TCCC for the military
Published: 29.05.2023

Module 18: Burns

This module discusses the management of burns in the Tactical Field Care (TFC) setting, highlighting your role as a Combat Medic/Corpsman.

Burns

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This module discusses the management of burns in the Tactical Field Care (TFC) setting, highlighting your role as a Combat Medic.

The assessment and management of a burn injury is taught during Combat Lifesaver training, and it is important to understand what their training and anticipated skill set is in order to assume care for the casualty and potentially initiate more advanced treatments.

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There are six cognitive and two performance enabling learning objectives covered in this module.

You will learn how to identify scene safety issues and actions required of a trauma casualty with burns before evaluation and care of the casualty, types and severity of burns, and how to estimate the percentage of the body surface involved in the burn.

You will also be able to identify progressive strategies and limitations for burn management in Tactical Field Care (TFC) as well as how to identify the indications, contraindications, and administration methods of Lactated Ringer's.

The performance objectives involve learning how to apply a dry dressing, demonstrating techniques to prevent heat loss (hypothermia), and initiating burn fluid resuscitation when indicated.

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Remember, you are now in the Tactical Field Care phase of care, so the focus has shifted from immediate life-threatening hemorrhage control while still under enemy fire in the Care Under Fire phase to the reassessment of all previous interventions, followed by the prevention and treatment of other injuries and complications such as burns.

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Burns are part of the “W” in the MARCH PAWS sequence, which stands for wounds.

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Burns can happen during firefights, explosions, or vehicle or aircraft crashes. The source of the burn can be from exposure to electrical, thermal, or chemical events. Each of these different sources has specific management principles both for you and the casualty’s safety and proper casualty treatment.

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Burn wounds are present in 5% to 15% of combat casualties. Although significant advancements in the care of burn casualties have been made in recent conflicts, burn patients still have unique management challenges and considerations. In fact, the combination of burn and non-burn injuries results in a synergistic increase in mortality. This can often be the result of inhalation injury or burn shock superimposed on hemorrhagic shock, making management and treatment decisions critically important.

Loss of the epidermal barrier causes a loss of moisture and fluids, loss of heat, lack of protection from infection, and initiation of an inflammatory process. The U.S. Army Institute of Surgical Research (USAISR) leads burn care efforts for the U.S. Military. They perform cutting-edge research to identify methods and techniques to improve outcomes in military burn casualties.

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A burned casualty is a trauma casualty first. Although the burn wounds can be distracting, you must address all other life-threatening injuries using the MARCH PAWS sequence first. Remember, all trauma treatments can be performed on or through burned skin.

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In an electrical injury, the first thing to do is to secure the power, if possible.

Otherwise, remove the casualty from the electrical source using a non-conductive object, such as a wooden stick. Then, move the casualty to a safe place. Low-voltage injuries such as wall outlets may cause arrhythmias in addition to burns. High-voltage injuries such as high-tension wires may cause deep tissue injury and can result in an explosion which can lead to other blunt trauma injuries.

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Ther­mal injury is the most common burn injury and involves direct damage to the skin and underlying structures by heat or flame. Since the temperature of the heat source and the time of contact with the skin determine the depth of the burn, the first step is to stop the source of the burning. This may entail smothering the flames or removing the casualty from the heat source, but always remember to protect yourself from getting burned while doing this.

Then, to assess and manage the burn, cut the clothing from around the burned area and gently lift it away. If the clothing is stuck to the burn, cut around the edges of the clothing that has adhered to the skin and leave it in place. Do not pull it off the burn. Be sure to avoid grabbing or further damaging burned areas by manipulating them during casualty movements.

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Chemical burns can be caused by many different types of chemicals present in vehicles, machinery, and even some weapons.

An example of a chemical is white phosphorus. It can be found in tank, mortar, and artillery rounds. White phosphorus ignites spontaneously when in contact with air, producing a yellow flame and white smoke in the wound bed.

To prevent continued burning, submerse the affected area in water, if possible.

If submersion is not possible, the dressing must be wet, which can be done by applying a wet barrier, such as water-soaked gauze, clothing, or mud, and covering with an occlusive dressing. Submersing the affected area removes the oxygen supply that causes the burning. Advise all first responders of the presence of a chemical burn. This presents an increased risk to all providers and must be clearly communicated.

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Burns range in severity. Here are visuals to help identify the severity of the burn, based on its depth.

  • Superficial, or first-degree burns, will appear reddened like a sunburn, which is painful and erythematous without blistering or open wounds.
  • Partial-thickness, or second-degree burns, will also appear reddened but may also have blisters.
  • Full-thickness, or third-degree burns, will be dry, stiff, leathery, and variable in color.
  • Subdermal Burns, or fourth-degree burns, extend through the subcutaneous tissue into fascia, muscle, and even bone.

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On the DD Form 1380, the percentage of coverage on the casualty’s body will need to be documented. The Rule of Nines will help with the estimation. The graphic here shows the approximation for each area of the body:

Eleven areas each have 9% body surface area (head, upper extremities, front and backs of lower extremities, and front and back of the torso having two 9% areas each). General guidelines are that the size of the palm of the hand represents approximately 1% of the burned area. When estimating, it is easiest to round up to the nearest 10. If half of the front or rear area is burned, the area would be half of the area value.

For example, if half of the front upper/lower extremity is burned, it would be half of 9%, or 4.5%. If half of the front torso is burned, say either the upper or lower part of the front torso, then it would be half of 18%, or 9%. Remember, the higher the percentage burned, the higher the chance for hypothermia.

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In this example, the areas burned are the left side of the anterior torso, which is 9%, the entire left upper extremity, front and back, which is 9%, and the front of the left lower extremity, which is also 9%. This adds up to a total body surface area burned of 27%. If you are going to use this for estimation of fluid resuscitation, you would round this up to 30%.

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Inhalation injury can cause difficulties with the airway and breathing. Inhalation injury should be suspected if the casualty was in an enclosed space such as a vehicle, a building, or a burning compartment in a ship at sea. Clinical exam findings suggestive of inhalation injury include facial burns, carbonaceous sputum, stridor, hoarseness, or cough. In these patients, special attention must be paid to the airway.

Facial burns, especially those that occur in closed spaces, may be associated with inhalation injury. Aggressively monitor airway status and oxygen saturation in such patients and consider early surgical airway for respiratory distress or oxygen desaturation.

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Inhalation injury can quickly compromise the airway due to edema and you must be ready for early intervention and possibly the need for an advanced airway. They may require a surgical airway to bypass the edema of the upper airway and oropharynx. These casualties should be monitored closely for potential airway issues. Do not place an NPA or extra-glottic in a casualty with signs of inhalation injury, as a surgical airway should be performed for signs of airway compromise in a burn casualty.

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All TCCC procedures can be performed on or through burned skin in a burn casualty. Remove all watches and jewelry from the burned area so they don’t cause constriction when swelling occurs. Cover the burned area with a dry, sterile dressing, if possible. For extensive burns (>20%), consider placing the casualty in the Heat-Reflective Shell or Blizzard Survival Blanket from the Hypothermia Prevention Kit in order to both cover the burned areas and prevent hypothermia.

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TAKE EARLY and aggressive steps to prevent further body heat loss.

Always be mindful of burns along with massive bleeding. Ensure bleeding is controlled first.

Burn patients are particularly susceptible to hypothermia. Extra emphasis should be placed on barrier heat loss prevention methods. Keep casualties off the ground and onto an insulated surface as soon as possible.

For extensive burns, those with >20% of the area burned, consider placing the casualty in the vapor barrier shell to cover the burned areas and prevent hypothermia.

Regardless of ambient temperature in the environment, actively prevent/manage hypothermia for burn patients using these methods.

Be mindful of warm weather and cool weather interventions. The addition of blood loss can cause the body’s temperature to drop even when it is hot outside. Never cover a tourniquet; keep it visible so medical personnel can easily see it.

Analgesia may be administered to treat burn pain. Antibiotic therapy is not indicated solely for burns but should be given to prevent infection in penetrating wounds.

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Fluid resuscitation for burn casualties is guided by the USAISR Rule of Ten. For burns > 20% TBSA, initiate fluid resuscitation as soon as IV/IO access is established.

REMEMBER: If hemorrhagic shock is also present, resuscitation for hemorrhagic shock takes precedence over resuscitation for burn shock.

Використовуйте лактат Рінгера, фізіологічний розчин або 6% розчин гідроксиетилкрохмалю.

Use Lactated Ringer’s, normal saline, or Hextend®. If Hextend is used, no more than 1000 ml should be given, followed by Lactated Ringer’s or normal saline as needed.

The initial IV/IO fluid rate is the %TBSA x 10 ml/hr for adults weighing 40-80 kg. For every 10 kg above 80 kg, increase the initial rate by 100 ml/hr.

Consider using oral fluids for burns up to 30% TBSA if the casualty is conscious and able to swallow.

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PDF Burn Dressing Skills Card

Burn Dressing

Read pdf

In this module, we discussed burn care.

We identified the treatment priorities in trauma and burn casualties and the special airway considerations in burn casualties with inhalation injuries.

We addressed the causes of burns and how to know the types of burns by severity and how to estimate the body surface area affected by a burn.

We also demonstrated estimating burn size with the Rule of Nines and how to calculate fluid resuscitation requirements with the USAISR Rule of Ten.

In addition, we demonstrated the application of a burn dressing and techniques to prevent heat loss in a burn trauma casualty.

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To close out this module, check your learning with the questions below (answers under the image).

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Check on learning

Answers

What kind of dressing should be placed on burned areas?

A dry sterile dressing

What should you do first when you encounter a casualty with an electrical burn?

Secure the power, if possible; otherwise, remove the casualty from the electrical source using a nonconductive object, such as a wooden stick.

What should you do first when you encounter a casualty with a thermal burn?

Stop the source of the burn

What size burn requires a fluid resuscitation?

For burns > 20% TBSA, initiate fluid resuscitation as soon as IV/IO access is established.

What would be the fluid infusion rate for a 90 kg person with a 40% burn according to the USAISR Rule of Ten?

500ml/hr. The initial IV/IO fluid rate is the %TBSA x 10 ml/hr for adults weighing 40-80 kg. For every 10 kg above 80 kg, increase the initial rate by 100 ml/hr. 40% x 10 ml/hr = 400ml/hr 400ml/hr + 100ml/hr = 500ml/hr

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