Fall - United States Special Operations Command

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available to military medical training facilities in the Training and Education section of the Military Health System website. a. Basic Management Plan for Care Under Fire 1. Casualties should be extricated from burning vehicles or buildings and moved to places of relative safety. Do what is necessary to stop the burning process. b. Basic Management Plan for Tactical Field Care 1. Facial burns, especially those that occur in closed spaces, may be associated with inhalation injury. Aggressively monitor airway status and oxygen saturation in such patients and consider early surgical airway for respiratory distress or oxygen desaturation. 2. Estimate total body surface area (TBSA) burned to the nearest 10% using the Rule of Nines. 3. Cover the burn area with dry, sterile dressings. For extensive burns (>20%), consider placing the casualty in the Blizzard Survival Blanket in the Hypothermia Prevention Kit in order to both cover the burned areas and prevent hypothermia. 4. Fluid resuscitation (USAISR Rule of Ten) 94 – If burns are greater than 20% of Total Body Surface Area, fluid resuscitation should be initiated as soon as IVIIO access is established. Resuscitation should be initiated with Lactated Ringer’s, normal saline, or Hextend. If Hextend is used, no more than 1000ml should be given, followed by Lactated Ringer’s or normal saline as needed. – Initial IVIIO fluid rate is calculated as %TBSA x 10cc/hr for adults weighing 40-80kg. – For every 10kg ABOVE 80kg, increase initial rate by 100ml/hr. – If hemorrhagic shock is also present, resuscitation for hemorrhagic shock takes precedence over resuscitation for burn shock. Administer IV/IO fluids per the TCCC Guidelines in Section 6 (PHTLS Manual, Sixth Edition). 5. Analgesia in accordance with the TCCC Guidelines in Section 12 (PHTLS Manual, Sixth Edition) may be administered to treat burn pain. 6. Pre-hospital antibiotic therapy is not indicated solely for burns, but antibiotics should be given per the TCCC guidelines in Section 14 (PHTLS Manual, Sixth Edition) if indicated to prevent infection in penetrating wounds. 7. All TCCC interventions can be performed on or through burned skin in a burn casualty. c. Basic Management Plan for Tactical Evacuation Care 1. Facial burns, especially those that occur in closed spaces, may be associated with inhalation injury. Aggressively monitor airway status and oxygen saturation in such patients and consider early surgical airway for respiratory distress or oxygen desaturation. 2. Estimate total body surface area (TBSA) burned to the nearest 10% using the Rule of Nines. 3. Cover the burn area with dry, sterile dressings. For extensive burns (>20%), consider placing the casualty in the Blizzard Survival Blanket in the Hypothermia Prevention Kit in order to both cover the burned areas and prevent by hypothermia. 4. Fluid resuscitation (USAISR Rule of Ten) – If burns are greater than 20% of Total Body Surface Area, fluid resuscitation should be initiated as soon as IV 110 access is established. Resuscitation should be initiated with Lactated Ringer’s, normal saline, or Hextend. If Hextend is used, no more than 1000 ml should be given, followed by Lactated Ringer’s or normal saline as needed. – Initial IVIIO fluid rate is calculated as %TBSA x 10cc/hr for adults weighing 40-80 kg. – For every 10kg ABOVE 80kg, increase initial rate by 100ml/hr. – If hemorrhagic shock is also present, resuscitation for hemorrhagic shock takes precedence over resuscitation for bum shock. Administer IV/IO fluids per the TCCC Guidelines in Section 5 (PHTLS Manual, Sixth Edition). 5. Analgesia in accordance with TCCC Guidelines in Section 11 (PHTLS Manual, Sixth Edition) may be administered to treat burn pain. 6. Pre-hospital antibiotic therapy is not indicated solely for burns, but antibiotics should be given per TCCC guidelines in Section 13 (PHTLS Manual, Sixth Edition) if indicated to prevent infection in penetrating wounds. Journal of Special Operations Medicine Volume 10, Edition 4 / Fall 10
7. All TCCC interventions can be performed on or through burned skin in a burn casualty. 8. Burn patients are particularly susceptible to hypothermia. Extra emphasis should be placed on barrier heat loss prevention methods and IV fluid warming in this phase. The above recommendations were unanimously approved. FOR THE DEFENSE HEALTH BOARD: Wayne M. Lednar, MD PhD DHB Co-Vice-President Gregory A. Poland, MD DHB Co-Vice-President REFERENCES 1. King S, Renz E: Management of Burns in TCCC. In Butler FK. Giebner S, McSwain N, Pons P. eds: Prehospital Trauma Life Support Manual. 7th Edition,2010. 2. Memorandum, Assistant Secretary of Defense for Health Affairs (ASD(HA)) Tactical Combat Casualty Care and Minimizing Preventable Fatalities in Combat. 6 August 2009. 3. Presentation: Tactical Combat Casualty Care, Prehospital Trauma Life Support: Defense Health Board Update on the Committee on Tactical Combat Casualty Care, by Dr. Frank Butler, 13 November 2009. 4. Presentation: Tactical Combat Casualty Care, TCCC Burn Management Guidelines, Trauma and Injury Subcommittee Update on the Committee on Tactical Combat Casualty Care, by Dr. Frank Butler, 4 November 2009. 5. Chung K, Wolf S, Cancio L, et al: Resuscitation of severely burned military casualties; fluid begets more fluid. J Trauma 2009;67(2):231 -237. 6. Ennis JL, Chung KK. Renz EM, et al. Joint Theater Trauma System Implementation of Burn Resuscitation Guidelines Improves Outcomes in Severely Burned Military Casualties. Journal of Trauma Injury, Infection, and Critical Care 2008; 64: S 146-S 152. 7. White CE, Renz EM. Advances in surgical care: management of severe burn injury. Crit Care Med 2008; 36(7 supp!.): S318-24. 8. National Association of Emergency Medical Technicians. Pre-Hospital Trauma Life Support Manual. 6th Edition, 2006. 9. Wesley, R. Burn Injuries. Anesthesia and Perioperative Care of the Combat Casualty. 1995; 515: ill. 10. Breederveld R, Tuinebreijer E. Incidence, Cause and Treatment of Burn Casualties Under War Circumstances. European Journal of Trauma and Emergency Surgery 2009;3:240. 11. Kauvar D, Wade C, Baer D. Burn Hazards of the Deployed Environment in Wartime: Epidemiology of Noncombat Burns from Ongoing United States Military Operations. J Am Coli Surg 2009; 209(4): 453-460. 12. Serghiou M, Cowan A, Whitehead C. Rehabilitation After Burn Injury. Clin Plastic Surg 2009; 36:675-686. 13. Alvarado R, Chung KK, Cancio LC, Wolf SE. Bum Resuscitation. Burns 2008; (Epub ahead of print). 14. Burn Care, November 2008. Joint Theater Trauma System Clinical Practice Guidelines. 15. Murray C, Hospenthal D. Prevention and Management of Combat-Related Infections Clinical Practice Guidelines Consensus Conference: Overview. The Journal o/Trauma Injury, Infection, and Critical Care 2008; 64:S207-S208. 16. Renz EM, et al. Long range transport of war-related burn casualties. J Trauma 2008; 64(2 suppl): S 136-45. 17. Cancio LC, Cramer Ge, Hoskins SL. Gastrointestinal fluid resuscitation of thermally injured patients. J Burn Care Res 2006; 27:561-569. 18. Chung KK, Blackbourne LH, Wolf SE, et al. Evolution of bum resuscitation in Operation Iraqi Freedom. J Burn Care Res. 2006; 27: 606-611. 19. Eastridge, B., et al. Trauma systems development in a theater of war: experiences from operations Iraqi freedom and operations enduring freedom. J Trauma 2006;61:1366-1373. 20. Cancio, Leopoldo et al. Burn Support for Operation Iraqi Freedom Related Operations, 2003 to 2004. Journal of Burn Care & Rehabilitation 2005; 26 (2): 151 -161. 21. National Bum Repository 2005 Report. American Burn Association. 22. Burris 00, Fitzhrans JB, Holcomb JB et al. editors: Emergency War Surgery, The Third United States Revision. Washington. DC, Borden Institute, 2004. 23. Bishop JF. Bum wound assessment and surgical management. Cril Care Nun; Clin N AM 2004;16: 145-177. 24. Santaniello JM, Luchette FA, Esposito TJ, et al. Ten year experience of bum, trauma, and combined bum/trauma injuries comparing outcomes. J Trauma 2004 Oct; 57(4):696-700. 25. Advanced Bum Life support manual. Chicago: American Burn Association; 2001. 26. Knaysi GA, Crikelair GF, Crosman B. The rule of nines: its history and accuracy. Plast Reconstr Surg 1968; 41: 560-563. 27. Southwood WF. The thickness of the skin. Plast Reconstr Surg 1955; 15(5): 423-429. 28. Lund CC. Browder NC. The estimation of areas of burn. Surg Gynecol Obstet 1944; 79: 352-358. TCCC Updates 95
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Volume 10, Edition 4 // Fall 10 Jou
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Fall 10 Volume 10, Edition 4 FEATUR
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From the Editor III
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MSgt Mike Maroney renders a salute
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medical system. 14 Although there a
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were collected using the University
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of VO 2max at lactate threshold (%V
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Figure 4: Anatomic location of the
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Warrior Model for Human Performance
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pacity testing should be incorporat
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During the O-Course training, physi
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triathletes was approximately seven
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52. Myer GD, Ford KR, Barber Foss K
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Jennifer B. Deluzio, MS Neuromuscul
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such isolated training increase the
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panied by an improvement in the fle
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Warrior Model for Human Performance
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sessions) with a range of 54-100%.
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side of daily Army PT. Finally, it
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musculoskeletal overuse injuries. A
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War on Terrorism, which lists as it
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MATERIEL AF PM has the most of the
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failed to reach the summit. All mem
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Scapula Fracture Secondary to Stati
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Page 61 and 62: testing over 450 Soldiers in less t
Page 63 and 64: Reply from ANDRE PENNARDT, MD, FACE
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Page 87 and 88: Excerpts from the Committee on Tact
Page 89 and 90: guidelines also support IO as the p
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Page 105 and 106: Meet Your JSOM Staff EXECUTIVE EDIT
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Fall - United States Special Operations Command

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