Guidelines for Burn Care Under Austere Conditions

The burn wound is central to all aspects of burn care. The size, depth, and condition of the burn wound directly impacts fluid resuscitation, hypermetabolic response, immune system dysfunction, and predicted survival. Optimal care of the burn wound requires specialized facilities and experienced burn nurses and surgeons, all of which are in limited supply under normal circumstances. These resources may become overwhelmed or unavailable as a result of a large-scale disaster in a developed country or the need to provide care in an austere or far-forward environment. In this monograph, we discuss adaption and modification of normal burn wound practices to accommodate austere or disaster environments. The integumentary system is the largest organ in the body. Intact skin is semipermeable to water and impermeable to bacteria. It functions as a barrier to infection, a regulator of heat and water loss, and a sense organ for pain, temperature, and touch. A burn converts intact skin into an open wound, disrupting these functions. The primary goal of burn wound care is to achieve wound closure. For partial-thickness burns, this usually involves debridement and placement of temporary dressings with the goals of avoiding infection, maintaining a protective environment, and facilitating normal wound healing. For full-thickness burns, surgical excision and skin grafting is necessary. There are thus four different circumstances in which burn dressings are required: partial-thickness burns (either debrided or not debrided); full-thickness burns with intact eschar; full-thickness burns with eschar excised but not grafted; and partial- or full-thickness burns which have been excised and grafted. No one dressing or antimicrobial is ideal for all of these circumstances. Before the practice of early excision and grafting, burn eschar was left in place for weeks to spontaneously separate from the underlying wound bed, leaving granulation tissue suitable for grafting. Because bacterial action was necessary for this process, burn wound sepsis was both common and expected. To address this problem, three effective topical agents were developed in the 1960s. The introduction of mafenide (mafenide acetate) in 1963 was followed by the introduction of aqueous silver nitrate solution in 1965 and silver sulfadiazine in 1968.1–5 These antimicrobials did not sterilize the burn wound, but rather kept the level of bacterial colonization to a manageable level.6 In contemporary practice, even the largest full-thickness burns are rapidly excised, often within 24 hours of burn center admission, making the choice of topical antimicrobial less important. In a large-scale disaster, the facilities and personnel needed to rapidly excise all full-thickness burn will be unavailable and eschar may need to remain in place for extended periods. This may revert us to standards of care practiced by burn centers in the 1960s. Review of burn textbooks from this period provide insight into how burn wounds can be managed when timely excision is not feasible. There are many situations in which burn care must be provided under austere conditions. In each such environment, the provider must develop a specific strategy to enable effective wound care. There are, however, some principles common to all situations: The provision of austere burn care “requires flexibility, common sense and an appreciation of imposed limitations.”7 New burn care routines must be developed “based on available material, personnel, operating room time and patient condition.”7 For example, it may be necessary to involve family in daily patient care or even physical therapy. Forget how you “do things back home.”7 In a mass casualty incident, standards will be diluted, ignored, or forgotten; personnel will be used beyond their usual roles or comfort zones. The importance of the physical plant cannot be overlooked when considering burn wound care and the risk of death from invasive infection. By means of what would now be called a “bundle” of interventions (individual isolation rooms, hand washing, microbial surveillance, and antimicrobial stewardship), McManus et al8 sustained a decrease in Gram-negative infections. Can these principles be transferred to an austere environment? Recent data from Iraq indicate that the answer is yes.9 Even in austere environments, basic infection control concepts can and must be pursued. Unfortunately, there may be a lack of adequate facilities for showering or bathing patients, a major problem requiring creative solutions.10 When beds for inpatient admission are lacking, outpatient care may be needed. Family members or others in the community must be trained to perform outpatient care, and follow-up may be challenging. In such situations, a dressing that does not need to be changed daily, such as a silver-impregnated dressing, may be preferable (see below). A lack of inpatient beds also argues in favor of early, aggressive excision and grafting in order to reduce inpatient length of stay, even if operating room time is limited. When a burn wound is closed surgically, the problem of burn wound care is largely solved and mortality reduced.11 Adequate resources will be lacking in a mass casualty situation, including burn-experienced personnel and supplies. A strategy for identifying, motivating, and training a team of personnel to perform burn wound care under supervision should be developed as part of the disaster plan. This is, perhaps, the single most important aspect of providing wound care in an austere environment. Supplies may also be limited. Topical antimicrobial agents, dressings, and medications (analgesics, sedation) will likely not be available.7 For example, mafenide acetate is commonly used for contaminated burn wounds, but this topical agent may be in limited supply. Topical antimicrobial (mafenide acetate) ability to reduce burn mortality is both age- and burn-size-specific.12 The maximal mortality benefit is achieved in young adult patients with the mid-range of wound size, that is, 40 to 79% TBSA.12 This provides a basis for triage in the face of a shortage of supplies. The best location for wound care should be identified. Although the operating room is often used for initial wound debridement, in a mass casualty wound care will need to occur in the ward or intensive care unit. Ideally, a dedicated wound care area allowing for patient bathing, privacy, and hand washing should be identified. Other requirements include a dressing supply cart and printed instructional handouts. Patients should be premedicated with narcotics and benzodiazepines if supplies permit. Ketamine should be used for large wounds; given the limited number of anesthetists, physicians and nurses will likely need to independently administer this drug. Family members should be brought into the wound care process to facilitate the transition to outpatient care. Before discussing the choice of topical antimicrobials, the process of dressing changes must be emphasized. This includes the following points: wound care including debridement and cleaning; premedication; inspection of the wound; and identification and rapid, thorough excision of infected wounds.13,14 Truly early excision is defined as removal of all full-thickness eschar 24 to 48 hr after injury, and concomitant closure of the wound with autograft and/or allograft. Early closure decreases the need for topical antimicrobials. Because the ability to excise and graft burns acutely is limited in most austere locations, patients often present in delayed fashion with heavily colonized or infected wounds caused by inadequate, infrequent, or nonexistent wound care. In this setting, mafenide acetate 11% cream has been effective.2 Mafenide acetate has unparalleled efficacy against Gram-negative organisms, penetrates full-thickness eschar and other poorly vascularized tissue beds, and has been effectively used in the treatment of combat wounds during several armed conflicts over a 50-year period. Mafenide acetate use resulted in a dramatic decrease in invasive Gram-negative burn wound infections and associated mortality in multiple wartime situations.3,15 The proven efficacy in combat wounds, which often have delays in excision and grafting, makes it attractive for use in austere care situations. Mafenide acetate has superior coverage for multidrug-resistant organisms (Pseudomonas aeruginosa, extended-spectrum β-lactamase-producing Klebsiella pneumoniae, Acinetobacter baumannii complex, and methicillin-resistant Staphylococcus aureus), but limited efficacy against yeast.16,17 Silver sulfadiazine may thus be used alternately to broaden coverage in a practice termed “alternating agents.”18 Silver sulfadiazine has poor coverage against Enterobacter species, and there are some known resistant strains of Pseudomonas.16 Wound care is performed twice daily; mafenide acetate cream is applied in the morning; and silver sulfadiazine cream is applied in the evening. Twice-daily dressing changes with agents, may not be in austere In many mafenide acetate is not In that situation, use of silver sulfadiazine as a agent may be necessary. The of dressing changes the of action of applied burn This practice is and is to perform care that care must be There are a of both and topical dressings effective for burn and or wound care that can be when mafenide and silver sulfadiazine are not These include dressings, and dressings are commonly used for both care and in There is now over of with dressings used for burn and care under austere and combat dressings in or in or have been used in combat practice in and the in These dressings are to by personnel and can be left in place for several the need for dressing The of silver makes it an ideal dressing over as can be with mafenide or silver sulfadiazine dressings less are to and were not to of in or for a large-scale burn mass casualty incident, dressings be for patient the dressings can be left in place for several patients can be to several for wound Silver dressings are not a for mafenide and silver sulfadiazine in patients with heavily contaminated wounds or in wounds with a of excision or dressing changes with the for these mafenide solution also has of proven under combat conditions. and efficacy of topical and aqueous mafenide against both and in an of open and with concomitant surgical mafenide has been used effectively in austere in the of solution will of the of an of mafenide when with provides aqueous to of the for dressing or solution for aqueous mafenide is an effective topical when used as a surgical for open and of are against a of burn including aeruginosa, species, Staphylococcus and Staphylococcus Klebsiella pneumoniae, Enterobacter and The of surgical debridement, and topical of solution the of burns and combat wounds in and solution was commonly used for burn care the of mafenide and silver to a of and is available as which is a solution of supply of burn antimicrobial is thus in disaster by the solution has a limited and must be The of nitrate to silver sulfadiazine A of nitrate and silver sulfadiazine is in as but is not by the and for use in the nitrate a eschar that as a microbial which excision and grafting to be The nitrate may also of injury, and thus decrease the to the nitrate has been and used to patients in early excision of burns was not feasible. can occur with this should be available if patient is and used as a temporary dressing after the in was and less to burn dressings and of the This is a has antimicrobial When dressings are unavailable or in is an the antimicrobial efficacy of this in the treatment of burn dressing changes as are if is in an austere are likely to invasive Gram-negative burn wound infection in patients have limited or wound care during the several after These patients will present with sepsis and with the of infection by and it is to the patient for the from excision of such heavily contaminated wounds may result in with a may be in these patients for involves the of of the daily of a or is in a of and into the eschar with a This is performed on admission and hours to When must be can be performed twice a for several Although austere is the following should be in a for burn wound and a a for wound care. a process for daily wound care and of topical antimicrobials and their adequate and inpatient by early and outpatient Mafenide and silver sulfadiazine should be used when include dressings and aqueous mafenide acetate have and will include a number of patients and on the the is that many patients from a burn disaster will present with or This on the and wound care for patients with burn by with limited in situations there are limited supplies. A burn is heat to the largest is of or and or within the are the underlying such as a and heat penetrates into these it the of these The the or the the skin is to a heat the the of a The burns in a disaster as and less for partial-thickness are all major and from this are patients with burns also have or associated burns are as outpatient in the developed to with triage during a The most common burn is a also as a burns involve the and are by to in patients with skin and are as The most common of a burn is when of the is this condition is not an on the burn burns should not be in Because of the of burn wounds, it should be that burns as burns early on may in into tissue and will have to be and managed as partial-thickness or full-thickness the and into part of the is a or It is by or to and is It should also be there is a of the burn called but is not for this of the the tissue remain partial-thickness burns will The the injury, the it for to Wound closure should be as may not occur and may be The full-thickness also as a when all of the and are by A full-thickness burn will not and requires grafting in order to this burns are by or a of the skin and may be to the from an supply in the are these wounds lack however, patients often the is is an as patients may to caused by partial-thickness burns or concomitant For all burn it is to the in the area of the burn injury, including to both the burn and all to the such as or other that heat or should also be the burn has it should be for a with available water For burns a hours this is not necessary. discuss the use of water water may be water the process by heat from into tissue also provides some initial For burn of water not associated with may as needed for Patients with burns will be to the wound is of water or dressings to burns for should be The most ideal for burns to be managed of the and achieve include a or others can and are to care for the Other include a patient has other or underlying condition to with or can the patient medications and of It is that all burn patients remain and this to the and patients, as can become over a period of initial the burn is limited to a includes and topical and/or may be applied if and does not with patients with Ideally, topical are given to the patient or for There are a of and that may be used for a as in the of this The burn requires dressing other to it and from the or other heat a disaster, supplies for dressing a burn wound may be available and may on of the there is a need as dressings for For partial-thickness or full-thickness burns that the of and can be managed as an use what is available for may from and water and dressings to the ideal use of topical and or silver-impregnated dressings, as in the on wounds, which less changes and may be in a burn There are four specific for a These include the injury, the injury, a dressing a to the is an with burn and should be during burns as to dressing should be burn wounds should be with water and For the wound, it is preferable to use an such as during a disaster, the available may be common These are For partial-thickness burns, should be and as with available is commonly used as an to and may be with supplies under the and This process should be to 24 the wound to of within to this process can be less the wound is an may be applied to or usually present this For burns that to be managed in the outpatient setting, it may be necessary to the process by or This tissue a of infection, and leaving it in place the Wound debridement is by washing the wound with and water and a to tissue from the a or of with water and an antimicrobial to tissue is the use of specialized dressings, known as or may also be used for of of these dressings include and For austere situations the of care, debridement may include debridement debridement can include of also known as from the circumstances partial- and full-thickness burns should be and debrided within the 24 hr of the this process is delayed the patient the burn however, in a disaster this may need to be to The goals for effective wound are to the wound infection, and the time from to healing. of size, full-thickness burns need surgical debridement and grafting to the changes should be the wound is closed or is present this an available may be Topical or antimicrobial are to colonization of the burn wound to or infection. include silver available as silver and mafenide available as mafenide agents should not be applied if the patient has a Topical such as may also be include and These topical agents the open wound from on the topical are should be applied to partial- or full-thickness burns and with a dressings are in some include or should be with or a of if are limited or the wound and should be and dressings and should be When a to and in will be present in an for the 24 to 48 hr after dressings or antimicrobial should be applied to partial-thickness burns or to all full-thickness burns the family or to the dressing daily, for silver-impregnated dressings, which can be left in place for to For wounds the an such as or are superior to a should be changed daily on and for for topical In all should be each dressing and the wound for of dressing for tissue and other of such as the of granulation for of infection, such as of the tissue the the of or a For partial- or full-thickness burns the not over a or may will the includes such as also an is over but provide is use of both an and the and that may result from use of a single should be on a basis for each patient and on underlying and a disaster, there may be an of medications in supply including supplies may be commonly in many as during austere for aspect of includes the of care with the be but a disaster, the and of may over from an of often In to the topical there is an of dressings with a of should use what is to the daily, that this may not be in mass casualty Patients with burns in a disaster must be for in a that provides treatment to the injury, but the limited of supplies and care for patient in a disaster may the of and to in what is to the of care, but when standards of care may have to be applied during a time of place patients with burns from with and the within this resources are Early on in the disaster, the of personnel, and supplies will be and you may to supplies from a of from or to The most for wound care is to the wound to the patient an of water is for the burn For burns to remain and that the wound has to be kept and the patient of the disaster will be beyond with burn this was developed there may or may not be and should be from on training and you are to perform or Early into the disaster, the of personnel, and supplies will be and the disaster, you may supplies from a of from to and outpatient and burns should be managed of the and patient care area for the to patient for on the of the wound the pain, and and to patient for available dressings and with water a burns can an the triage process should with and burns of the care the wound and dressings with 24 if will be by of supplies. the a burn may be and infection may and for changes within The austere to the surgical care of burn The burn care, including and is and it is to perform excision and grafting of burns in a of by that a patient can be from the austere to a location with burn care this should be the of for example, was the strategy in the care of during the and the conflicts in Iraq and For a number of to the in to the for care in a was also as requiring should be transferred to an a triage such as that by and by of burn patients of the austere is most often the burn center may be with the disaster and may be to a burn is necessary on the in the area of the disaster, and in in these will on the of and physical This on which may be to the as There should be a appreciation of what and be in an austere environment. the in it necessary to triage most patients with burns to the The of burns burns would this of on a this In the of combat and a number of beds, there was a lack of it that patients with burns of of the or a poor control in a physical plant of and training on the part of personnel and for inpatient of to include The is important and a for what can be in the austere environment. In burn initial debridement and such as are performed the or in the burn intensive care unit. In an austere setting, however, the operating room may be a for these initial The operating room is likely the ward to have the environment, personnel, and needed for wound care. This may or may not be in an austere environment. The to a patient to excision and grafting in an austere must be and aspect of the must be given The of and team cannot be In to burn team members in burn personnel may have to burn and to include loss, and a environment. Before on in an austere environment, the should the operating room team to the and the in to include the following environment, and of and by and the surgical for for skin dressings surgical and burn wound coverage dressings, mafenide acetate solution on should also to the These may for example, use of hand to and use of to for imposed by surgical in the austere should not from that in a burn with the following The must and the of in order to the level of the other members of the The of that excision should be limited to or hr time should be in the austere environment, if the other team members are or if the is in the austere for the an adequate supply is not the that can be excised a single will be limited. The of and agents may also be may be performed with or The excision may be performed the with a or an or The is to as tissue as or For surgeons, the into the tissue may be to and may be the best to the is also and is usually associated with less during excision is by in normal and are and as on the should be the and applied for a of the and are is with the or care is in the austere environment. infection control is must be to inspection of the wounds and must have a of for graft and and will be if from and physical are not In the of may be wound may be for wound care. Patients and their family members will in will a to injury, to include level of in must be of these and must be in to patient Although the of this has been to burn to an austere may also be to care of a of burn is in how best to to these the of burn care, of the may be to the patient risk of and Other can be performed in a fashion by surgeons, but may be important to a burn to a in or include of burn including the major or The care of the patient under the following a disaster, or in a one of the a care provider can we be to the When patients burn of the austere When is not and and for burn the need to perform both and the with a burn team Review supply and requirements the and of to the and of the team for infection patients, family and in physical and goals and