The Treatment of Burn Injuries During Military Action
C. Krawehl-Nakath
German Armed Forces Central Hosital Koblenz,
Department XIV -Trauma Surgery / Burns Care Unit
Rübenacher Straße 170, D-56072 Koblenz
Summary
During military actions, soldiers with serious burn injuries must receive medical treatment that corresponds to the highest of medical standards. Owing to the up-to-date material resources and high professional level of the ambulance service, the Germon Armed Forces are able to meet these requirements.
For the topical wound treatment during military actions, it is strongly recommended that in conjunction with standardised routine procedures, wound dressings manufactured from carbon fibre fabrics be used. This method, also known as the Koblenz Model, is easy to handle and has no side effects.
|
Any country whose soldiers take part in military manoeuvres within different international programs, has to make provisions so that theirsoldiers receive the most up-to-date medical care in case of injury or illness. In order to achieve this goal, the Inspector of the Ambulance Service of the Germon Armed Forces promulgated two guidelines in April 1993. Some amendments were introduced in these directives in September 1995. The basic concept is to guarantee soldiers during military actions the medical care that corresponds to the highest German medical standards. It appears to be insightful that the principles of rescue and of medical emergency care should be applied during military manoeuvres.
For these purposes two main areas of treatment come into question, namely
-pre-clinical attendance
-clinical attendance
each of which is subdivided in turn in three additional areas A, B and C according to the definitions given below:
Area of performance A: pre-clinical attendance. emergency medical attendance.
Under military operations, proper self-help and proper help to comrades are of primary importance (see Al) .They give basis to the efficient medical emergency assistance in the field hospitals (see A2) .The vital functions of the patient's organism should be maintained, the state of his health stabilised so that further transport to the Area of performance B becomes possible.
Area of performance B: urgent clinical attendance.
The urgent clinical assistance is performed in field hospitals of military operations. These hospitals of a "flexible nature" are containerised to a great extent, are self-sufficient and ready to render all the required medical care to seriously injured patients or to provide the necessary medical care
untill the transport of the patient into the area of performance C can be completed.
Area of performance C: further medical care/final medical care such as rehabilitation.
All the medical assistance required at this point is available in German military and civilian hospitals.
Here, the proper high-quality medical care of burn-injured soldiers should be carried out by properly trained staff.
In view of all the organisational requirements, the question arises, where and to what extent the proposed scheme of medical treatment of severely burn-injured soldiers can be realised in practice.
Area of performance Al: Self-help and help to comrades.
The emphasis here is the rescue work, removal of burned clothing, placing the injured person in the correct position, application of emergency bandages, and transport to the place of the emergency
assistance. At this stage, the necessary requisites formore complete treatment should be created.
Area of performance A2: Pre-clinical attendance.
The emphasis here lies in cooling and coverage of the burn wounds with dry and sterile dressings. The whole-body sheets, so called Burnsets should be used as well. In order to prevent a drop in body temperature, it is necessary to cover the patient with blankets. Venous infusion with Ringerssolution must be started at this phase of treatment. Since it is difficult to estimate the extent/depth of the burn at the place of accident, we initiate a therapy of one litre Ringer's solution as bolus and then continuing therapy with one litre per hour. Here must be pointed out, that colloids and corticoids are not indicated during the initial stages of treatment since they can negatively affect the rehabilitation process. In case of inhalation trauma or accompanying mechanical trauma,intubation should be carried out in order to guarantee the proper transport conditions. The intake either of 0,25-0,5 mg/kg BW (Body Weight) of Ketanest - Dormicum is necessary.
Area of performance B: Clinical acute attendance.
Treatment of 2nd degree burn injuries or of 3rd degree burn injuries with up to 15% of the body surface being affected, can be treated in this area of performance. As a rule, these patients and patients with more severe burn trauma, for example, severe burn traumas caused by electric current or of thermomechanical origin, should be treated in specialised hospitals of their homelands. Hence, the organisation of proper transport becomes of prime importance for the area of performance B.
The detailed description of the treatment of patients with burn injuries within the area of performance B, follows below:
1. After cleansing the patient and carrying out of the necessary debridement, the extent and the depth of the burn injury has to be determined and documented.
2. Afterwards the fluid requirement according to the Baxter Parkland formula 4 ml x kg BW (Body Weight) x % VKOF (Burned Body Surface) is calculated for the dosage with Ringer' s solution. One half of this amount should be given in the first eight hours, the rest should be given in the following sixteen hours. The calculation using the so called Ludwigshafen modell, is even more simple. The fluid replacement is accomplished in five time intervals during over a period of two days, as described below:
Four time intervals 0-4 h, 4-8 h, 8-16 h, 16-24 h during the first day with the amount of fluid calculated as 1 ml x kg BW x % VKOF1. In the fifth time interval that is 24 hours long, the patient receives 4 ml x kg BW x % VKOF1. The simplest parameter to check if fluid replacement is adequate is the urine production/hour of > 50 ml/hour.
As a rule, the protein replacement begins after 24 hours when the mediator-caused capillary leak
ceases and the loss of proteins must be compensated. The respective calculations are done according to the formula % VKOFl x BW = ml HA 5% or Bjseko. We prefer to use Biseko since it contains not only serum proteins but immunoglobulins, transport proteins and inhibitor proteins as well. Coagulation factors, PPSB, FFP, AT III should be also replaced depending on the patient's condition.
In order to monitor the patient, urine production, RR, pulse frequency, CVP, temperature curve and
body weight must be conrolled. Regular smear cultures should be taken from the wound,tracheal secretion and urine, in order to be able to choose the appropriate antibiotics in case of an infection or sepsis. Prophylactical antibiotic treatment is not indicated, since it could cause development of bacterial resistance.
Parenteral nutrition begins on the third day post trauma. It consists of amino acids, carbohydrates, lipids, vitamins and trace elements. The enteral nutrition through gastric or duodenal tube has to begin 6 hours post trauma in order to prevent the translocation of bacteria in a trauma-induced intestinal atonia.
3. For over one year now, we have implemented a new method of topical treatment of burn injuries, known as the KOBLENZ MODEL. Burn injuries are treated with carbon fibre wound dressings Sorusal or Legius. Being very easy to handle, this method is well suited for treatment of burn injuries caused during military actions. The procedure begins with the routine desinfection of the injury with povidone-iodine, in case of iodine allergy, silver-sulphadiazine is used. Then a carbon fibre cloth dressing (either Sorusal or Legius is laid on the wound and fixed with mull bandages. Due to their woven structure, the carbon fibre dressings have large surface; because of their hygroscopicity they are able to absorb large quantities of fluids exudating from burn wounds. Moreover, the dressing Legius can be soaked with antiseptic solutions such as povidone-iodine or silver-sulphadiazine and laid on the wound, thus minimising the dangerof infection. Since carbon is a chemically inert substance, the dressing normally does not adhere to the wound but clings to it well. If the dressing adheres to the wound, it can be easily removed without injuring the epithelium or granulating tissues, by injection of saline solution underneath the dressing. Consequently, the dressing change is a painless procedure that is well tolerated by patients. The use of the dressings manufactured from carbon fibre fabrics prevents maceration of the burn and results in cases of 2nd (b) or 3rd degree burn injuries in formation of dry eschars. When Sorusal or Legius are used for treatment of surface burns the epithelisation occurs within 8-12 days.
Another important advantage of this method of treatment is the comparatively quick drying out of burn wounds and the possibility to determine the extent and depth of the injury. Consequently, the estimation and completion of the so called "burn map" become substantially easier.
4. The primary goal of the operative treatment of burns is debridement; if necessary, escharotomy of circular burn injuries, stabilisation of accompanying traumas of mechanical origin, or surgery of the injured internal organs must be performed. Beginning with the fifth day post trauma,tangential or epafascial necretomy of the deeply burned areas are performed and a split-skin graft transplanted (Mesh-Graft Technique.) In the case of facial and wrist burns, full-thickness skin grafts (for example,
for eyelids,fingers) and/or unmeshed split-skit grafts (for example, for dorsum of the hand, extensor sides of the fingers) are transplanted. This is done in order to obtain better functional and aesthetic effects later on. Operative therapy should not be performed until the 14th day post trauma day in order to prevent sepsis.
5. Physiotherapy, pulmonary physiotherapy and psychological attendance are of crucial importance for the successful treatment of patients with burn injuries/traumas for successful healing and in order for the patient to overcome the physical and psychological consequences of the accident.
6. Summary.
It becomes clear from the above text that even during the complicated military operations, high-qualified medical care can be rendered even to patients with burn injuries of the highest grade.
