Which burn fluid resuscitation formula is best? Does it really matter?
What can happen if you over resuscitate? Under?
What can cause an increase or decrease in the demand of fluids?
What can you do if you are running out of Lactated Ringers?
As a Lt. Cmmdr. with the U.S. Navy, Dr. Cairns was on duty and a principle responder to the KAL flight that crashed in 1997 in Guam. Dr. Cairns was instrumental in developing the level of preparedness at the Naval Hospital there which received and managed dozens of critical patients in the morning following the crash of the 747.
Dr. Cairns has served North Carolina as a Burn Trauma Surgeon at the state’s Burn Center at UNC. In 2006, Dr. Cairns was named as the Director of the North Carolina Jaycee Burn Center and is nationally known as a leader in Burn Trauma Care. He is a John Stackhouse Distinguished Professor of Surgery, an Associate Professor of Surgery, Microbiology and Immunology at the University of North Carolina at Chapel Hill School of Medicine.
Be sure to read the Clinical Practice Guideline discussed in this and a prior episode with Dr. Doug Powell. In this episode we will take another look at the CPG from another perspective.
Burn Care Priorities:
If burns occur due to a combat injury treat all life threats as recommended by the CoTCCC first using the SMARCH E PAWS B acronym to assess a casualty and to prioritize treatment.
- S – Security/Shoot Back
- M – Massive Bleeding
- A – Airway
- R – Respirations
- C – Circulation
- H – Hypothermia
- E – Eye Injuries
- P – Pain Control
- A – Antibiotics
- W – Wound Dressing
- S – Splinting
- B – Burn Treatment
As you can see, burn treatment is all the way at the end of the traditional acronym. This could cause confusion as many of the treatments overlap and some are even contraindicated in cases involving only burns as in the case of antibiotics. The following addresses aspects of burn care which may be present in combat injuries and the traditional priorities of combat casualty care.
Safely Stop the burning process! Thermal, electrical or chemical burns can continue to do damage after the a patient is simply removed. This is akin to Security in a combat situation
Massive Bleeding must be controlled immediately with tourniquets or wound packing. Don’t get distracted by an especially large or grotesque burn if both injuries are present.
Photo by DJ Struntz
Airway: Control the airway early while you still can. A ketamine cricothyroidotomy may be a good choice especially in the case of burns to the neck and face.
Respirations: Ensure no other chest injuries are present requiring vented chest seals or needle decompressions and that the patient is breathing normally. If later in the presentation an escharotomy may be indicated to allow for proper expansion of the chest.
Circulation: As other injuries are assessed and addressed, calculate Total Body Surface Area using the rule of 9s or the Lund and Browder Chart if you packed a cheat sheet. Initiate fluid resuscitation with lactated ringers following ISR rule of 10s for burns or whole blood for any hemorrhagic shock.
Hypothermia: Keep the patient even warmer than normal! Covering with silver impregnated dressings along with traditional blankets and hypothermia kits can also help prevent infection later.
The presence of thermal facial burns puts the patient at high risk for exposure keratopathy. Loss of the normal blink reflex, impaired tear production, abnormal tear film dynamics, and incomplete eyelid closure, combined with the inability to relay ocular complaints all contribute to the development of exposure keratopathy and increase the risk for infectious keratitis. Patients with head and facial burns with eyelid involvement are especially prone to entropion (with burned eyelash stubs abrading the cornea) as well as exposure keratopathy from scar-related lid retraction and proptosis from orbital congestion.
-Gentle horizontal taping of lids with hypoallergenic tape in conjunction with ocular surface protection to protect the eyes. Evaluate the eyes and instill a surface protectant at least every 8 hours. Ensure the surface of the eye is not dry, there is no pressure on the eye, pupil reactivity has not changed, and the eyelids are completely closed to protect the eye.
Pain: control should be initiated as soon as feasible.
Antibiotics should be witheld initially unless the patient has concurrent penetrating injuries.
Photo Courtesy: https://iloveyoumonkey.wordpress.com/tag/invanz/
Wound debridement can be considered if the environment and resources permit
Be sure to monitor urine output as detailed in our previous post.
After you listen to Dennis and Dr. Cairns check out our past post with Dr. Doug Powell as he presents the rest of our CPG.
The Advanced Medic Instructors Training program is a collaborative effort between the University of North Carolina, School of Medicine, the University of North Carolina Hospitals both based at Chapel Hill, North Carolina and the United States Army Special Operations Command for Medical Training (USASOM) based at Fort Bragg, North Carolina.
Trained and certified as Nationally Registered Paramedics, these medics have also completed the Advanced Tactical Practitioner program (USSOCOM equivalent certification) with many of the participants having practiced their skills in isolation and in austere settings that include foreign theaters of conflict and peace.
This novel program focuses on furthering the medical training and education of these personnel in the setting of an academic medical center for the purpose of providing professional clinical internship, to obtain necessary clinical observation and hands-on experience from clinical medicine, to trauma and burn trauma management of the critically injured.
Areas of concentration for this program include but are not limited to: the North Carolina Jaycee Burn Center, Burn Center ICU, the Surgical ICU, OR’s for Burn, Trauma and Vascular Surgery, Anesthesia ranging from regional anesthesia to procedural sedation to general anesthesia and general clinical care settings.
This 160-hour program centers around the principles that academic medicine at the University of North Carolina is one of the best teaching environments in the world, and USSOCOM certified Medics are some of the most skilled combat medical personnel in the world. Thus, this program is an extraordinary opportunity for these two leaders to collaborate and further the cause of preparing this group for future missions.
- Develop and enhance skills in clinical assessment and treatment of patients and their families while in the setting of an academic medical center.
- Understand that practice-based learning involves investigation and evaluation of patient care, appraisal and assimilation of scientific evidence, and improvements in patient care.
- Understand anatomy, physiology, pathology and natural history, and the effects they have on body function and their role in effective patient care.
- Describe different etiology and develop definitive treatments.
- Learn to formulate patient care plans based on careful analysis and investigation of clinical presentation.
- Develop a deeper understanding effective patient care plans.
- Demonstrate an awareness of and responsiveness to the larger context and system of healthcare and the ability to call on system resources to provide care that is of optimal value.
- Understand and practice high quality, cost-effective patient care
- Demonstrate knowledge of risk-benefit analysis in patient care plans.
- Demonstrate an understanding of the role of different specialists and other health care professionals in overall patient management.
- Explain the rationale for performance and diagnostic criteria in screening and imaging.
- Learn how to track, document, monitor, and modify patient care plans based on clinical presentations and expected outcomes.
- Demonstrate an ability to collaborate and communicate with other healthcare professionals in managing quality, cost-effective care for patients with complex healthcare needs.
- Understand and develop knowledge and skills in the assessment and treatment of patients in various hospital settings, including but not limited to Burn Center, Surgical Intensive Care Unit, Operating Rooms, Emergency Department, etc.
- Recognize treatments for various etiologies.
- Demonstrate the ability to recognize and initiate treatment of various clinical presentations.
- Observe and participate in patient care alongside other health care providers during various clinical procedures.
Instructors from the United States Army Special Operations Command, at Fort Bragg, North Carolina. These are experienced providers of medical care, who at times are isolated from ancillary support, and providing care in austere and harsh environments in time of war and peace.
Prehospital Providers: Continuing education credits are pending.
Registration and Fees:
Registration is limited to personnel provided by the United States Army and closed to civilian personnel. Individual registration is managed remotely by the United States Army Special Operations Command for Medical Training at Fort Bragg, NC.
The cadre of instructors for this program includes physicians, and other personnel so designated by the University of North Carolina School of Medicine and the University of North Carolina Hospitals.
Program Director: Bruce A. Cairns, MD