Burn Casualty Care in the Deployed Setting.

Management of wartime burn casualties can be very challenging. Burns frequently occur in the setting of other blunt and penetrating injuries. This clinical practice guideline provides a manual for burn injury assessment, resuscitation, wound care, and specific scenarios including chemical and electrical injuries in the deployed or austere setting. The clinical practice guideline also reviews considerations for the definitive care of local national patients, including pediatric patients, who are unable to be evacuated from theater. Medical providers are encouraged to contact the US Army Institute of Surgical Research (USAISR) Burn Center when caring for a burn casualty in the deployed setting.

The Care of Thermally Injured Patients in Operational, Austere, and Mass Casualty Situations.

Burn injury affects a half million people in the United States annually. The severe thermal injury can have long-term debilitating effects. The management of burn patients in austere and operational environments is more complex. Mass casualty incidents can result in a large number of patients with multiple traumatic injuries, which often include burn injury. Appropriate triage of casualties is essential. Severely burned patients should be evacuated to a burn center if possible. Airway management and fluid resuscitation of burn patients present unique challenges. Supplies, resources, and expertise to maintain a definitive airway may not be readily available. Airway adjuncts can be helpful but judicious use of resources is warranted in the austere setting. Traditional resuscitation of severe thermal injury is not practical in the austere environment. Oral resuscitation and in rare cases rectal hydration may be utilized until the patient can be transported to a medical facility. Much has been learned about the management of burn and polytraumatized patients after mass casualty incidents such as the September 11, 2001 terror attacks and the Pope Air Force Base disaster. A well-coordinated emergency preparedness plan is essential. The care of burn patients in austere, operational, and mass casualty situations can tax resources and manpower. The care of these patients will require creativity and ingenuity. Burn patients can be difficult to manage under normal circumstances but the care of these patients under the above situations complicates the management severalfold.

The impact of patient weight on burn resuscitation.

BACKGROUND: Optimal fluid resuscitation of burn patients with burns greater than 20% total body surface area is critical to prevent burn shock during the initial 24 hours to 48 hours postburn. Currently, most resuscitation formulas incorporate the patient's weight when estimating 24-hour fluid requirements. The objective of this study was to determine the impact of weight on fluid resuscitation requirements and outcomes during the initial 24 hours after admission. METHODS: We performed a retrospective review of patients admitted to our burn intensive care unit from December 2007 to April 2013, resuscitated with a computerized decision support system. We classified patients into body mass index (BMI) categories of underweight (BMI: <18.5), normal (BMI: 18.5-24.9), overweight (BMI: 25.0-29.9), or obese (BMI: >30.0). We also calculated the percent difference from ideal body weight (IBW) and compared 24-hour fluid volumes received. RESULTS: Patients with missing weight and/or height values were excluded from the study, resulting in a final cohort of 161 patients for analysis. Mean total body surface area was 42 ± 20% with a full thickness burn of 18 ± 23%. Mean age, weight, and height were 47 ± 19 years, 83 ± 19 kg, and 68 ± 4 inches, respectively. IBW for this cohort was 68 ± 11 kg with a BMI of 28 ± 6. Univariate analysis showed significant differences in 24-hour resuscitation volumes (mL/kg) between normal and obese patients (p < 0.05). Further analysis revealed that increasing percent difference from IBW was associated with lower fluid volumes. Although obesity was not associated with inhalation injury or renal replacement therapy, it was correlated to an increased risk for mortality (p < 0.05). CONCLUSION: This analysis showed that increasing weight was associated with lower fluid resuscitation volume requirements and a higher mortality rate, despite the low incidence of inhalation injury and renal replacement therapy in our obese patients. The use of actual body weight to drive resuscitation volumes may result in overresuscitation of obese patients, depending on the resuscitation formula. Further studies are needed to better explain the relationship between mortality and obesity in burn patients. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.

Treatment of complex medical emergencies in a forward deployed setting: a case of out-of-hospital cardiac arrest.

The Joint Trauma System in Afghanistan, while designed for the care of injured patients, can provide timely, multimodal, coordinated care for nontraumatic medical emergencies as patients are evacuated from theater. To illustrate this, a case of out-of-hospital cardiac arrest is presented. The patient was able to receive all recommended components of postcardiac arrest care in a timely, coordinated manner at four different medical treatment facilities and while traveling over 8,600 miles with critical care provided en route.

Role of platelet-rich plasma in acceleration of bone fracture healing.

Platelet-rich plasma (PRP) is a common therapy for acceleration of maxillofacial and spinal fusion bone-graft healing. This study analyzes the therapeutic role of PRP during long-bone fracture healing evaluated Lewis rats. Following creation of unilateral open femur fractures, either 500 microL thrombin-activated PRP (PRP treated group) or 500 microL saline (control group) were applied once to the fracture site. Fracture healing was analyzed after 1 and 4 weeks. Following 4 weeks of fracture healing, radiographic analysis demonstrated higher callus to cortex width ratio (P < 0.05) in the PRP group (PRP: 1.65 +/- 0.06; control: 1.48 +/- 0.05). Three-point load bearing showed increased bone strength following PRP treatment (PRP: 60.85 +/- 6.06 Newton, control: 47.66 +/- 5.49 Newton). Fracture histology showed enhanced bone formation in the PRP group. Immunohistochemistry and Western-blotting demonstrated healing-associated changes in transforming growth factor (TGF)-beta1 and bone morphogenetic protein (BMP)-2. Our results suggest that PRP accelerates bone fracture healing of rat femurs via modulation of TGF-beta1 and BMP-2 growth factor expression.