Evolution of Burn Resuscitation in Operation Iraqi Freedom

Abstract

Burns are common in all military conflicts, comprising approximately 10% of all casualties. Of these, nearly 20% are categorized as severe, or involving greater than 20% TBSA, and require significant intravenous resuscitation.1 A unique set of challenges have emerged during the present conflict associated with global evacuation of burned soldiers, adding a new dimension to the alreadycomplex and often-controversial topic of the burn resuscitation.2 Critical advances in air evacuation of the war wounded, thorough prewar planning, and sustained burn care education of deployed personnel have proven vital in the optimal care of our injured soldiers.

Long Range Transport of War-Related Burn Casualties

“…Patients with severe facial burns, those demonstrating signs or symptoms suggestive of inhalation injury, and those with large burns for which a significant resuscitation and associated edema are anticipated, are often preemptively intubated soon after injury to ensure airway protection and mechanical ventilatory support. Appropriate volume replacement in the burn patient can be very challenging, requiring that the practitioner provide adequate intravascular replacement, whereas simultaneously striving to avoid the potentially devastating complications associated with high-volume crystalloid resuscitation as noted by Chung et al 12 Primary and secondary trauma surveys of the combat injured often reveal multiple injuries, including multiple open soft tissue wounds, in addition to burn wounds. Many casualties are injured while traveling in a moving vehicle and need evaluation for blunt injury, as well as penetrating injury from an explosion.…”

Now and Then: Combat Casualty Care Policies for Operation Iraqi Freedom and Operation Enduring Freedom Compared With Those of Vietnam

“…The policy was influenced by concerns about the reported incidence of thromboembolic events among injured patients arriving in Germany and at Walter Reed Army Medical Center. Al- 18 The policy recommended use of low molecular weight heparin (LMWH) and intermittent pneumatic compression for emergency trauma surgery patients, with consideration for higher doses of LMWH and possibly placement of inferior vena cava filters in very high risk patients and patients with contraindications to heparin such as intracranial hemorrhage, significant solid organ injury, etc. This important policy made routine the use of DVT prophylaxis in Iraq and positively impacted the incidence of clotting events at medical facilities along the evacuation chain.…”

Joint Theater Trauma System Implementation of Burn Resuscitation Guidelines Improves Outcomes in Severely Burned Military Casualties

“…It became clear that rapid global evacuation of burn patients, usually occurring in the first few critical hours after injury, had created a unique and challenging set of problems that required resolution to optimize care. 1 First, the responsibility of burn resuscitation of the war wounded in the critical days immediately after injury lies on the shoulders of physicians and nurses who do not specialize in burn care and whose priorities are not focused on stabilization and evacuation to the place of definitive care. Second, the burn casualty will typically be cared for by a number of providers at multiple levels in the evacuation chain before arriving at the burn center.…”

“…Of these, nearly 20% are categorized as severe or involving greater than 20% total body surface area (TBSA) and require significant intravenous resuscitation. 1 To prevent organ failure and death, optimal resuscitation while avoiding over-resuscitation morbidity is critical in the first 24 hours to 48 hours postburn. 1,2 The United States Army Institute of Surgical Research Burn Center is the sole burn treatment facility in the Department of Defense serving active duty personnel in addition to its role as the regional burn center for South Texas.…”

“…1 To prevent organ failure and death, optimal resuscitation while avoiding over-resuscitation morbidity is critical in the first 24 hours to 48 hours postburn. 1,2 The United States Army Institute of Surgical Research Burn Center is the sole burn treatment facility in the Department of Defense serving active duty personnel in addition to its role as the regional burn center for South Texas. Since the beginning of 2003, our burn center has admitted nearly 600 military casualties sustaining burns in Iraq and Afghanistan.…”