TRIAGE PRINCIPLES

- Triage of patients to an expectant category may be required if their burns exceed local capacity to treat and rehabilitate. Local capacity refers to either the deployed U.S. MTF, or the local national healthcare system, depending on medical rules of engagement and U.S. MTF bed space.
- Another method for doing triage is based on the Baux score, defined as the age plus the burn size. For example, a 20-year-old with an 80% TBSA burn has a Baux score of 20+80 = 100. At a Baux score of 100, the risk of death in a CONUS burn center is currently about 50%. In a mass-casualty or austere setting in which triage is required, a reasonable approach is to use scarce resources for patients with a Baux score of 100 or less.
- The above considerations mean that accurate calculation of burn size is essential to preclude wrongly placing a patient with a survivable burn in the expectant category. Burn size is often over-estimated by inexperienced personnel. Use the Lund Browder chart carefully (Appendix B).
- Consideration should also be taken for concomitant inhalation injury, medical co-morbidities, and nonburn trauma, all of which can increase mortality.
- Call the Burn Center for consultation.
- If caring for expectant casualties, provide adequate comfort-care measures.

The following factors should be considered when assessing whether to provide definitive care to a host-nation patient in the deployed setting:

- The deployed team’s experience and skill level in burn care
- The bed capacity of the deployed hospital
- The tactical situation on the ground (e.g., the likelihood of casualty influx)
- The availability of dressings and other burn-specific supplies
- The quality and capacity, if any, of local host-nation facilities to provide follow-on care
- The availability of non-governmental organizations to provide care to certain patient groups, such as children

The following facts should be borne in mind as well:

- Burn patients in CONUS typically require one day of hospitalization per percent burn (e.g., a 30% TBSA burn patient requires on average a 30-day hospitalization).
- Because of infection risk, and unlike other forms of trauma, burns in excess of about 20% TBSA constitute a life-threatening problem until the wounds are largely closed. Likewise, deep burns of functional areas like the hands and periorbital structures represent limb- or eyesight-threatening problems until the wounds are healed. These considerations should influence the interpretation of the medical rules of engagement for host-nation burn patients.
- The 50% TBSA cut off for host-nation patients employed during OIF and OEF must be interpreted in the context of burn depth, not just burn size. A full thickness burn of 50% TBSA is much harder to take care of (and more likely to be lethal) than a superficial partial thickness burn of 50% TBSA. The full-thickness burn will require multiple surgeries. The superficial partial-thickness burn may heal spontaneously with topical care. Also, clinical assessment of burn depth may change over time because of the effects of burn shock on wound perfusion. Thus, verification of burn depth and size after completion of resuscitation is a prudent best practice when deciding whether to proceed with definitive care, or not—especially in patients with burns at the margin, that is, about 50% TBSA or slightly greater.

It is sometimes difficult to determine the full extent of the full thickness burn at the time of initial presentation. For patients with combined partial- and full-thickness burns initiate resuscitation and allow the partial thickness component to declare itself. After approximately 48-72 hours, reassess the patient to more accurately estimate the percentage of full-thickness burn.

Burn injuries may initially appear survivable, but skin-graft loss, infections, or other complications may transform a potentially survivable injury into a fatal one. Be aware of this possibility and the potential change to an expectant category.