BENT 2016 12 Suppl 261 107126 - PDF document

B-ENT, 2016, 12, Suppl. 26/1, 107-126 The most common causes of burn injuries are �ames 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 their treatment and evolution are sometimes more peculiar. Lessons learned from recent ongoing armed con�icts, for example in Afghanistan and Iraq, should improve the management of war-related burn injuries in austere environments. Recent con�icts produced many burn casualties (5-The WHO estimates that 300,000 persons die around the world each year from �red-related burn injuries. The incidence of burn injury is higher in low- and middle-income countries. In Europe, the the high-income group and 4.5 in the low-income 08-jennes-.indd 107 2/11/16 14:17 108S. Jennes 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 �gure on the life expectancy of this category of = age + TBSAb + 17 (if If Baux: 100, mortality (M): 25 %; if Baux: 140, Tobiasen abbreviated burn severity index If ABSI &#x 1%;;&#x if ;T.6;ABSI 1&#x 1%;;&#x if ;T.6;1, 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 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 for (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 �rst 96 h injuries and amputations. In addition, the (burn) wounds arising on Middle Eastern battle�elds 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 battle�eld 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-By de�nition, the seriously burned patient, or a patient with major burns, presents a burned area, or otherwise ful�ls one of the admission criteria to a burn wound centre (Annex 2). Burns can be classi�ed 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 Burns of more than 40% TBSAb are the most serious, as they can result in the death even of physically �t soldiers. The prognosis for patients with patients 40% TBSAb is often guarded, especially in the elderly patients ( 60 years) or if associated with severe are limited to the epidermis. They are painful and erythematous.superficial second degree or partial thickness burnsThese 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. are deeper than the skin, involving the underlying structures such as fascia, muscle and bones. Table 1 08-jennes-.indd 108 2/11/16 14:17 Prehospital and in-hospital interventions through a poultice effect. Rings and chains should Check vital ABC functions:Check vital ABC (airway, breathing, circulation) functions and administer oxygen (this is vital in the case of victims of enclosed �res and in the case of Cool the burn wounds as quickly as possible 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 �owing 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%, �ve minutes of cooling is suf�cient. 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 �ve 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 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 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 In-hospital or in-the-air management, during If the medical team is the �rst 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 in�ammable or toxic products (e.g., fuel tanks), lethal fumes or potential building collapse. If the �re�ghters have already arrived before the medical assistance, the chief �re�ghter 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. At the point of injury or in its immediate vicinity, witnesses or parents will condu

ct �rst aid. The call for medical assistance is the �rst 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 speci�c acts of �rst aid are:If the clothes are burning, the �re should be extinguished by rolling the victim on the ground, soaking him with water (see “cooling”). The victim will not be helped if the �rst-aid workers also burn themselves. It is therefore important that the act of extinguishing the �re takes place without further injury to the helpers. Carbonized clothes that of heat energy ought to be removed as quickly as possible, provided they are not �xed 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 08-jennes-.indd 109 2/11/16 14:17 110S. Jennes 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 �uid 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 If haemorrhagic shock is also present, resuscitation for haemorrhagic shock takes Medical assistanceThe algorithms used by the EMSB or ATLS courses –ABCDEF or ABCDE, respectivelyapplied 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 �ngers, Wallace’s Rule of Nines and the Lund and Browder diagram. This initial evaluation is extremely important when determining the necessary rate of �uid 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 dif�cult and often incorrect when the person treating these burns is an inexperienced clinician. Substantial errors in estimating burn extent result in signi�cant undercalculation or overcalculation of �uid Evaluation of depth: distinctions must be drawn between burned and non-burned areas, wounded and healthy (or very super�cially damaged) skin (�rst degree burns

should never be included in the assessment of the burned surface , open subcutaneous tissues (or masked by blisters) and intact skin.is �rst 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, speci�cally, need direct copious irrigation to avoid scarring. Such irrigation is only effective when performed accident. Further decontamination can be carried out under local anaesthesia in the ED. Care must be taken to ensure the ef�uent 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 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 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 Elevate burned areas:Evaluate burned areas in order to prevent oedema The burn wound should be left untreated but covered wrap or cling �lm. 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 Tactical combat casualty combat care guide-The basic management of a burn casualty under �re Facial burns: be aware of inhalation injuries, especially those that occur in closed spaces. 08-jennes-.indd 110 2/11/16 14:17 Prehospital and in-hospital interventions the means of transport. This is of vital importance in determining the likelihood of survival in severe 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. Venous 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 suf�cient 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 intraosseous needle. In such a case, femoral venous punctur

e 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 Fluid resuscitation should be initiated as soon 15% in an adult or over 10% in a child. On the battle�eld and in mass burn casualty disasters, evaluation and treatment can be life-saving. 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 lesions are masked or concealed. Patients with minor burns and an associated lesion usually fall into the �rst category. However, it is not unusual to miss a life-threatening problem in a victim with 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 traf�c accidents (especially those of high velocity or associated with ejection), explosions, electrocutions, jumps (e.g., jumping from a window) or falls. The for patients unable to give a history due to unconsciousness, intubation, psychiatric disturbance, intoxication or drugs in�uence.All of these patients should be considered as potentially polytraumatized or poly-injured and managed as such (Figure 1). This �rst 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, �rst lumbar vertebra fracture/ ABA 08-jennes-.indd 111 2/11/16 14:17 112S. 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 hr post-burn). However, in the case of shock that is dif�cult to manage, or in the absence of crystalloid, an albumin-containing solution or even fresh frozen plasma (FFP) can be In the absence of LR (Hartmann®), other balanced crystalloids such as Plasmalyte® (from Baxter) or 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 �rst choice during the 昀

69;rst 4-8 h post- a greater burn size – 20-25% TBSAb – could be acceptable. Before arriving at hospital, it is often dif�cult to precisely determine �uid requirements using resuscitation formulae such as that from In order to compensate for this dif�culty, 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 speci�c 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 children) TBSAb 20%, start IV/IO �uid with LR at a rate of %TBSAb x 10 cc/h for adults weighing 40-80 kg, and for every 10 Prehospital and in the EDLR at a rate of 10 ml/kg/h if TBSAb < 50%LR at a rate of 20 ml/kg/h if TBSAb > 50%LR: 3 ml/kg/h over 24 h with half over the first 8 h and Albumin 20% or 4%: 0.75-1 g/kg over 24 h from the 6Haemodynamic goals of fluid resuscitation (in order to 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 2LR: lactated Ringer’s solution; HR: heart rate; MAP: mean arterial pressure; CVP: central venous pressure; UO: urinary Table 3LR: lactated Ringer’s solution; HR: heart rate; MAP: mean arterial pressure; CVP: central venous pressure; UO: urinary Prehospital and in the EDLR at a rate of 10 ml/kg/h if TBSAb < 50%LR at a rate of 20 ml/kg/h if TBSAb > 50%LR: 3 ml/kg/h over 24 h with half over the first 8 h and LR-glucose 5%: 100 ml/kg/d (0-10 kg), 50 ml/kg/d Albumin 20% or 4%: 0.75-1 g/kg over 24h from the 6Haemodynamic goals of fluid resuscitationHR > 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%25%if CVP 10 cmH2O: start dobutamine for a ScvO2 > 65% 08-jennes-.indd 112 2/11/16 14:17 Prehospital and in-hospital interventions 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 fentan

yl (1-3 µg/kg) or with ketamine alone (1-2 mg/kg). The disadvantage of etomidate as an cortisol secretion, so necessary at times of shock and intense stress. Succinylcholine can be used without danger of life-threatening hyperkalaemia within the �rst 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 ()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 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 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 re�ex) during transport and reduce the risks of accidental or auto-extubation. Modern myorelaxants show few undesirable The crucial element in �uid resuscitation is the time at which it is started. This should be within the �rst 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 In the context of a �re 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 P�zer company), 5 g in adults or 7

0 mg/kg in children, is an antidote that has been long recognized, but was only approved by the FDA on 15 December 2006A high dose of vitamin C could Electrical burns caused by high voltage currents pose a particular risk of hidden injuries. The �uid volumes calculated according to the burned zones only at the points of entry and exit underestimate the real �uid requirements. The calculated �uid requirements should thus be increased by 50% or calculated on the basis of 8-12 ml/kg/%TBSAb during the �rst day. The risk of acute renal failure Respiratory resuscitationSystematic oxygen therapy at high oxygen concentrations is justi�ed 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 �re is CO intoxication. Tracheal intubation and mechanical ventilation are indicated in patients with extensive burn injuries intoxication.( 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 dif�cult circumstances, and may even demand emergency tracheotomy in equally challenging 08-jennes-.indd 113 2/11/16 14:17 114S. Jennes evaluate pulmonary compliance by observing insuf�ation pressures and tidal volumes. If frank ischaemia develops, an escharotomy is indicated in order to avoid necrosis, ventilatory dif�culties 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 dif�culties ( 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 (�rst-generation cephalosporin). Third degree circumferential cervical burn wounds require escharotomies at both lateral sides to reduce the risk of intracranial hypertension caused by an 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 hypothermia. A comfortable ambient temperature for a burned patient lies betw

een 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 �uids Ambulance, helicopter and plane are all recognized means of transport for burns victims: ambulance for short distances ()helicopter for medium ranges (100 – 400 km) and &#x 100;&#x km;;&#x 000;plane for long haul ( 400 km). Helicopter transport has not shown any bene�t 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 traf�c 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, dif�cult driving conditions due to heavy traf�c, the need for a specialized medical effects. Cisatracurium and rocuronium are very Propofol is not advised during the �rst 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 rhabdomyolysis. These features inevitably lead to death even in young patients. This complication is known as the propofol-related infusion syndrome anaesthesia and for facilitating endotracheal intubation. Anaesthesia of the burned patient in the early phase of hypovolemic, distributive and cardiac shock is a dif�cult undertaking. If it is badly managed, it leads to worsening of the shock state and an increase in �uid administration (�uid creep).The development of abdominal compartment 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 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 steroidal anti-in�ammatory drugs (NSAID) are contraindicated in severe burns within the �rst 48 h due to the increased risk of renal failure and gastric Every deep circular burn of the neck, a limb or of the trunk should be appraise

d speci�cally: locate arterial pulses, assess capillary re�ll, observe the plethysmographic curve on a pulse oximeter, determine skin sensibility and temperature, 08-jennes-.indd 114 2/11/16 14:17 Prehospital and in-hospital interventions 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 con�icts and publications in the specialized literature, this 1-2-4 rule is subject to discussion. Today, we increasingly Advanced �rst aid and life-saving emergency procedures, more speci�cally bleeding and airway control, should be performed within the �rst 10 mins after injury by trained and equipped non-medical �rst responders; these are the so-called 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 Strategic evacuation for coalition casualties to a Role 4 hospital must be performed by well-trained caregivers – ideally by a burn team comprising 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 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 �ight or in the minutes following landing. In-�ight 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 Which means of transport to the military Two principles that have a profound impact on morbidity and mortality are the continuity of care Figure 2A and 2BCase of a severely burned victim (TBSAb 60%) with three associated lesions: right renal contusion, �rst lumbar vertebra fracture/displacement with compression of the

cauda equina (A) and pelvis fracture (B). He jumped from the second �oor. Figure 3In the current operating theatre, rotary wing assets are essential 08-jennes-.indd 115 2/11/16 14:17 116S. Jennes deteriorating gas exchange and deepening of the compartment syndrome and central neurological ischaemia that will singularly worsen the prognosis Avoid insuf�cient 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: MAPdelayed 60-70 mmHg (aim for higher values in hypertensive patients); HR 140/min (80-140/minUO between 0.3-1 ml/kg/h; CVP between 1-10 cmHO (for PEEP ≤ 5 CI > 2.5 L/min. m²; SVV < 15; ScvO2 > (jugular-subclavian catheter); SvO2 > 60-The laboratory goals of resuscitation in burn shock are: albumin above 2.0 and below 2.5 g/dl; lactic acid &#x 3 m;&#xmoL/;&#xL; 0;&#x.700;BE -4; Hct (In order to attain these objectives, volume loading should be achieved with LR (Hartmann®) 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 order 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 . The best “window” for evacuation should be de�ned or individualized: should the victim be evacuated during burn shock? Transporting unstable patients during the �rst 24 h may be dangerous, but after 72 h may be too late (for large TBSAb there is injury, or both).Sometimes an unstable patient will be evacuated because one cannot provide appropriate treatment on the �eld (e.g., evacuation for haemo�ltration or Evacuation strategies can vary from war to war. care will tend to become even more unstable. Evacuation to expert care, even for unstable Intensive care aspects3.1.1.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 Avoid excessive �uid resuscitation (�uid 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. 08-jennes-.indd 116 2/11/16 14:17 Prehospital and in-hospital interventions Early septic shock and in this case start The seriously burned patien

t is polytraumatized and should undergo a primary and secondary evaluation that is as exhaustive as for any multitrauma patient – such as those of road traf�c 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, contraindicated for use in burns and septic shock by the company Fresenius itself) and glucose. These various treatments have no place in the resuscitation Remember to use fast track enteral nutrition at a (GR) 8 h post-burn. If the traf�c GR 100 ml, begin Do not forget to perform suf�ciently 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% After the resuscitation deep phase ( 48-72 h)Satisfactory tissue perfusion, especially Satisfactory haemostasis by infusion of platelets (platelet nadir around the fourth day), FFP if APTT and/or PT is prolonged, red cell 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.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 re�ex delay in gastric emptying is related to ml/kg/h in children. If the CVP exceeds 8-10 cmH(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)No propofol infusion during the �rst 48-96 h! Propofol is not advised during the �rst 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 If shock persists in spite of adequate �lling and inotropic/vasoconstrictor support, think about the Adrenal insuf�ciency (transitory depression by admin

istration of etomidate), which calls for the administration of hydrocortisone (50 mg / 6 h or Cyanide poisoning, which calls for treatment with hydroxocobalamin (Cyanokit®) – 5g IV for Undetected passive smoke inhalation, occurring very frequently in the seriously burned, which increases the patient’s �uid requirements by 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 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 Vitamin de�ciency, notably thiamine – upon admission vitamins should always be administered haemorrhagic, obstructive (cardiac tamponade, tension pneumothorax, massive pulmonary 08-jennes-.indd 117 2/11/16 14:17 118S. Jennes 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 �ora, 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 signi�es 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 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 Resort to avulsion (Figures 2,7B) instead of tangential excision (Figure 5) – avulsion has the advantage of reducing bleeding and autografts stress and the opioid treatment of pain. The horizontal position of the patient facilitates gastroesophageal re�ux. The preventive administration of prokinetic drugs is recommended during the evacuation of the patient, as is the semi-sitting position (30°). Enteral feeding shou

ld be started at a rate of 20 ml/h during the �rst day and progressively increased by 100% enteral feeding solutions that are rich in protein and calories (1.5 kcal/ml). Stop enteral nutrition position for a lengthy period of time (bath or surgical operation) to prevent the risk of aspiration Topical antibacterialsThe role of topical antibacterials in the �ght 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 We are of the opinion that a thick layer should 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 in�uenced by the bacterial �ora that colonize or infect the burn wounds Table 4). Bathing frequency plays a crucial role in the �ght 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 antibacterialsZones of applicationFlamazine® silver sulfadiazineMost frequently used during the first weekCerium and silver sulfadiazine All deep second and third degree wounds that will not be Isobetadine® povidone iodine1x/other dayReserved for allograft and autograft sitesMafenide acid Sulfamylon® 1x/other dayIf wound is infected with Gram-positive organismsTable 4 08-jennes-.indd 118 2/11/16 14:17 Prehospital and in-hospital interventions Use grafting techniques resistant to infection (e.g., Meek-Wall). No full-skin (unmeshed) grafts, even over the tracheotomy site and sites for venous Meshing 2:1 or 3:1, coupled with a sandwich Limit excision to no more than 20% TBSAb in 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 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 08-jennes-.indd 119 2/11/16 14:17 120S. Jennes Swabs and cultures (nose, throat, sputum, burn 11.WeightLR: lactated Ringer’s solution; UO: urinary output; IV: intravenous; PPI: proton pump inhibitor; SC: subcutaneous; AB: antibiotic; LMWH: low LR for UO between 0.3-0.5 ml/kg/h (adults); Vitamins and trace elementsPPI IV, LMWH, analgosedationInotropes/vasopressors for MAP > 65 mmHgKetamine IV for wound careWeight (increase in weight

of 5-40% of body Enteral feeding 60 ml/h (1.5 L / 24 h)Albumin 20% to maintain albumin / 24 h) 2.0 g/dl Vitamins and trace elementsPPI IV, LMWH, analgesia, sedationNorepinephrine for MAP > 65 mmHgReturn to admission weight between day seven Targeted antibiotic therapyAcute medical and surgical treatment of major burns:O2, physiotherapy, tracheal intubation, Escharotomy, fasciotomyTetanus prophylaxis Preparation for the reception of a seriously burned patient in the emergency room or any other resuscitation area:ETT, Ventilator, CVC, AC, NGT, BC, TM, EP, # dobutamine, # norepinephrine, # epinephrineCyanoKit®, Tevax®, Tetaglobuline®Material for burn wound care (gauze swabs, Labs: complete screen including Hb, arterial blood gas, lactate, HbCO, alcohol, urine RX thorax, Echo-Doppler ultrasonic scan, full-body CT scan11.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.LR 3 ml/kg/%TBSAb (50% administered in the �rst 8 h; 50% administered in the remaining 16 h for UO between 0.3-0.5 ml/kg/h (adult) or Vitamins and trace elements IVAlbumin 20% from sixth hour (0.75 g/kg / 24 h Enteral nutrition: start at 20 ml/hr (paediatrics: PPI IV, AB (if soiled wounds, septic shock, purulent expectoration, immune system If smoke, aerosols inhalation: bronchodilators, Dobutamine and/or norepinephrine to counteract hypotension associated with Hydrocortisone 50 mg / 6-8 h if etomidate used, or if potential Addison’s disease 08-jennes-.indd 120 2/11/16 14:17 Prehospital and in-hospital interventionsFailure to provide adequate pain relief is one of the pitfalls of the treatment of burn victims. Burn pain can be classi�ed as post-traumatic pain. Even in the century, the treatment of burn pain remains a challenge to modern medicine because of the high intensity of pain (Vthe AS 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 dif�cult to control even 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 hypermetabolism and promotes swifter healing of Isolate/insulate the wound from the ambient air The best ro

ute 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 ef�cient pain control, increased risk of many supplementary administrations and, ultimately, enhanced risk of accumulation and worsening haemorrhagic shock). Opioids can promote the �uid should be administered for burn wounds greater than 10% TBSA during the �rst two days because of the risk of acute kidney injury and gastro-duodenal 2) The �rst steps in the management of burn pain are: stop the burning process, irrigate the wound with running water if possible (for cooling) and objects or circulating air (cling wrap, humid non-adherent dressing and antimicrobial creams). 3) Ef�cient control of burn pain requires powerful painkillers (level three on the WHO scale).4) Morphine is the �rst choice painkiller in austere environments. Ketamine is an alternative when an anaesthesiologist is present (for protection of the airways, prevention of nightmares and 5) The best route for administration of potent 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 ef�cient pain control, increased risk of many supplementary administrations and, ultimately, enhanced risk of accumulation and worsening haemorrhagic shock).6) The best way to intravenously administer opioids is to titrate the doses according to its effect 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, 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 08-jennes-.indd 121 2/11/16 14:17 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 often integrated. Burn pain and phantom limb pain blocks (fascia iliaca, femoral nerve, etc.) or with pregabalin or gabapentin.Approximately 80% of severely

burned casualties 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 the nose is also a consequence of thermal injuries. wound care. Nasal intubation, nasogastric tubes and �xation 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 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 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 08-jennes-.indd 122 2/11/16 14:17 Prehospital and in-hospital interventionsalveoli. Bronchial casts result from sloughing and haemorrhage (Figure 9 B). In order to prevent bronchial tree from desquamated epithelial debris and clots. Adequate airway management should therefore involve careful pulmonary sanitation using bronchoscopy, incentive spirometry, mobilization of aerosols containing N-acetylcysteine, beta-receptor agonists and heparin (5000 units / 4 h) in humidi�ed, warmed oxygen. Many Belgian burn centres use intermittent percussive ventilation (IPV) to administer the aerosols. The ef�cacy 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, ABA: American Burn AssociationABLS: Advanced

Burn Life SupportABSI: Abbreviated Burn Severity IndexATLS: Advanced Trauma Life SupportBWC: Burn Wound CentreCBRN: Chemical, Biological, Radiological or DCS: Damage Control SurgeryED: Emergency Department EMSB: Emergency Management of Severe BurnsEMS: Emergency Medical ServicesMEDEVAC: Medical EvacuationMERT: Medical Emergency Response TeamNSAID: Non-Steroidal Anti-In�ammatory DrugsPHTLS: Prehospital Trauma Life Support PTSD: Post-Traumatic Stress DisorderTBSAb: Total Body Surface Area burnedTCCC: Tactical Combat Casualty Care USAISR: US Army Institute of Surgical Research WHO: World Health Organization Causes of burn injuries in hospitalized adults and children at the Causes of burn injuries in children 0-16 years old at the Brussels Annex 1 08-jennes-.indd 123 2/11/16 14:17 Annex 2Burn Centre Admission Criteria (Royal Decree 19 Signi�cant burns from chemical or electrical Burn wounds and psychosocial history Lyell’s syndrome/toxic epidermal necrolysis (TEN), SSSS (staphylococcal scalded skin 11.Important skin injuries due to trauma or diseases on a electrical TBSAb 10%* TBSAb = total body surface area burnedBurn Centre Referral Criteria (from the American A burn centre may treat adults, children or both.Burn injuries that should be referred to a burn centre include:Partial thickness burns greater than 10% total Burns that involve the face, hands, feet, Electrical burns, including lightning injury.Inhalation injury.Burn injury in patients with pre-existing medical disorders that could complicate management, prolong recovery or affect mortality.Any patient with burns and concomitant trauma 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 Burned children in hospitals without quali�ed personnel or equipment for the care of children.Burn injury in patients who require special Care of the Injured Patient 2006, Committee on Trauma, American College of Surgeons.Annex 3Classification of burn wounds according to depth:Classification of burn wounds according to cause:The surface area burned:* TBSAb = total body surface area burned 08-jennes-.indd 124 2/11/16 14:17 Prehospital and in-hospital interventions Risk factorsFull thickness burn 3° Abbreviated Burn Severity Index (Tobiasen)Annex 5Calculation of the burn surface area with the Rule of Surface of the palm = 1% of the TBSA For 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) 08-jennes-.indd 125 2/11/16 14:17 126S. Jennes . Emer

g Med J.2004;21(1):112-114.Latenser BA. Critical care of the burn patient: The �rst 48 Crit Care Med.Warden GD. Burn shock resuscitationWorld J Surg.Mitra B, Fitzgerald M, Cameron P. Fluid resuscitation in ANZ J SurgMyburgh JA, Finfer S, Bellomo R, Billot L, Cass A, Gattas D. Hydroxyethyl starch or saline for �uid resuscitation in ;367(20):1901-1911.Tanaka H, Matsuda. Reduction of resuscitative �uid volumes in severely burned patients using ascorbic acid administration: a randomized, prospective study. Arch Sur. Ciof� WG. Inhalation injury. In: Barry B. Ed. Burn care and therapy. Mosby, St Louis, 1998: 36-59.Parke TJ, Stevens JE, Rice AS, Greeenaway CL, Bray RJ, Smith PJ, Waldmann CS, Verghese C. Metabolic acidosis and fatal myocardial failure after propofol infusion in children: �ve case reports. 1992;305(6854):613-616.Fong JJ, Sylvia L, Ruthazer R. Predictors of mortality in Care Med. Judkins KC. Aeromedical transfer of burned patients: a review with special reference to European civilian practice. Sullivan SR, Friedrich JB, Engrav LH. “Opioid creep” is real and may be the cause of “�uid creep”Serge JennesBurn Wound CenterQueen Astrid Military Hospital1120 BrusselsTel.: 0032 2 264 4982Serge.jennes@mil.beThe educational committee of the Australian and New Zealand Burn Association Limited ACN 054 089 520. Emergency management of severe burns (EMSB).manual. Australian and New Zealand Burn Association Ltd 1996, Albany Creek, 2003.American college of surgeons, committee on trauma. Advanced trauma life support for doctors ATLS®. American college of surgeons, 633 A WHO plan for burn prevention and careWorld Health Organization, Geneva, 2008. Available at: http://www.who.int/violence_injury_prevention. Accessed September 20, 2016.American Burn Association. National burn repository, report of data from 2002-2011. Chicago 2012. Available at: http://www.ameriburn.org/2012NBRAnnualReport.pdf. Friedrich JB, Sullivan SR, Engrav LH, Round KA, Blayney CB, Carrougher GJ, Heimbach DM, Honari S, Klein MB, Saf�e JR. The phenomenon of “�uid creep” in acute burn J Burn Care Res.Osler T, Glance LG, Hosmer DW. Simpli�ed estimates of the probability of death after burn injuries: extending and J Trauma. Tobiasen J, Hiebert JM, Edlich RF. The abbreviated burn Ann Emerg Med.Joint theater trauma system clinical practice guideline (JTTS 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. 6 Ed. PHTLS, November 2009. Available at: http://rohrmed.com/documents/TCCC.pdf. Accessed September 29, 2016. 08-jennes-.indd 126 2/1