Burns: Military Options and Tactical SolutionsSteven J. Thomas, MD, George C. Kramer, PhD, and David N. Herndon, MD
Burn injury remains a constantsource of morbidity and mortality in themilitary environment. The logistic con-straints of combat casualty care can makeit impossible to provide the large volumesof crystalloid typically used for burn re-suscitation. Unlike penetrating trauma,the immediate and sustained fluid re-quirements necessary for resuscitation ofthermal injury preclude the use of limitedor hypotensive resuscitation. We examinethe physiology, traditional resuscitation
strategies, and rationales for the use ofnovel regimens in the resuscitation ofthermal injury. Although strategies suchas early use of colloids or hypertonic sa-line may not reduce morbidity or mortal-ity when compared with large-volume in-fusions of lactated Ringer’s, they can bevolume sparing for some hours and sus-tain life until more definitive therapy isinitiated. An intriguing hypothesis is thatoral resuscitation can effectively restoreplasma volume after thermal injury. We
present data from recent experiments ofgastric and intestinal infusions of an oralrehydration solution in a porcine burnmodel that demonstrates restoration ofplasma volumes and improvement in he-modynamic parameters associated withsignificant gastric emptying and intestinalabsorption.
It was soldiers saving soldiers. Soldiers putting out fires. Sol-diers putting out fires on other soldiers; soldiers draggingsoldiers out of fires; resuscitating; giving soldiers CPR; puttingtourniquets on limbs that have been severed; putting out fireson their bodies, sometimes with their own hands. Anythingthey could do to care for their buddies that were most seriouslyinjured, they were doing. They can’t do that without knowinghow. They respond in a way that they would in combat.1
Any military operation is fraught with the possibility ofdisaster. The opening paragraph described the actions ofthe medics and soldiers on March 23, 1994, at Pope Air
Force Base. Two aircraft collided, creating a massive fireballthat brought death and injury to more than 100 paratroopers.Nine were killed instantly and two more died en route to thehospital. Fifty-one casualties were treated and released, 25 weresent to intensive care units, 30 were sent to inpatient wards, and13 were transferred to additional hospitals. Twenty-four soldiersdied. The outcome of this incident could have been significantlyworse had it not occurred on a military base, during daylight,with immediate medical support available and the availability ofrapid evacuation to nearby hospitals.1
One of the challenges in the new combat milieu will bethe management of burn victims. Burns are a consistent causeof military mortality and morbidity. The overall mortality hasremained approximately 4% of the total deaths from WorldWar I to Desert Storm.2,3 The percentage of burn injury of allcasualties ranges from 10% to 30%, depending on the type ornature of the conflict.4 The use of tanks, armored vehicles,aircraft, and battleships can increase the proportion of ther-mal injuries. Seventy percent of the tank casualties in theYom Kippur War were burn, as were 34% of all navalcasualties during the Falklands War. In Vietnam during theperiod 1965 to 1973, there were 13,047 burn injuries.5 Be-tween March 1966 and July 1967, there were 445 patientswith burns admitted to U.S. Army Hospitals in Vietnam.6
Most of those burn patients required no fluid at all. Thoserequiring fluid received approximately 4.5 L of blood and 5.8L of intravenous (IV) fluids. Thirty-five percent of the burnpatients returned to duty in Vietnam, 64% were evacuated,and 1% died. Half the burns were accidental (54%) and therest (46%) were combat related. This example suggests that alarge percentage of military burn injuries are accidental andnot directly attributable to the combat environment.
Modern warfare is often fought in an urban environmentwith its own attendant risks, which are significantly differentfrom those found on the conventional open battlefield. Theincreased lethality of the munitions used today deployed in abuilt-up environment can lead to high rates of blast injuriesand burn injuries associated with fire. This can significantlyincrease the actual number of soldiers injured and inflict alarge amount of collateral damage to a civilian population. Inaddition, these urban battles are often prolonged, as recentlyseen in Jenna, Palestine, where a running battle continued forover 4 days, preventing evacuation and making treatment ofburn casualties a formidable task. Because of the nature of themilitary environment, their exists the possibility that a sud-
Submitted for publication August 7, 2002. Accepted for publicationAugust 26, 2002.
and Physiology (G.C.K.), The University of Texas Medical Branch,Galveston, Texas.
Supported by Shriners Hospitals of North America; Resuscitation Re-search Laboratory; Department of Anesthesiology, The University of TexasMedical Branch; and Office of Naval Research contract N00014-00-1-0362.
G.C.K. is an inventor on a University of California-owned patent onhypertonic saline dextran.
Address for reprints: George C. Kramer, PhD, Departments of Anesthe-siology and Physiology, The University of Texas Medical Branch, 301 Univer-sity Boulevard, Galveston, TX 77555-0801; email: [email protected].
DOI: 10.1097/01.TA.0000065013.27877.F3
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den, overwhelming, disastrous mass casualty situation canoccur. Below are two illustrative examples.
JULY 1967, THE USS FORRESTAL OFF THE COASTOF VIETNAM
An A-4 Phantom fighter preparing for take-off acciden-tally launched a rocket into a fully armed and fueled A-4Skyhawk. The heat detonated a 1,000-lb bomb, blowing ahole in the deck and igniting stored fuel. One hundred thirty-four crewman died in the ensuing firestorm. It is interesting tonote that the 134 causalities from this one incident werealmost three times the total number of sea-related combatdeaths (n � 58) and 8% of the total Navy deaths during theVietnam conflict (134 of 1,626).
APRIL 25, 1980, OPERATION “EAGLE-CLAW,”IRANIAN DESERT
An RH-53 helicopter pilot, disoriented by dust, collidedwith a C-130. The site of impact was the C-130’s refuelingcompartment, creating a wall of flames, which immediatelyimmolated five of the C-130 flight crew. The radio operatoron the lower deck was instantly engulfed by flames but wasdragged from the aircraft by a Delta Force soldier. Thesituation worsened as hundreds of rounds of ammunition andantitank rockets began exploding. The two Marine helicopterpilots, although severely burned, managed to extricate them-selves. The remaining casualties were evacuated by C-130with a 3-hour flight time and Delta Force medics caring forthem en route. Four severely burned soldiers were resusci-tated and transported to stateside burn units.
There is often limited availability of fluids for the initialtreatment of combat casualties, and casualty evacuation canbe delayed hours and as much as days. Consequently, muchdiscussion has centered on the role of limited or hypotensiveresuscitation. It has been suggested that in many cases, lim-ited resuscitation may be more effective than large-volumeIV infusions.7,8 Hypotensive resuscitation may in fact be anacceptable treatment for penetrating torso injuries.9 However,its role is in no way suggested in the management of burntrauma. The massive fluid shifts and profound hypovolemiaunderscore the absolute requirement for fluid replacement. Ifleft untreated, a full-thickness burn � 25% total body surfacearea (TBSA) will inevitably lead to burn shock.
“Burn injury is the greatest dysregulator of homeostasisof any injury and is not easily treated.”10 Hemorrhagic hy-povolemia can often be effectively treated with limited re-suscitation combined with the body’s own potent compensa-tory mechanisms. In contrast, burn shock is a complexinterplay of microvascular dysfunction, inflammatory medi-ator release, and circulating depolarizing factors that result inmassive fluid shifts from the vascular space into the intersti-tial and cellular space.6 Initially, the patient becomes hypo-volemic with decreased plasma volume, decreased cardiacoutput, increased peripheral resistance, decreased urine out-put, and hemoconcentration. This is complicated by the de-
velopment of edema both at the burn site and in nonburnedtissue.11 The amount of edema is related to the volume andtype of resuscitative fluids given.12,13 The edema is generatedby diffuse increases in microvascular permeability and alter-ations in all the Starling forces.11
MORTALITYMajor burn mortalities have decreased remarkably over
the last 50 years (Table 1).14 Between 1942 and 1952, half thechildren between the ages of 1 and 14 years with 50% TBSAburns were killed. Today, nearly half of the children with a98% TBSA burn will survive if treated in a specialized burntreatment unit, whereas a 70% TBSA burn will kill 50% ofthe patients between the ages of 15 to 44, and a 50% TBSAburn will kill 50% of patients aged 50 to 64 years. However,even the mortality for the elderly has been markedly de-creased by modern resuscitative regimens.
One of the primary reasons for this mortality decrease inmajor thermal burn is our increased understanding of how toresuscitate burn patients. Critical to this improvement is theearly resuscitation of the patients.14 Other areas of improve-ment have been in the control of infection, support of thehypermetabolic responses to trauma, and early closure of theburn wound.
A recent article by Wolf et al. analyzed the mortalitydeterminants in massive pediatric burns (� 80% TBSA) in103 children.15 The major determinants of mortality in thesepatients were total body area surface burned, age, inhalationinjury, time to resuscitation, and the amount of initial resus-citation fluids (Table 2). The amount and timing of fluid
Table 1 Burn Mortality: The Percent TBSA thatProduces LD50 for Different Age Groups
Age Groups (yr)
0–14 15–44 45–64 �65
Bull and Fisher (1942–52) 49 46 24 102,807 patients n � 1,366 n � 967 n � 330 n � 144
Bull (1967–70) 64 56 40 171,922 patients n � 962 n � 565 n � 246 n � 144
Curreri and Abston(1975–79)
77 63 38 23
1,508 patients n � 803 n � 413 n � 178 n � 114SBI/UTMB (1980–99) 98 70 46 19
2,164 patients n � 1,524 n � 450 n � 127 n � 63
Table 2 En Route Variables
Survivors(n � 69)
Nonsurvivors(n � 34)
Univariatep Value
Multivariatep Value
Time to IV Start(h)
0.6 � 0.2 2.2 � 0.5 0.001 0.004
Fluid in first 24 h(mL/m2burn/h)
431 � 20 487 � 51 0.210 0.277
Transport time(% � 48 h)
71 74 0.429 0.247
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resuscitation are major contributors to mortality in massiveburn. Wolf et al. found that the most significant contributor tomortality among the resuscitation requirements was not thetype or volume of fluid given within the first 24 hours, buthow soon after injury the fluid was started (Fig. 1). Early andprompt resuscitation of the patient can drastically reduce themortality of a massively burned patient. This should certainlybe the main concern of the military on the new urban battle-field, where delays in evacuation times of 2 to 9 hours areanticipated. During the “Black Hawk Down” firefight inMogadishu, Somalia, the tactical situation resulted in a 14-hour evacuation time.16 Without prompt and adequate resus-citation, a burn victim in this scenario would convert from anotherwise survivable injury with limited morbidity into avirtually guaranteed fatality.
The concept of limited or hypotensive resuscitation mayhave its place in the resuscitation of patients with penetratingtrauma and perhaps even to some extent in blunt traumaticinjury. However, our knowledge of burn shock and the dataof Wolf et al. suggest that limited resuscitation has no placein the treatment of burns.15 It should be one of the highestpriorities for the military to develop the logistic and treatment
modalities to provide prompt and adequate resuscitation forthe burn victim in all tactical environments.
COMBAT MANAGEMENT OF THE THERMALLYINJURED PATIENT
The key aspect of burn patient management is early andadequate resuscitation of the patient. The patient will rapidlybecome hypovolemic and fluid should be administered, ide-ally within the first minutes after the initial burn injury. TheParkland formula (4 mL/kg of lactated Ringer’s per percentTBSA burn injury)17 is the most widely used formula todayfor estimating the 24-hour fluid requirements for adults (Ta-ble 3). Current recommendations of the Advanced Burn LifeSupport advocate giving half of the fluids in the first 8 hoursand the other half in the subsequent 16 hours after the burn.The greatest quantity of salt is given in the first 24 hourspostburn; in the second 24 hours, more hypotonic solutionsare often administered to replace the evaporative water loss.In practice, the Parkland formula is just an estimate of need,as the actual infusion rates are often greater and are adjustedto maintain an adequate urine output of 0.5 to 1 mL/kg/h.This presents a logistic nightmare for combat medics. If three
Fig. 1. Time to intravenous access: survivors vs. non-survivors. From Wolf SE, Rose JK, Desai MH, Mileski JP, Barrow RE, Herndon DN.Mortality determinants in massive pediatric burns. Ann Surg. 225:554–569.
Table 3 Fluid Volume Estimates in the First 24 H for a 70-kg Man with a 40% Burn
Evans Formula(24-hr total � 7,000 mL,48-h total � 12,400 mL,
urine � 30–50 mL/h)
Brooke Formula(24-h total � 7,000 mL,48-h total � 12,400 mL,
urine � 30–50 mL/h)
Parkland Formula(24-h total � 11,200 mL,48-h total � 14,000 mL,
urine � 30–50 mL/h)
Colloid 1.0 mL/kg/% (2,800 mL) 0.5 mL/kg/% (1,400 mL) NoneCrystalloid 1.0 mL/kg/% (2,800 mL) 1.5 mL/kg/% (4,200 mL) 4.0 mL/kg/% (11,200 mL)Free water 2,000 mL 2,000 mL None
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soldiers suffer a 50% TBSA injury and evacuation is delayedfor 8 hours, a total of 24 L (53 lb) of fluid is prescribed; avolume more than that is carried by a typical platoon ofsoldiers.
We advocate the use of more efficient volume expandersthat can reduce the early requirement of fluids, if those fluidsare shown to provide no deleterious effect on outcome. Thegenerally accepted formulations to be considered are earlyuse of colloids or hyperosmotic saline or their combination.
Fluids that Reduce Volume RequirementsThe choice of fluids in burn resuscitation remains con-
troversial. Colloids are not widely used as initial resuscitativefluids for burns. Because burn induces a diffuse increase invascular permeability, it is argued that initial colloid replace-ment would not remain within the intervascular space andwould further exacerbate fluid shifts and edema. One clinicalstudy showed that although fluid requirements were de-creased with colloid solutions, there were subsequent in-creases in lung water.18 This suggests that the use of colloidsin the first 24 hours postinjury can lead to the later develop-ment of pulmonary edema. In contrast, many centers in Eu-rope report excellent clinical results with the routine use ofearly colloid solutions as initial treatment. Early volumesparing has been reported with albumin, hetastarch, anddextran.12,13,19,20 Even if colloid administration has no ben-eficial effect on outcome—if it simply lowers early volumeneeds—its use could be lifesaving for combat casualty carebecause corpsmen and soldiers can carry only limited resus-citative fluids. Although colloids for the initial managementof burns may reduce early volume needs, further research isneeded to establish the best infusion regimens for early col-loid use in burns and their subsequent responses andoutcomes.
Hyperosmotic saline can rapidly restore plasma volumewith smaller infused volumes and has been used by manycenters for burn resuscitation. A meta-analysis of 10 clinicaltrials of 450 to 800 mOsm hypertonic saline solution wasperformed by Milner, who showed a 36% reduction in thefirst-24-hour fluid needs compared with the isotonic-treatedpatients.21 A small-volume formulation of 7.5% hypertonicsaline/6% dextran 70 (HSD) is approved for clinical use inEuropean countries for the initial treatment of trauma. Figure2 shows plasma volume expansion of a small 4-mL/kg vol-ume of HSD versus a large 25-mL/kg volume of lactatedRinger’s (LR) solution in 40% TBSA burn-injured sheep.22
The relative volume expansion after HSD infusion is 10 timesthat of LR.21 HSD has been shown by Elgjo et al. to rapidlyimprove hemodynamics and to have early volume-sparing(8–10 hours) effects in the resuscitation of burn injury.23 Insheep models of 40% TBSA burn, Elgjo et al.23 showed thatvolume requirements were reduced by 80% after an initial30-minute infusion of 4 mL/kg HSD followed by lactatedRinger’s infused to maintain normal urine outputs. A reboundof fluid needs occurred at 8 to 10 hours postburn, suggesting
no long-term volume sparing, as the total fluid requirementsover a 48-hour period were the same when LR only was used.Rapid infusion of HSD was initially recommended for thetreatment of trauma and hemorrhagic hypovolemia, but morerecent data suggest slower infusions are equally or moreadvantageous.24 With rapid 2-minute infusions of HSD, aninitial hyperosmolarity and hypernatremia can be severe andcan lead to cardiac arrhythmias and unnecessarily fast volumeexpansion after burn injury.25 In particular, burn resuscitationis a slow 24- to 48-hour process compared with the acuteresuscitation of hemorrhagic blood loss. In studies of burnresuscitation using higher doses (8–10 mL/kg) and slowerinfusion rates (2–4 hours), prolonged volume expansion andreduced edema have been reported. Also, these infusion reg-imens can reduce or prevent the rebound of the fluid require-ments seen with more rapid infusions.26 Although a 4-mL/kgbolus infusion may be beneficial for hemorrhagic shock, aslower infusion rate at a higher dose may be the most effi-cacious infusion regimen for burn resuscitation. Short-termresuscitation needs could certainly be met with a small vol-ume of hypertonic-hyperoncotic solution. In an evacuationcenter or staging area where large volumes are not availablefor hours, a slow administration of HSD may have distinctphysiologic and logistic advantages.21,27–29
Hypertonic resuscitation has been shown to be safe inhemorrhage and trauma with preexisting dehydration;30–33
however, there is a limit to the dose that can be safelyadministered. Huang et al. infused exceedingly high doses ofvarious hypertonic saline solutions into burn-injured patientsover 24 to 48 hours and found significantly increased renalfailure and a higher mortality rate compared with isotonic
Fig. 2. Plasma volume expansion measured after a 30 min infusionof 25 ml/kg of lactated Ringers or 4 ml/kg of HSD. Infusion wasstarted 60 minutes after a 40% TBSA full thickness burn in sheep.Plasma volume was decreased about 11 ml/kg or 25% of preburnlevels by the injury. From Liu B, Elgjo GI, Tølløfsrud S, WilliamsCA, Prough DS, Kramer GC. Blood volume expansion after hyper-tonic saline dextran 70 (HSD) or lactated Ringer’s infusions innormal and burn injured sheep. J Burn Care Rehabil. 2000;21:S143.
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regimens.34 Although this study contrasts all previous studiesof hypertonic resuscitation of burns, it suggests that verylarge doses or sustained infusion can be deleterious.
Combined InjuriesCombined injuries such as hemorrhage and burn injury
occur in combat. We have few data on how best to treat thesepatients, but fluid needs will be increased, and standard end-points such as urine output and blood pressure are likely toadequately guide therapy. A commonly encountered com-bined injury is burn and inhalation injury. In the militaryenvironment, a large percentage of injuries occur withinclosed spaces (e.g., buildings, tanks, or planes), which resultsin an increased frequency of concomitant inhalation injuries.Smoke inhalation injuries have been shown to require addi-tional fluid, 2 mL/kg/% TBSA burn, to maintain a urineoutput of 0.5 to 1.5 mL/kg/h.35,36 Underresuscitation of theburn patient exacerbates late pulmonary edema and increasesthe pulmonary failure rate.36 Initially after smoke injury,there is an increase in extravascular lung water, clinicallymanifested by a decrease in oxygenation occurring approxi-mately 20 hours postinjury. During this period of time, thepatient must be adequately resuscitated or the subsequentpulmonary edema will significantly worsen.
ORAL FLUID REPLACEMENT IN THE BURN PATIENTOne of the major problems when addressing the medical
response to the combatant is the availability and portability ofsterile replacement fluids. A packaged liter of LR solutionweighs 2.3 lb and has a volume of 1,200 cm3. To resuscitatea 70-kg adult with a 40% TBSA burn would require approx-imately 6 L of IV fluid in the first 8 hours. Put another way,this would be approximately 14 lb of resuscitative fluids and7,200 cm3 of space that an individual medic would have tocarry, just for one patient. One strategy to reduce the amountof IV fluids would be the partial or complete use of fluidreplacement with oral hydration.
The World Health Organization (WHO) has used oralrehydration solution (ORS) with tremendous success as afirst-line therapy for severe diarrhea and cholera in children.These children have massive fluid losses and are volumecontracted. When ORS packets are mixed with potable water,the resultant sodium/glucose/bicarbonate solution is readilyabsorbed by the intestine and restores normal hydration. Al-though the mechanism and composition of the fluid loss fromsecretory diarrhea are different from burn, both types ofpatients are significantly hypovolemic and can die withoutthe administration of fluid.37 In theory, the large amounts offluid replacement needed in thermal injury can be replaced inthis manner. Fluids could be taken orally or administered bynasogastric tube (NGT), the placement of which could easilybe performed by a medic with minimal skill levels.
Therapeutic RationaleThe gastrointestinal (GI) tract normally absorbs 7 to 10 L
of fluid per day and can absorb larger volumes when chal-lenged. Limiting factors include the rate of gastric emptyingand the rate of intestinal absorption. There is very littleabsorption through the stomach. The bulk of the absorption offluid and electrolytes occurs through the small and largeintestines. Fluid arriving in the duodenum rapidly reachesosmotic equilibrium with plasma. Intestinal enterocytes haveextremely effective transporters for glucose and other nutri-ents. Sodium transport is linked to the active transport ofglucose, other sugars, and most amino acids. The net result isthat water is osmotically transferred from the lumen to theplasma. Each absorbed glucose molecule is linked to 2 mol-ecules of sodium and 223 molecules of water.38 Water ab-sorption and secretion occur solely in response to the osmoticforces produced by the transport of organic solutes and ions.
Gastric Emptying of FluidsThe stomach capacity varies from approximately 50 mL
when empty to 1,000 mL when distended, with only minimalchanges in gastric pressures. The rate of gastric emptying isthe limiting factor in the absorption of liquids. The rate ofgastric emptying is primarily controlled by two major factors,the composition of the drink and the volume of the drinkingested. A carbohydrate solution of 2.5% or less will emptythe stomach at essentially the same rate as equal volumes ofwater alone, whereas a carbohydrate solution of 6% or greaterslows emptying.39
The rate of gastric emptying is exponentially related togastric volume.40 Figure 3 shows gastric volume versus timeredrawn from data on human volunteers after drinking dif-ferent volumes of a saline-glucose solution.41 Increasing thevolume of the stomach activates mucosal stretch receptors,promoting faster emptying. It is the total volume that is
Fig. 3. Gastric emptying measured in human volunteers usingdilution of tracer phenol red after drinking a sodium glucose solu-tion. From Costill DL, Saltin B. Factors limiting gastric emptyingduring rest and exercise. J Appl Physiol. 1974;37:679–683.
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important, and this includes the volume of the fluid ingestedplus the volume of the gastric secretions. By giving repeatedboluses of solution into the stomach, it should be possible tomaintain a constant or nearly constant rate of gastricemptying.
Composition of Oral Hydration SolutionsThe composition of the optimal oral replacement fluid
has not been determined and will likely vary for differentindications. The World Health Organization has had greatsuccess with their slightly hypertonic ORS solution contain-ing glucose, sodium, chlorine, and bicarbonate. It is easilyformulated by adding WHO ORS powder packets to water(Table 4) Monafo used a 600-mOsm hypertonic lactatedsaline solution (HLSS) containing sodium, racemic DL-lac-tate, and chloride to orally resuscitate 10 burn injurypatients.42 Gatorade, Powerade, and other related sportsdrinks are low in sodium (5–20 mmol/L) because they aredesigned to replace perspiration losses and to be palatable.39
It seems logical that a solution similar to LR or HLSS withthe addition of glucose with an osmolarity range of 260 to330 mOsm/L given by drinking or infusion through an NGTcould rapidly be absorbed and provide the large volume andsodium necessary for burn resuscitation.
Oral Resuscitation after Burn InjuryBefore the 1930s, a 200-mOsm solution of sodium chlo-
ride was used orally in conjunction with IV fluid in themanagement of burn shock.37 Moyer et al. administeredblood and Locke’s solution enterally or intravenously toburned dogs.37 We have found only four references to oralresuscitation after burn injury, all of which suggest effective-ness (Table 5). Monafo, in a limited study of 10 patients,42
reported on resuscitation after major burn injuries using 600-mOsm HLSS in which patients were both orally and intrave-
nously resuscitated. Monafo reported “it was discovered thatHLSS solution (iced to be made palatable) was easily toler-ated orally in significant amounts without apparent GI dys-function.” He used HLSS to partially resuscitate four burnadults with 30% to 95% TBSA burns and three children with22% to 58% TBSA burns. These severely injured patients hadmostly full-thickness injuries. Patients received 10% to 60%of their fluid loading in the first 24 hours from oral fluids; alarger 60% to 90% of fluid loading in the second 24 hourswas from oral delivery. One wonders how much ice andvolume and dilution occurred in Monafo’s patients. Thisreport shows that at least partial oral resuscitation of severeburns can be successful and that it can be accomplished witha hypertonic solution without glucose. It was not clearwhether the solution was administered initially or after IVresuscitation was ongoing. Furthermore, from the data pre-sented, it is not possible to compare the relative effectivenessof oral delivery versus intravenous infusion. To our knowl-edge, this study of oral resuscitation of large full-thicknessburns with HLSS has never been followed up either clinicallyor experimentally.
El-Sonbaty recently reported good results with oral re-suscitation of 20 children with 10% to 20% TBSA burns,using the WHO ORS.43 The depth of the burns was notpresented, but we can assume that most of the patients did notpresent in burn shock, as the children’s mothers, under thesupervision of a nurse, administered the oral hydration. Thevolume and rate of oral hydration with WHO ORS in thisstudy was identical to the standard Parkland formula. El-Sonbaty reported that oral hydration was as effective as IVLR Ringer’s, also administered at the Parkland rate in 20control patients. Again, there is no way to accurately comparerelative vascular expansion or effectiveness of the twogroups. Burn injuries of 10% to 20% TBSA do not necessar-ily induce hypovolemic shock. Patients in both groups devel-
Monafo42 Adults and children (n � 9) 10–90 Hypertonic lactated saline 600El-Sonbaty43 Children (n � 10) 10–20 WHO ORS 331Jiang44 Anesthetized dogs (n � 7) 30 Glucose/NaCl/HCO3 Burn
Drink347
Thomas(unpublished)
Anesthetized pigs (n � 5) 40 WHO ORS 331
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oped hyponatremia (125–130 mEq/L) on day 5 postinjury,but otherwise had unremarkable outcomes. A comparison oforal hydration solutions versus IV solutions, shown in Table4, suggests that hyponatremia may be a problem with mostoral formulations and that oral resuscitation of burned pa-tients may require a higher sodium concentration solution,such as that used by Monafo.
Jiang reported the only preclinical controlled study oforal resuscitation that we have found.44 Anesthetized dogswere inflicted with a 30% partial-thickness burn and thentreated with a 347-mOsm “burn drink” of glucose NaCl andNaHCO3 (Table 4). Total volume administered over 24 hourswas the Parkland formula, 4 mL/kg/% TBSA burn. Controlswere untreated burn and burns treated with a 1:10 dilution ofthe burn drink (35 mOsm). Impressive improvements inplasma volume, cardiac output, and urine output were shownfor oral resuscitation, but only for the more concentrated347-mOsm burn-drink group.
On the basis of these encouraging data, we have performedexperiments in isoflurane-anesthetized pigs subjected to a full-thickness 40% TBSA burn injury and resuscitated with gastric orintestinal infusion of WHO ORS. Pigs have a GI system similarto humans. These studies in severe burns treated by GI resusci-tation demonstrated that there could be significant gastric emp-tying, intestinal absorption, plasma volume expansion, diuresis,and hemodynamic improvements.
Intestinal absorption was measured with phenol red (32mg/L) continuously infused and mixed with the WHO ORSinto the proximal duodenum at the Parkland rate of 350 mL/hafter a 40% TBSA burn injury in a 35-kg anesthetized pig. Atriple-lumen intestinal feeding catheter was placed in theintestine though a small surgical opening in the stomach.Sampling from two distal intestinal sites, 5 and 25 cm distalto the infusion site, allowed the measurement of downstreamconcentration of phenol red and the calculation of fluidabsorption.45,46 Figure 4 shows calculated intestinal absorp-tion before and for 3 hours after burn injury. The averagepostburn absorption rate calculated per meter length of intes-tine was 83.3 mL/h, suggesting that it would take 4 m ofintestinal length to fully absorb a volume equal to the Park-land rate. The duodenojejunal intestine in a 30- to 35-kg pigis approximately 5 to 6 m long. We measured plasma volumeexpansion and hemodynamic improvement after intestinalinfusion. Baseline cardiac output of 5.1 L/min fell to 3.8L/min at 60 minutes postinjury, but increased to 5.8 L/minafter 2.5 hours. Base excess/deficit and lactate both showimprovement with resuscitation (Fig. 5). Plasma volume (in-docyanine green dilution) was decreased by burn injury andthen increased after intestinal infusion by 6.3 mL/kg, a valueequal to 18% of the intestinal dose of WHO ORS. Ourprevious studies of intravenous resuscitation of burn injuryshow that only 10% to 15% of intravenous lactated Ringer’ssolution typically remains in the circulation after burninjury;22 thus, enteral resuscitation may provide a level ofvolume expansion similar to that of IV infusion.
Gastric InfusionsWe measured gastric emptying during gastric infusion of
WHO ORS and vascular volume and hemodynamics in twostudies. In the first study, we infused WHO ORS at a fixedrate of 10 mL/h (Parkland rate for 40% TBSA burn injury) for90 minutes before and for 150 minutes starting at 30 minutespostinjury (Fig. 6). Gastric volume was measured every 30minutes with additional small doses of concentrated phenolred using the method of George and Hunt.47,48 Figure 6shows cumulative infused volume and cumulative gastricemptying. Gastric emptying is apparent both before and afterburn, but at a rate approximately half that of the infusedParkland rate. Hemodynamics improved, but not to a levelconsistent with good resuscitation.
Figure 7 shows data from an experiment with a gastricinfusion rate increased to twice that of the Parkland rate.Cardiac output decreased after burn injury and increased afterresuscitation. Blood hemoglobin shows hemoconcentrationafter burn injury and hemodilution during resuscitation,whereas urine output increased to Parkland target levels of0.5 mL/kg/h or better after 2 to 3 hours of resuscitation. Boththe tracer measurement of gastric emptying and the fluidcontent measurements of the stomach and intestine producedsimilar results; they showed that half of the gastric infusionleft the stomach and nearly all of this volume was absorbed.Thus, a Parkland volume was administered to the circulationwhen WHO ORS was infused into the stomach at two timesthe Parkland rate. We have not performed studies with IVresuscitation in this model, but our experience with similarsheep models suggests that oral resuscitation may have aslower initial onset of hemodynamic effectiveness but that,after 3 to 4 hours, it can be similarly effective.
Fig. 4. Intestinal absorption is shown during intestinal infusion ofWHO ORS and phenol red in a 40% TBSA full thickness burn-injured anesthetized pig. Solution infused at Parkland rate or 10ml/kg per hour. Absorption measured with sampling from a triplelumen intestinal catheter as described in references 45, 46.
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Burn Care in the Tactical Combat SituationButler et al. established stages of care for use in the
special operations forces, which serves as an excellent frame-work for examining the tactical management of battlefieldcasualties.49 The stages of care described are as follows: (1)care under fire (the care rendered by the medic or buddy aidat the scene while the casualty is still under effective hostile
fire); (2) tactical field care (care rendered by the medic orcorpsman when the casualty is no longer under effectivehostile fire; and (3) combat care evacuation (care occurringonce the casualty has been picked up by an aircraft/vehicle/boat). The medical management of the casualty under thesesituation takes into consideration such factors as “enemy fire,medical equipment limitations, widely variable evacuationtime, tactical considerations, and the unique problems en-tailed in transporting casualties that occur in specialoperations.”49 Advanced Trauma Life Support was not de-signed for use in the combat environment. It was designed forhospital use under optimal conditions. The question that canbe asked is, “Given these set of constraints, how should themedic manage the burned soldier?”
Stage 1: Care Under FireThe first priority is to stop the burning process. In most
cases, cold water will stop the burning process and reduceheat damage. However, with extensive burns, water coolingmay cause hypothermia and should be avoided with largeburns when its use will lower body temperature. Assumingthat the soldier is conscious, the use of an oral rehydrationfluid could be self-administered or given by combat lifesaveror buddy aid. The resuscitative process would begin evenwhile under hostile fire. Mixed in a canteen, the ORS couldbe given almost immediately. In the unconscious patient, thethrust of care at this point would be to retrieve and return the
Fig. 6. Cumulative gastric infusion and gastric emptying is plottedfor a 90 min gastric infusion before and for 160 min after a 40%TBSA burn injury in an anesthetized pig. Gastric emptying measuredwith dilutions of small samples phenol red as described in refer-ences 47, 48.
Fig. 5. Base excess and lactate measured serially measured before and after a 40% TBSA injury in an anesthetized pig resuscitated withintestinal infusion of WHO ORS as described in Figure 4.
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patient to a safe area as soon as the tactical situation allows.As in all tactical scenarios, the person rendering aid shouldcontinue to return fire, prevent further injury to the causalityor injury to him- or herself, and attempt to bring the causalityto a place of safety as soon as the tactical situation allows.
Stage 2: Tactical Field CareIf IV access is obtained and adequate lactated Ringer’s is
available, standard Parkland resuscitation can be started. Ifnot, hypertonic resuscitation and/or oral fluids should beconsidered. If we look at a 70-kg soldier with a 40% TBSA
burn injury, using the Parkland formula as a guide, we findthat the soldier will require 11,200 mL of fluid over the first24 hours, the first half of that to be given over the first 8hours.
In tactical situations where intravenous lines can bestarted, a 250-mL hypertonic saline could be administeredover 2 to 4 hours to maintain initial plasma volume expan-sion. This could in essence “prime the system,” allowing timefor oral absorption to occur, taking advantage of the delayfrom time of ingestion to effective intestinal absorption. Theearly saline infusion may prevent the decrement in intestinalabsorption and motility resulting from splanchnic ischemia.Gastric emptying is optimal at gastric volumes between 600and 800 mL. By continuing to give these fluids as a bolus ata rate of 4 mL/kg every 20 minutes, one can actually maintaina high rate of gastric emptying and satisfy fluid replacementrequirements. The use of prepackaged solution packets, sim-ilar to those of the WHO ORS, would be simple and easy touse. Each solider could actually carry some packets in his orher cargo pockets to be used for self-care or buddy aid.
We cannot overstate the fact that the primary determi-nant of mortality in thermal injury is the rapid and adequatereplacement of fluids. The actual type of fluid administered isless likely to be a factor than how promptly fluid therapy isbegun. As seen in the study by Wolf et al.15 of 103 childrenwith � 80% TBSA burn injuries, 69 children survived. Of thesurvivors, each had an intravenous line started in 0.6 � 0.2hours. In the 39 nonsurvivors, it took 2.2 � 5 hours to get anintravenous line started (Fig. 1).17 The longer it takes toestablish vascular access and administer fluids, the morelikely it is that burn victims will die. In patients sustainingmassive burn injuries that have a greater than 4-hour delaybefore fluid administration, the chances of surviving becomepractically zero.
Resuscitation should begin during tactical field care if atall possible. The longer the delay, the larger the patient’sinitial volume deficits. After the initial ABCs, fluid must beadministered either orally, by NGT, IV, or by a combinationthereof. Some special operations teams “precannulate” beforecombat deployment, and have had excellent results. This isbest suited for short-term, direct-action missions. This cannotbe routinely recommended but, depending on the unit and/ormission, it is a viable option that facilitates rapid fluid re-placement under duress.
The delivery of fluids via intraosseous (IO) injectionseems ideally suited to this environment and has been rec-ommended for combat casualty care.50 When there are delaysbecause of difficulties establishing intravenous lines, IO nee-dles would provide rapid access, and are easy to insert afterminimal training. Most importantly, during the chaos thatoccurs in combat, the IO technique is not likely to be forgot-ten and requires minimal technical skills to perform. In theburn patient, intravenous access can be extremely difficult toobtain secondary to edema and eschar.49 Two new IO devicesfor adults have recently been introduced (Pyng Medical and
Fig. 7. Cardiac output, blood hemoglobin concentration and urineflow rate plotted before and after a 40% TBSA burn injury in ananesthetized pig. The only resuscitation was provided by gastricinfusion of WHO ORS started 60 min after injury. Data suggests thatgastric infusion of WHO ORS effectively increases vascular volumeand hemodynamics after a moderate burn injury.
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WaisMed) and may facilitate the utility of IO access. Animalresearch has suggested acute resuscitation efficacy with IOdelivery of hypertonic saline dextran; however, a recent re-port suggests that soft tissue and bone necrosis can develop 2to 4 days after treatment.51,52
Along with the other discussants, we recommend as aninitial resuscitative fluid the use of HSD administered at aslow rate of 2 mL/kg/h. This will expand the plasma volumeand initially stabilize the patient. We also advocate that eachsoldier carry one 250-mL 7.5% hypertonic saline-dextranintravenous packet in his cargo pocket. This accomplishestwo things: first, it decreases the load the medic must carry;second, it makes the provision of fluid replacement that mucheasier if fluids do not have to be located before use. It is in thefield that the massive fluid losses must be replaced with orwithout an NGT placement. Continuous oral replacementshould be considered. An initial 500- to 600-mL bolus, ap-proximately a canteen with one packet of rehydrating solutes,followed by bolus feedings of 2 to 4 mL/kg every 20 minutesshould maximize gastric emptying. This could theoreticallymeet the patient’s ongoing resuscitative needs and could beadministered by virtually anyone, freeing up the medic forother patient management. The ideal fluid replacement“drink” for burn shock is yet unknown but should be inves-tigated. Once established, such a formulation could be storedin small, lightweight, individual packets. The individual sol-dier should carry these as well.
We are suggesting the use of new solutions and oraltherapy for the management of burn injury in an environmentwhere long delays in evacuation may occur, but these con-cepts require further research regarding their efficacy andsafety before they can be fully implemented. At present, westill must rely on intravenous therapeutics to maintain ther-mally injured patients.
Stage 3: Combat Casualty Evacuation CareCare at this level depends somewhat on the level of care
provider accompanying the evacuation vehicle (physician,nurse, physician assistant, or medic). Resuscitation must con-tinue. A definitive airway may be needed. A full secondarysurvey can begin at this time. Advanced Trauma Life Supportprotocols should begin here. Burn dressings need to be ap-plied. Escharotomies should be performed as necessary.
CONCLUSIONS AND FUTURE DIRECTIONSThe optimal resuscitative regimen has yet to be devel-
oped for combat casualty care of burn injuries. Substantialanimal research into the use of colloids and hypertonicsolutions and studies of their use by many burn centershave demonstrated early volume-sparing effects. HSD hasbeen shown to safely reduce volume requirements andreduce mortality in penetrating trauma.53,54 HSD is inclinical use in Europe and should be considered for use byNATO medics to generate data on the military use of HSD.There is also evidence that HSD optimizes burn outcomes
compared with large volumes of isotonic crystalloids.However, the key question is, are the clinical outcomesbetter or equivalent with hypertonic or colloid solutions ortheir combination compared with isotonic fluids whenearly volume must be limited? The answer awaits actualuse in military operations, as controlled trials are likely tobe impossible to perform.
Further evaluations on the safety of IO infusion of HSDare needed, and until then can only be recommended forisotonic fluids. Theoretically, oral replacement may providean alternative for the combat situation. However, the theoryneeds to be tested in controlled animal trials to evaluate itseffectiveness. Our preliminary data, along with those ofJiang,44 suggest that oral replacement can be effective inrestoring plasma volume and maintaining hemodynamic sta-bility. Oral fluids have traditionally been contraindicated be-fore surgical stress and for patients in hemorrhagic shock,burn shock, or trauma. It is likely that oral hydration solutionswill never be recommended for abdominal or thoracictrauma. However, in burn injuries, there should be no directcompromise of the GI tract. However, the only studies weknow of (Table 5) suggest that oral resuscitation can be usedto resuscitate burn shock in animals and humans. Thesestudies need to be followed up to fully evaluate the mecha-nisms, efficacy, and any deleterious effects. Different oralresuscitation regimens and formulations need to be comparedin moderately and severely burned models.
We suggest that oral hydration solutions may be lifesav-ing in conditions where intravenous therapy is logisticallyimpossible. It could be considered in special operations war-fare or mass casualties when no alternatives exist. Further-more, there may be advantages to early intestinal or enteralresuscitation even if it can only be performed in hospitals.Although early enteral feeding has been traditionally avoidedin burn patients, it has recently been demonstrated to be safeand effective for nutrition when started immediately withhospital care of patients with large burns or used before,during, and immediately after surgery of burned patients.55,56
It is possible that the gut will benefit from early enteralresuscitation, particularly when specific nutrients are in-cluded in formulations. Oral resuscitation may increase in-testinal blood flow and result in better maintenance of gutbarrier integrity.
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