Progress in the care of burn victims
From the US military to civilian air medical transport, Amy Gallagher explores decades of discoveries and developments in best practices, medical equipment and technological advancements that have shaped medical care in the air for burn patients
In the second half of the 20th Century, the chance of survival after a severe burn increased consistently due to a cumulative cadre of innovations, research studies, and technological advancements, including improved formulas for fluid resuscitation and early excision of burn wounds, all of which have led to more effective patient stabilization and decreased mortality rates.
While outcomes for burn patients have improved dramatically, about 450,000 people in the US receive medical attention for burn injuries per year; and, of those, an estimated 4,000 die annually from fire and burns, per the American Burn Association (ABA).
Answering the call to provide improved care for those burn patients is the air medical transport burn flight teams in both the military and civilian sectors.
Swift care, quick transport
Since 1949, the US Army Institute of Surgical Research (ISR) Burn Flight Team (BFT) has provided aeromedical evacuation of burn patients, while providing worldwide assessment, evaluation and treatment of casualties sustaining thermal injuries related to both combat and non-combat events.
According to Leopoldo C. Cancio, MD, FACS, Director, ISR Army Burn Center, the biggest changes are the applications of Continuous Renal Replacement Therapy (CRRT) and the Extracorporeal Membrane Oxygenation (ECMO) machines to the armamentarium of the Center’s BFT. “This enables worldwide evacuation of casualties whose organ failure severity would normally make them unsalvageable,” said Cancio, who joined the staff as a burn surgeon in 1995. In 2014, Cancio retired from the Army and now works as a government civilian in the same position.
‘Test bed’ for high technology
The envelope with respect to how technology is used is constantly being pushed, explained Cancio: “The CRRT and ECMO programs are good examples. The Burn Center employs some of the hardest working and most talented nurses. It’s not surprising that the CRRT and ECMO programs were started in the Burn Center and thereafter migrated to the rest of the hospital.”
In fact, the Burn Center serves as a ‘test bed’ for high-technology solutions for critically ill patients. “The development and fielding of the Army’s Special Medical Emergency Evacuation Device (SMEED) platform has also strengthened the air medical evacuations during recent conflicts,” Cancio told AirMed&Rescue. The SMEED platform attaches to the standard National Atlantic Treaty Organization (NATO) litter, and provides a solid, but lightweight platform, onto which the ventilator, monitor, pumps, and suction machine are secured.
Earlier excisions, lower infections, faster evacuations
Early burn wound excision is now performed within the first few days after burn injury and has resulted in improved survival and infection control in severely burned patients. “The leading cause of burns sustained on the recent battlefields of Iraq, Afghanistan, and Syria has been the improvised explosive device (IED),” said Cancio. Since the Army began receiving casualties from the wars in 2003, it has emphasized earlier excision, a surgical procedure where the burn wound is removed in the operating room, followed by grafting of the burn wound, he explained.
Faster evacuation means faster surgical treatment, and eventually recovery
“The burn wound serves as a portal for infection to enter the body, as well as a stimulus for inflammation,” Cancio explained. “The sooner we can remove the burned skin and achieve wound closure through healing, the lower the risk of infection and the faster the inflammatory process resolves.”
Since 2003, the BFT has been transporting burned combat casualties from the US military hospital in Landstuhl, Germany, to the Burn Center in San Antonio. With greater efficiency in aeromedical evacuation and transport, burned combat casualties have arrived at the Burn Center three to four days after injury.
"Faster evacuation means faster surgical treatment, and eventually recovery,” said Cancio.
Finding the ‘sweet spot’ for optimal care
“The main challenges in flight are perennial,” said Cancio. “Placing a critically ill burn patient on an aircraft requires a careful balance of the risks and benefits of flight.” Evacuating a patient while performing ongoing burn-shock resuscitation is problematic, he said. “The risks include over- or under-resuscitation, either of which can be lethal,” he continued. Postponing transport is also problematic; the risks of pneumonia, wound infections, and other complications mount with each day postburn. “It is important to find the ‘sweet spot’ – as soon as possible after resuscitation, day two post-burn – may be the safest time for transport.”
Burn care has been recognized as a multidisciplinary team effort since at least World War II. “Our most important innovation [since then] is not technological, but human,” explained Cancio. “During the recent conflicts, and beyond, we’ve enhanced the way we ‘do’ teamwork even further.” This effort to build stronger, more effective teams results in providing safer care, he said.
Airway management ‘top of the list’
Air Method Corporation’s Tina Giangrasso, Senior Vice-President of Clinical Services, said that for her, airway management is at the ‘top of the list’ in terms of improvements to burn patient care.
Evidence-based research practices of administering a new formula of fluid with one liter of ascorbic acid (vitamin C) over a 24-hour period strengthens cell membranes so a lot less fluid is required, lessening ventilator time, said Giangrasso. “The past decade has also delivered advanced technological practices, including the C-MAC videolaryngoscope,” said Giangrasso.
The blade is inserted into a patient’s airway to pass a breathing tube into the trachea, which has been one of the biggest improvements in available technology, she explained. “Effectively implementing C-MAC intubation for airway management when patients have an airway injury and need to be intubated can be challenging,” she said. This can be a very risky procedure requiring clinical expertise, said Giangrasso.
Identifying the tactical, operational and strategic
Within the past decade, BFT Chief Flight Nurse Michael Mueller, RN, said implementing the Joint Trauma System (JTS) has proven to be the most beneficial for the BFT: “The JTS has to be one of the best improvements to patient outcomes in the past 10 years. This system is widely credited to our previous ISR commander, who envisioned the tactical need, the operational need, and the strategic need to deploy a trauma system.”
The JTS is dedicated to the reduction of morbidity and mortality, and to improved survivability for all trauma patients in wartime and peacetime. “We employ an organized approach to provide improved trauma care across the continuum of care to trauma patients – battle injury and non-battle injury,” Mueller said.
Early activation enhances initial care
Clinical Staff Development Specialist for Air Evac Lifeteam, Sue L. Parrigin, said the company’s advancements include:
- Advanced airway management,
- Utilization of mechanical ventilation,
- Fluid resuscitation, and
- Pain management.
Advances in pain management in the field have enabled air medical crew members to safely manage pain
"Advances in pain management in the field have enabled air medical crew members to safely manage pain,” she said. “Early activation of air medical services provides rapid access to initial management of airway and lung injuries, and initiation of fluid resuscitation, have enhanced the initial care of burn patients.”
Triage and rapid transport of patients to regional burn centers, allowing early excision and treatment of burn wounds, have decreased the overall mortality, said Parrigin.
A host of options for better care
Clinicians working with burn patients, whether military or civilian, have a multitude of care options available to them now, thanks to the hard work, innovation and dedication of the teams working with patients, and behind the scenes developing new technology and care pathways. Immediate, high-level care at the scene, followed by swift extraction to the nearest centre of excellence, means that survival and recovery rates will continue to improve – as long as HEMS bases can continue to serve their local communities.
New algorithm, ‘more straightforward’
“Airway and breathing support with humidified oxygen and fluid resuscitation with warm fluids, with the next step in the algorithm to assess circulation,” Purdom told AirMed&Rescue.
The ability to rapidly assess burn depth with a new algorithm has generated greater understanding through widespread educational efforts. “We are seeing many clinics, hospitals and EMS systems applying the latest burn care algorithms to the burn patient, which helps in the successful care and treatment,” said Thompson.
While assessing burn depth can be subjective, the new algorithm is more straightforward, said Purdom. “In the past, we used to do our best to immediately identify a TBSA greater than 20 per cent to know the amount of partial-thickness burns (2nd degree) and full-thickness burns (3rd degree),” said Thompson. “We immediately begin fluid replacement to identify the exact fluid calculations. This process has changed since I started working in EMS. Now, if the burn is greater than 20 per cent, we don’t spend valuable time estimating the TBSA.”
In addition, the TBSA uses the ‘rules of nine’ based on the size of the patient’s hand, including the fingers (valued at one per cent), explained Purdom. (see graphic below)
After a rapid assessment of the burn severity, preventing hypothermia is an ongoing challenge, but improved with corporate innovation. ASTNA board member-at-large Casey Thompson is a Clinical Education Manager, Life Flight Network. She told AirMed&Rescue: “Keeping patients warm in Montana can be a challenge, especially during below-zero temperatures. This led to the production of an insulated blanket designed with Life Flight specifications.” These blankets, along with the aircraft heat, are warming blankets for normothermia.
Life Flight Network services the Pacific Northwest and Intermountain West from bases throughout Oregon, Idaho, Montana, and Washington. “In rural areas, we may be the first EMS on scene and sometimes the only provider caring for the burn patient,” she said.
In addition to the burn injury, Thompson and her partner, a paramedic, look for other injuries that could be lethal, such as circulation issues to rule out shock and head injuries. Among all of the medical equipment, advanced technological devices, monitors, and tubes, there is always room for the basic touch, from one human to another.
“I am a big believer in the power of touch and kindness,” she said. “I immediately place my hands on the patient’s arm and introduce myself to let them know I’m going to provide excellent care. A smile and an introduction can go a long way in reducing the patient’s anxiety.”
Best practices in sepsis prevention
Infection and sepsis are among the most prominent causative factors in burn-related mortality and morbidity, stated NIH research.
As an Air & Surface Transport Nurse Association (ASTNA) member and past-president, Sharon Purdom, Flight Nurse and National Clinical Education Manager for Med-Trans Corporation, noted the greatest changes to burn patients include the administration and monitoring of fluid resuscitation, and best practices in sepsis prevention.
Sepsis is a major cause of death in our severe burns patients
"Sepsis is a major cause of death in our severe burns patients,” she explained. “While we have a much better understanding of sepsis in our trauma and critical disease patients, sepsis in burn patients is much different. The burn patient continues to be at risk and requires constant monitoring for any subtle changes.”
Close monitoring includes rapid shock resuscitation, early escharotomy, enclosure of burn wounds, metabolic support, immunoregulation and anti-inflammation, and reinforcement of organ support.