*Link to Burn Wound Management in Prolonged Field Care, 13 Jan 2017 CPG 23

Special Considerations in Burn Injuries

Chemical Burns

NOTE: Refer to the JTS Inhalation Injury and Toxic Industrial Chemical Exposure CPG for additional information.

- Expose body surfaces, brush off dry chemicals, and copiously irrigate with clean water. Large volume (>20L) serial irrigations may be needed to thoroughly cleanse the skin of residual agents. Do not attempt to neutralize any chemicals on the skin.
- Use personal protective equipment to minimize exposure of medical personnel to chemical agents.
- White phosphorous fragments ignite when exposed to air. Clothing may contain white phosphorous residue and should be removed. Fragments embedded in the skin and soft tissue should be irrigated out if possible or kept covered with soaking wet saline dressings or hydrogels.
- Seek early consultation from the USAISR Burn Center (DSN 312-429-2876 (BURN); Commercial (210) 916-2876 or (210) 222-2876; email: usarmy.jbsa.medcom-aisr.list.armyburncenter@health.mil

Electrical Burns

- TCCC ASM and CLS personnel should remove the patient from the electricity source while avoiding injury themselves.
- For cardiac arrest due to arrhythmia after electrical injury, follow advanced cardiac life support (ACLS) protocol and provide hemodynamic monitoring if spontaneous circulation returns.
- Small skin contact points (cutaneous burns) can hide extensive soft tissue damage.
- Observe the patient closely for clinical signs of compartment syndrome.
- Tissue that is obviously necrotic must be surgically debrided.

NOTE: Escharotomy, which relieves the tourniquet effect of circumferential burns, will not necessarily relieve elevated muscle compartment pressure due to myonecrosis associated with electrical injury; therefore, fasciotomy is usually required.

- Compartment syndrome and muscle injury may lead to rhabdomyolysis, causing pigmenturia and renal injury.
- Pigmenturia typically presents as red-brown urine. In patients with pigmenturia, fluid resuscitation requirements are much higher than those predicted for a similar-sized thermal burn.
- Isotonic fluid infusion should be adjusted to maintain UOP 75-100 mL/hr. in adult patients with pigmenturia.
- If the pigmenturia does not clear after several hours of resuscitation consider IV infusion of mannitol, 12.5 g per liter of lactated Ringer’s solution, and/or sodium bicarbonate (150 mEq/L in D5W). These infusions may be given empirically; it is not necessary to monitor urinary pH. In patients receiving mannitol (an osmotic diuretic), close monitoring of intravascular status via CVP and other parameters is required.
- Seek early consultation from the USAISR Burn Center (DSN 312-429-2876 (BURN); Commercial (210) 916-2876 or (210) 222-2876; email : usarmy.jbsa.medcom-aisr.list.armyburncenter@health.mil

Pediatric Burn Injuries

- Children with acute burns over 15% of the body surface usually require a calculated resuscitation.
- Place a bladder catheter if available (size 6 Fr for infants and 8 Fr for most small children).
- The Modified Brooke formula (3 mL/kg/%TBSA LR or other isotonic fluid divided over 24 hours, with one-half given during the first 8 hours) is a reasonable starting point. This only provides a starting point for resuscitation, which must be adjusted based on UOP and other indicators of organ perfusion. Goal UOP for children is 0.5-1mL/kg/hr.
- Very young children do not have adequate glycogen stores to sustain themselves during resuscitation. Administer a maintenance rate of D5LR to children weighing < 20 kg. Utilize the 4-2-1 rule: 4ml/kg for the first 10kg + 2ml/kg 2nd 10kg + 1ml/kg over 20kg.
- In children with burns > 30% TBSA, early administration may reduce overall resuscitation volume.
- Monitor resuscitation in children, like adults, based on physical examination, input and output measurements, and analysis of laboratory data.
- The well-resuscitated child should have alert sensorium, palpable pulses, and warm distal extremities; urine should be glucose negative.
- Cellulitis is the most common infectious complication and usually presents within 5 days of injury. Prophylactic antibiotics do not diminish this risk and should not be used unless other injuries require antimicrobial coverage (penetrating injury or open fracture).
- Most antistreptococcal antibiotics such as penicillin are successful in eradicating infection. Initial parenteral administration is advised for most children presenting with fever or systemic toxicity.
- Nutrition is critical for pediatric burn patients. Nasogastric feeding may be started immediately at a low rate in hemodynamically stable patients and tolerance monitored. Start with a standard pediatric enteral formula (i.e. Pediasure) targeting 30-35 kcal/kg/day and 2g/kg/day of protein.
- Children may rapidly develop tolerance to analgesics and sedatives; dose escalation is commonly required. Ketamine and propofol are useful procedural adjuncts.
- When burned at a young age, many children will develop disabling contractures. These are often very amenable to correction which may be performed in theater with adequate staff and resources.
- Seek early consultation from the USAISR Burn Center (DSN 312-429-2876 (BURN); Commercial (210) 916-2876 or (210) 222-2876; email burntrauma.consult.army@mail.mil).
- Opportunities for pediatric surgical care provided by Non-Governmental Organizations (NGOs) may be the best option but require the coordinated efforts of the military, host nation, and NGOs.

Rule of Nines

On the DD Form 1380 the percentage of coverage on the casualty’s body will need to be documented. The Rule of Nines will help with the estimation. The below figure shows the approximation for each area of the body:

- Eleven areas each have 9% body surface area (head, upper extremities, front and backs of lower extremities, and front and back of the torso having two 9% areas each).
- General guidelines are that the size of the palm of the hand represents approximately 1% of the burned area.
- When estimating, it is easiest to round up to the nearest 10.
- If half of the front or rear area is burned, the area would be half of the area value.
- For example, if half of the front upper/lower extremity is burned, it would be half of 9%, or 4.5%. If half of the front torso is burned, say either the upper or lower part of the front torso, then it would be half of 18%, or 9%.
- Remember, the higher the percentage burned, the higher the chance for hypothermia.
- For children, the percentage of BSA is calculated differently due to the distinctive proportion of major areas.