EPIDEMIOLOGY OF MILITARY BURN INJURY

Military burn injury occurs during both routine global operations and during combat. The epidemiology of burn injury is largely dependent on the operational environment and is commonly associated with combat involving armored vehicles and war at sea. Accidental injuries involving chemicals, electricity, and the handling of explosives or burning waste can also occur during routine military operations.1-3 A DoD Trauma Registry (DoDTR) analysis from 2003 through 2014 found that primary burn injury accounted for 5% of all non-battle injuries (NBI) during Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF).4 An analysis of 196 extended submarine patrols in the late 1990’s found that burn injury accounted for 5.6% of medical events and injuries typically occurring in mechanical (e.g., engine rooms and trash disposal areas) and food preparation areas; 3.2% were categorized as electrical injuries occurring in mechanical areas.5 A 50-year analysis (1970-2020) of all documented mishaps during U.S. naval operations found that fire, burn, and electrical injuries decreased over time. There were 103 different mishap events resulting in 923 burn and/or smoke inhalation casualties with an associated 13% mortality. During the 50 years, reported electrical injuries were rare (32 casualties), but highly lethal (90.6% mortality).6 A 70-year analysis (1950-2020) of 27 major fires that occurred on U.S. Navy capital ships (including aircraft carriers and large amphibious warships) found an overall mortality of 23%. In those fires impacting more than 5% of the crew, the associated mortality was 29%. 7

During OIF/OEF ground combat operations, primary burn injury accounted for 2.4% of all Battle Injuries (BI).4 An analysis of the Expeditionary Medical Encounter Database from 2001 through 2018 identified 2507 deployed service members who sustained and survived a total 5551 burns. Of these, 86% were BI and 14% NBI. Most occurred from some type of blast injury (82%) with 9% inhalation injury and 29% traumatic brain injury rates of all deployed burn injury survivors; 65% occurred during a mounted posture and 23% while dismounted. In this cohort of survivors, most burns were relatively small with 92% involving <20% total body surface area (TBSA) and 85% <10% TBSA. The head and neck sustained burns in 34% and the upper extremity in 39%, most of which (19%) occurred in the hand.8 A separate analysis of the DoDTR from 2011 through 2017 found that burns accounted for 13.61% of the total number of battle injuries sustained during combat. In this cohort, most burns were also relatively small, with 11.52% <20% TBSA and 1.23% >20% TBSA. 1

During war at sea, burn injuries are common when combatant vessels are attacked. Comprehensive analyses of surviving U.S naval casualties from lost warships during World War II demonstrate a burn injury rates of 22-26%. After Kamikaze attacks, the burn injury rate was 30% among survivors.9,10 During the 1982 Falklands war, characterized by a significant naval warfare component, as many as 21% of battle casualties sustained burn injury and 12% of total casualties suffered inhalation injury. The 1988 Exocet missile attack on the USS Stark and the 2000 water-borne improvised explosive device attack on the USS Cole resulted in a 15.5% burn injury rate and a 10.3% inhalation injury rate among survivors. 3

It is also important to note that burn injuries during war on land or sea generally do not occur in isolation, and combined burn and traumatic injuries are associated with higher mortality rates and a greater likelihood for concomitant inhalation injury. 8, 11