GUIDELINES FOR PATIENTS WHO CANNOT BE EVACUATED FROM THEATER
Care provided in theater is not envisioned to be definitive care. Definitive care for US service members is provided at the USAISR Burn Center in San Antonio, Texas. Coalition forces progress along the evacuation chain in order to return to their home nation health care facilities. Unfortunately, the care available to local national patients may fail to compare to the definitive care available for US and coalition forces. Care decisions are to be made in the context of the available continuum of care for the patient in their nations of origin.
- Calculate burn size using a Lund and Browder chart (Appendix B and Appendix C.) Triage of local national casualties to an expectant category may be required if their burns exceed the host nation’s ability to treat and rehabilitate (e.g. full thickness burns >50% TBSA). If caring for expectant casualties, provide adequate comfort care measures. Take into consideration inhalation injury, medical co-morbidities, and extremes of age, which can increase mortality.
- For patients with combined partial and full thickness burns of 50% TBSA or greater, with less than half of the burn being full thickness, initiate resuscitation and allow the partial thickness component to declare itself as it is sometimes difficult to determine the full extent of the full thickness burn at the time of initial presentation. After approximately 48-72 hours, reassess the patient to estimate the percentage of full thickness burn more accurately.
- Consider inhalation injury in relationship to the TBSA burned when deciding whether to classify the patient as expectant; a patient with a 40% TBSA burn and inhalation injury will likely not do as well as a patient with a 40% TBSA burn without inhalation injury.
- Burn injuries may initially appear survivable, but skin graft loss, infections, or conversion of donor site(s) to full thickness wounds themselves may transform a potentially survivable injury into a fatal one. Be aware of this possibility and the potential change to an expectant category.
- The transition from aggressive care to comfort care is a difficult decision, especially when the care team has worked exhaustively to maximize survival. The attending surgeon should elicit objective input from medical colleagues, nurses, and facility leadership in making the decision to transition to comfort care as it will solidify the process and assist with closure, especially for those engaged in the care of the patient for extended periods.
- For patients with a less than 50% TBSA burn, proceed with resuscitation and plan for early excision and grafting within a week to maximize chance of survival.
- Skin substitutes such as allograft (deceased donor skin) and biologic dressings such as xenograft (pig skin) are not readily available outside CONUS. The extent of burn excision should be guided by the amount of autograft (split thickness donor skin) available. Do not excise wounds if autograft is not available. Tangential excision should be employed, if possible, to preserve viable dermis and subcutaneous fat. The non-viable dermis is excised to healthy, punctate bleeding dermis. Fascial excision is reserved for subdermal burns that extend well into the subcutaneous tissue, and for those burns which are heavily colonized or infected.
- If patients arrive with open burn wounds, surgically excise to a healthy wound bed and apply negative pressure wound dressing (NPWD) until granulation tissue is noted. If NPWD is not available, apply gauze dressings moistened with an antimicrobial solution such as 5% mafenide acetate (Sulfamylon) until further surgical debridement can occur.
- Meshing of split thickness skin grafts will maximize available donor skin. Rarely is there a need to mesh skin wider than 2:1; meshing wider than 3:1 is not recommended due to poor outcomes without comprehensive long term rehabilitation outside of a burn center.
- Utilize dilute epinephrine solution (1:1,000,000 concentration) to infiltrate subcutaneous tissue by clysis prior to harvesting of donor skin with dermatome. This process will minimize blood loss at the donor site(s). Likewise, dilute epinephrine solution provides topical hemostasis during excision of burns. To control raw surface area bleeding apply a non-adherent dressing (e.g., Telfa ), followed by a lap pad soaked in the dilute epinephrine solution.
- Take the patient to the OR for staged excisions and grafting of the full thickness burns with a goal of complete excision within one week of injury. Consider using a NPWD over fresh autograft with intervening non-adherent layer (e.g. Dermanet or negative pressure Silverlon). If NPWD is not available, sew a bulky bolster dressing over the graft site using a non-adherent layer or silver nylon against the split thickness graft. Leave the post-operative dressing in place for 3-5 days.
- Following NPWD removal, use Sulfamylon moistened gauze dressings for approximately 5-7 days. When graft interstices are closed transition to a topical agent such as Bacitracin or polymicrobial ointment.
- Whenever resources are available, perform extensive dressing changes in the OR (not ICU or ward), especially early in the treatment process when wounds remain open. This allows for optimal pain control (with airway protection as needed), improves inspection of wounds, and provides a clean and warm environment.
- Gram negative bacterial and fungal colonization followed by infection is associated with a high rate of graft loss and increases mortality. Liberal use of dilute Dakin’s solution (1/4 strength or 0.125% sodium hypochlorite) to cleanse colonized burn wounds is recommended. Delay grafting procedures until colonization and infection are controlled.
- Once the grafts are healed, continue to keep patient clean, using showers when available.
- Early ambulation and physical therapy, is critical to the long-term functional outcome in burn patients. Once post-operative dressings are removed, perform range of motion of all affected joints.
- Early and continuous nutrition is vital to wound healing. Even patients who are able to eat may need supplementation to meet calorie goals. Provide approximately 35kcal/kg/day to burned adults. Consult a nutritionist when available. Use a nasoenteric feeding tube to provide a high protein, low fat enteral formula and administer a daily multivitamin.