JOINT TRAUMA SYSTEM CLINICAL PRACTICE GUIDELINE
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1 JOINT TRAUMA SYSTEM CLINICAL PRACTICE GUIDELINE Burn Care Approved November 2013
2 Burn Care Goal. The goal of this CPG is to provide practical, evidence-based, recommendations for optimal care of burn casualties who generally fall into one of two categories: military casualties who most frequently sustain burns related to an explosion and can be rapidly evacuated out of theater for definitive care; and local national patients, often children, who commonly sustain burns from accidents, who present for care at military medical facilities with no possibility of definitive care beyond that provided in theater.
3 Burn Care Contact the US Army Institute of Surgical Research (USAISR) Burn Center as soon as possible at DSN (BURN) or Commercial (210) or Commercial (210) Early consultation will facilitate coordination of care to include possible activation of Burn Flight Team to assist with movement back to CONUS. Inability to contact the Burn Center should not delay the evacuation process.
4 Note this version of BFS will be updated soon #2: Use Rule of Tens to calculate Adult starting rate #1: Contact ISR Burntrauma.consult. #3: Titrate LR hourly to achieve UOP ml/hr and tissue perfusion Refer to the attached Worksheet for formulas and additional information 1/9/2015 #4: At hour 24 calculate actual 24hr fluid if > 250ml/kg monitor for fluid overload
5 Burn Resuscitation Worksheet Initiate AFTER completion of trauma assessment and interventions Adults only: Refer to CPG for pediatric resuscitation 1. Contact USAISR Burn Center (DSN ) or Date/Time contact: POC: by: 2. Estimated Pre-burn Weight (wt): kg (Average Service Members are 82 ± 15 kg) 3. Estimate Total Burn Surface Area (TBSA) using Rule of Nines (refine with Lund-Browder) Partial thickness (2nd) % + Full thickness (3rd) % = TBSA % IF TBSA >40%: intubate (use ETT 7.5 fr to facilitate bronchoscopy) IF TBSA <15%: formal resuscitation may not be required, provide maintenance and/or oral fluids 4. Standard Burn Resuscitation Fluid: Lactated Ringers (LR) or Plasmalyte 5. Calculate INITIAL Fluid Rate (adults): IF wt < 40kg: 2ml x %TBSA x wt(kg) 16 = ml/hr IF wt 40kg: %TBSA x 10 = ml/hr IF wt > 80kg: add 100ml/hr to initial rate for every 10 kg>80: adjusted initial fluid rate = ml/hr (Example: 100kg patient with 50% TBSA burn = 50% x 10 = 500 ml ml = 700 ml TOTAL for first hour) 6. If Inhalation Injury Present: administer aerosolized heparin in albuterol (5,000 u Q4 or 10,000 units Q6 hours) 7. Titrate Resuscitation Fluid: maintain target UOP 30-50ml/hr (Q 1 hour) IF rhabdomyolysis present: use target UOP ml/hr (Contact USAISR) Goals: UOP >30 but <50ml/hr; adequate tissue perfusion (normalized lactate/base deficit), MAP >55 mmhg Minimum fluid rate 125/hr * Avoid fluid boluses ** Too much fluid as dangerous as too little 1/9/2015
6 High risk for over resuscitation/abdominal compartment syndrome: If hourly rate 1,500ml/hr x 2 hrs OR If total 24 hr volume exceeds: wt(kg) x 250ml= ml (includes all infused fluids) - Contact USAISR Burn Center (DSN ) - Consider adjuncts - Check bladder pressures Q4hrs (>20 mmhg notify MD) - Avoid surgical decompression (significant mortality risk in burns) Adjuncts: 1. Colloids: 5% albumin/ffp (hextend only if others unavailable) * Colloids not preferred until hour 8-12; can consider earlier in difficult resuscitation Infuse at ml/hr according to chart below based on patient weight and burn size 2. Vasopressors: (REF: "Burn CPG, 12 JUN13, 9.b., pg.7) Contact USAISR Burn Center (DSN ) Ensure adequate volume (CVP trend 6-8 cm H 2 O); maintain MAP > 55 mmhg Maintain ionized Ca >1.1 mmol/l Start with vasopressin mg/min. DO NOT TITRATE Second line pressor: norepinepherine 2-20mcg/min Consider adding dobutamine 2-5mcg/kg/min if volume adequate Continued refractory hypotension: consider epinephrine infusion Refractory shock: consider adrenal insufficiency, give hydrocortisone 50mg Q6 hrs Manage acidemia (ph<7.2): use ventilatory interventions first, then bicarbonate or THAM infusion 3. Renal replacement therapy if available (Contact USAISR DSN ) 1/9/2015
7 Assessment/Interventions: Complete full secondary trauma exam Ensure thermoregulation; administer warmed fluids; cover with space blanket Partial thickness (2 nd degree): blanch, moist, blisters, sensate Full thickness (3 rd degree): leathery, white, non-blanching, dry, insensate, thrombosed vessels Protect eyes with moisture shields if corneas exposed or blink reflex slow (NOT Fox shield) Prompt intubation for facial burns, suspected inhalation injury, TBSA >40% anticipate induction-associated hypotension; secure with cloth tie, no tape; reassess ETT position at teeth Q1 hr Intubated patients require oro/naso-gastric tube for decompression IV administration of proton-pump inhibitor Monitor bladder pressure at least Q4hrs for large burns or high volume resuscitations (Burn CPG, 2013, page 7) Abdominal compartment syndrome: decreased UOP, increased pulmonary pressures, difficulty ventilating, bladder pressure trending > 20 mmhg Avoid decompressive laparotomy; consider percutaneous peritoneal drainage with catheter Reduce crystalloid volume using colloid or vasopressors Monitor pulses hourly: palmar arch, dorsalis pedis, posterior tibial with Doppler Consider escharotomy if signal diminished; refer to CPG for technique Monitor extremity compartment pressures as clinically indicated Elevate burned extremities at all times Extremity compartment syndrome: pain, paresthesia, pallor, paralysis, pulselessness (late sign) Fasciotomy may be required Wound care Thoroughly cleanse burn wounds, preferably in OR Select topical antimicrobial in consultation with Burn Surgeon based on product availability, expected transport time, etc Acceptable to cover burns with dry sheets or clean dressings for first 24 hours All definitive surgical burn interventions done at USAISR
8 Superficial Burn (1 st Degree) Caused by a minor flash or sun Superficial - involves only the epidermis Skin intact, red in color Dry surface, no blisters Painful, hypersensitive Heals in approximately 3-6 days *** not part of TBSA calculation 8
9 Superficial Partial Thickness Burn (2 nd Degree) Involves the epidermis and part of dermis Mottled red color Blisters or weeping Very painful / nerve endings exposed Usually heals in days without surgery Minimal scarring 9
10 Deep Partial Thickness Burn (2 nd Degree) Extends more deeply into the dermis Decreased moistness Skin is pale in color Absent or prolong blanching Some healing in days, requires skin grafting 10
11 Full Thickness Burn (3 rd Degree) Dermis is destroyed Translucent, parchment-like or leathery appearance, charred Dry surface, thrombosed blood vessels Painless, non-blanchable Requires grafting 11
12 Full thickness circumferential torso burn w/ escharotomy Anterior torso escharotomy White waxy Thick yellow leathery eschar Full thickness burn Mid back Partial thickness Partial thickness Upper Left back White waxy eschar White waxy eschar
13 BLE circumferential full thickness burns w/ medial and lateral escharotomies
14 Burn Care Performance Improvement Core Measures All patients who suffered second and/or third degree burns of 20% TBSA had the Burn Flow Sheet initiated and completely documented at the first MTF providing treatment and all subsequent MTFs until their arrival at a definitive care MTF in CONUS. All patients who suffered circumferential extremity full thickness burns with known or suspected development of neurovascular compromise of the involved limb had appropriate escharotomy performed.
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