Page 89 - JSOM Summer 2022

Pathophysiology and Treatment of Burns

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Ryan Payne, NREMT-P *; Erik S. Glassman, MS, FP-C ;
Michael L. Turman, PhD ; Leopoldo C. Cancio, MD, FACS 4
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ABSTRACT
Management of burn patients in the prehospital and prolonged to practice specific skill sets such as: PFC treatment algo-
field care environments presents complex patient care and lo- rithms, telemedicine, and work/rest cycles. Additionally, med-
gistical challenges. The authors discuss the pathophysiology, ics should obtain more clinical hours to practice critical care
diagnostics, longitudinal concerns, and treatment involved in interventions, such as intubations and ventilator management.
the care of such patients. Training these skill sets leads to both improved patient out-
comes and operator success.
Keywords: burns; prehospital; critical care; military medicine;
Special Operations medicine
Pathophysiology
Burn injury presents a complex but predictable series of physi-
ologic derangements caused by both local direct tissue damage
Introduction
and, in larger burns (> 10–20% TBSA), the resulting systemic
Management of burn patients in the prehospital and pro- inflammatory response. The extent of local injury is driven
longed field care (PFC) environments presents complex patient by duration of exposure and the temperature of the injurious
care and logistical challenges. Burn injuries often co-occur agent (flame, surface, or liquid). Additional injury mechanisms
with mechanical trauma and require scarce specialty resources are noted in chemical and electric injuries. Some variability in
over prolonged periods for definitive care. Effective manage- the systemic response is seen regardless of the mechanism of
ment of this patient population requires an understanding of injury; the magnitude of that response is proportional to the
the underlying pathology, methods to assess extent of the in- extent of the burn.
jury, resources to provide supportive care, and access to expert
consultation. The long-range ocean rescues that US Air Force Both the local and systemic responses to these injuries involve
pararescuemen (PJs) have performed in recent years provide damage to the microvasculature. Burned tissue can be con-
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a framework for medical providers to enhance their clinical ceptualized as consisting of three distinct zones. These zones
decision-making. are concentric rings that vary in depth and severity depend-
ing on their proximity to the heat source. At the center of the
Between 2011 and 2018, US Air Force pararescuemen have burn, a zone of coagulation is noted. This zone is character-
performed 14 long-range ocean rescues involving 22 patients. ized by irreversible tissue damage due to protein denaturation
Of these 22 patients, 10 (45%) sustained burns of greater than and thrombosis within the microvasculature. Outside this re-
20% the total body surface area (TBSA); the median burn size gion is a zone of underperfused tissue. This zone of stasis may
in the latter group was 70% TBSA. Many of these patients re- be salvaged with effective resuscitation. However, failure to
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quired advanced critical care interventions such as fluid resus- improve tissue perfusion through adequate resuscitation, or
citation, placement of advanced airways, ventilator support, other factors, can lead to tissue loss. Most patients will have
medication management, wound debridement, and escharoto- some expansion of the zone of coagulation as parts of the zone
mies. Performing these interventions comes with a unique set of stasis become necrotic. Finally, the outermost zone around
of challenges, given the limited amount of medical supplies the burn is referred to as the zone of hyperemia. The tissue in
available and the austere environments in which many provid- this zone is inflamed but not injured, and has minimal risk of
ers may find themselves. undergoing necrosis. 4,5

Among the various lessons learned from these operations, per- Reduced cardiac output and hemodynamic changes due to
haps the most significant recommendation is training. Treating multiple mechanisms (e.g., hypovolemia, decreased contrac-
in the PFC environment requires specific tactics, techniques, tility) is a first hallmark symptom of the post-injury phase. 6,7
and procedures that are not inherent to paramedic-level train-
ing focused on point-of-injury care. We recommend that PFC Systemic impacts of serious burns are initiated by release of
training scenarios be conducted to allow the medical provider a number of inflammatory mediators. The two phases of the
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*Correspondence to ryan.payne.9@us.af.mil
1 SSgt Ryan Payne is a paramedic and affiliated with the 48th Rescue Squadron, Davis-Monthan Air Force Base, Tucson, AZ. Erik S. Glassman is
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a paramedic affiliated with the US Department of State, Washington, DC. Michael L. Turman is affiliated with Long Island University, Brooklyn
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Campus, Brooklyn, NY. COL (Ret) Leopoldo C. Cancio is a physician affiliated with the US Army Institute of Surgical Research, JBSA Fort
Sam Houston, TX.
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