b-ent 12 management of burn wounds of the head and neck region

B-ENT, 2016, 12, Suppl. 26/1, 107-126

1. Introduction

The most common causes of burn injuries are flames and hot liquids (Annex 1). Two thirds of paediatric burn injuries are scald injuries (Annex 1). Flames cause more severe burn wounds requiring intensive care than do hot liquids (Annex 1). The temperature of oil is very often over 100 °C and the injuries are deeper than those associated with hot water. Electrical and chemical burns are the fourth most common cause of burn injuries (Annex 1), and their treatment and evolution are sometimes more peculiar. Lessons learned from recent ongoing armed conflicts, for example in Afghanistan and Iraq, should improve the management of war-related burn injuries in austere environments. Recent conflicts produced many burn casualties (5-10% of all casualties are burn victims).3

The WHO4 estimates that 300,000 persons die around the world each year from fired-related burn

injuries. The incidence of burn injury is higher in low- and middle-income countries. In Europe, the death rate per 100,000 of the population is 0.7 in the high-income group and 4.5 in the low-income group. This difference is explained by the varying use of prevention strategies such as smoke detectors, regulation of hot water heaters, safety of electrical wiring, etc. The American Burn Association (ABA) reported in its 2012 National Burn Repository that, of the cases report with a known aetiology, fire/flame injuries represent 44%, scald injuries 33%, “contact with hot object injuries” 9%, electrical injuries 4% and chemical injuries 3%.5

Fluid resuscitation strategies have been dras-tically revised because of the high number of complications arising from over-resuscitation, otherwise known as “fluid creep”.6,7 Smoke in-halation injuries still carry a high burden of morbidity and mortality. Burn injuries have become more complex, often involving blast

Management of burn wounds of the head and neck region

S. Jennes1, B. Hanchart2, E. Keersebilck1, T. Rose1, O. Soete1, PM. François1, H. Engel1, F. Van Trimpont1, C. Davin1, M. Trippaerts1, B. Vanderheyden1, L. Etienne1, C. Lacroix1, S. Teodorescu1, S. Mashaekhi1, P. Persoons1, D. Baekelandt1, S. Hachimi Idrissi3 andJ.-B. Watelet4

1Burn Wound Center, Queen Astrid Military Hospital, Rue Bruyn 1, 1120 Neder-over-Heembeek, Brussels, Belgium; 2Department of Emergency Medicine, CHU UCL Dinant-Godinne-Namur, Docteur Thérasse, 1 B-5530, Yvoir, Belgium; 3Department of Emergency Medicine, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium; 4Department of Otorhinolaryngology, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium

Key-words. Major burn; burn shock; fluid resuscitation; smoke inhalation injury; cooling; escharotomies; facial burn wound.

Abstract. Management of burn wounds of the head and neck region. Management of the severely burned patient is very often a challenge, not only due to major disturbances in anatomy and physiological processes, but also because the relatively low incidence of this pathology in both civilian and military practice results in care providers’ lack of experience. The purpose of this educational document is to provide doctors confronted with these formidable trauma patients with basic management guidelines as well as some practical tips. In summary, and most importantly, these patients should be treated as any other multitrauma patient. First aid is essential and can be provided by non-medical staff. Initial medical management should focus on the usual, familiar trauma algorithms of ABCDEF from the emergency management of severe burns (EMSB) manual1 or the ABCDEs of the manual of advanced trauma life support (ATLS)2 or advanced burn life support (ABLS). Medical care should proceed through the following steps – Step one: establish a reliable intravenous infusion; step two: protect the airway; step three: establish and maintain a haemodynamic state compatible with sufficient organ perfusion in order to reduce aggravation of the burn wounds and increase overall survival likelihood; step four: provide analgesia with adequate sedation and provide anaesthesia for escharotomy, fasciotomy or other surgical injuries; step five: maintain normothermia; step six: feed the patient by starting enteral nutrition as early as possible; step seven: prevent infection using antiseptic wound management, systemic antibiotics and tetanus prophylaxis. All of these intricate steps require continuous reassessment and adjustment, but the existence of other wounds (blast injuries, penetrating and blunt trauma) even further complicates the management of burn casualties.

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smoke inhalation, pre-existing organ dysfunction (cirrhosis, chronic obstructive pulmonary disease, malignancy, etc.) or severe trauma. Prognostic scoring systems have been proposed, aiming to put a figure on the life expectancy of this category of patient:

- Baux Index8 = age + TBSAb + 17 (if associated with smoke inhalation injury)

If Baux: 100, mortality (M): 25 %; if Baux: 140, M ≥ 90% (survival impossible).

- Tobiasen9 abbreviated burn severity index (ABSI): (annex 4)

If ABSI < 4, M < 1%; if ABSI > 11, M > 90%.In the light of the experience obtained by our burn

centres and the aforementioned scoring systems, well thought-out medical reaction plans have been established, along with alternative planning in case of failure. Unfortunately, there are often only two possibilities: either long, drawn-out, maximum multidisciplinary treatment, or comfort therapy leading to a rapid, inevitable demise. The choice between these two options is decided in consultation between the family doctor, the patient’s family and the specialist doctors dealing with the patient. For host nation burn casualties, full thickness burns of 50% or greater TBSAb could lead to preference for the second solution.10

As far as major burns are concerned, there is no place for improvisation. Management is a race against time and death. Mistakes are ill-afforded. The aim of the following document is to provide a useful management outline for the care of the seriously burned patient (TBSAb > 20%, deep face burn and/or severe smoke inhalation injury). Here are our recommendations for the management of the severely burned patient within the first 96 h post-burn, grouped into two sections:

injuries and amputations. In addition, the (burn) wounds arising on Middle Eastern battlefields are often contaminated or even infected with so-called “superbugs” (multidrug resistant bacteria). The management of infectious complications in vulnerable burn victims represents a huge burden for military healthcare. Military sanitation, hygiene and nursing care must be rethought in order to deal with the challenges posed by multidrug resistant bacteria. New initiatives to tackle the problem of antibiotic resistance are beyond urgent. One of these initiatives is phage therapy. Historically, military medical services have played a crucial role in the development of phage therapy.

The ultimate goal of the initial resuscitation of severely burned casualties on the battlefield or in civilian life is the successful and timely preparation of the patient for (aeromedical) evacuation to a burn wound centre. Pain control is of the utmost importance to prevent the development of hyperalgesia, neuropathic pain and/or post-traumatic stress disorder (PTSD).

By definition, the seriously burned patient, or a patient with major burns, presents a burned surface area of more than 10% of the total surface area, or otherwise fulfils one of the admission criteria to a burn wound centre (Annex 2). Burns can be classified according to their depth (degree) (Table 1), surface area (total body surface area burned, TBSAb) and cause (Annex 3).

Burns of between 15-40% TBSAb are considered to be very serious as they are life-threatening. Burns of more than 40% TBSAb are the most serious, as they can result in the death even of physically fit soldiers. The prognosis for patients with > 40% TBSAb is often guarded, especially in the elderly (> 60 years) or if associated with severe

First degree burns are limited to the epidermis. They are painful and erythematous.

In superficial second degree or partial thickness burns, all the epidermis and the upper layer of the underlying dermis are burned. These burns are characterized by clear blisters and weeping. Theses burns are painful and blanch with pressure.

Deep second degree or deep partial thickness burns involve the deeper layers of the dermis. Theses burns are covered by layers of red and white dermis that do not blanch with pressure and are characterized by haemorrhagic blisters. They are difficult to distinguish from third degree burns.

Third degree/full thickness burns involve the epidermis and all the dermis. They are not painful and are insensitive to touch. They may be dark brown or tan with a leathery texture.

Fourth degree burns are deeper than the skin, involving the underlying structures such as fascia, muscle and bones.

Table 1Classification of burn wounds according to depth.

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Prehospital and in-hospital interventions 109

through a poultice effect. Rings and chains should be removed before oedema begins to develop.

2.1.2. Check vital ABC functions:Check vital ABC (airway, breathing, circulation) functions and administer oxygen (this is vital in the case of victims of enclosed fires and in the case of shock).

2.1.3. Cooling: Cool the burn wounds as quickly as possible using lukewarm water (20 °C) in order to prevent aggravation of the lesions from a wave of persisting deep heat energy and to reduce the pain. It is recommended that cooling should last 15-20 minutes under flowing water at 20 °C (8 °C – 25 °C), but care should be exercised to avoid central hypothermia, especially in the young or elderly. For TBSAb > 20%, five minutes of cooling is sufficient. Rinsing a burn wound under a tap, a shower or even a watering hose is the most effective technique. Soaking or using a spray can also help. The application of wet towels is less effective because they do not come into close contact with the entire burned zone and they quickly warm up in contact with the body. In order to provide a useful alternative, therefore, they must be frequently changed. As far as the seriously burned patient is concerned, cooling should be carried out with care, especially if the victim is unconscious (high risk of hypothermia). After five minutes, the burns should be dried and the patient kept warm. Dressings with liquid gels (Water-Jel® Technologies or Burnshields® Burnshield Premium® Cape Town, South Africa) can be an alternative to water cooling for extensive burns and during transport. However, their prolonged application has not been validated and can increase the risk of hypothermia. In order to reduce this risk, it is useful to increase ambient temperature to 30 °C and to keep non-burned zones covered. Ice and freezing water are contraindicated. The extreme cold induces vasoconstriction with deepening of the burn wounds and increases the risk of hypothermia. In order to detect hypothermia, the patient’s temperature must be recorded – this vital sign is too often neglected. The two sayings “cool then reheat” and “cool the burn, reheat the patient” summarize the main aim of cooling. This ought to be carried out as quickly as possible and remains effective until 3 h after the accident; if possible, it should be carried out using running water.

- Extra-hospital management of the severely burned patient.

- In-hospital or in-the-air management, during the first 96 h post-burn.

2. Extra-hospital management of the severely burned patient

If the medical team is the first to arrive at the site of the incident (as bystanders or as doctors), it is very important to evaluate the danger before intervening. The victim will not be helped if the rescuer gets hurt or burned. Potential dangers must also be taken into account, such as the presence of inflammable or toxic products (e.g., fuel tanks), lethal fumes or potential building collapse. If the firefighters have already arrived before the medical assistance, the chief firefighter must be informed of your arrival. The medical team must ask him or her where they can work in a safe environment without disturbing the other rescue teams. It is also important to be informed of the potential evolution of the situation to evaluate whether any reinforcement would be useful. The management of a disaster will not be discussed in this chapter.

2.1. First aid

At the point of injury or in its immediate vicinity, witnesses or parents will conduct first aid. The call for medical assistance is the first link in the chain of aid. Then, a medical team from the medical service takes over. The emergency medical mobile service will provide advanced trauma life support (ATLS) and will prepare the evacuation to a burn wound centre. The specific acts of first aid are:

2.1.1. Stop the burning process: If the clothes are burning, the fire should be extinguished by rolling the victim on the ground, by enveloping and binding him with a blanket or by soaking him with water (see “cooling”). The victim will not be helped if the first-aid workers also burn themselves. It is therefore important that the act of extinguishing the fire takes place without further injury to the helpers. Carbonized clothes that remain hot or even burning and act as a reservoir of heat energy ought to be removed as quickly as possible, provided they are not fixed to the skin. If the clothes are soaked in hot or caustic liquid, they ought to be taken off as quickly as possible because they can result in deepening of the burn wounds

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Cautiously monitor the airways and consider early surgical intervention if respiratory distress occurs.

- Estimate TBSAb with the Rule of Nines.- Cover the burn area with dry, sterile dressings

(a blizzard survival blanket if TBSAb > 20%).- Fluid resuscitation (USAISR Rule of 10):

if TBSAb > 20%, start IV/IO fluid with lactated Ringer’s solution (LR) at a rate of %TBSAb x 10 cc/h for adults weighing 40-80 kg. For every 10 kg above 80 kg, add 100 ml/h.

- If haemorrhagic shock is also present, resuscitation for haemorrhagic shock takes precedence.

2.3. Medical assistance

2.3.1. Primary and secondary survey - The algorithms used by the EMSB or ATLS courses –ABCDEF or ABCDE, respectively – applied by traumatologists regarding burns setting, are nevertheless pertinent to the resuscitation of patients with major burns. The severely burned patient must be initially evaluated just like any other trauma patient in order to avoid missing a life-threatening lesion masked by the distracting nature of the burns.

- Evaluation of the burned surface area using the Rule of the Palm (palm, including fingers, representing 1% of the surface area of the patient), Wallace’s Rule of Nines and the Lund and Browder diagram. This initial evaluation is extremely important when determining the necessary rate of fluid resuscitation, placement of catheters, method of transport, likely prognosis and evacuation to a nearby hospital or burn centre. The rapid determination of percentage TBSAb can be difficult and often incorrect when the person treating these burns is an inexperienced clinician. Substantial errors in estimating burn extent result in significant undercalculation or overcalculation of fluid requirements.

- Evaluation of depth: distinctions must be drawn between burned and non-burned areas, wounded and healthy (or very superficially damaged) skin (first degree burns should never be included in the assessment of the burned surface area), open subcutaneous tissues (or masked by blisters) and intact skin.

- Associated lesions: when the burned patient is first seen by medical or paramedical staff, rapid

Decontamination of chemical burns should be carried out as soon as possible using lukewarm water and should last for a minimum of 30-60 minutes. Chemical eye burn wounds, specifically, need direct copious irrigation to avoid scarring. Such irrigation is only effective when performed within seconds of the injury at the scene of the accident. Further decontamination can be carried out under local anaesthesia in the ED. Care must be taken to ensure the effluent does not come into contact with healthy skin, in order to avoid further contamination and burning as even diluted concentrations of the product can have toxic effects (phenols).

2.1.4. Undressing:Burned clothing should be removed, especially if it is soaked in hot or caustic liquid that can further deepen the burns through a poultice effect; rings, bracelets, watches, belts and tight clothing should all be removed as well as any metal coins as these retain heat. In the case of chemical burns, it is useful to place contaminated clothing in a plastic bag in order to avoid further accidental contamination.

2.1.5. Protection against hypothermia: Aluminium or another blanket should be applied to isolate the patient from the environment in order to avoid convective heat loss (air contact with the skin is responsible for at least 50% of heat loss).

2.1.6. Elevate burned areas:Evaluate burned areas in order to prevent oedema and ischaemia due to swelling.

2.1.7. Cover the burn:The burn wound should be left untreated but covered by a clean or sterile towel, or even plastic cling wrap or cling film. At this stage, the burn wound is considered to be sterile and has to be protected from infection. Do not waste time applying costly and sophisticated antibiotic-based dressings, as these will only be removed in order to evaluate the burns when the patient arrives at the burn centre.

2.2. Tactical combat casualty combat care guide-lines11

The basic management of a burn casualty under fire comprises the following:

Facial burns: be aware of inhalation injuries, especially those that occur in closed spaces.

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the means of transport. This is of vital importance in determining the likelihood of survival in severe burns victims.

At this stage, the burns should not only be considered as wounds that must be protected from infection. The patient is also in a state of current or impending hypovolemic shock, at risk of hypothermia and hypoxaemia, and usually suffers from very intense pain and anxiety.

2.3.2. Vascular accessVenous access is acquired as soon as possible in healthy skin or, if necessary, in a burned zone. One large calibre peripheral venous line – 18-16 G – is sufficient in the majority of cases. Two peripheral lines are highly desirable if the patient is to receive medication via a syringe pump or if he is intubated and ventilated or if he is to be evacuated by helicopter. Central venous access is foreseen only in the case of failure to place a peripheral line or an intraosseous needle. In such a case, femoral venous puncture is then preferred. An arterial blood sample can be taken to analyse arterial blood gas tension as well as carboxyhaemoglobin (HbCO). Portable blood gas analysers (e.g., i-STAT, Abbott) allow an almost instantaneous measurement of arterial blood gas tension on-site.

2.3.3. Fluid resuscitationFluid resuscitation should be initiated as soon as possible when the burned surface area is over 15% in an adult or over 10% in a child. On the battlefield and in mass burn casualty disasters,

evaluation and treatment can be life-saving. Whereas the majority of minor burns are not associated with other lesions (smoke inhalation, blast injury, intoxication, open wounds, fractures, contusions, head or thoracic injuries, acute myocardial infarction, etc.) such complications are more likely in the severely burned patient. Whatever the area of the burn, burns patients fall into two categories: 1. those in whom associated lesions are easy to recognize; 2. those in whom associated lesions are masked or concealed. Patients with minor burns and an associated lesion usually fall into the first category. However, it is not unusual to miss a life-threatening problem in a victim with extensive burns where the impressive nature of the burns themselves captures all of the attention of the medical team.

- The history of the accident, obtained from the patient or from bystanders, should alert the clinician to the possibility of coexisting lesions: road traffic accidents (especially those of high velocity or associated with ejection), explosions, electrocutions, jumps (e.g., jumping from a window) or falls. The possibility of such history should also be considered for patients unable to give a history due to unconsciousness, intubation, psychiatric disturbance, intoxication or drugs influence.

All of these patients should be considered as potentially polytraumatized or poly-injured and managed as such (Figure 1). This first assessment determines not only which catheters should be placed and what therapy should be initiated, but also

Figure 1A and 1BCase of a severely burned victim (TBSAb 60%) with three associated lesions: right renal contusion, first lumbar vertebra fracture/displacement with compression of the cauda equina (A) and pelvis fracture (B). He jumped from the second floor.

A B

A

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112 S. Jennes

Considering the major changes in vascular permeability within the burn wounds, and outside of the case of extensive burn injuries (> 20% TBSAb), colloids are not indicated immediately (not before the 6-8th hr post-burn). However, in the case of shock that is difficult to manage, or in the absence of crystalloid, an albumin-containing solution or even fresh frozen plasma (FFP) can be used. Colloids like starches are contraindicated18,19. In the absence of LR (Hartmann®), other balanced crystalloids such as Plasmalyte® (from Baxter) or NaCl 0.9% can be used with the same formulae. Glucose-containing solutions should be avoided for the initial resuscitation of the burned patient, children included. The risks of hyperglycaemia and osmotic diuresis are considerable given the context of the metabolic stress produced by the thermal injury (catecholamine and cortisol release). In children, LR (Hartmann®) solution is the crystalloid of first choice during the first 4-8 h post-burn.

a greater burn size – 20-25% TBSAb – could be acceptable. Before arriving at hospital, it is often difficult to precisely determine fluid requirements using resuscitation formulae such as that from Parkland Hospital.12-15 In order to compensate for this difficulty, we recommend for adults, as well as for children, volume expansion with crystalloid, if possible LR, at a rate of 10 ml/kg/hr if the TBSAb < 50% and 20 ml/kg/hr if the TBSAb is > 50%, without exceeding 1.5 L/h (Table 2). This is merely a rule of thumb. This formula, like all the others, serves only as an initial guide, and will later be adapted to the specific haemodynamic parameters and, especially, to the diuresis (aim: 0.3-0.5 ml/kg/hr in adults, 0.5-1 ml/kg/hr in children) (Table 3). Another user-friendly formula is that of the USAISR – the Rule of 10: if TBSAb > 20%, start IV/IO fluid with LR at a rate of %TBSAb x 10 cc/h for adults weighing 40-80 kg, and for every 10 kg above 80 kg, add 100 ml/h.

Prehospital and in the ED

LR at a rate of 10 ml/kg/h if TBSAb < 50%

LR at a rate of 20 ml/kg/h if TBSAb > 50%

In the ICU

LR: 3 ml/kg/h over 24 h with half over the first 8 h and half over the following 16 h

Albumin 20% or 4%: 0.75-1 g/kg over 24 h from the 6th h post-burn

Haemodynamic goals of fluid resuscitation (in order to avoid over-resuscitation)

HR > 80/min and < 140/min; MAP > 65 mmHg; CVP < 10 mmHg (with PEEP ≤ 5)

Keep UO between 0.3-0.5 ml/kg/h with hourly LR rate adaptation during the first 48 h:

if UO < 0.3 ml/kg/h: increase LR rate by 25%

if UO > 0.5 ml/kg/h: decrease LR rate by 25%

if CVP > 10 cmH2O: start dobutamine for a ScvO2 > 65%

Table 2Fluid resuscitation guidelines for severe adult burn casualties (TBSAb > 20%)LR: lactated Ringer’s solution; HR: heart rate; MAP: mean arterial pressure; CVP: central venous pressure; UO: urinary output; ScvO2: oxygen central venous saturation.

Table 3Fluid resuscitation guidelines for severe child burn casualties (TBSAb > 20%)LR: lactated Ringer’s solution; HR: heart rate; MAP: mean arterial pressure; CVP: central venous pressure; UO: urinary output; ScvO2: oxygen central venous saturation.

Prehospital and in the ED

LR at a rate of 10 ml/kg/h if TBSAb < 50%

LR at a rate of 20 ml/kg/h if TBSAb > 50%

In the ICU

LR: 3 ml/kg/h over 24 h with half over the first 8 h and half over the following 16 h

LR-glucose 5%: 100 ml/kg/d (0-10 kg), 50 ml/kg/d (10-20 kg), 20 ml/kg/d (> 20 kg)

Albumin 20% or 4%: 0.75-1 g/kg over 24h from the 6th h post-burn

Haemodynamic goals of fluid resuscitation (in order to avoid over-resuscitation)

HR > 100/min and < 180/min; MAP > 55 mmHg; CVP < 10 cmH2O (with PEEP ≤ 5)

Keep UO between 0.5-1.0 ml/kg/h with hourly LR rate adaptation during the first 48 h:

if UO < 0.5 ml/kg/h: increase LR rate by 25%

if UO > 1.0 ml/kg/h: decrease LR rate by 25%

if CVP > 10 cmH2O: start dobutamine for a ScvO2 > 65%

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Initial intubation is by the orotracheal route in adults and the nasotracheal route in children. Intubation is performed under general anaesthesia using propofol (1-3 mg/kg), midazolam (0.1-0.2 mg/kg) or diazepam (0.1 mg/kg), associated perhaps with an opioid – sufentanil (0.1-0.3 µg/kg) or fentanyl (1-3 µg/kg) or with ketamine alone (1-2 mg/kg). The disadvantage of etomidate as an induction agent is the suppression of endogenous cortisol secretion, so necessary at times of shock and intense stress. Succinylcholine can be used without danger of life-threatening hyperkalaemia within the first 48 h after a burn. Following this time, succinylcholine can cause a sudden, lethal hyperkalaemia. This adverse effect contraindicates its use in the burned patient. The advantages of succinylcholine are its rapid onset (< 60 s) and its short duration of action (< 5 mins). Anaesthetists preferentially use non-depolarizing relaxants due to their long duration of action and slow offset. A high dose of rocuronium (1 mg/kg) allows for rapid intubation (within 90 s) and can be antagonized effectively and almost instantaneously by sugammadex 16 mg/kg (Bridion®). Tracheal intubation is followed by nasogastric tube placement. Mechanical ventilation avoids increased oxygen consumption due to increased respiratory work and avoids the risks associated with impaired thoracic mechanics, exhaustion and respiratory depression secondary to use of opioids. However, mechanical ventilation depresses cardiac output, requiring compensation with the use of increased volume loading and/or the use of vasopressors and inotropes (epinephrine, norepinephrine, ephedrine, dobutamine). Maintenance of anaesthesia is best achieved using agents that show minimum cardiovascular depression. We recommend benzodiazepines by continuous infusion (in a syringe pump); midazolam 0.1-0.3 mg/kg/h or diazepam in a bolus of 5 mg in association with opioids – sufentanil 0.1-0.3 µg/kg/h, fentanyl 1-3 µg/kg/h or morphine 0.05-0.1 mg/kg/h. Ketamine is a good alternative to opioids in a dose of 0.5-1.5 mg/kg/h. Continuous relaxation is not advisable as it prevents any possibility of neurological evaluation and facilitates the development of polyneuropathies. Repeated injections of a bolus dose of relaxant facilitate ventilation (diminution/abolition of the cough reflex) during transport and reduce the risks of accidental or auto-extubation. Modern myorelaxants show few undesirable

The crucial element in fluid resuscitation is the time at which it is started. This should be within the first hour post-burn for burn wounds exceeding 20% of the TBSAb. Once the perfusion rate has been calculated, it is important to keep this rate as steady as possible. Any sudden volume expansion only serves to aggravate the oedema and any sudden diminution can be followed by a state of cardiovascular collapse. The use of a Dial-a-Flo® (Hospira) is an acceptable alternative to the infusion pumps used in hospitals.

In the context of a fire in an enclosed space, severe, refractory and unexplained initial shock, cardiac arrest, severe arrhythmias or coma should suggest cyanide intoxication. Hydroxocobalamin (Cyanokit® Meridian Medical Technologies, Inc., a Pfizer company), 5 g in adults or 70 mg/kg in children, is an antidote that has been long recognized, but was only approved by the FDA on 15 December 2006. A high dose of vitamin C could be considered for parenteral treatment17.

Electrical burns caused by high voltage currents pose a particular risk of hidden injuries. The fluid volumes calculated according to the burned zones only at the points of entry and exit underestimate the real fluid requirements. The calculated fluid requirements should thus be increased by 50% or calculated on the basis of 8-12 ml/kg/%TBSAb during the first day. The risk of acute renal failure can be reduced by systemic alkalinization.

2.3.4. Respiratory resuscitationSystematic oxygen therapy at high oxygen concentrations is justified by the inevitable oxygen debt and the frequency of associated high levels of carboxyhaemoglobin in cases of smoke inhalation injury. The most common cause of death at the scene of a fire is CO intoxication.22 Tracheal intubation and mechanical ventilation are indicated in patients with extensive burn injuries (> 60% TBSAb), or in cases of evident clinical respiratory distress. Intubation should never be postponed for more than a few hours in the case of cervico-facial burns because the progressive worsening in oedema accelerates between 4-8 h post-burn, reaching a maximum between 12-36 h. An excessive delay will risk asphyxia requiring intubation in extremely difficult circumstances, and may even demand emergency tracheotomy in equally challenging conditions.

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evaluate pulmonary compliance by observing insufflation pressures and tidal volumes. If frank ischaemia develops, an escharotomy is indicated in order to avoid necrosis, ventilatory difficulties or intra-abdominal compartment syndrome. These incisions should take place within 3-6 h post-burn. They are best carried out within the hospital setting using either a sterile blade or an electrical scalpel. Escharotomies should only in exceptional circumstances be performed outside the hospital. If a long delay before arrival in hospital is foreseen (> 6 h), due to evacuation problems or in the case of a disaster, escharotomies ought to be performed beforehand. They are performed under general anaesthesia and antibiotic prophylaxis (first-generation cephalosporin). Third degree circumferential cervical burn wounds require escharotomies at both lateral sides to reduce the risk of intracranial hypertension caused by an obstruction of the jugular flow (Figure 2).

2.4. Transport

The thoroughness of preparation before evacuation is the best guarantee of successful transportation. In the case of facial burns, elevation of the head by 20-30° relative to heart level will limit facial and cerebral oedema. Heating in the vehicle and isolation using blankets are necessary to prevent hypothermia. A comfortable ambient temperature for a burned patient lies between 25 and 33 °C. Unnecessary jolting, acceleration and deceleration should be avoided as this induces further haemodynamic instability. Clinical monitoring of cardiovascular, respiratory, neurological and renal function should guide the administration of fluids and analgesia.

Ambulance, helicopter and plane are all recognized means of transport for burns victims: ambulance for short distances (< 100 km); helicopter for medium ranges (100 – 400 km) and plane for long haul (> 400 km). Helicopter transport has not shown any benefit over road transport in terms of survival or morbidity (Figure 3). However, it does save time, allows for easier access to the accident zone (especially in the presence of heavy traffic or in austere environments) and allows for the transportation of a specialized medical team to the scene. Indications for helicopter transport are: a distance > 100 km, difficult driving conditions due to heavy traffic, the need for a specialized medical

effects. Cisatracurium and rocuronium are very safe, even though the rare risk of anaphylactic shock can never be excluded.

Propofol is not advised during the first 72 h post-burn as it induces severe and harmful vasodilation and myocardial depression. Furthermore, in high doses it can cause the demise of multitrauma patients, or patients with head injuries or severe burns, due to shock, rhythm disturbance, renal failure or rhabdomyolysis. These features inevitably lead to death even in young patients. This complication is known as the propofol-related infusion syndrome (PRIS).19-20 Propofol should be reserved for inducing anaesthesia and for facilitating endotracheal intubation. Anaesthesia of the burned patient in the early phase of hypovolemic, distributive and cardiac shock is a difficult undertaking. If it is badly managed, it leads to worsening of the shock state and an increase in fluid administration (fluid creep).6-7 The development of abdominal compartment syndrome seriously worsens the prognosis.

2.3.5. Analgesia, sedation and anaesthesiaAs with any trauma emergency, analgesia, sedation and anaesthesia must be provided in the context of hypovolemic shock and a full stomach. Anxiolysis is desirable without arterial hypotension and is usually provided by a benzodiazepine (midazolam, lorazepam or diazepam). Talking and communicating with the patient in a calm manner can be reassuring and reduces anxiety. Informing next of kin is often a priority for many burns victims. Facilitating this can make management much easier.

Analgesia is best provided by administering potent intravenous opioids: morphine, piritramide, fentanyl or sufentanil. The intramuscular, subcutaneous and oral routes are to be avoided due to unreliable systemic absorption associated with the shock state and delayed gastric emptying. Non-steroidal anti-inflammatory drugs (NSAID) are contraindicated in severe burns within the first 48 h due to the increased risk of renal failure and gastric stress ulcers.

2.3.6. EscharotomiesEvery deep circular burn of the neck, a limb or of the trunk should be appraised specifically: locate arterial pulses, assess capillary refill, observe the plethysmographic curve on a pulse oximeter, determine skin sensibility and temperature,

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and the timeliness of treatment. Traditionally, the following timelines were applied for NATO operations. Advanced trauma care should be available within 1 h of injury. The principle surgical planning timeline is to provide primary surgery within 1 h. However, when this is not feasible, the planning timelines may be extended to 2 h for the provision of DCS and 4 h for primary surgery. Following experience in recent conflicts and publications in the specialized literature, this 1-2-4 rule is subject to discussion. Today, we increasingly accept the following:

- Advanced first aid and life-saving emergency procedures, more specifically bleeding and airway control, should be performed within the first 10 mins after injury by trained and equipped non-medical first responders; these are the so-called “platinum 10 minutes”;

- MEDEVAC assets should reach the seriously injured casualty with skilled medical aid within 1 h of wounding at most; by skilled medical aid we mean the provision of ATLS by medical personnel;

- Casualties that require surgery should, where possible, arrive in a facility equipped for this within 2 h of the injury.

The evolution from the 1-2-4 rule towards the 10’-1-2 rule calls for well-trained combat life savers and the use of medicalized rotary wing assets that can be deployed and employed far into the future.

Strategic evacuation for coalition casualties to a Role 4 hospital must be performed by well-trained caregivers – ideally by a burn team comprising an anaesthesiologist or intensive care physician, a respiratory physiotherapist and an ICU nurse with

team on-site or the necessity of assuring the quickest inter-hospital transfer (e.g., for paediatric patients). No objective standardized national or international criteria for helicopter evacuation exist. In reality, the choice of mode of transport in these situations very often depends on subjective evaluation. One thing remains certain, however – the medical team undertaking the transport should be experienced and the quality of preparation before evacuation should be rigorous in order to avoid dramatic sequelae during the flight or in the minutes following landing. In-flight monitoring and resuscitation of the burned patient is the domain of the medical practitioner and should not be left to the inexperienced. Helicopter transport certainly has its place in transporting seriously burned patients in major catastrophes.

Which means of transport to the military operating theatre?

Two principles that have a profound impact on morbidity and mortality are the continuity of care

A

B

Figure 2A and 2BCase of a severely burned victim (TBSAb 60%) with three associated lesions: right renal contusion, first lumbar vertebra fracture/displacement with compression of the cauda equina (A) and pelvis fracture (B). He jumped from the second floor.

Figure 3In the current operating theatre, rotary wing assets are essential for the safe and quick evacuation of the severely wounded.

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116 S. Jennes

deteriorating gas exchange and deepening of the burn wounds, which can induce intra-abdominal compartment syndrome and central neurological ischaemia that will singularly worsen the prognosis (Figure 4).

Avoid insufficient volume loading or delayed volume loading (under-resuscitation) that will aggravate the shock and its complications (renal failure, deepening of the burns, intestinal ischaemia, gastro-duodenal ulceration, MOF, etc.)

The haemodynamic objectives of resuscitation in burn shock are: MAP > 60-70 mmHg (aim for higher values in hypertensive patients); HR < 140/min (80-140/min)33; UO between 0.3-1 ml/kg/h; CVP between 1-10 cmH2O (for PEEP ≤ 5 cmH2O); CI > 2.5 L/min. m²; SVV < 15; ScvO2 > 65-70% (jugular-subclavian catheter); SvO2 > 60-65% (Swan-Ganz catheter).

The laboratory goals of resuscitation in burn shock are: albumin above 2.0 and below 2.5 g/dl; lactic acid < 3 mmoL/L; BE > -4; Hct < 48% (Hb < 16 g/dl).

In order to attain these objectives, volume loading should be achieved with LR (Hartmann®) according to the Parkland formula, or the Rule of 10, and a slow infusion of albumin solution 4-20%. Albumin solution 20% should be introduced 6-8 h post-burn at a dose of 0.75-1 g/kg/day in order to keep albumin concentration > 2.0 g/dl. Serum albumin concentration should be monitored every 12 h. The principle aim is to maintain a diuresis between 0.3 and 0.5 ml/kg/hr in adults and 0.5-1.0

many months or years of experience working in a burn centre. In the literature, the best window within which to evacuate severely burned patients to a Role 4 hospital is as soon as possible or before the 5th day26. The best “window” for evacuation should be defined or individualized: should the victim be evacuated during burn shock? Transporting unstable patients during the first 24 h may be dangerous, but after 72 h may be too late (for large TBSAb there is risk of burn shock followed by sepsis or acute lung injury, or both).

Sometimes an unstable patient will be evacuated because one cannot provide appropriate treatment on the field (e.g., evacuation for haemofiltration or embolization of bleeding in a Role 4 hospitals).

Evacuation strategies can vary from war to war. On the other hand, an unstable patient in non-expert care will tend to become even more unstable. Evacuation to expert care, even for unstable patients, is then warranted. Expertise is crucial.

3. In-hospital management during the first 96 hours post-burn

3.1. Intensive care aspects

3.1.1. From admission until 48 h post-burn (protocol of the Brussels Burn Wound Centre)Certainly attempt to treat burn shock, but be aware that overly aggressive treatment can be harmful for the patient.

Avoid excessive fluid resuscitation (fluid creep) as this produces a “Michelin man” effect with

Figure 4Over-resuscitation worsens the victim’s pulmonary function, already impaired by severe smoke inhalation injury in this young boy. High-frequency percussive ventilation (VDR-4®) and nitrogen oxide were helpful.

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- Early septic shock and in this case start intravenous antibiotics.

The seriously burned patient is polytraumatized and should undergo a primary and secondary evaluation that is as exhaustive as for any multitrauma patient – such as those of road traffic accidents – by looking beyond the burn wounds. Other life-threatening lesions such as tension pneumothorax, head injuries or abdominal trauma must be excluded. A total body CT scan and ultrasound examination should be performed early. Avoid the administration of bicarbonate, furosemide, starches (hydroxyethyl starches are contraindicated for use in burns and septic shock by the company Fresenius itself) and glucose. These various treatments have no place in the resuscitation of major burns.

Remember to use fast track enteral nutrition at a rate of 20 ml/h to begin. Measure the gastric residue (GR) 8 h post-burn. If the GR > 100 ml, begin intravenous erythromycin at a dose of 250 mg/8 h.

Do not forget to perform sufficiently deep escharotomies in the case of circular burns (risk of venous or even arterial occlusion). Palpate the limbs and abdomen, and inspect the ventilation pressures. Re-evaluate the quality of the escharotomies after 24 h by re-palpation of the neck, limbs and abdomen. Intra-abdominal pressure monitoring should be performed for burn wounds over 40% TBSAb.

3.1.2. After the resuscitation phase (> 48-72 h)Every measure is taken to ensure the following:

- Satisfactory tissue perfusion, especially cutaneous (volume loading, dobutamine).

- Satisfactory haemostasis by infusion of platelets (platelet nadir around the fourth day), FFP if APTT and/or PT is prolonged, red cell concentrates in case of severe anaemia.

- Minimal contamination of the wounds by use of frequent and thorough baths, the judicious use of topical antibacterials (silver sulfadiazine with or without cerium, povidone iodine, mafenide acid, etc.) and systemic antibiotic therapy.

3.1.3. Enteral feedingThis is fundamental practice. Ideally, it should be initiated as soon as possible after the injury (usually 3-4 h post-burn). The major associated risk is pulmonary aspiration secondary to gastroparesis. The reflex delay in gastric emptying is related to

ml/kg/h in children. If the CVP exceeds 8-10 cmH2O (taking the PEEP level into account), dobutamine should be introduced at a dose of 3-5 µg/kg/min. Noradrenaline should be added to counteract the vasodilator effects of sedation and/or early septic shock. Watch out for oversedation (opioid creep)22.

No propofol infusion during the first 48-96 h! Propofol is not advised during the first hours post-burn as it induces severe and harmful vasodilation and myocardial depression. In high doses, furthermore, it can lead to death in multitrauma patients or patients with head injuries or severe burns due to shock, rhythm disturbance, renal failure or rhabdomyolysis. These features inevitably lead to death even in young patients. This complication is known as propofol-related infusion syndrome (PRIS)19-20.

If shock persists in spite of adequate filling and inotropic/vasoconstrictor support, think about the following possible causes:

- Adrenal insufficiency (transitory depression by administration of etomidate), which calls for the administration of hydrocortisone (50 mg / 6 h or 1000 mg / 8 h).

- Cyanide poisoning, which calls for treatment with hydroxocobalamin (Cyanokit®) – 5g IV for adults and 70 mg/kg for children.

- Undetected passive smoke inhalation, occurring very frequently in the seriously burned, which increases the patient’s fluid requirements by almost 50%.

- Myocardial depression secondary to coronary disease, CO poisoning or cardiodepressive factors released from necrotic tissues; if CO poisoning is diagnosed, it is wise to administer 100% O2 for 12-24 h to deal with the late release of CO molecules bound to mitochondrial cytochromes.

- Intoxication from other substances the patient may have ingested or inhaled (alcohol, benzodiazepines, barbiturates, β-blockers, cocaine, heroin, amphetamines, ecstasy, etc.). Do not forget to ask for toxicological analysis of the patient’s urine and be sure to review the result.

- Vitamin deficiency, notably thiamine – upon admission vitamins should always be administered (B1 300 mg / 12 h, B6 300 mg / 12 h, C 1000 mg / 12 h, K 10 mg / 12 h).

- Other causes of shock: cardiogenic, haemorrhagic, obstructive (cardiac tamponade, tension pneumothorax, massive pulmonary embolism) or anaphylactic.

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since bathing frequency can sometimes favour the development from colonization to infection. Burn wounds are best thoroughly cleaned and debrided on a daily basis. The choice of topical agent is determined not only by the bacterial flora, but also by the appearance of the burns. Infection of burn wounds is a clinical diagnosis performed at the bedside. This clinical diagnosis can be supported by the presence of large numbers of germs (+++) cultured from wound swabs. The presence of only a few, or moderate numbers of bacteria in the cultures signifies contamination, colonization of the burn, or infection in a wound that has been cleaned or even disinfected before the cultures were taken. The technique and context of taking the culture is of great importance to the interpretation of the results.

Arguments in favour of infection are: peripheral redness (cellulitic appearance), new oozing or oedema within the burns, the presence of greenish pigments caused by pseudomonas or yellowish pigments caused by other bacteria and a change in the appearance of the burn wounds over time. These diagnosis criteria necessitate good reporting and communication between medical personnel and the nursing staff who bathe the patient. Documentation of the appearance of burn wounds is highly advisable, right from the start (Figure 7A).

Surgical principles:- Surgical planning should be organized following multidisciplinary discussion.- Early excision and covering with autografts. - Resort to avulsion (Figures 2,7B) instead of tangential excision (Figure 5) – avulsion has the advantage of reducing bleeding and autografts placed on muscular fascia are more often successful (Figure 6).- Spare donor sites: always harvest the least surface area possible!

stress and the opioid treatment of pain. The horizontal position of the patient facilitates gastroesophageal reflux. The preventive administration of prokinetic drugs is recommended during the evacuation of the patient, as is the semi-sitting position (30°). Enteral feeding should be started at a rate of 20 ml/h during the first day and progressively increased by 100% a day up to a maximum rate of 80 ml/h. Choose enteral feeding solutions that are rich in protein and calories (1.5 kcal/ml). Stop enteral nutrition 1-2 h before placing the patient in the horizontal position for a lengthy period of time (bath or surgical operation) to prevent the risk of aspiration pneumonia.

3.2. Surgical aspects

3.2.1. Topical antibacterialsThe role of topical antibacterials in the fight against infection is fundamental and too often forgotten by medical staff. The patient with major burns requires frequent renewal of all topical antibacterials. In our opinion, they should be renewed once every 24 h.

We are of the opinion that a thick layer should be applied, or at least a good layer following careful cleansing and disinfection with aqueous chlorhexidine solution (0.5%) or isobetadine. The major role of the nurse in cleansing and debriding wounds during the bath cannot be over emphasized.

The choice of topical agent should be influenced by the bacterial flora that colonize or infect the burn wounds Table 4). Bathing frequency plays a crucial role in the fight against colonization, infection and sepsis due to infected burn wounds (wound sepsis). The best prevention of wound sepsis is daily bathing sessions. A patient who has become unstable should also undergo daily bathing. Bathing every two to three days does not have the same effect,

Topical antibacterials Frequency of application Zones of applicationFlamazine® silver sulfadiazine 1x/day Most frequently used during the first weekCerium and silver sulfadiazine Flammacerium®

1x/day First choice if TBSAb > 40%All deep second and third degree wounds that will not be excised before two weeksBurns that do not need to be re-evaluated

Isobetadine® povidone iodine 1x/other day Reserved for allograft and autograft sitesMafenide acid Sulfamylon® 1x/day For the earsFuracine® 1x/other day If wound is infected with Gram-positive organisms

Table 4Major tropical antibacterials

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- Cover the donor sites with keratinocytes.- Use grafting techniques resistant to infection (e.g., Meek-Wall). No full-skin (unmeshed) grafts, even over the tracheotomy site and sites for venous access.- Meshing 2:1 or 3:1, coupled with a sandwich technique using allografts and keratinocyte sprays.- Limit excision to no more than 20% TBSAb in one operation.

Figure 5Tangential excision causes massive bleeding

Figure 6The Meek-Wall technique of autograft offers many advantages in the surgical treatment of extended full thickness burn wounds: parsimony (less donor skin is used to cover the same area), blood sparing, greater resistance against infection and less post-surgery bleeding.

Figure 7A: Burn wound infection of the back of a severely burned patient (TBSAb 90%). B: The same patient: excision of the infected wound by avulsion method.

A B

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10. Swabs and cultures (nose, throat, sputum, burn wounds, groin, urine)

11. WeightLR: lactated Ringer’s solution; UO: urinary output; IV: intravenous; PPI: proton pump inhibitor; SC: subcutaneous; AB: antibiotic; LMWH: low molecular weight heparin.

3.3.3. Second day post-burn (24-48 h post-burn):1. LR for UO between 0.3-0.5 ml/kg/h (adults);

0.5-1.0 ml/kg/h (children)2. Glucose + ions (PO4

+3, Mg+2)3. Albumin 20% or 4% (SSPP) to maintain

albumin > 2.0 g/dl4. Enteral feeding 20-40 ml/h5. Vitamins and trace elements6. PPI IV, LMWH, analgosedation7. Inotropes/vasopressors for MAP > 65 mmHg8. AB in case of soiled wounds, septic shock,

purulent expectoration 9. Ketamine IV for wound care10. Weight (increase in weight of 5-40% of body

weight)

3.3.4. Third day post-burn and later:1. Glucose5% + electrolytes (PO4

+3, Mg+2)2. Enteral feeding 60 ml/h (1.5 L / 24 h)3. Parenteral feeding4. Albumin 20% to maintain albumin > 2.0 g/dl

AND < 2.5g/dl5. Vitamins and trace elements6. PPI IV, LMWH, analgesia, sedation7. Norepinephrine for MAP > 65 mmHg8. Return to admission weight between day seven

and 12 (furosemide)9. Targeted antibiotic therapy

3.3.5. Acute medical and surgical treatment of major burns:1. O2, physiotherapy, tracheal intubation,

ventilation2. Fluid resuscitation, inotropic agents3. Analgesia and sedation4. Escharotomy, fasciotomy5. Tetanus prophylaxis6. Early enteral nutrition7. Normothermia

3.3. Summaries of hospital management during the first 96 h post-burn

3.3.1. Preparation for the reception of a seriously burned patient in the emergency room or any other resuscitation area:1. Pre-warm the room (30-35 °C)2. # LR (Hartmann®) or NaCl 0.9% 3. ETT, Ventilator, CVC, AC, NGT, BC, TM, EP,

otoscope, fiberscope, scalpel, arterial blood gas4. Sedation: # sufentanil, # midazolam5. # dobutamine, # norepinephrine, # epinephrine6. CyanoKit®, Tevax®, Tetaglobuline®7. Material for burn wound care (gauze swabs,

chlorhexidine, silver sulfadiazine)8. Labs: complete screen including Hb, arterial

blood gas, lactate, HbCO, alcohol, urine toxicology screening, HCG, serology

9. RX thorax, Echo-Doppler ultrasonic scan, full-body CT scan

10. ECG11. Weighing machine#: Infusion pump or syringe pump; ETT: endotracheal tube; CVC: central venous catheter; AC: arterial catheter; NGT: nasogastric tube; BC: bladder catheter; TM: thermometer; EP: eye protection; LR: lactated Ringer’s solution.

3.3.2. The first 24 h post-burn:1. LR 3 ml/kg/%TBSAb (50% administered in

the first 8 h; 50% administered in the remaining 16 h for UO between 0.3-0.5 ml/kg/h (adult) or 0.5-1.0 ml/kg/h (child)

2. Vitamins and trace elements IV3. Albumin 20% from sixth hour (0.75 g/kg / 24 h

or 3.5 ml/kg / 24 h)4. Enteral nutrition: start at 20 ml/hr (paediatrics:

1 ml/kg/h)5. PPI IV, AB (if soiled wounds, septic shock,

purulent expectoration, immune system depression), LMWH, analgesia, sedation

6. If smoke, aerosols inhalation: bronchodilators, heparin (100 U/kg), N-acetyl cysteine Q4 h

7. Dobutamine and/or norepinephrine to counteract hypotension associated with sedation and positive pressure ventilation

8. Hydrocortisone 50 mg / 6-8 h if etomidate used, or if potential Addison’s disease

9. Burn wound care 1x/day

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4. Pain management

Failure to provide adequate pain relief is one of the pitfalls of the treatment of burn victims. Burn pain can be classified as post-traumatic pain. Even in the 21st century, the treatment of burn pain remains a challenge to modern medicine because of the high intensity of pain (VAS > 4/10) and the long duration of treatment (one to two days per percentage of TBSA burned). Burn injuries are characterized by severe pain in the acute phase (Figure 8). After some time, the burn pain is difficult to control even with very high doses of morphine. Peripheral and central sensitization mechanisms are responsible for the development of nociceptive hyperalgesia. Opioid-induced and nociceptive hyperalgesia are well-known mechanisms encountered during the treatment of burn wounds. The use of NMDA antagonists (like ketamine) will reduce the development of nociceptive hyperalgesia. Adequate treatment of pain can prevent or reduce the occurrence and severity of hyperalgesia, allodynia, neuropathic pain and post-traumatic stress disorders (anxiety and depressive disorders). It also reduces hypermetabolism and promotes swifter healing of the wounds.

Isolate/insulate the wound from the ambient air with cling wrap or a sterile dressing or cream.

The best route for administration of potent analgesics (ketamine, morphine) is intravenous. Avoid the intramuscular, subcutaneous, oral or sublingual routes, when possible, in burn wounds

covering more than 20% TBSA. Burn shock can delay the absorption of the drug, which can result in less efficient pain control, increased risk of many supplementary administrations and, ultimately, enhanced risk of accumulation and worsening of the shock secondary to injuries (burn shock, haemorrhagic shock). Opioids can promote the fluid creep syndrome described by Pruitt22. No NSAID should be administered for burn wounds greater than 10% TBSA during the first two days because of the risk of acute kidney injury and gastro-duodenal ulcerations.

5. Summary (take home message)

1) Partial thickness burn wounds are very painful.2) The first steps in the management of burn pain

are: stop the burning process, irrigate the wound with running water if possible (for cooling) and isolate the wound from any contact with external objects or circulating air (cling wrap, humid non-adherent dressing and antimicrobial creams). Cooling hydrogel dressings are controversial.

3) Efficient control of burn pain requires powerful painkillers (level three on the WHO scale).

4) Morphine is the first choice painkiller in austere environments. Ketamine is an alternative when an anaesthesiologist is present (for protection of the airways, prevention of nightmares and hallucinations).

5) The best route for administration of potent analgesics (ketamine, morphine) is intravenous. Avoid the intramuscular, subcutaneous, oral or sublingual routes, when possible, in burn wounds covering more than 20% TBSA. Burn shock can delay the absorption of the drug, which can result in less efficient pain control, increased risk of many supplementary administrations and, ultimately, enhanced risk of accumulation and worsening of the shock secondary to injuries (burn shock, haemorrhagic shock).

6) The best way to intravenously administer opioids is to titrate the doses according to its effect on the pain with the use of a pain scale (visual analogical scale).

7) Opioids can rapidly cause hyperalgesia. To prevent this, we recommend the combined use of morphine with analgesics acting on other receptors (acetaminophen, tramadol, lidocaine, ketamine, pregabalin, gabapentin, tricyclic antidepressants, N2O).

Figure 8Intrarectal sedation with midazolam 0.3-0.5 mg/kg and ketamine 5-10 mg/kg allows a good level of analgesia and anxiolysis for the debridement of partial thickness burn wounds TBSAb 12% of a young child.

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8) We do not recommend the use of NSAID in burn wounds covering more than 10% of TBSA and/or for any critical trauma victims because of the risk of renal failure, haemorrhagic diathesis and gastro-duodenal ulcerations. NSAID are initially contraindicated for any severely burned patients.

9) Good pain control reduces the incidence of chronic pain, chronic anxiety and depression (PTSD), favours a quicker return to work and swifter healing of the wounds, and provides high troop morale.

10) Blast injuries and burn injuries are very often integrated. Burn pain and phantom limb pain are best prevented by the early use of regional blocks (fascia iliaca, femoral nerve, etc.) or with pregabalin or gabapentin.

6. Involvement of the ENT specialist

Approximately 80% of severely burned casualties sustain burn wounds to the head and neck. Ear cartilage is very prone to infection (chondritis) and requires meticulous local care on a daily basis. It is recommended that burned ears are treated with the application of antiseptic and antibacterial creams once a day, especially using mafenide acetate on open dressings. Destruction of various parts of the nose is also a consequence of thermal injuries.

Infection must be prevented by frequent, gentle local wound care. Nasal intubation, nasogastric tubes and fixation of a nasal endotracheal tube to the nasal septum all predispose the nose and alar cartilages to necrosis. The oral route is thus preferred to avoid the development of pressure necrosis.

Inhaled hot gases will burn the nasopharynx and oropharynx, as well as the larynx. This results in the rapid onset of severe swelling. Airway obstruction quickly ensues and is heralded by the onset of a number of classic symptoms and signs: anxiety, hoarseness, cough, shortness of breath, fatigue and stress. This ultimately leads to hypoxaemia and cardiac arrest. The upper and lower airways must be maintained and protected by a tracheal tube placed through the mouth or via a surgical incision in the neck. Sometimes oral intubation is impossible despite the use of sophisticated devices. The timely intervention of an ENT specialist in performing a tracheostomy can thus be life-saving (Figure 9 A).

Thermal injuries are classically limited to the upper airways. Burn injuries to the trachea and lower respiratory tract are the results of chemical insults. Toxic substances such as acids and alkalis are transported on soot particles to the deepest parts of the lungs. Their irritant effects on the respiratory mucosa produce oedema and sloughing in the bronchi, and pulmonary oedema if they reach the

Figure 9A and 9BA: full thickness burn of the face 24 h post-burn requiring urgent tracheostomy due to upper respiratory distress and failure of tracheal intubation. B: bronchial cast dislodged by bronchial fiberscope from a victim suffering from severe smoke inhalation.

A B

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alveoli. Bronchial casts result from sloughing and haemorrhage (Figure 9 B). In order to prevent respiratory distress, it is necessary to clear the tracheo-bronchial tree from desquamated epithelial debris and clots. Adequate airway management should therefore involve careful pulmonary sanitation using bronchoscopy, incentive spirometry, mobilization and coughing, in addition to the administration of aerosols containing N-acetylcysteine, beta-receptor agonists and heparin (5000 units / 4 h) in humidified, warmed oxygen. Many Belgian burn centres use intermittent percussive ventilation (IPV) to administer the aerosols. The efficacy of this combination has been well demonstrated in smoke inhalation injuries. N-acetylcysteine, a mucolytic agent and antioxidant, should be administered in doses of 300 mg per inhalation aerosol, between three and six times daily, together with or following administration of beta-receptor agonists like salbutamol or fenoterol. The use of beta-receptor agonists in combination with anticholinergic drugs, such as ipratropium, might also be considered.

7. Abbreviations:

ABA: American Burn AssociationABLS: Advanced Burn Life SupportABSI: Abbreviated Burn Severity IndexATLS: Advanced Trauma Life SupportBWC: Burn Wound CentreCBRN: Chemical, Biological, Radiological or NuclearCPR: Cardiopulmonary Resuscitation DCR: Damage Control ResuscitationDCS: Damage Control SurgeryED: Emergency Department EMSB: Emergency Management of Severe BurnsEMS: Emergency Medical ServicesGS: Gastric ResidualM: MortalityMEDEVAC: Medical EvacuationMERT: Medical Emergency Response TeamNMDA: N-Methyl-D-AspartateNSAID: Non-Steroidal Anti-Inflammatory DrugsOR: Operation RoomPEEP: Positive End Expiratory Pressure PHI: Prehospital Interventions PHTLS: Prehospital Trauma Life Support PRIS: Propofol-Related Infusion SyndromePTSD: Post-Traumatic Stress DisorderRF: Risk Factors

TBSAb: Total Body Surface Area burnedTCCC: Tactical Combat Casualty Care USAISR: US Army Institute of Surgical Research WHO: World Health Organization

Annex 1ACauses of burn injuries in hospitalized adults and children at the Brussels BWC, 2014 (N=248).

Annex 1BCauses of burn injuries in children 0-16 years old at the Brussels BWC, 2014 (N = 77).

Annex 1CCauses of burn wounds in the High Care of the Brussels BWC, 2014 (N = 66).

8. Annex 1, 2, 3, 4 and 5

Annex 1

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Annex 2

Burn Centre Admission Criteria (Royal Decree 19 March 2007):1. TBSAb* > 10%: < 10 years or > 49 years2. TBSAb > 20%: 10-49 years3. TBSAb 3° > 5%: all ages4. Burn wounds involving face, hands, feet, joints,

genitals5. Significant burns from chemical or electrical

origins6. Smoke inhalation injuries7. Burn wounds and serious co-morbidities8. Burn wounds and psychosocial history

(including neglected children)9. Burn wounds associated with severe trauma 10. Lyell’s syndrome/toxic epidermal necrolysis

(TEN), SSSS (staphylococcal scalded skin syndrome)

11. Important skin injuries due to trauma or diseases on a TBSAb > 10%

* TBSAb = total body surface area burned

Burn Centre Referral Criteria (from the American Burn Association):A burn centre may treat adults, children or both.Burn injuries that should be referred to a burn centre include:1. Partial thickness burns greater than 10% total

body surface area (TBSA).2. Burns that involve the face, hands, feet,

genitalia, perineum or major joints.3. Third degree burns in any age group.4. Electrical burns, including lightning injury.5. Chemical burns.6. Inhalation injury.7. Burn injury in patients with pre-existing medical

disorders that could complicate management, prolong recovery or affect mortality.

8. Any patient with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality. If the trauma poses the greater immediate risk in such situations, the patient may be initially stabilized in a trauma centre before being transferred to a burn unit. Physician judgment will be necessary in such situations and should be in concert with the regional medical control plan and triage protocols.

9. Burned children in hospitals without qualified personnel or equipment for the care of children.

10. Burn injury in patients who require special social, emotional or rehabilitative intervention.

Excerpted from Guidelines for the Operation of Burn Centers (pp. 79-86), Resources for Optimal Care of the Injured Patient 2006, Committee on Trauma, American College of Surgeons.

Annex 3

Classification of burn wounds according to depth:- First degree- Superficial second degree/partial thickness- Deep second degree/deep partial thickness- Third degree/full thickness- Fourth degree

Classification of burn wounds according to cause:- Fire/Flame- Scald- Contact- Electrical- Chemical- Radiation

The surface area burned:- TBSAb < 15% = moderately severe- TBSAb > 15% but < 40% = severe- TBSAb > 40% = very severe

* TBSAb = total body surface area burned

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Risk factors ScoreSex Woman

Man10

Age 0-2021-4041-6061-8081-100

12345

Smoke inhalation 1Full thickness burn 3° 1

TBSA burned 1-1011-2021-3031-4041-5051-6061-7071-8081-9091-100

12345678910

Score Survival probability(%)< 44-56-78-9

10-11> 11

9998

80-9050-7020-40< 10

Annex 4Abbreviated Burn Severity Index (Tobiasen)

Annex 5

Calculation of the burn surface area with the Rule of Nines and the Rule of the Palm

Annex 5ASurface of the palm = 1% of the TBSA

Annex 5BFor children: Subtract 1% from the head per year over the age of one. Add this 1% to both lower limbs (0.5% per lower limb)10 years old = adult

Annex 4

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20. Fong JJ, Sylvia L, Ruthazer R. Predictors of mortality in patients with suspected propofol infusion syndrome. Crit Care Med. 2008;36(8):2281-2287.

21. Judkins KC. Aeromedical transfer of burned patients: a review with special reference to European civilian practice. Burns. 1988;14(3):171-179.

22. Sullivan SR, Friedrich JB, Engrav LH. “Opioid creep” is real and may be the cause of “fluid creep”? Burns. 2004;30(6):583-590.

Serge JennesBurn Wound CenterQueen Astrid Military HospitalRue Bruyn 11120 BrusselsBelgiumTel.: 0032 2 264 4982Fax: 0032 2 264 4987Email: [email protected]

References

1. The educational committee of the Australian and New Zealand Burn Association Limited ACN 054 089 520. Emergency management of severe burns (EMSB). Course manual. Australian and New Zealand Burn Association Ltd 1996, Albany Creek, 2003.

2. American college of surgeons, committee on trauma. Advanced trauma life support for doctors ATLS® student course manual. 8th ed. American college of surgeons, 633 N. Saint Clair Street Chicago, 2008.

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7. Saffle JR. The phenomenon of “fluid creep” in acute burn resuscitation. J Burn Care Res. 2007;28:382-392.

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10. Joint theater trauma system clinical practice guideline (JTTS CPG). Burn care. Approved 21 Nov 2009. CENTCOM JTTS CPG development, approval, implementation and monitoring. Available at: http://www.usaisr.amedd.army.mil/cpgs.html. Accessed September 20, 2016.

11. Tactical combat casualty care guidelines. 6th Ed. PHTLS, November 2009. Available at: http://rohrmed.com/documents/TCCC.pdf. Accessed September 29, 2016.

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