55 Clinical
The early management of the burned patient in the Naval service
Surg Lt OJA Rylah, Surg Cdr JJ Smith
Abstract
Burns represent a perpetual threat in military combat and are a pervasive threat in the land, maritime and air arenas. Therefore, it is imperative that military clinicians are well versed in managing burns in order to ensure optimal survival and recovery. This article aims to explore the epidemiology, pathophysiology, assessment and early management of the burned patient with a focus on the austere maritime environment and current military guidance.
Introduction (areas of cosmetic and functional importance) (2 Burns account for approximately 15% of wartime injuries and can cause signifi cant morbidity and mortality (1). • Combat burns directly related to munitions. Between 2001 and 2007 there were 134 UK Armed Forces • Combat burns related to ignition of fuel, Personnel who required repatriation, mainly from Iraq propellants and clothing. and Afghanistan, as a result of burn injuries (2). Burns • Accidental burns related to working with vehicles, can be devastating injuries that are a perpetual threat in fuel, chemicals and electrical equipment. the maritime environment. Their management has been • Accidental burns related to cooking, hot liquids, the source of much debate, as illustrated by the discussion smoking. on the early treatment of burns and scalds afl oat by Staff Box 1. Epidemiology of military burns Surgeon PT Sutcliffe in the August BMJ of 1907. In this article he outlines the epidemiology facing the mariner. He also debates the relative pros and cons of the dressings Pathophysiology available to him. This was clearly a controversial topic of Energy transferred by scald, fl ame, contact with hot the time and much of the management of burns remains material, chemicals (acid and alkali) or electrocution leads so now (3). In this centenary edition of the Journal of the to the irreversible denaturing of proteins. The extent of Royal Naval Medical Service, we present a summary of burn injury is dependent on the degree and duration of the United Kingdom (UK) Defence guidelines for initial contact. There is both a local and systemic response to burn management of burn injury. injury with implications beyond the visible physical injury (5). The full details are beyond the scope of this article, but Epidemiology they include: Overall, burns affected 21% of all UK casualties in the • Skin function loss - physical barrier against friction/ Falklands confl ict; eighty-three servicemen sustained shearing forces, infection, chemicals and ultraviolet burns in RFA SIR GALAHAD alone, 46 of whom required light. Excess water loss/absorption, reduced evacuation to the UK for further care (4). Wartime burns production of vitamin D, loss of temperature, account typically for 5-15% of all casualties and up to sensation (pain/loss of sensation) and skin-specifi c 50% of burned casualties have other concomitant injuries immune down-regulation (6). (1). The most common causes of burns experienced in the • Cardiovascular - increased capillary permeability military environment are listed in Box 1 (2). and fl uid shift from intravascular to extravascular compartments. Between 2001 and 2007 there were 134 UK Armed Forces • Respiratory - bronchoconstriction and Adult personnel who sustained burns in the military environment Respiratory Distress Syndrome. and required evacuation, most of whom were land-based • Metabolic effects - increase in Basal Metabolic Rate. personnel in Iraq and Afghanistan. 60% of cases were • Immunological - non-specifi c down-regulation of the ‘accidental’ and mainly affected the face, legs and hands systemic immune response. J Royal Naval Medical Service 2015, Vol 101.1 56
The simplest pre-hospital aid is the technique of serial halving:
Look at the front aspect of the body and in your mind’s eye divide it into quarters.
- Is over half of what you see burnt? - If not, is between half and a quarter of what you see burnt? - If not, is it less than a quarter?
Now repeat this for the back aspect of the body and combine the results. This should allow you to estimate the burn size as being in one of the following groups:
- Roughly more than half of the body burnt (>50%) - Roughly between half and a quarter of the body burnt (<50%, >25%) - Roughly between a quarter and an eighth of the body burnt (<25%, >12%) - Roughly less than an eighth of the body burnt (<12%)
In very large burns it is often easier to work out how much is not burnt. Box 2. Serial halving.
Figure 1. The Lund and Browder chart. Figure 2. The rule of nines. Assessment the whole body. The literature shows that any adult with The magnitude of response is related to the volume of a burn greater than 15% TBSA and any child with greater tissue damaged; assessment therefore focuses on burn area, than 10% TBSA burn will benefi t from the prophylactic expressed as percentage of total body surface area (% TBSA) administration of intravenous fl uids to replace fl uid lost and depth (5). These factors indicate the likely prognosis through the burn injury (5). and dictate the requirement for surgical intervention. The most accurate way to estimate % TBSA burn is with a Morbidity and mortality are signifi cant in adults with burns Lund & Browder chart, applied to a patient who has been over 40% TBSA, even if managed in a specialist unit (7). completely exposed and thoroughly cleaned (Fig 1) (8). In burns over 20% TBSA, the infl ammatory process affects However, this is impracticable in most forward settings, 57 Clinical
Superficial Deep Superficial partial thickness partial thickness Deep Sensation Painful Painful Dull None Appearance Red, shiny Dry, whiter Cherry red Dry, white, leathery/ charred Blanching to pressure Yes + quick to return Yes +slow to return No No
Table 1. Assessment of burn depth. and is usually completed at a developed field hospital (RN) vessels also store sterile gel dressings, which are useful with access to secondary care treatment (so-named Role following this to continue to cool the wound, affording further 3 facility). Initially an approximate assessment is possible analgesia of the affected area. Litmus paper can be used to using serial halving (Box 2) or the ‘Rule of Nines’ (Fig assess the reversal of either acidification or alkalinisation of 2) (1, 9, 10). The palmar surface of the casualty’s hand tissue in chemical burns (1, 5, 11, 12). including the fingers equates to 1% TBSA and can be used to estimate small areas of burn. Immediate medical care Burn casualties must be assessed as for any other seriously The classification of the depth of a burn is purely by injured casualty. Battlefield Advanced Trauma Life Support description of its appearance. Burns involve either the full (BATLS) principles should be followed and a primary thickness of the skin (full thickness burns), or only part of survey carried out using the
adequate chest excursion (and therefore normal respiratory other causes should be treated in parallel, and should be function) is the most likely burn-related cause of respiratory considered as independent of fl uid requirements for the compromise in the fi rst 24 hours, along with inhalational burn injury. The burned patient should have two wide-bore injury or chemical pneumonitis. If the airway is clear and cannulae sited, ideally through non-burned skin. If this is there are signs of respiratory distress, other causes need to not practical, intraosseous access is a possible alternative. be considered such as pneumothorax or haemothorax. Intravenous fl uids are required for >15% TBSA burned, though it is also reasonable to give fl uid resuscitation to Circulation patients with smaller burns. BATLS guidance attempts to Hypovolaemic shock may occur after large burn injury, but it simplify initial burn resuscitation fl uid management, and takes some time (normally hours) to manifest a measurable divides patients into ‘large man – large burn – large bag’, change in clinical signs. If shock is present, other causes or ‘small man – small burn – small bag’. Exact volumes are should be sought and excluded. Hypovolaemic shock from calculated once the patient is fully exposed and % TBSA
Figure 3. Superfi cial dermal burns.
Figure 4. Full-thickness burns. 59 Clinical
calculated. Clinical Guidelines for Operations (CGOs) give Minor burns guidance using a ‘burns calculator’, which is also useful in Epidermal and small, superficial burns are managed the early management of the burned patient (1). with simple first-aid techniques and should not require evacuation. Minor burns are those that should heal in a Neurological deficit short period of time without impairing function, enabling Reduced cerebral function may be caused by hypoxia the patient to stay safely in the maritime environment. The secondary to an inhalation injury. Other injuries should not initial management is still important as this can reduce the be overlooked, and alcohol and/or drug ingestion should depth of the burn and prevent need for treatment in some be considered. A neurological examination should be cases. Early discussion with a burns specialist is advised if undertaken to exclude significant head injury (1). there is doubt. Burns leading to complications, for example burns to flexor or extensor compartments of limbs that may require physiotherapy, fall outside the minor category for Exposure, environment and extremities these purposes. The entire body should be inspected for burns and other injuries. Hypothermia is avoided by inspecting one limb Burns should be cleaned with mild chlorhexidine soap at a time. Constricting items of clothing, including rings, solution (Hibiscrub®), enabling assessment of the burn. boots and belts should be removed. If there are deep, Large blisters may be de-roofed using sterile scissors or circumferential burns of the trunk or limbs, escharotomy hypodermic needles, allowing the wound to be assessed may be indicated at Role 1 if the evacuation time is for depth and size, and dressed with a non-adherent burns prolonged (1). dressing, which can then be wrapped with a dry dressing.
Other initial interventions Dressings should be changed at 24 hours and the wound Burns can be extremely painful and the patient is often reassessed at 48 hours. The dressings are then changed as anxious, so intravenous analgesia (usually morphine or required, but no less than every five days. Any burn that is ketamine) is recommended (1). not healed at two weeks requires referral to a burns plastic surgeon (2, 6-8). Any deterioration of the wound, or more Initial management complex burn, should have the management discussed with Following the primary survey and immediate interventions, a specialist. the patient should be extracted from the area of assessment. The patient should be kept warm and covered in a clean, Fluid resuscitation dry sheet for transport to the sickbay. Wounds and blisters Fluid resuscitation is required for all burns over 15% TBSA may simply be covered at this point using the first-aid burns in adults and 10% in children. The crystalloid required kits available on board, or covered with cling film, which for the first 24 hours is calculated using the ‘restricted’ forms a clean barrier to the environment and allows cooling Parkland Formula (where 2ml is used in place of 2-4ml). and visualization of the burn (1, 12). Burn ointments do This is used by British Armed Forces in preference to the have their place for the conservative management when standard Parkland Formula: evacuation is delayed, after discussion with a burns specialist (2, 10). 2 ml Hartmann’s solution x %TBSA burn x kg body weight The Parkland Formula stipulates that half of the total fluid Burns are generally sterile and if cared for appropriately do requirement for the first 24 hours is given in the first eight not require antibiotics in the initial stages. However, in a hours from the time of injury, with the other half over conflict environment, antibiotics should be started early as the subsequent sixteen hours. If there is a delay in fluid the environment means that the wound should be considered resuscitation the rate of infusion should be increased to to be contaminated (2). A booster of tetanus vaccine should ensure that the first 50% is infused within the first 8 hours also be considered if the patient is not up-to-date. As the from the time of the burn injury (1, 5, 9-11, 13). apparent extent of the burns evolve it is vital to reassess and document the burned area and depth of burns (2, 6). This is only a guide to fluid management, as fluid requirements vary according to the clinical picture. Advice The primary survey and subsequent assessment of %TBSA should be sought from a specialist. Hartmann’s solution allows appropriate triage of the patient. Minor burns are is the fluid of choice, and the volume infused should be common, and many can be dealt with on board, whilst titrated to urine output and other clinical parameters. The other more severe injuries may require further intervention patient requiring intravenous fluid resuscitation should and onward transfer. Below is a flow chart from the CGOs be catheterised early in the clinical pathway. Increased giving guidance on evacuation priorities (Fig 5) (10). volumes (on top of the volumes suggested by the Parkland J Royal Naval Medical Service 2015, Vol 101.1 60
Formula) are often required in inhalation injuries, high- Role 3 medical care is delayed and the injury is of sufficient voltage electrical injury and in children, who also need severity to warrant it. The eschar is normally insensate maintenance fluid in addition to resuscitation fluids (1, 5, but, as the incision extends into healthy tissue, it is painful 9-11, 13). and necessitates appropriate analgesia for the procedure. Discussion with an expert, if time permits, is advised prior Fluid resuscitation aims to maintain perfusion of injured or to proceeding to escharotomy. Afterwards, the wounds susceptible tissue areas and prevent burn wound extension. should be dressed; incisions should be packed with alginate The balance is difficult as under-resuscitation leads to dressing (such as Kaltostat®), and the burn covered with hypoperfusion, and over-resuscitation may precipitate a non-adherent dressing such as Mepitel® (alternatives worsening oedema and tissue hypoxia. A crude, but are Jelonet™ or Paranet™) which is then covered with effective, indicator of resuscitation is urine output. In adults an absorbant gauze/Melolin™ wrapped in a simple crepe a urine output of 0.5-1.0ml/kg/hour should be the target. bandage. The use of Flamazine™ in this setting is not High-voltage electrical burns (>1000 volts) frequently recommended, as there is no evidence for its efficacy and it cause rhabdomyolysis, so a urine output of 1.5-2mL/kg/ can be detrimental to wound care (1, 5, 9, 11, 12, 14). hour is desirable to reduce the likelihood of acute tubular necrosis. Burns related to specific factors Electrical Burns The decision regarding ongoing fluid administration after As electricity passes through the body it generates heat, the initial 24 hours should be made in discussion with a causing burns. These may be classified as high- (>1000 burns specialist; indeed all burns requiring intravenous volts) and low- (<1000 volts) voltage burns, and lightning resuscitation should be discussed. These patients require burns. evacuation back to the United Kingdom for further care. In all but the most minor cases, other patients who sustained Low-voltage burns such as those sustained from most burns injuries should always be discussed with a UK burns domestic electrical equipment tend to cause burns at entry specialist to assist in making the decision on whether to and exit sites, each of which must be sought. The burn often evacuate the patient (1, 5, 9-11, 13). extends through to deep structures. High-voltage burns are Escharotomies characterised by entry and exit wounds with massive local Deep burns that encircle any part of the body are termed destruction of tissue. There may be multiple entry and exit circumferential, and may result in inelastic skin (eschar) wounds as the electrical current arcs across joints. Entire that does not accommodate stretching in the context of compartments can be destroyed, even without involving oedema. This causes pressure to rise within the tissue the overlying skin. Patients with electrical burns are prone capillary beds, and this may threaten perfusion of the to compartment syndrome, so it is necessary to monitor the extremity. Circumferential chest burns can prevent chest limbs for neurovascular compromise. Escharotomies and/or wall expansion necessary for normal ventilation. This is a fasciotomies may be required. surgical emergency and necessitates urgent action in which Cardiac dysrhythmias can occur following passage of escharotomy may need to be performed. It is unusual for an electrical current across the thorax. Cardiopulmonary escharotomies to be required in the first two hours following resuscitation is often effective and efforts to resuscitate the injury, so if possible the procedure should be avoided in the patient should ideally be continued until the patient reaches Role 1 setting. definitive care. The patient should ideally have cardiac monitoring and a 12-lead ECG if available. Given the An incision is made through the burned tissue to the isolated operating areas of many vessels at sea, a level of subcutaneous fat – but not underlying fascia unless a pragmatism is required, and if unsuccessful after a prolonged fasciotomy is required – in order to release tension and attempt at resuscitation it is not unreasonable to stop (1). allow expansion of the affected burned area. Incisions are made along the mid-lateral and medial aspects of the Chemical burns limbs, avoiding underlying anatomical structures. For the Chemical burns are transferable by cross contamination, so chest, longitudinal incisions are made along the anterior it is vital that all staff involved in the care of the burned axillary line to the subcostal region (1,9). The lines are patient wear appropriate personal protective equipment. joined by a chevron-shaped incision parallel to the subcostal The patient’s clothes and fluid used for irrigation should margin. This creates a mobile section to allow for proper also be considered contaminated. chest excursion (Fig 6). These incisions should ideally be performed using electrocautery for haemostasis, but this With chemical burns, the mainstay of treatment is copious is unlikely to be available outside an operating theatre irrigation with water following removal of any dry powders environment. Escharotomies should be performed in a clean or lumps. All clothing should be removed and irrigation operating theatre and only performed at sea if evacuation to should continue for 30 minutes. 61 Clinical
The burn must be treated with calcium gluconate either topically or by infi ltration of the affected area in order to prevent further injury. It should be noted at sea that calcium gluconate is not held in the standard Medical Equipment Table for Service Afl oat (METSA). These burns must be discussed with a burns specialist and urgent care sought (5, 12).
Mass casualty situations A patient with severe burn injuries takes up a signifi cant amount of resources in terms of personnel, equipment and operating theatre time. In a mass casualty situation triage is important. Factors that reduce the chance of survival are inhalation injury (other than isolated oropharyngeal burns), deep burns over 80% TBSA, age over 60 and signifi cant concomitant injury or illness. Presence of two or more of these risks should prompt consideration of the use of an expectant (T4) category in mass casualty situations. In this situation, no treatment other than analgesia is given to patients in this category, as they are unlikely to survive and so the limited resources are best focused on patients who are more likely to survive (9).
In mass casualty situations it is reasonable to give oral fl uids to patients that tolerate them with a TBSA burn of less than 20%. An oral hydration solution such as Diarolyte™ should be used (RN vessels carry large quantities of this), though Figure 5. Evacuation prioritisation from Role 1. a normal diet with plenty of water is probably as effective Acid burns (other than hydrofl uoric acid mentioned below) (1,12). Unfortunately many burned patients will suffer from tend to cause superfi cial burns by producing an eschar. reduced gut absorption as a systemic effect of the burn Alkali burns tend to penetrate deeper, so should be irrigated injury, complicating their management (1,5,11). for longer. Once the burning process has been stopped, the treatment is similar to burns of other causes. Application Care beyond Role 1 or Role 2 Afl oat of any dressing whilst contamination is present may cause Once the patient has reached a defi nitive care facility, the further injury. mainstay of treatment for deep burns is excision of necrotic tissue and skin grafting, ideally from the patient’s own Very serious injury can follow a seemingly minor exposure unburned skin. Severe burns require intensive care whilst to chemicals; systemic effects are possible, and vigilance undergoing the initial surgical management. Large burns is required. All chemical burns should be discussed with cause multi-system morbidity such as cardiac dysfunction, an expert at the earliest opportunity, especially if there is renal failure, cerebral hypoxia and infections, all of which ophthalmic involvement, as specifi c countermeasures may can be life threatening. These patients also have a high be required (1,11). calorie requirement and frequently require parenteral or nasogastric feeding in addition to oral feeding. The severely Hydrofl uoric acid burns burned patient should be managed in a specialist burns We mention the special case of hydrofl uoric acid burns centre by a multi-disciplinary team. as they can be severe, have a specifi c antidote and result from exposure to a substance that is extensively used in Burned patients can suffer from permanently disfi guring dockyards. Burns resulting from hydrofl uoric acid continue injuries. There is often both physical and psychological after apparent exposure to the injurious material has been morbidity; recovery requires early psychological and terminated and irrigation is not suffi cient to terminate the physical therapy to allow the best possible outcome. injury. The chemical penetrates deep into the tissues prior Severely injured patients require prolonged hospital to dissociating into H+ and F- ions, causing injury. This admissions before admission to a rehabilitation unit and means that the skin involved may not show signifi cant signs subsequently re-integration into a life outside formal care of burns and that the injury is often deeper than it appears. (5, 11). J Royal Naval Medical Service 2015, Vol 101.1 62
grounds that recovery compatible with Service life is not possible. This is variable and must be assessed on a case- by-case basis, as there is no guidance on burn size and occupational health implications. A small burn to the hand may impede the ability of the serviceman whilst a larger burn to the torso may not.
Conclusion The nature of war means that burn injuries will remain an issue for medical staff. It is important that all Royal Naval Medical Service personnel are able to provide care for the burned patient, employing the principles outlined in BATLS and CGOs. These simple principles will serve to save the lives of men and women serving the RN and wider Armed Forces community. The burned patient can present a complex clinical picture and often requires advanced medical, physical and psychological therapy. It is imperative that the initial management is delivered to a high standard. The burned patient generally requires evacuation from the maritime or land warfare environment to a defi nitive Figure 6. Escharotomy lines of incision. treatment facility for on-going care. No burned patient should be kept aboard any RN vessel without discussion Occupational considerations in the RN/ UK Armed Forces with a burns specialist, as evacuation is usually appropriate The occupational implications of burns for those serving in all but the most minor cases. in the Armed Forces are on a spectrum from full recovery with no limitations through to medical discharge on the
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Authors Surgeon Lieutenant O Rylah RN Queen Alexandra Hospital [email protected]
Surgeon Commander J Smith RN Queen Alexandra Hospital