Field Management of Burns
Lieutenant Colonel Curtis P. Artz, MC, USA
During the period from February 13, 1953, to August 1, 1953, seven burned patients were studied at the 46th Surgical Hospital in Korea. Several burned patients were seen in other hospitals; and conferences were held with various medical officers in the theater concerning their experiences in the management of burns in the field. Two conferences were held with the physicians in charge of the Burn Ward at the Tokyo Army Hospital.
Of the seven burned patients treated at the 46th Surgical Hospital, two had 30 percent full- thickness injury, with 5 or more percent partial-thickness burn. Both patients with full-thickness burns were injured from gas stove explosions. With the exception of the face, which was exposed, these patients were treated with the Universal Protective Dressing. They received initial fluid replacement therapy at the 46th Surgical Hospital and were in good condition when evacuated. On the eighth day following injury, one of these patients was admitted to the Burn Study Ward at Brooke Army Hospital; his initial dressings and experimental hand splints were in place. The other patient was admitted to Brooke Army Hospital on the 11th day following injury; but all of his dressings had been changed except those on his hands where experimental hand splints were in place. Follow-up study on these two patients showed that they withstood evacuation to the United States quite well, and the experimental splints had held the hands in good position.
When one patient accidentally stepped in front of a flame thrower, he experienced a 95 percent, full-thickness burn. He expired 8 hours after admission to the hospital.
Four patients sustained 10 to 15 percent full-thickness burns of various parts of the body. Comparison of the use of the exposure method and the Universal Protective Dressing showed that healing occurred at the same rate in these patients. However, patients in the field hospital stated that the dressed areas were more comfortable than the exposed areas. These patients were treated during the late winter months, and they complained of a moderate amount of cold and discomfort in the exposed areas. It was observed that these patients could be moved more easily when dressings were in place. On the other hand, good results were obtained by the exposure method; and this type of therapy is feasible in a field hospital.
The Universal Protective Dressing proved to be of considerable value. On July 21, 1953, an evaluation report on its use was sent to the Surgeon of the 8th United States Army. Various items in this report are listed below.
1. During the period from February 1953 to July 1953, the 46th Surgical Hospital used 100 Universal Protective Dressings.
2. A few of these 100 dressings were used on five patients who had suffered severe burns; and the others were used on patients with large wounds of the extremities.
3. Several follow-up questionnaires were completed and inserted into the patients` charts at the time of evacuation.
4. It was observed that the Universal Protective Dressing was most efficacious in the management of burns. It did not soak through for several days. It was pliable and could be molded to the affected part. The thickness of the present dressing appeared to be adequate. A thicker dressing would be less desirable because it would be more difficult to apply evenly; and it could not be used to exert an even pressure. The two sizes in use at present appear to be satisfactory (22 x 36 inches, and 22 x 16 inches).
5. Most of the dressings were applied over large wounds of the extremities or over multiple wounds of the extremities. A great deal of time is saved in the application of this type of dressing. It is absorptive and serves to splint the affected part. It proved to be useful in the early management of wounds in a forward surgical unit.
6. Packaging of the Universal Protective Dressing is satisfactory. However, the roll of bandage is not satisfactory because it has insufficient elasticity. A chemically crinkled bandage would be desirable. The package should also include four rolls of bandage with the 22 x 36 inch dressing.
7. Universal Protective Dressings are of great advantage, since they afford considerable saving of time. They should be made available to all medical installations in forward areas.
Prior to their admission to the surgical hospital, all burned patients had had their wounds débrided. In most instances, the wounds had been washed with soap arid water and some type of covering had been applied. This treatment appeared to be satisfactory, since the burned surfaces had been cleansed thoroughly, devitalized tissue had been removed, and dressings had been applied to wounded areas. As evacuation time in the case of most burned patients was between 2 and 4 hours, it appears that some type of clean covering is necessary before a patient is transported to an installation where more definitive therapy may be carried out. It is imperative that original dressings be removed in order that physicians who are responsible for replacement therapy can estimate the severity of injuries.
Suggestions for the Management of Burns in the Field
At the Battalion Aid Station
The patient suffering from discomfort should be given morphine intravenously; and he should also be given dextran. If dextran is not available, saline solution should be started. The burned area should be covered with some type of dry, sterile dressing if it is available. For this initial cover of the injured area, a Universal Protective Dressing is ideal, since it affords a good splint during the period of transportation. It is unnecessary to cover burns of the face. A burned patient should be evacuated to a clearing station or a surgical hospital. At a clearing station, all burned patients should receive fluid replacement therapy and definitive local care; then they should be removed to an evacuation hospital 48 hours later. If the chain of evacuation is from the clearing station to the surgical hospital and thence to the evacuation hospital, it would seem wise to perform definitive local care and fluid replacement therapy at the surgical hospital.
At the Clearing Station or Surgical Hospital
All dressings should be removed as soon as the patient arrives, and the general status of the patient and extent of injury should be evaluated. Fluid replacement therapy should take precedence over local care. A catheter should be placed in the bladder and a cannula inserted in a vein in patients whose burns involve more than 20 percent of their body surface.
Replacement Therapy. Fluid replacement therapy should be estimated in accordance with the percentage of body surface burned and the size of the patient. Adequacy of this therapy and rate of administration of fluids should be governed by the output of urine which should be kept at from 30 to 50 cc. per hour. Fluid therapy may be estimated by the method outlined in Tables 1 and 2.
In general, the colloid requirements can be met in large, full-thickness burns with a ratio of 1 unit (500 cc.) of dextran to 2 or 3 units of blood. In partial-thickness burns, dextran should be used primarily for colloid replacement.
A rapid, easy method of estimating the amount of fluid required is by the use of the fluid calculator prepared by the Surgical Research Unit at Brooke Army Medical Center (Fig. 1). This calculator should be available in all clearing stations and surgical hospitals.
Patients who have sustained burns of less than 20 percent of their body surface may be resuscitated with oral fluids. A well refrigerated, salt-soda. solution containing 3 gm. of sodium chloride and 1.5 gm. of sodium bicarbonate per liter is well tolerated. This solution should be administered for 2 days.
Table1. Fluid Replacement Therapy in the First Twenty-four Hours
Table2. Fluid Replacement Therapy in the Second Twenty-four Hours
FIGURE1. A pocket-sized, plastic, fluid calculator for burns. The opposite side shows the requirements for 3d-degree burns.
Local Care of the Burn Wound. As soon as fluid replacement therapy is assured, the patient should be taken into the operating room and, under aseptic conditions, the burned surfaces should be cleansed with soap and rinsed with copious amounts of water. All blisters should be broken, debris removed, and detached epithelium cut away. No local applications of any sort should be used. If permitted to remain exposed, the face, neck, and upper chest heal well. The patient appears to be more comfortable when these areas are exposed. All other areas should be dressed with the Universal Protective Dressing. In the event that these dressings are not available, all areas may be exposed.
It is important that the hands be placed in a position of function; and they should be bandaged with a large occlusive dressing. The dressings should remain in place for approximately 10 days, unless there is undue pain, fever, saturation, or other evidence of infection. Always give tetanus toxoid. Systemic penicillin should be administered in large doses for a minimum of 5 days, and thereafter antibiotics given on specific indications. It is wise to perform a tracheotomy in the case of full- thickness burns of the face. If the eyelids are burned deeply, a tarsorrhaphy should be performed (between the
5th and 10th day); otherwise ectropion will develop with subsequent drying and ulceration of the cornea.
A tracheotomy must be performed when respiratory tract involvement is suspected; and fluids must be administered cautiously thereafter to avoid pulmonary edema.
Usually initial cleansing is performed on the freshly burned surface under intravenous morphine analgesia. If a patient is received after development of inflammation and sensory nerve irritation, it may be necessary to add minimum amounts of sodium pentothal, and 50 percent nitrous oxide with 50 percent oxygen for basal narcosis.
Other Aspects of Management of Burns
All patients, except those with very minor burns, should be evacuated on about the third day to an evacuation hospital providing replacement therapy has been assured. Patients with minor burn wounds may be treated at the battalion aid station or clearing station and then held for a few days until healing is complete.
At the evacuation hospital, patients should be further evaluated at the time of their first change of dressing. Further movement rearward to a general hospital in the Communications Zone is dependent upon the local policy of evacuation.
It seems desirable to designate as burn centers certain evacuation and Communications Zone hospitals, as well as hospitals in the Zone of Interior. Patients with this type of injury receive better care when they are treated by a specially trained team who are experienced in the care of burns.
1. Artz, C. P.; Reiss, E.; Davis, J. H.; and Amspacher, W. H.: The Exposure Treatment of Burns. Ann. Surg.137: 456, 1953.
2. Reiss, E.; Stirman, J. A.; Artz, C. P.; Davis, 3. H.; and Amspacher, W. H.: Fluid and Electrolyte Balance in Burns. 3. A. M. A. 152: 1309, 1953.
3. Reiss, Eric, and Artz, C. P.: Current Status of Research in the Treatment of Burns. Mil. Surg.114: 187, 1954.
4. Artz, Curtis P., and Reiss, E.: Calculator for Estimating Early Fluid Requirements in Burns. J. A. M. A.155: 1156, 1954.