Page 39 - 2022 Spring JSOM

TABLE 19 Continued
PCC Role-based Guidelines for Burn Management
Intervention Paradigm
TCCC - TCCC -
CMC CMC Medications • Prophylactic antibiotics (oral or IV) are not indicated for burn injury in the absence of infection.
(Roles 1a/1b) • Penetrating wounds or open fractures should be treated with antibiotics according to current TCCC guidelines.
Medications • After several days, if the patient develops cellulitis (spreading erythema around edges of burn), treat for gram-
(Role 1c) positive organisms, (e.g., cefazolin or clindamycin).
• If patient develops invasive burn wound infection (signs: sepsis/septic shock, changes in color of wound, possible
foul smell of wound), treat with broad-spectrum antibiotics.
Wounds • Minimum: Cover with clean sheet or dry gauze. Leave blisters intact. Avoid wet dressings.
(Role 1a) • Better: Clean wounds by washing with any clean water (preferably with antibacterial soap if available), dress
wounds with any available dressings; optimize wound and patient hygiene to the extent possible given the
environment.
• Best: Clean wounds by scrubbing gently with gauze and clean water, followed by gauze dressing.
• DO NOT debride blisters until the patient has reached a facility with surgical capability.
• Every patient with facial burns should have a thorough eye exam. Conduct an eye exam early, before edema begins.
• If a corneal injury is identified, use a rigid shield to cover the eyes and apply ophthalmic erythromycin or neomycin
ointment every 2 hr.
Wounds • Better: Clean wounds and debride loose skin by washing with any clean water (preferably with antibacterial soap
(Roles 1b/1c) if available), dress wounds with any available dressings; optimize wound and patient hygiene to the extent possible
given the environment.
• Best: Clean wounds by scrubbing gently with gauze and chlorhexidine gluconate solution (if available) in clean
water, apply topical antimicrobial cream followed by gauze dressing.
Monitoring • Monitor vital signs and urine output (UOP) closely.
• Minimum: Use other measures If unable to measure UOP, adjust IV rate to maintain HR less than 140, palpable
peripheral pulses, good capillary refill, intact mental status.
• Better: Capture all spontaneously voided urine in premade or improvised (i.e., Nalgene water bottle) graduated
®
cylinder; >180mL every 6 hr is adequate for adults.
• Best: Measure UOP with Foley catheter (burns to the penis are NOT a contraindication to catheter placement)
• Ensure all above interventions are completed by TCCC ASM, CLS and CMC personnel.
• Conduct inventory of all resources.
• Document all pertinent information on PCC Flowsheet (attached.)
• Additional interventions include:
Airway • Minimum: Allow casualty to maintain airway. Edema after burn injury causes most supraglottic airway devices
(Roles 1a/1b/1c) such as LMAs to be inadequate.
• Better: Facial burns may be associated with inhalation injury. Aggressively monitor airway status and consider
early surgical airway for respiratory distress or oxygen saturation and/or EtCO2 (purple-gold colorimetric device).
• Best: Indications for endotracheal intubation include: a comatose patient, symptomatic inhalation injury, deep
facial burns, and burns over 40% TBSA.
• Utilize an EMMA (or other Capnography) EtCO device if possible.
2
• Use a large-bore endotracheal tube if inhalation injury is suspected (Size 8 ETT or larger is preferred for adults).
• Secure ETT with cotton umbilical ties (standard adhesive ETT holders do not work around burned skin).
• Frequently reassess position of the ETT during the acute resuscitation period as edema waves and wanes.
*Link to Burn Wound Management in Prolonged Field Care, 13 Jan 2017 CPG 23

Pediatric Burn Injuries ■ Nutrition is critical for pediatric burn patients. Nasogastric feed-
■ Children with acute burns over 15% of the body surface usually ing may be started immediately at a low rate in hemodynamically
require a calculated resuscitation. stable patients and tolerance monitored. Start with a standard pe-
■ Place a bladder catheter if available (size 6 Fr for infants and 8 Fr diatric enteral formula (i.e., Pediasure) targeting 30–35kcal/kg/day
for most small children). and 2g/kg/day of protein.
■ The Modified Brooke formula (3 mL/kg/%TBSA LR or other iso- ■ Children may rapidly develop tolerance to analgesics and seda-
tonic fluid divided over 24 hr, with one-half given during the first tives; dose escalation is commonly required. Ketamine and propo-
8 hr) is a reasonable starting point. This only provides a starting fol are useful procedural adjuncts.
point for resuscitation, which must be adjusted based on UOP ■ When burned at a young age, many children will develop disabling
and other indicators of organ perfusion. Goal UOP for children contractures. These are often very amenable to correction which
is 0.5–1mL/kg/hr. may be performed in theater with adequate staff and resources.
■ Very young children do not have adequate glycogen stores to sus- ■ Seek early consultation from the USAISR Burn Center (DSN 312-
tain themselves during resuscitation. Administer a maintenance rate 429-2876 (BURN); Commercial (210) 916-2876 or (210) 222-
of D5LR to children weighing < 20 kg. Utilize the 4-2-1 rule: 4mL/ 2876; email burntrauma.consult.army@mailmil).
kg for the first 10 kg + 2mL/kg 2nd 10 kg + 1mL/kg over 20 kg. ■ Opportunities for pediatric surgical care provided by Non-Govern-
■ In children with burns > 30% TBSA, early administration may mental Organizations (NGOs) may be the best option but require
reduce overall resuscitation volume. the coordinated efforts of the military, host nation, and NGOs.
■ Monitor resuscitation in children, like adults, based on physical Rule of Nines
examination, input and output measurements, and analysis of lab- On the DD Form 1380 the percentage of coverage on the casualty’s
oratory data.
■ The well-resuscitated child should have alert sensorium, palpable body will need to be documented. The Rule of Nines will help with the
estimation. The below figures shows the approximation for each area
pulses, and warm distal extremities; urine should be glucose negative.
■ Cellulitis is the most common infectious complication and usually of the body (see Figures 2 and 3):
Eleven areas each have 9% body surface area (head, upper extrem-
■
presents within 5 days of injury. Prophylactic antibiotics do not ities, front and backs of lower extremities, and front and back of
diminish this risk and should not be used unless other injuries re- the torso having two 9% areas each).
quire antimicrobial coverage (penetrating injury or open fracture).
■ Most antistreptococcal antibiotics such as penicillin are successful ■ General guidelines are that the size of the palm of the hand rep-
resents approximately 1% of the burned area.
in eradicating infection. Initial parenteral administration is advised ■ When estimating, it is easiest to round up to the nearest 10.
for most children presenting with fever or systemic toxicity.
Prolonged Casualty Care Guidelines | 37