SPECIAL CONSIDERATIONS

#### Burn injury in deployed environment: non-clinical pearls

Documentation of resuscitation throughout the continuum of care is lifesaving. Providers must document resuscitation!

1. Communication with the USAISR Burn Center is essential, starting at the Role 2 level of care.
2. It is logistically challenging, yet important to maintain supplies for burn patients at the Role 3 (Theater Hospitalization) role of care. In large-scale combat operations, this will likely include maintenance of supplies for Role 2 capabilities.
3. Caring for host national patients with burns depends on the theater’s current medical rules of eligibility. Host national patients with greater than 60% TBSA burns might be considered expectant according to medical, tactical, and operational environments.

ANTIMICROBIAL PROPHYLAXIS

Prophylactic systemic antibiotics are not indicated for burn injury in the absence of infection. Penetrating wounds or open fractures should be treated with antibiotics according to respective guidelines. See the Wound Care section for discussion of topical antimicrobials.

- Administer tetanus prophylaxis as for any trauma patient.
- If wound infection is diagnosed clinically (e.g., burn-wound cellulitis, purulent drainage, marked changes in the color of the eschar, or ongoing conversion of partial thickness burns to full thickness burns), direct empiric therapy against Gram-positive and Gram-negative bacteria is indicated based on known geographic susceptibilities. If these data are unavailable, broad coverage with vancomycin for Gram positive organisms and a carbapenem (meropenem) or 4th generation cephalosporin (cefepime) for gram negative organisms is advised. If in the Role 1 environment and only have Ertapenem, that is acceptable.

INHALATION INJURY

Smoke inhalation injury is mediated by inhaled toxic gases and carbonaceous particles (soot).

- Risk factors for inhalation injury include burns sustained in an enclosed space (structure, vehicle, or shipboard fires); extensive TBSA; flame burns of the face; and extremes of age.
- Inhalation injury is associated with a higher mortality, especially in burn wounds with >40% TBSA.
- Clinical signs include progressive voice changes, soot about the mouth and nares, dyspnea, and respiratory distress. Hypoxemia may be a late finding. (See Initial Burn Survey for airway management recommendations). If available, bronchoscopy should be used to confirm diagnosis, grade injury severity, and lavage for debris removal.
- Patients diagnosed with inhalation injury should receive aerosolized unfractionated heparin, 5000 units per ETT every 4 hours; mix heparin with albuterol, as heparin can induce bronchospasm.

Carbon monoxide (CO) toxicity include those exposed to smoke from burning hydrocarbons (e.g., vehicle or generator exhaust) or cellulose-containing materials (wood, paper, charcoal).

- Symptoms of CO toxicity include confusion, stupor, coma, seizures, and cardiac ischemia.
- Treatment: Administer 100% oxygen and measure carboxyhemoglobin levels via co-oximetry if available.

Cyanide is encountered in fires involving certain nitrogen-containing materials such as polyurethane. Initial symptoms include dizziness, headache, nausea, and anxiety.

- High-dose exposure causes rapid onset of coma, seizure, respiratory depression, hypotension, and tachycardia. Lactate levels > 8 mmol/L suggest cyanide toxicity.
- Treatment: Administer 100% oxygen via mechanical ventilation. Hydroxocobalamin (Cyanokit) is the preferred antidote; infuse 5 g IV over 7 minutes. It may be infused over 2-5 minutes in cases of cardiac arrest or severe hypotension and may be repeated if no clinical improvement. Cyanokit should be available at every Role 3 hospital, and at Role 2 hospitals as well if there is a high risk of managing burn casualties. Role 2 MTFs (including Role 2 capable combatant vessels) should be equipped with Cyanokits if evacuation to Role 3 MTFs is long or not permissive. Cyanokit typically causes dramatic red/violaceous coloration of skin, mucus membranes, and urine; it may also cause hypertension and acute kidney injury.

Hydrogen fluoride (HF) is a byproduct of standard fire-suppression systems. Exposure to HF may result in rapidly progressive or fatal respiratory failure despite minimal external evidence of injury. Symptoms include shortness of breath, cough, hypoxia, and hypocalcemia; there must be a high level of suspicion for HF inhalation.10

- Treatment of HF inhalation injury is primarily supportive.
- Telemetry monitoring and measure calcium levels. If hypocalcemia is present, administer IV calcium followed by nebulized calcium gluconate (1.5 ml of 10% calcium gluconate in 4.5 ml water) q4hr until normalization of serum calcium levels.
- Consider steroids if symptoms do not improve.

Refer to the Inhalation Injury and Toxic Industrial Chemical Exposure CPG for additional information.4

OPHTHALMIC INJURY

- Every patient with facial burns should have a thorough eye exam, including Wood’s lamp exam with fluorescein, when available. If available, consult an ophthalmologist for all patients with facial burns or corneal injury verified by Wood's lamp exam. Eye exams should be done early, before facial edema sets in.
- If no injury exists, lubricate the eyes of intubated patients every 2 hours with Lacri-lube.
- If a corneal injury is identified, use a Fox shield to cover the eyes and apply ophthalmic erythromycin ointment at least every 2 hours.
- If there is suspicion of an open globe injury, no drops or ointment should be applied, place a Fox eye shield, and refer to an ophthalmologist as soon as possible.
- If resuscitation exceeds 200 mL/kg/TBSA, and/or in the presence of full thickness periorbital burns, perform intraocular pressure measurement using a tonometer (and consult an Ophthalmologist); the patient may require urgent lateral canthotomy and cantholysis.

Refer to Eye Trauma: Initial Care CPG for additional information.4

LINES AND TUBES

- Suture and/or staple all venous and arterial catheters in place, as tape does not adhere to burned skin. Do not circumferentially tape lines around extremities; this may further impede circulation and cause limb ischemia as extremities swell during resuscitation.
- Use umbilical ties to secure endotracheal, orogastric, nasogastric and Dobhoff tubes. Note that ties around the ETT may occlude the balloon tubing if they are too tight, giving the appearance of a cuff leak as the balloon is not actually inflated.

GASTROINTESTINAL PROPHYLAXIS

- Burn patients, regardless of age, are prone to nausea and vomiting as well as stress ulceration.
- Place orogastric or nasogastric tube in all intubated patients for gastric decompression during resuscitation and later for enteral nutrition.
- Administer IV proton pump inhibitor or similar agent to all patients with >20% TBSA burn injury.

CIRCUMFERENTIAL BURNS, ESCHAROTOMY, & EXTREMITY COMPARTMENT SYNDROME

Escharotomy is normally performed for circumferential full thickness burns.

Check pulses (preferably using a Doppler flowmeter if available). If pulse is decreased or absent:

- Rule out hypovolemia.
- If not hypovolemic, perform escharotomies.

Escharotomy incises the skin only, not the fascia and is usually sufficient for limb ischemia caused by burns unless there is underlying muscle damage, over-resuscitation, or combined injury. The requirement for escharotomy or fasciotomy usually presents in the first 48 hours following injury. If the need for either procedure has not been identified within the first 24-48 hours, then circulation is likely to remain adequate without surgical intervention.

- A patient who required escharotomy or fasciotomy at a lower echelon of care should always have their extremity compartments reassessed upon arrival at the next echelon of care. Extension of the incision(s) may be required to restore circulation. This situation can occur if large IV fluid volumes are given during transport, compounding tissue edema. The threshold for escharotomy should be low in patients requiring transportation but must consider the ability to monitor.
- Absent Doppler signals or pulses that are diminishing on hourly exams should prompt immediate consultation with a burn surgeon and strong consideration of surgical decompression with escharotomies.
- Repeat the vascular exam hourly. If available, use a handheld Doppler flowmeter to assess the palmar arch and the radial, ulnar, dorsalis pedis, and posterior tibialis arteries. A triphasic signal in the above vessels is considered normal. Consider performing escharotomy early, based upon the vascular exam.

Elevation of the burned extremities (especially the upper extremities) above the level of the heart is required to decrease edema and prevent compartment syndrome.

Escharotomy

CLINICAL INDICATIONS:

Deep partial-thickness or full-thickness circumferential burns to arms or legs.

- This may mimic compartment syndrome or act like a tourniquet, reducing arterial circulation resulting in ischemia or necrosis of the limb.
- Pulses will feel diminished on exam even after elevation.

Circumferential, full thickness burns to the chest wall.

- This can result in restriction of chest wall expansion and decreased compliance causing difficulty oxygenating and ventilating of intubated patients.
- Clinical manifestations of chest wall restriction include rapid, shallow respirations; poor chest wall excursion; and severe agitation.

CONTRAINIDICATIONS: No contraindications

- Escharotomy is performed by incising circumferential full-thickness burns.
- Extend escharotomy incisions the entire length of the circumferential portion of full-thickness burn.
- The depth of the incision should be through the dermis into the subcutaneous fat. Carry incisions across involved joints (Figure 2).
- Although full thickness burn is insensate, this is a painful procedure, and patients will often require moderate sedation with benzodiazepines and IV narcotics.
- An escharotomy performed to the proper depth should not result in significant bleeding, especially if electrocautery is used. The bleeding that does occur can usually be controlled with electrocautery or topical hemostatics (i.e., Combat Gauze, Avitene). It may require suturing using a silk stitch.
- Upon completion of the escharotomy, reassess perfusion. If circulation is restored, the extremity should be dressed and elevated above the level of the heart. Continue to assess pulses hourly for at least 12-24 hours.

Figure 2. Escharotomy Incisions

Fasciotomy

Optimal fluid resuscitation and prompt escharotomy usually mitigates the need for fasciotomy. Consider fasciotomy in the operating room (OR) if pulses remain undetectable after complete escharotomy.

Due to the frequency of extremity injuries seen among combat casualties, fasciotomies on burned extremities may be required for those with:

- delayed revascularization.
- hemorrhage requiring massive resuscitation.
- fractures, crush, or blast injuries.

Following escharotomy or fasciotomy, late bleeding may occur as circulation is restored. Examine the surgical site every few minutes for up to 30 minutes for signs of new bleeding, which is usually easily controlled with electrocautery.

Refer to Acute Extremity Compartment Syndrome and the Role of Fasciotomy in Extremity War Wounds CPG for additional information. 23

Abdominal Compartment Syndrome

Massive fluid replacement (> 250 mL/kg within 24 hours) is a risk factor for abdominal compartment syndrome (ACS), a clinical diagnosis which includes increased bladder pressure, increased airway pressure, oliguria, and hypotension.24,25 Bladder pressure > 20 mmHg warrants consideration of therapeutic paracentesis which may provide partial relief. A bladder pressure > 30 mmHg, when measured accurately, is a serious finding that mandates immediate assessment and treatment.

Decompressive laparotomy, when performed for ACS in patients with massive burns, almost always indicates a nonsurvivable situation. The decision to pursue decompressive laparotomy must consider this fact.24

PLEASE CALL THE BURN CENTER PRIOR TO PROCEDURE! Avoiding over resuscitation is key to avoiding ACS.

If the patient requires a decompressive laparotomy, perform a standard midline incision followed by temporary abdominal closure. If the abdominal wall skin is burned, adhesive drapes for negative pressure wound dressings will not adhere to the skin edges. Use of Stomahesive paste or another barrier is recommended.

Chemical Burns

1. Expose body surfaces, brush off dry chemicals, and copiously irrigate with clean water. Large volume (> 20 L) serial irrigations may be needed to thoroughly cleanse the skin of residual agents.
2. Do not attempt to neutralize any chemicals on the skin.
3. Use personal protective equipment to minimize exposure of medical personnel to chemical agents. Resuscitation strategy and goals for patients with chemical burns are the same as for thermal injuries.
4. White phosphorus fragments ignite when exposed to air. Clothing may contain white phosphorus residue and should be removed.

a. Fragments embedded in the skin and soft tissue should be irrigated out if possible or kept covered with soaking wet dressings. Note that if the dressings dry the white phosphorus may ignite them.

b. Urgently retrieve deeply embedded fragments in the OR.

c. Use a Wood’s lamp to help locate the fragments. Monitor calcium levels closely and treat hypocalcemia with IV replacement.

d. Plan a second-look operation within the day to identify missed fragments.

Refer to Inhalation Injury and Toxic Industrial Chemical Exposure CPG for additional information.4

Electric Injury

1. First responders should remove the patient from the electricity source while avoiding injury themselves.
2. In cases of cardiac arrest due to arrhythmia after electrical injury, follow advanced cardiac life support (ACLS) protocol and provide hemodynamic monitoring if spontaneous circulation returns.

Special considerations for electrical injury:

- Extremity compartment syndrome: Particularly with high-voltage electric injury (> 1000 V), skin contact points (cutaneous burns) of limited extent can hide extensive soft-tissue damage. Observe the patient closely for clinical signs of compartment syndrome (refer to the Circumferential Burns section above), and the Extremity Compartment Syndrome or Appendix E).
- Fasciotomy vs escharotomy: Fasciotomy is typically required for extremity compartment syndrome caused by electrical injury. Note that escharotomy, which relieves the tourniquet effect of circumferential burns, will not relieve elevated muscle compartment pressure due to myonecrosis associated with high-voltage electric injury.
- Rhabdomyolysis: Compartment syndrome and muscle injury may cause rhabdomyolysis, causing pigmenturia and acute kidney injury. Patients with clinically significant pigmenturia will have visibly red or brown urine. If available, monitor CK levels every 6 hours. Balancing crystalloid resuscitation to avoid renal failure without over resuscitation is a challenge in these patients.
- Increased fluid goals: Fluid resuscitation requirements are higher than those predicted for a similarly sized thermal burn. Isotonic fluid infusion should be adjusted to maintain UOP 75-100 mL/hr in adult patients with pigmenturia until it resolves (urine returns to clear or light yellow). Urinalysis-based heme pigment tests remain positive longer and should not be used for determining when to stop treatment.