INTRODUCTION

Although burns sustained during military operations (whether combat and non-combat in nature) constitute a relatively small percentage (5%-15%) of injuries, they have an outsized impact on all involved. Burns are painful and potentially debilitating injuries. Even burns to a small surface area can be incapacitating for the casualty. Burns also significantly strain the resources of deployed military medical units.

Optimal treatment of burn injuries includes management of the physiologic changes related to the burn but also of any associated traumatic injuries. Resuscitation of the burn casualty is generally the most challenging aspect of care during the first 24 hours. The challenge is further augmented if the patient has other injuries, such that priorities for burn resuscitation may conflict with those for mechanical trauma care. An example of this dilemma is the casualty with both traumatic brain injury and extensive burns, in which large-volume fluid resuscitation for burn shock places the patient at risk of worsening cerebral edema. Such combined injuries are unusual in civilian practice but are more common on the battlefield.

The battlefield continuum of care requires frequent casualty movement. This presents a unique challenge to burn care and demands prudent judgment. The need to get casualties off the battlefield and to facilities with more resources must be balanced with the real possibility of deterioration of unstable patients during flight. The future operating environment with delayed evacuation will have additional challenges and may require more burn casualties to remain in the area of operations. Optimal care requires a concerted effort on the part of all providers along this continuum – documentation is essential in burn management, especially resuscitation documentation. Both over resuscitation and under resuscitation can be lethal in burn casualties.

The goal of this Clinical Practice Guideline (CPG) is to provide guidance and recommendations for care of burn casualties in the deployed or austere settings. During recent U.S. Central Command operations, U.S. Service Members with burns were rapidly evacuated out of theater. This is ideal given the extensive resources needed to manage large burns; however, the trauma system must communicate effectively when it comes to resuscitation. In 2006, burn patients from Iraq were massively over resuscitated along the continuum of care – this resulted in deaths from survivable burn wounds. The Burn Care CPG was one of the very first JTS CPGs to address this problem and the burn resuscitation flowsheet is an essential element of care to ensure burn casualties are not over resuscitated as they transfer back to the U.S. Army Institute of Surgical Research (USAISR) Burn Center. In the future, rapid transport may not be possible, so every military provider must be knowledgeable in initial burn care resuscitation and management. Host national casualties with burns who cannot be evacuated require a large number of resources and expertise in burn care. The operational environment influences how these casualties are managed and multiple factors (resources, expertise, availability of rehabilitation, nutritional support, prolonged ICU care, and multiple trips to the operating room) must all be considered.

NOTE: If caring for a burn casualty, contact the USAISR Burn Center as soon as possible. Early consultation will facilitate coordination of care to include possible activation of the Burn Flight Team to assist with movement back to the continental U.S. (CONUS). Inability to contact the Burn Center should not delay the evacuation process. Contact the Theater Patient Movement Requirements Center as soon as possible to coordinate aeromedical evacuation.