may reduce IV fluid require-
43
austere environments for hemorrhagic shock. Indeed, one re- ments, which should also be examined. The current study of
48
cent animal study has already tested the absorption capability oral rehydration fluid preferences based on palatability, re-
in the large intestine with colonic fluid. The solution used vealed that currently available solutions carry sufficient pal-
49
was normal (0.9%) saline administered through a catheter, atability while maintaining the osmolarity of the WHO-ORS,
which may be safe in unconscious patients and avoids limita- which is important considering its life-saving track record.
tions of gastric emptying and reduced intestinal motility. On Taken together, while there are many operational advantages
the other hand, the absorptive capacity of the large intestine is of this resuscitation strategy, many questions on efficacy, vol-
not as high as the small intestine. Lacking any clinical data on umes, additives, etc. remain unanswered.
this strategy for burn resuscitation, its use cannot be recom-
mended at this time. Funding
US Army Medical Research and Materiel Command and
Using Enteral Fluids: Other Considerations Congressionally Directed Medical Research Program award
While leveraging the body’s natural mechanism of hydration #W81XWH-16-0041 provided funding for this project.
seems promising from a clinical efficacy standpoint, there
are other logistical considerations that confer advantages to Disclaimer
enteral resuscitation. The weight carried by medics has been The views expressed in this article are those of the author(s)
steadily increasing in the past several conflicts. The small in- and do not reflect the official policy or position of the US
testine can absorb 15 to 20L of water per day. For a 70kg Army Medical Department, Department of the Army DoD, or
50
adult with a 40% TBSA burn injury, clinical practice guide- the US Government.
lines (2 to 4mL/kg/%TBSA) recommend infusing 5.6 to 11.2L
in the first 24 hours. These numbers equate to anywhere from Financial Disclosure
12 to 24 lb of fluid alone. In PFC and other delayed trans- The authors have indicated they have no financial relation-
port scenarios, access to these volumes of heavy fluids may not ships relevant to this article to disclose.
be feasible. The lightweight sachets that present the ORS in
powder form will help decrease the weight that combat medics Author Contributions
have to carry in their ruck. This will help with maneuverability DB and BG conceived the study concept. JL and BG recruited
as well as lower fatigue and strain put on the combat medics participants and performed studies. DB and MD obtained
out on missions. funding. DB wrote the first draft, and all authors approved the
contents of the final manuscript.
The technical expertise needed for using enteral fluids is also
much lower than for IV fluids. IV fluids assume vascular ac- References
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For enteral fluids, there is not much concern when it comes 2. Rowan MP, Cancio LC, Elster EA, et al. Burn wound healing and
treatment: review and advancements. Crit Care. 2015;19:243.
to sterility, and requirements are a clean source of potable 3. Cancio LC, Batchinsky AI, Dubick MA, et al. Inhalation injury:
water. The ORS packets are reconstituted very easily with a pathophysiology and clinical care proceedings of a symposium
clearly defined volume of water. The packets could be carried conducted at the Trauma Institute of San Antonio, San Antonio,
in large quantities with very little concern of keeping these TX, USA on 28 March 2006. Burns. 2007;33(6):681–692.
packets in sterile environments. This allows the combat med- 4. Chung KK, Blackbourne LH, Wolf SE, et al. Evolution of burn
ics as well as any combat lifesavers attached to the platoon to resuscitation in operation Iraqi freedom. J Burn Care Res. 2006;27
(5):606–611.
provide rapid treatment in tactical environment. These oral 5. Kauvar DS, Wolf SE, Wade CE, et al. Burns sustained in combat
rehydration packets could be placed in each Servicemember’s explosions in Operations Iraqi and Enduring Freedom (OIF/OEF
IFAK (individual first aid kit), which would make access to explosion burns). Burns. 2006;32(7):853–857.

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