GUIDELINES FOR PATIENTS WHO CANNOT BE EVACUATED

Definitive care is defined as surgical excision and grafting with healing of burns. For U.S. Service Members it is provided at the USAISR Burn Center at Brooke Army Medical Center, Fort Sam Houston, TX. Partner and/or ally forces progress along the evacuation chain to return to their home nation healthcare facilities. Depending on the theater of operations, the care available to local national patients may not compare to that available for U.S. and partner/ally forces.

For U.S. and partner/ally service members who cannot be evacuated to a higher role of care for days to weeks:

1. Call the Burn Center for consultation
2. Debride burns within 24 hours postburn as described above.
3. Perform daily wound care as described above based on available resources.
4. For patients with a less than 50% TBSA burn, proceed with resuscitation and wound debridement as described above if resources allow.
5. Burns in excess of 20% TBSA general require early excision and grafting within a week to maximize chance of survival.
6. If performing excision and grafting (refer to Appendix F), contact the USAISR Burn center prior to the procedure if possible.

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.

CONSIDERATIONS FOR PEDIATRIC PATIENTS

Deployed teams frequently care for injured local national children. Burn care for children generally follows adult recommendations, with a few modifications as itemized below.27 See Appendix C: Pediatric Lund Browder Burn Estimate and Diagram.

Airway patency can be lost early in small children with facial burns, inhalation injury, or extensive body burns. Modest mucosal edema can quickly compromise a small airway. Carefully securing the ETT with umbilical ties and adequate sedation are important to prevent unplanned extubation.

Peripheral or intraosseous vascular access may suffice initially, but central venous access is more reliable during formal burn resuscitation; catheters should be sewn in place.

Children with burns under 10% TBSA usually do not need a calculated resuscitation. They can be given 1.5x calculated maintenance rate (see 4-2-1 Rule below) and have diapers weighed for urine output. If they can eat, they should be allowed access to bottle feeds. Some of these children can be supported enterally, with nasoenteric infusions of an oral resuscitation formula (see Appendix G).28

Children with acute burns over 10% of the body surface usually require a calculated resuscitation. Place a bladder catheter (size 6 Fr for infants and 8 Fr for most small children). The formula for pediatric resuscitation is as follows. The volume for the first 24 hours is 3 x weight in kg x TBSA. Half of this is programmed for infusion during the first 8 hours. This yields a starting rate of TBSA x weight in kg x 1.5 / 8 mL/hr.

The fluid rate should be adjusted based on UOP and other indicators of organ perfusion. The goal UOP for children is 0.5-1 mL/kg/hr. Decrease or increase the isotonic fluid rate by approximately 20-25% per hour to maintain this UOP.

Children do not have adequate glycogen stores to sustain themselves during resuscitation. Administer a maintenance rate of D5LR to children <13 years of age. Utilize the 4-2-1 rule: 4 ml/kg for the first 10 kg + 2 ml/kg 2nd 10 kg + 1 ml/kg over 20 kg. This maintenance rate is in addition to the isotonic infusion calculated for burn resuscitation and is not titrated.

In children with burns > 30% TBSA, early administration of a colloid may reduce overall resuscitation volume. If needed, initiate 5% albumin at the child’s calculated maintenance rate (use the 4-2-1 rule) and subtract this from the isotonic fluid rate; the albumin rate is maintained while the isotonic fluid is adjusted based on UOP.

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. Monitor electrolytes every 8 hours during the first 72 hours to diagnose hypo- and hypernatremia and hypocalcemia. If available, monitor calcium levels and replete to maintain iCa >1.1.

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 them. Most anti-streptococcal antibiotics such as penicillin are successful in eradicating this infection. Initial IV antibiotics are 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 (e.g., Pediasure) targeting 30-35 kcal/kg/day and 2 g/kg/day of protein.

Children may rapidly develop tolerance to analgesics and sedatives; dose escalation is commonly required. Ketamine is a useful procedural adjunct. Propofol should be avoided during burn shock.

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.

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.