Even before the surgeon lays eyes on a trauma patient, he or she may be asked to provide guidance or advice in the treatment of the combat casualty in preparation for staged evacuation. Intubation of patients with facial burns is rarely required immediately following injury, except in cases where the severity of the burn constricts the soft tissue around the mouth and nose so as to restrict the airway. One common error on the part of frontline medics in the initial treatment of burn casualties is the routine action of administering 2 liters of crystalloid whether it is indicated or not. This action can prove harmful, especially in a patient with burns isolated to the face and/or hands. The often excessive or unneeded crystalloid fluid simply contributes to edema of the burned body area while providing little or no systemic benefit. It is reasonable to simply initiate peripheral intravascular access and start crystalloid fluids at a maintenance rate for patients with smaller-size burns (less than 10% TBSA ) or just hep-lock them until they arrive at a hospital facility. Do not bolus IV fluids when treating burn patients as this will lead to interstitial edema and does not contribute much to resuscitation other than morbidity.

First-line providers are encouraged to cover the burned tissue with a clean, nonadherent dressing and avoid the use of any topical cream or ointment if it is anticipated that the patient will be evacuated rapidly. Silver nylon dressing materials are generally not indicated as an initial burn dressing unless large areas of epidermis have been lost, in which case the silver nylon dressings work well to protect the underlying dermis during transport. Blisters may be left intact during transport as they provide an initial biological protective layer. Blisters may be drained or opened when their expansion leads to severe pain, such as in the case of burns to the palms of the hands.

In general, approaching the burn patient as a trauma patient is the key to successful treatment and avoidance of missed injuries. While the burn is often the most dramatic (and distracting) injury, it is not immediately life threatening. These patients should be thoroughly evaluated like any other trauma patient, and in fact they probably warrant an even more detailed search for severe associated injury. One of the reasons that we don’t see more burns in the combat setting is that modern blast devices are incredibly powerful and deadly. Most victims close enough to the blast to suffer thermal burns die at the scene, so those that make it to you should be assumed to have multiple external and internal injuries.

Assessment of airway and breathing includes ensuring that full-thickness eschar is not restricting ventilation. Full-thickness burns to the thorax can rapidly lead to respiratory acidosis from inadequate excursion which is rapidly remedied by the performance of thoracic escharotomies along the anterior axillary lines and other regions as indicated (Fig. 30.1). Circumferential extremity burns with any evidence of impaired distal perfusion should also prompt immediate escharotomy. Escharotomy , in contrast to fasciotomy, can be readily performed at the bedside using knife and/or electrocautery (Fig. 30.2). There is little if any added morbidity since the eschar will eventually be removed. If the burn is partial thickness (red dermis) but severe swelling mandates escharotomy, then sedation will be required. If full-thickness burns require escharotomy, sedation may not be required. If escharotomy is to be done, try to refrain from making incisions on unburned skin. It is not required to follow the drawings exactly when making escharotomy incisions. If you have the choice between moving an incision to create an adequate escharotomy through burned skin and unburned skin, move the incision to save unburned skin.

Resuscitation remains one of the most challenging aspects of burn care. The morbidity of both over-resuscitation and under-resuscitation of the burn casualty is well described. Accurate resuscitation begins with an accurate assessment of the percentage of body surface area burned (Fig. 30.3). Remember that you should only count areas with partial- or full-thickness burns; superficial burns (i.e., sunburn) are excluded. Careful analysis of the process of burn resuscitation in the field has revealed the persistent difficulty in initiating and maintaining a consistent resuscitation across the spectrum of care and through the evacuation process. In an effort to simplify the process, Chung and colleagues developed the Rule of Ten as a tool for providers. The Rule of Ten provides an easy method of calculating the initial resuscitation fluid rate using the estimated burn size alone (utilizing the Rule of Nines). The initial fluid resuscitation rate, in milliliters per hour, is calculated by multiplying the total body surface area burned by 10 and is adjusted based upon the patient’s response as measured by urine output with a target of 30–50 ml/h. This rule is for adult patients (40–80 kg). Modest increases or decreases in IV fluid rate less than 20% of the current rate are recommended to avoid unnecessary volume changes.

Rule of Ten: Multiple estimated burn size (%TBSA ) × 10 to equal the initial rate of crystalloid resuscitation fluid. If the patient weighs more than 80 kg, add 100 ml of fluid per hour per 10 kg over 80 kg.

There are times when infusion with crystalloid is not adequate to achieve maintenance of adequate perfusion while avoiding the morbidities associated with hypervolemia. The addition of colloids such as 5% albumin may reduce the crystalloid requirements. In the multi-trauma patient, fresh frozen plasma (FFP ) will provide very good colloid resuscitation in addition to correction of coagulopathy. After the initial 12 h of resuscitation, it is reasonable to run an FFP or 5% albumin drip at 50 ml/h in addition to crystalloid as necessary to maintain a perfusing blood pressure as measured by urine output (.5 ml/kg/h in adults, 1 ml/kg/h in children) after the first 12 h of resuscitation. This rate can be adjusted down in children as necessary. If hypotension related to burn shock persists despite aggressive fluid resuscitation, the use of low-dose vasopressin (not more than 0.04 u/min.) may be advised. High-dose vasopressin, norepinephrine, or other pressors are not advised as they shunt blood away from dermis, potentially increasing the burn penumbra. Recommendations regarding these and other adjuncts to resuscitation are provided as updates to the Joint Theater Trauma System (JTTS ) Clinical Practice Guidelines which are readily available online (Fig. 30.4).

Treatment of the burn wound initially includes cleansing the skin with an antibacterial soap such as Hibiclens^® . The application of topical antimicrobials such as silver sulfadiazine (Silvadene^® ) or mafenide (Sulfamylon^® ) cream is an effective method of decreasing the degree of skin colonization. More recently, the use of a silver nylon dressing (Silverlon^® , Silverseal^® ) has found acceptance in the burn community due to their ease of application and documented effectiveness. One of the main advantages of using these materials in the military environment is the ability to place the wraps over multiple types of soft tissue wounds, including burns, and leave them in place with minimal maintenance during the evacuation process.

Adults with burns involving more than 20% and children (<5 years old) or elderly adults (>51 years old) with burns more than 10% of their total body surface area (TBSA ) should be admitted to an intensive care unit (ICU) environment due the multiple organ systems affected and need for close monitoring and intervention. Airway management, pulmonary toilet, and ventilator support are routinely required, especially when the patient has sustained inhalation injury associated with the burn. It must be remembered that inhalation injury is only suffered when patients are burned in a closed environment (in a house, in a car, in an MRAP vehicle). Scald burns, brush fires, and gasoline flash burns are not associated with inhalation injury even if the face is involved. Rarely, inhalation injury may be an isolated injury, but one that requires significant pulmonary support.

As facial edema progresses, protection of the soft tissue of the face while simultaneously securing the airway can be challenging. The RT and bedside nurse must ensure that any securing device or tie used to secure the endotracheal tube is tight enough to eliminate excessive movement, but not so tight as to cause injury. Alternative approaches to this problem also include stapling silk endotracheal tube tapes to the skin of the upper lip, using an umbilical tape harness, wiring of the ETT to a molar tooth using stainless steel wire, or early performance of a tracheostomy (Figs. 30.5 and 30.6).