Page 67 - 2022 Ranger Medic Handbook

Burn Management
TCCC Application
Care Under Fire: Casualties should be extricated from burning vehicles or buildings and moved to places of relative
safety. Do what is necessary to stop the burning process.
Tactical Field Care: Facial burns, especially those that occur in closed spaces, may be associated with inhalation injury
and/or carbon monoxide inhalation. Aggressively monitor airway status and oxygen saturation in such patients and
consider early surgical airway for respiratory distress or oxygen desaturation. Estimate total body surface area (TBSA)
burned to the nearest 10% using the rule of nines. Cover the burn area with dry, sterile dressings. For extensive burns SECTION 2
(> 20%), if available, consider placing the casualty in a ready-heat blanket from the Hypothermia Prevention and Man-
agement Kit to both cover the burned areas and prevent hypothermia. Initiate fluid resuscitation (USAISR Rule of Ten):
If burns are greater than 20% of TBSA, fluid resuscitation should be initiated as soon as IV/IO access is established.
Resuscitation should be initiated with crystalloids. Do not use more than 3L of NS due to the risk of causing hyperchlore-
mic metabolic acidosis. Initial IV/IO fluid rate is calculated as %TBSA × 10mL/hr for adults weighing 40–80 kg. For every
10 kg ABOVE 80 kg, increase initial rate by 100mL/hr. If hemorrhagic shock is also present, resuscitation for hemorrhagic
shock takes precedence over resuscitation for burn shock. Treat the burn patient IAW the Pain Management Protocol.
Prehospital antibiotic therapy is not indicated solely for burns, but antibiotics should be given as indicated for other
traumatic injuries. All TCCC interventions can be performed on or through burned skin in a burn casualty.
Tactical Evacuation: Initiate any tactical field care interventions not previous performed. Burn patients are particularly
susceptible to hypothermia. Extra emphasis should be placed on barrier heat loss prevention methods and IV fluid
warming in this phase.
Extended Care
Extended care in the prehospital environment will remain focused on prevention of hypothermia, airway, and vital sign
monitoring as well as initiation of fluid resuscitation avoiding bolus fluids if possible. Elevate injured extremities 30–45°.
Documentation of input/out of fluids must be initiated and evacuated with patient to the next higher facility. Fluid re-
suscitation will be in accordance with the USAISR rule of ten. Assess distal circulation of all extremities by palpating
the radial, dorsalis pedis, and posterior tibial arteries. If a pulse is palpable in one or more arteries in each extremity
escharotomy is not indicated.
Inhalation burns should be assumed with any burns to the face and neck and may require aggressive airway manage-
ment. Inhalation injury is further exacerbated by retained soot and chemicals. Not every patient with soot in the airway
will require airway management. Use clinical judgment and assess the patient before taking the airway. Remember,
inhalation injury is mostly a chemical injury that will benefit from removing the chemical. Suction the airway carefully
using the endotracheal suction tubing if available to remove both secretions and soot or chemical materials. Irrigation
of any kind in the field is not warranted and will most likely move materials to unaffected airways or pulmonary tissue.
Burn Guidelines: Do not administer prophylactic antibiotics for burns without other combat wounds. Splint burned
hands and feet in position of function with dressings separating digits. Aggressively manage pain and hypothermia for
critical burn patients. Commercial burn dressings are not required and add little to patient care. In the acute phase do
not be distracted by a burn. DO NOT OVER RESUSCITATE WITH IV FLUIDS. RECORD STRICT I/OS AND MAINTAIN
0.5–1mL/kg/hr UOP.
Escharotomy: The requirement for escharotomy usually presents in the first few hours following injury. If the need for
either procedure has not presented in the first 24 hours, then circulation is likely to remain adequate without surgical
intervention. Escharotomy is normally performed when an extremity has a circumferential full-thickness burn. If the burn
is superficial or not circumferential and pulses are absent, consider inadequate circulation from other causes such as
hypovolemia, hypotension, or occult traumatic injury. If indicated, extend escharotomy incisions the entire length of the
full-thickness burn and carry across the joint when the burn extends across the joint. In the lower extremity, make a
mid-lateral or mid-axial incision with a surgical knife through the dermis to the level of fat. It is not necessary to carry
the incision to the level of fascia. Although full-thickness burn is insensate, the patient will often require intravenous pain
management during this procedure. Perform pain management or sedation as required. On completion of mid-lateral or
mid-medial escharotomy, reassess the pulses. If circulation is restored, bleeding should be controlled and the extremity
dressed and elevated at a 30–45° angle. Assess pulses hourly for at least 12–24 hours. If circulation is not restored, per-
form a second incision on the opposite side of the extremity. For upper extremities, place the hand in the anatomic posi-
tion (palm facing forward) and make an incision in the mid-radial or mid-ulnar line. Ulnar incisions should stay anterior
(volar) of the elbow joint to avoid the ulnar nerve, which is superficial at the level of the elbow. If pulses are not restored,
a second incision may be necessary on the opposite side of the extremity. If both the hand and arm are burned, con-
tinue the incision across the mid-ulnar or mid-radial wrist and onto the mid-ulnar side of the hand or to the base of the
thumb and then the thumb webspace. Following escharotomy, late bleeding may occur as pressure is decompressed
and circulation restored. Examine the surgical site every few minutes for up to 30 minutes for signs of new bleeding.
Pediatric Body Surface Area:
head = 18%, torso front = 18%, torso back = 13%, unilateral buttock = 2.5%, arm = 9%, leg = 15% (7.5% per side).
2022 RANGER MEDIC HANDBOOK 53