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Joint Theater Trauma System Implementation of Burn Resuscitation Guidelines Improves Outcomes in Severely Burned Military Casualties

Ennis, Jody L. RN, BSN; Chung, Kevin K. MD; Renz, Evan M. MD, FACS; Barillo, David J. MD, FACS; Albrecht, Michael C. MD; Jones, John A. BS, BBA; Blackbourne, Lorne H. MD; Cancio, Leopoldo C. MD, FACS; Eastridge, Brian J. MD, FACS; Flaherty, Steven F. MD, FACS; Dorlac, Warren C. MD; Kelleher, K S. MD; Wade, Charles E. PhD; Wolf, Steven E. MD, FACS; Jenkins, Donald H. MD; Holcomb, John B. MC

The Journal of Trauma: Injury, Infection, and Critical Care: February 2008 - Volume 64 - Issue 2 - p S146-S152
doi: 10.1097/TA.0b013e318160b44c
Presented Papers

Background: Between March 2003 and June 2007, our burn center received 594 casualties from the conflicts in Iraq and Afghanistan. Ongoing acute burn resuscitation as severely burned casualties are evacuated over continents is very challenging. To help standardize care, burn resuscitation guidelines (BRG) were devised along with a burn flow sheet (BFS) and disseminated via the new operational Joint Theater Trauma System to assist deployed providers.

Methods: After the BRG was implemented in January 2006, BRF data were prospectively collected in consecutive military casualties with >30% total body surface area (TBSA) burns (BRG Group). Baseline demographic data and fluid requirements for the first 24 hours of the burn resuscitation were collected from the BFS. Percentage full thickness TBSA burns, presence of inhalation injury, injury severity score, resuscitation-related abdominal compartment syndrome, and mortality were collected from our database. Individual charts were reviewed to determine the presence of extremity fasciotomies and myonecrosis. These results were compared with consecutive military casualties admitted during the 2-year- period before the system-wide implementation of the BRG (control group).

Results: One hundred eighteen military casualties with burns >30% TBSA were admitted between January 2003 and June 2007, with n = 56 in the BRG group and n = 62 in the control group. The groups were different in age, but similar in %TBSA, %full thickness, presence of inhalation injury, and injury severity score. There was no difference in the rate of extremity fasciotomies or the incidence of myonecrosis between groups.

Conclusions: The composite endpoint of abdominal compartment syndrome and mortality was significantly lower in the BRG group compared with the control group (p = 0.03). Implementation of the BRG and system-wide standardization of burn resuscitation improved outcomes in severely burned patients. Utilization of the joint theater trauma system to implement system-wide guidelines is effective and can help improve outcomes.

From the United States Army Institute of Surgical Research (J.L.E., K.K.C., E.M.R., D.J.B., M.C.A., J.A.J., L.H.B., L.C.C., B.J.E., C.E.W., S.E.W., J.B.H.), Fort Sam Houston, Texas; Landstuhl Regional Medical Center (S.F.F., W.C.D.), Landstuhl, Germany; National Naval Medical Center (K.S.K.), Bethesda, Maryland; Wilford Hall Medical Center (D.H.J.), San Antonio, Texas.

Submitted for publication October 30, 2007.

Accepted for publication October 30, 2007.

Disclaimer: The views expressed herein are those of the authors and do not necessarily reflect those of the Army Medical Department or the Department of Defense.

Address for reprints: Jody L. Ennis, RN, BSN, USAISR Burn Center, 3400 Rawley E. Chambers Drive, Fort Sam Houston, TX 78234; email:

© 2008 Lippincott Williams & Wilkins, Inc.