相關筆記
Wilderness Medical Society Clinical Practice Guideline on Care of Burns in the Wilderness (WEM volume 36 Issue 4, December 2025)
這篇指引是給醫護人員看的. 一般民眾可能不容易理解, 有些
重點整理.主要針對到院前的處置
1. 燒傷創面冷卻療法(Cooling of burn wounds), 燒傷面積小於體表面積10%（TBSA）的，儘快用12至18°C（53至64°F）的水沖洗20至30分鐘。
2. 如果沒有流動的水，也可浸泡在冷水中。
3. 在受傷後60分鐘內開始冷水療法(Cool water therapy)，仍然有效。
4. 冷水療法可減少燒傷深度、體表面積燒傷面積（TBSA）降低、植皮需求減少、癒合時間縮短, 也有助於控制疼痛。
5. 多數情況, 水泡若能保持完整儘量不弄破. 維持水泡完整可降低感染率.可減少疼痛. 已經破裂的水泡或很可能破裂的水泡可清除. 用針抽吸(aspiration)水泡內的液體或者將水泡整個移除(去頂)各有優缺點. 細針抽吸引流可以避免水泡自己破裂, 避免傷口受到汙染. 恢復較快(水泡能維持傷口濕度,也有物理性保護的效果)
6. 淺層二度燒燙傷可使用吸水性泡棉敷料
7. 深二度燒燙傷可使用抗生素藥膏或蜂蜜(指引內容說支持使用蜂蜜的文獻很多); 抗生素軟膏優於過去常使用的磺胺銀. 若12-24小時內可送到醫院則不用先塗藥膏(藥膏是為了降低未來一兩天的感染)
(其他可作為臨時燒燙傷敷料的東西包括:綠茶、木瓜醬、獼猴桃、薑黃和椰子油.可生物降解的臨時基質、聚乳酸皮膚替代物、透明質酸酯基質和去細胞魚皮移植片)
(中文使用google翻譯)
摘要
為了指導臨床醫生在偏遠地區護理燒傷患者的最佳實踐，荒野醫學會召集了一個專家小組，制定了一份基於循證醫學的臨床實踐指南。指南提出了現場緊急護理的建議，並根據美國胸腔科醫師學會的標準，對支持性證據的品質以及治療風險和潛在危害的平衡性進行分級。
引言
全球每年有超過800萬人因燒傷而受傷，其中18萬人死亡，低收入和中等收入國家的疾病負擔最為沉重。 燒傷佔荒野地區所有傷害的2%至9%。面積較小、傷情較淺的燒傷通常可以順利癒合，並在現場進行處理，但重度燒傷患者需要轉運。本實踐指引旨在降低野外及其他資源匱乏地區燒傷患者的發生率。它側重於偏遠地區燒傷患者護理的特殊方面，並非旨在取代關於燒傷患者護理的一般知識。
摘要
為了指導臨床醫生在偏遠地區護理燒傷患者的最佳實踐，荒野醫學會召集了一個專家小組，制定了一份基於循證醫學的臨床實踐指南。指南提出了現場緊急護理的建議，並根據美國胸腔科醫師學會的標準，對支持性證據的品質以及治療風險和潛在危害的平衡性進行分級。
引言
全球每年有超過800萬人因燒傷而受傷，其中18萬人死亡，低收入和中等收入國家的疾病負擔最為沉重。 燒傷佔荒野地區所有傷害的2%至9%。面積較小、傷情較淺的燒傷通常可以順利癒合，並在現場進行處理，但重度燒傷患者需要轉運。本實踐指引旨在降低野外及其他資源匱乏地區燒傷患者的發生率。它側重於偏遠地區燒傷患者護理的特殊方面，並非旨在取代關於燒傷患者護理的一般知識。
方法：
我們在PubMed資料庫中檢索了一系列文獻，主題包括初步穩定、燒傷急救、燒傷面積和深度的評估、水皰的處理、液體復甦、燒傷敷料、疼痛管理、疏散以及遠距醫療的應用。文章由專家小組進行審查，並根據其在艱苦環境下的適用性進行優先排序，然後根據證據強度進行分級。證據強度分級採用美國胸腔科醫學會（ACPC）的分類方案。 對於證據薄弱或缺失的主題，我們參考了野外和燒傷專科醫生的專業知識來補充建議。
現場評估：
初步評估：
在確保現場安全後，對燒傷患者的初步評估遵循創傷復甦的典型優先順序。13,14燒傷通常外觀觸目驚心，若未對患者進行系統性評估，則可能遺漏其他嚴重病灶。該評估應遵循 ABCDE 原則，即氣道、呼吸、循環、功能障礙以及暴露和環境控制。 燒傷患者氣道管理的傳統指徵包括鼻毛燒焦、口腔或痰液中有煙灰、聲音沙啞、喘鳴或明顯呼吸困難。
有鑑於許多在到達燒傷中心前接受氣管插管的患者可能並不需要插管，促使美國燒傷協會提出了更嚴格的插管標準：對於出現氣道阻塞症狀（如聲音沙啞或喘鳴）、全層面部燒傷、呼吸窘迫、上呼吸道創傷、無法清除分泌物、精神狀態改變、低氧血症、高碳酸血症或血流動力學不穩定的患者，應進行氣管插管。目前尚缺乏足夠的證據指導在燒傷患者中使用鼻咽通氣道或聲門上通氣道，但如果氣道管理的指徵是上呼吸道水腫，則這些通氣道可能無效。 曾有報導稱，一名被雷擊的患者成功接受了現場環甲膜切開術。 如果具備適當的藥物和設備（包括鎮靜劑和可能的肌肉鬆弛劑），則應為有現場氣道管理指徵的患者進行氣管插管。如果患者有插管指徵，但現場沒有進行經口或經鼻氣管插管的設備，則可能需要建立外科氣道。現場氣道管理難度極高，可能需要等待具備高階氣道管理技能、設備和藥物的救援人員。
燒傷患者通常不會出現精神狀態改變，一旦出現，應進一步評估其原因，例如低血壓、頭部損傷或吸入性中毒。雖然最近的一例病例報告對這一傳統觀念提出了挑戰，但人們通常認為露天火災中吸入性損傷和吸入性中毒的情況很少見。該病例報告描述了一名燒傷死亡患者，他在自家院子裡焚燒灌木和生活垃圾時，吸入了致命濃度的一氧化碳和可測量的氰化物。吸入性損傷是由暴露於火焰或過熱氣體、顆粒物和化學刺激物以及吸入煙霧和肺組織局部缺氧引起的。 露天火災中的熱和煙霧往往會消散。
一氧化碳和氰化物是火災中可能存在的特定吸入性毒素，會導致患者精神狀態改變。一氧化碳中毒的典型症狀是精神狀態改變，少數患者會出現典型的櫻桃紅唇。 治療方法是將病人轉移到空氣流通的地方，並在條件允許的情況下給予氧氣。在房屋火災中，氰化物會從家具墊和地毯等合成材料的燃燒中釋放出來，但氰化物也會從塑膠、乙烯基、紙張和羊毛等戶外休閒用品的燃燒中釋放出來。 補充氧氣有助於氰化物中毒的治療，而根治性治療方法是給予氰鈷胺素或硫代硫酸鈉合併亞硝酸鈉。
燒傷患者的低血壓繼發於血管內液體滲漏至細胞外間隙或第三間隙，通常在初始損傷後 6 至 12 小時才會出現，因此，在初步評估期間發現低血壓需要評估是否存在其他創傷。
建議：
我們建議燒傷患者的初步評估應遵循創傷照護的一般原則。
等級：強烈推薦，高品質證據。
我們建議對燒傷後早期出現精神狀態改變或低血壓的患者進行評估，以排除其他病因。
我們建議對燒傷後早期出現精神狀態改變或低血壓的患者進行評估，以排除其他病因。
等級：強烈推薦，中等品質證據。
急救
衣物可能繼續陰燃，因此應立即撲滅任何明火，並將燒焦的衣物從患者身上移除。應移除所有肢體上的首飾和任何可能隨著時間推移而收緊或束縛的物品，並進行仔細的血管檢查。
燒傷創面冷卻療法已應用數百年。燒傷面積小於體表面積10%（TBSA）的，應在燒傷發生後儘快用12至18°C（53至64°F）的水沖洗20至30分鐘。 如果 沒有自來水，浸泡在冷水中也是可以接受的。如果在受傷後60分鐘內開始冷水療法，仍然有效。飲用水優於未經處理的地表水，但使用未經處理的水會增加感染風險的證據很少。不應使用冰，因為在豬模型中，與冰相比，冷水能更快促進上皮再生。 我們沒有找到關於使用雪的證據，但不建議直接將雪敷於燒傷創面，因為雪的性質與冰相似。但是，雪可以用來冷卻治療用水。冷水療法的使用與燒傷深度減少、體表面積燒傷面積（TBSA）降低、植皮需求減少、癒合時間縮短有關。 冷水療法也有助於控制疼痛。體溫過低在體表面積燒傷面積較大的患者中更為常見，且與死亡率升高有關。其他體溫過低的危險因子包括現場停留時間延長、年齡較大、需要氣道管理、精神狀態改變。目前尚無充分證據支持在現場安全降溫的最大體表面積。救援人員應權衡在環境條件和預計到達最終治療地點所需時間下發生體溫過低的風險，以及如果不進行冷水療法治療，更大或更深的傷口可能導致更高的發病率。
急救
衣物可能繼續陰燃，因此應立即撲滅任何明火，並將燒焦的衣物從患者身上移除。應移除所有肢體上的首飾和任何可能隨著時間推移而收緊或束縛的物品，並進行仔細的血管檢查。
燒傷創面冷卻療法已應用數百年。燒傷面積小於體表面積10%（TBSA）的，應在燒傷發生後儘快用12至18°C（53至64°F）的水沖洗20至30分鐘。 如果 沒有自來水，浸泡在冷水中也是可以接受的。如果在受傷後60分鐘內開始冷水療法，仍然有效。飲用水優於未經處理的地表水，但使用未經處理的水會增加感染風險的證據很少。不應使用冰，因為在豬模型中，與冰相比，冷水能更快促進上皮再生。 我們沒有找到關於使用雪的證據，但不建議直接將雪敷於燒傷創面，因為雪的性質與冰相似。但是，雪可以用來冷卻治療用水。冷水療法的使用與燒傷深度減少、體表面積燒傷面積（TBSA）降低、植皮需求減少、癒合時間縮短有關。 冷水療法也有助於控制疼痛。體溫過低在體表面積燒傷面積較大的患者中更為常見，且與死亡率升高有關。其他體溫過低的危險因子包括現場停留時間延長、年齡較大、需要氣道管理、精神狀態改變。目前尚無充分證據支持在現場安全降溫的最大體表面積。救援人員應權衡在環境條件和預計到達最終治療地點所需時間下發生體溫過低的風險，以及如果不進行冷水療法治療，更大或更深的傷口可能導致更高的發病率。
建議
我們建議將燒傷面積小於體表面積10%的傷口用涼水沖洗20分鐘。
等級： 強烈推薦，證據品質中等。
我們建議，如果存在體溫過低的風險，則不應在現場對燒傷部位進行冷卻。
我們建議，如果存在體溫過低的風險，則不應在現場對燒傷部位進行冷卻。
等級： 弱推薦，低品質證據
燒傷深度分類
最淺的燒傷被歸類為表皮燒傷。這類燒傷僅涉及表皮最外層。皮膚會發紅，觸感發熱。不會形成水皰，皮膚乾燥。由於未損傷深層的神經血管結構，這類傷口往往非常疼痛。表皮燒傷通常在受傷後一週內癒合，且不會留下疤痕。
根據感染風險和預期癒合情況，部分厚度燒傷可分為 2 個不同的類別。
表淺部分皮質燒傷後，真皮和表皮之間會在燒傷發生後的12至24小時內形成水皰。這些水皰通常較薄，容易自發性破裂。水皰破裂後，其下方的皮膚會濕潤滲液，受壓後容易變白。由於下方的組織結構未受損，因此這類傷口會非常疼痛。淺層部分皮質燒傷通常會在7至21天內癒合，很少會留下明顯的疤痕。由於水皰會在受傷後的最初幾天內形成，因此隨著燒傷的進展，定期評估傷口情況並根據傷口的變化重新計算燒傷面積非常重要。
深度二度燒傷涉及真皮深層，損傷毛囊和腺體組織。傷口呈濕潤或蠟狀，顏色斑駁，表面覆蓋焦痂。這類深層傷口比前文討論的淺層燒傷感染風險更高。預計自癒需要3至9週，且常伴隨增生性瘢痕。這類傷口需要專業的燒傷中心進行治療。
全層燒傷涉及表皮和真皮的所有層次，並延伸至皮下組織。這類傷口會導致皮下組織的神經血管結構受損，全層燒傷區域通常感覺喪失。初次評估時，燒傷焦痂通常仍完整，呈現黑色或皮革狀覆蓋。這類傷口無法自愈，需要由燒傷專科醫生進行切除和處理，以最大程度地減少攣縮和疤痕形成。
四度燒傷的特徵是筋膜、肌肉、肌腱和骨骼都受損。這種情況通常會導致肢體截肢，並且同樣需要專門的燒傷護理。
燒燙傷面積估算
燒燙傷面積的評估是燒傷患者初期照護的關鍵步驟。
體表面積百分比（%TBSA）的估算是基於淺二度燒傷、深二度燒傷和全層燒傷的面積。完整皮膚區域必須密切監測其轉化情況，但只有當傷口轉化為二度燒傷（以水皰形成為標誌）時，才將其計入體表面積百分比。
燒傷面積估算方法有多種。 「九分法」常用於成人，兒童和嬰兒則有改良版（圖1）。倫德-布勞德圖表以圖形方式呈現燒傷面積。 「手掌法則」指出，患者手掌（包括手指）的面積約佔其體表面積的1%。 此方法便於現場操作，但往往會高估燒傷面積，尤其當燒傷面積超過體表面積的10%時。
圖1.成人和嬰兒燒傷面積估算的「九分法」。經美國燒傷協會許可使用。
目前市面上有一些以智慧型手機為基礎的燒傷面積計算器，可以輔助計算燒傷面積。這些計算器是基於“九分法”計算，並且適用於成人。它們還可以根據計算出的燒傷面積百分比（%TBSA）和患者體重，提供燒傷液復甦建議。
對燒傷患者進行精確的體表面積燒傷百分比（%TBSA）評估至關重要，因為它決定了初始復甦液輸注速度和轉運決策。現場對燒傷面積的估計並不完全可靠，因為醫護人員常常高估%TBSA，尤其是兒童病患。
推薦
我們建議採用經過驗證的方法計算體表面積燒傷百分比（%TBSA），以指導復甦和轉運決策。 等級： 強烈推薦，證據品質中等。
燒傷面積估算方法有多種。 「九分法」常用於成人，兒童和嬰兒則有改良版（圖1）。倫德-布勞德圖表以圖形方式呈現燒傷面積。 「手掌法則」指出，患者手掌（包括手指）的面積約佔其體表面積的1%。 此方法便於現場操作，但往往會高估燒傷面積，尤其當燒傷面積超過體表面積的10%時。
圖1.成人和嬰兒燒傷面積估算的「九分法」。經美國燒傷協會許可使用。
目前市面上有一些以智慧型手機為基礎的燒傷面積計算器，可以輔助計算燒傷面積。這些計算器是基於“九分法”計算，並且適用於成人。它們還可以根據計算出的燒傷面積百分比（%TBSA）和患者體重，提供燒傷液復甦建議。
對燒傷患者進行精確的體表面積燒傷百分比（%TBSA）評估至關重要，因為它決定了初始復甦液輸注速度和轉運決策。現場對燒傷面積的估計並不完全可靠，因為醫護人員常常高估%TBSA，尤其是兒童病患。
推薦
我們建議採用經過驗證的方法計算體表面積燒傷百分比（%TBSA），以指導復甦和轉運決策。 等級： 強烈推薦，證據品質中等。
水泡管理
目前缺乏指導野外水皰處理的實證醫學證據。最大的爭議在於是否應保留水皰完整，還是應在切除或不切除水皰頂部的情況下排出水皰內的液體。水皰內的液體是無菌的，能夠提供濕潤的環境，促進傷口癒合和上皮化。然而，水皰液中含有血栓素和其他發炎介質，這些物質會導致血管收縮，並可能幹擾傷口癒合。 1987 年的一項直接對比研究表明，與清創相比，保留水皰可以減少細菌定植並更好地控制疼痛。2020 年， 《急診醫學年鑑》 發表了一篇題為「臨床爭議」的文章，探討了早期住院治療中清創的利弊。在野外或其他資源匱乏的環境中，感染控制和疼痛控制都至關重要。
另一種治療水皰的方法是抽吸水皰液。 Ro 等人比較了抽吸和去頂兩種治療方法，發現兩種方法各有優劣，但在某些傷口癒合方面，抽吸組更勝一籌。抽吸便於水皰的包紮，並可能防止水皰自發性破裂，從而避免潛在的污染。
建議
我們建議在大多數情況下不要處理水皰。
我們建議在大多數情況下不要處理水皰。
等級： 弱推薦，證據品質低。
我們建議對已破裂的水皰和可能自發性破裂的大水皰進行清創。
我們建議對已破裂的水皰和可能自發性破裂的大水皰進行清創。
推薦等級： 弱推薦，證據品質中等。
如果水皰限制了關節活動或位於難以自行排出的位置，我們建議透過小窗口進行抽吸或引流。
如果水皰限制了關節活動或位於難以自行排出的位置，我們建議透過小窗口進行抽吸或引流。
推薦等級： 弱推薦，證據品質低。
液體復甦
燒傷面積達到體表面積的20%或以上可導致休克，液體復甦是挽救生命的措施。目前有許多燒傷復甦公式，尚無普遍接受的公式。液體復甦是一個動態過程，需要頻繁評估患者是否有終末器官灌注不足的跡象，並謹慎地調整液體輸注量。如果液體復甦不足或延遲，可能導致組織流失增加、休克、多重器官衰竭甚至死亡。如果液體復甦過度，毛細血管滲漏會導致水腫，並可能引起成人呼吸窘迫症候群、筋膜室症候群和其他併發症。任何等滲液體均可用於院前液體復甦，但首選平衡溶液， 例如乳酸林格氏液。 避免這些併發症的關鍵在於準確評估燒傷面積。一些智慧型手機應用程式也有助於評估燒傷患者的液體需求。
美國燒傷協會建議如下：
•對於燒傷面積小於 20% 的體表面積燒傷，口服復甦是合適的，因為這些燒傷不會引起嚴重的全身性發炎、水腫的快速形成或未燒傷組織的血管擴張。
•燒傷面積達到體表面積的 20% 或以上的成人和兒童應進行靜脈輸液進行容量復甦。
•許多常用的公式估計，在最初 24 小時內，晶體液的需求量為 2 至 4 mL·kg –1 體重/%TBSA。
•液體復甦應依成人尿量調整，以維持尿量為 0.5 至 1.0 mL·kg –1 ·h –1 ， 兒童尿量為 1 至 1.5 mL·kg –1 ·h –1 。
•某些人群預計會增加液體需求，例如全層燒傷患者、吸入性損傷患者、橫紋肌溶解症患者以及復甦延遲的患者。
•對於沒有輸液幫浦的院前急救人員來說，嬰兒每分鐘滴注 20 滴（60 mL·h –1），兒童患者每分鐘滴注 40 滴（約 125 mL·h –1），成人每分鐘滴注 80 滴都是合理的。
在資源匱乏的環境中，對於燒傷面積達體表面積40%的患者，已採用口服補液療法。 口服補液鹽可使用市售產品配製，也可自行配製（表1）。如無法取得市售產品，可使用添加鹽的「安全」當地飲料或補充鹽片，但總鈉含量不得超過口服補液鹽的建議量。鈉攝取過量可能導致噁心和嘔吐。口服補液速度應與預期的靜脈輸液速度相符。如果患者無法耐受所需的口服液體量，可插入鼻胃管輔助輸液。在極端情況下，如果無法透過其他途徑輸液，可將液體注入皮下組織或透過直腸灌注（稱為直腸灌注）進行 輸液。69 如果無法正式測量尿量且疏散延遲，救援人員應滴定輸液，使受害者產生大量淡黃色尿液。
表 1.口服補液鹽配方。
世界衛生組織配方簡單公式1公升清水 1公升清水
6茶匙糖 6茶匙糖
3/8 茶匙鹽 ½ 茶匙鹽
¼ 茶匙代鹽（氯化鉀）
½ 茶匙小蘇打
建議
我們建議對體表面積燒傷面積小於20%的燒傷患者進行口服補液復甦。
推薦等級： 強烈推薦，證據品質中等。
我們建議，對於燒傷面積超過體表面積20%的患者，如果條件允許，應立即開始靜脈輸液復甦。
我們建議，對於燒傷面積超過體表面積20%的患者，如果條件允許，應立即開始靜脈輸液復甦。
等級： 強烈推薦，高品質證據。
考慮到現場救護的限制，我們建議以 2 mL·kg⁻¹/%TBSA 的劑量作為起始劑量。
考慮到現場救護的限制，我們建議以 2 mL·kg⁻¹/%TBSA 的劑量作為起始劑量。
推薦等級： 弱推薦，證據品質中等。
我們建議，對於燒傷面積不超過體表面積40%的燒傷，口服補液可能就足夠了。
我們建議，對於燒傷面積不超過體表面積40%的燒傷，口服補液可能就足夠了。
推薦等級： 弱推薦，證據品質中等。
我們建議在極端情況下可採用其他途徑進行液體復甦，包括鼻胃管、皮下浸潤和直腸灌注。
我們建議在極端情況下可採用其他途徑進行液體復甦，包括鼻胃管、皮下浸潤和直腸灌注。
推薦等級： 弱推薦，證據品質中等。
我們建議監測患者的容量狀態，並根據需要調整輸液量。
我們建議監測患者的容量狀態，並根據需要調整輸液量。
等級： 強烈推薦，證據品質中等。
燒傷敷料
磺胺嘧啶銀曾長期是燒傷敷料的標準治療方法，但現在已被抗生素軟膏基本取代。抗生素軟膏的療效與磺胺嘧啶銀相當甚至更佳，而且更常被納入急救箱。如果到最終治療的時間少於12至24小時，則無需使用抗生素軟膏或特殊敷料。吸水性泡棉敷料，如Mepilex™（Mölnlycke Health Care，Peachtree Corners，GA），適用於表淺部分厚度燒傷，可留置長達1週，從而最大限度地減少換藥帶來的疼痛。水凝膠敷料在燒傷癒合方面顯示出良好的前景，並且無需處方即可購買。大量文獻支持使用蜂蜜作為臨時燒傷敷料。其他一些在資源匱乏地區可能可用的、具有動物或體外療效證據的物質包括綠茶、木瓜醬、獼猴桃、薑黃和椰子油。74-76 這些敷料可用於紗布或不沾鍋敷料下。其他建議在偏遠地區使用的敷料包括可生物降解的臨時基質、聚乳酸皮膚替代物、透明質酸酯基質和去細胞魚皮移植片。 77如果無法取得 專用敷料，任何乾淨乾燥的布料均可用於覆蓋傷口。
雖然局部應用抗生素可以減少細菌定植和感染風險，但不應預防性使用口服或全身性抗生素。預防性使用抗生素可能會增加日後感染抗藥性細菌的風險。
建議
我們建議對淺層部分皮層燒傷使用吸水性泡棉敷料。 推薦等級： 弱推薦，證據品質中等。
如果現場處理或撤離會延誤，我們建議對深度二度燒傷患者使用抗生素軟膏或蜂蜜。 等級： 強烈推薦，證據品質中等。
我們認為，與其它類型的敷料相比，吸水泡棉敷料可能更易於現場操作。 推薦等級： 弱推薦，證據品質中等。
鎮痛
對於小面積或表淺燒傷，非處方鎮痛藥如對乙醯氨基酚和非類固醇類抗發炎藥物可能就足夠了，應作為多模式鎮痛方案的一部分，用於所有無禁忌症的患者。然而，燒傷疼痛劇烈，患者可能需要處方止痛藥。 <sup> 80</sup> 充分控制疼痛與較低的心理後遺症發生率有關。<sup>81,82 </sup>在超急性期， 冷敷傷口有助於控制疼痛。<sup>83</sup> 由於擔心全身吸收可能導致毒性，局部使用利多卡因存在爭議，但它可能對小面積燒傷有效。 <sup> 84</sup> 催眠、音樂療法和虛擬實境等輔助療法已在住院環境中應用，但尚無關於這些幹預措施在院前環境中有效性的數據。85-87鴉片 類藥物是住院病患疼痛控制的主要手段，而氯胺酮廣泛用於手術疼痛和減少鴉片類藥物的使用。 80野外醫學會發布的《偏遠地區急性疼痛治療臨床實踐指南》 對野外鎮痛藥物和輔助用藥進行了全面的綜述。 88
建議
我們建議先使用非處方止痛藥來治療疼痛。 等級： 強烈推薦，證據品質中等。
我們建議使用鴉片類藥物或氯胺酮等輔助藥物來控制疼痛（如有條件）。 等級： 強烈推薦，證據品質中等。
急救箱
野外急救包中的許多物品都有助於治療燒傷，例如抗生素軟膏、無菌敷料、補液鹽和止痛藥。對於燒傷風險較高的探險隊，可以考慮攜帶更多物品，例如靜脈輸液、水凝膠敷料以及麻醉劑或其他高級止痛藥。
燒傷患者的疏散
目前尚缺乏足夠的證據來指導哪些類型的燒傷需要轉運。野外醫學會傷口管理指南引用了 1C 級證據，指出對於以下需要更高水平護理（野外環境無法提供）的燒傷患者，應進行轉運<sup> 89</sup>：
•
氣道或吸入性損傷
•
胸部燒傷導致通氣功能受損
•
手、腳、生殖器、黏膜或臉部嚴重燒傷
•
環週燒傷，包括部分或全層燒傷。
•
燒傷面積超過體表面積5%的全層燒傷
•
體表面積超過10%至20%的部分厚度燒傷
•
感染性燒傷
•
燒傷伴隨無法控制的疼痛
•
雷擊傷
•
電燒傷
•
化學灼傷
此外，我們建議，如果出現以下情況，應加快疏散速度：
•
眼睛灼傷，導致視力受損或異物感；
•
任何需要現場進行高級氣道管理的燒傷；
•
任何需要現場焦痂切開術或筋膜切開術的燒傷；
•
即將出現筋膜室症候群的跡象；
•
嚴重創傷引起的燒傷；
•
燒傷時尿量減少（<30–50 mL·h –1）；
•
其他灌注減少的跡象（例如，精神狀態改變、活動減少、皮膚彈性下降、眼窩凹陷等）；
•
燒傷伴隨低體溫；
•
深度部分或全層燒傷，燒傷面積大於體表面積的 5%；
•
淺層部分燒傷，燒傷面積大於體表面積的 10% 至 20%；
•
關節處部分或全層燒傷；
•
嬰兒（<2 歲）燒傷面積超過體表面積 5%；
•
疑似一氧化碳或氰化物中毒引起的燒傷；
•
燒傷導致受害者無法繼續在現場活動。
這意味著大多數燒傷患者需要撤離，只有輕微燒傷才適合嘗試現場救治。
轉運前應進行充分的穩定處理，包括開始液體復甦、確保氣道通暢（如有必要）以及骨折固定。轉運過程中應繼續治療，包括監測生命徵象和精神狀態、鎮痛以及調整液體復甦劑量。可使用低溫包裹來預防體溫過低。<sup>90 , 91</sup> 如果到達最終治療的時間不足24小時，燒傷敷料應保持完整。如果轉運延遲，可能需要重新檢查傷口，觀察燒傷深度是否加深或是否有感染跡象。
遠距醫療
遠距醫療已被證明能夠提高燒傷面積的評估準確性，從而降低燒傷患者過度分診和分診不足的發生率。遠距醫療還能提高燒傷治療資源的使用率。 92-96
推薦
我們建議使用遠距醫療來促進現場救護。 等級： 強烈推薦，證據品質中等。
結論
這些指南是基於實證醫學的建議，旨在為野外和其他條件艱苦環境下的燒傷患者提供護理。現場燒傷患者的照護必須考慮傷情嚴重程度、可用資源、環境條件以及到達最終治療機構的時間/距離。
Abstract
To provide guidance to clinicians about best practices in caring for burn patients in remote settings, the Wilderness Medical Society convened an expert panel to develop an evidence-based clinical practice guideline. Recommendations for field-expedient care are made, with recommendations being graded using the American College of Chest Physicians criteria for the quality of supporting evidence and balance of risks and potential harms of treatment.
Introduction
Globally, burns cause >8 million injuries annually with 180,000 deaths, with the highest burden of disease in low- and middle-income countries.1–3 Burns account for 2 to 9% of injuries occurring in the wilderness.4–11 Burns that are small and superficial generally will heal uneventfully and can be managed in the field, but patients with more severe burns require evacuation. The goal of this practice guideline is to reduce the morbidity of burn injuries sustained in the wilderness and other low-resource settings. It focuses on unique aspects of care of burned patients in the remote settings and is not intended to replace general knowledge about care of burned patients.
Methods
A series of literature reviews was conducted in PubMed on topics including initial stabilization, burn first aid, estimating size and depth of burns, management of blisters, fluid resuscitation, burn dressings, pain management, evacuation, and use of telemedicine. Articles were reviewed by a panel of experts and prioritized based on applicability in the austere setting and then graded on the strength of evidence. The American College of Chest Physicians classification scheme was used to grade the strength of the evidence.12 The expertise of wilderness and burn practitioners was used to supplement recommendations for topics where the evidence was weak or nonexistent.
Field Assessment
Initial Evaluation
After ensuring that the scene is safe, the initial evaluation of the burn patient follows the typical priorities of trauma resuscitation.13,14 Burns are often visually impressive, and other serious pathology may be missed if a methodical evaluation of the patient is not completed. This evaluation should follow the ABCDE format of airway, breathing, circulation, disability, and exposure and environmental control.14
Traditional indications for airway management in burn patients include singed nasal hair, soot in the mouth or sputum, hoarse voice, stridor, or significant dyspnea.15 Recognition that many patients intubated prior to arrival at a burn center may not have required intubation led to stricter criteria being proposed by the American Burn Association: Intubation should be performed for patients with signs of airway obstruction such as hoarseness or stridor, full-thickness facial burns, respiratory distress, upper airway trauma, inability to clear secretions, altered mentation, hypoxia, hypercarbia, or hemodynamic instability.14,16,17 There is little evidence to guide the use of nasopharyngeal or supraglottic airways in burn patients, but they may fail if the indication for airway management is upper airway edema.18 Successful field cricothyroidotomy was described for a patient who sustained a lightning strike.19 Patients with indications for airway management in the field should be intubated if appropriate medications and equipment are available, including sedation and, potentially, paralytics. A surgical airway may be required if patients have indications for intubation and equipment is not available to perform oral or nasal endotracheal intubation. Field airway management is fraught with difficulty and may require awaiting rescue personnel with advanced airway skills, equipment, and medication.
Altered mental status is not an expected finding in burn injuries, and its presence should prompt further evaluation for its etiology, such as hypotension, head injury, or toxic inhalation. Inhalation injury and toxic inhalations are considered rare in open-space fires, although a recent case report has challenged this dogma. It describes a lethal level of carbon monoxide and measurable cyanide in a burn fatality patient who was burning brush and household debris in his yard.20 Inhalation injuries are caused by heat from exposure to flame or superheated gas, particulate matter, and chemical irritants inhaled with smoke and local hypoxia in the pulmonary tissue.21 Heat and smoke tend to dissipate in open-space fires.
Carbon monoxide and cyanide are specific inhalation toxins that may be present in fires and cause patients to have altered mental status. Carbon monoxide toxicity presents with altered mental status, with the classic cherry red lips seen in a minority of patients.22,23 Treatment is moving the patient to open air with oxygen administration, if available. In house fires, cyanide is released from burning of synthetic materials such as furniture cushions and carpet, but cyanide is also released from combustion of outdoor recreation supplies such as plastics, vinyl, paper, and wool.24 Supplemental oxygen is helpful in cyanide poisoning, and definitive treatment is administration of cyanocobalamin or sodium thiosulfate with sodium nitrite.
Hypotension in burn patients is secondary to extravasation of intravascular fluid into the extracellular or third-space compartment and does not typically result until 6 to 12 h after the initial injury, so hypotension during the initial evaluation requires evaluation for other traumatic injuries.25,26
To provide guidance to clinicians about best practices in caring for burn patients in remote settings, the Wilderness Medical Society convened an expert panel to develop an evidence-based clinical practice guideline. Recommendations for field-expedient care are made, with recommendations being graded using the American College of Chest Physicians criteria for the quality of supporting evidence and balance of risks and potential harms of treatment.
Introduction
Globally, burns cause >8 million injuries annually with 180,000 deaths, with the highest burden of disease in low- and middle-income countries.1–3 Burns account for 2 to 9% of injuries occurring in the wilderness.4–11 Burns that are small and superficial generally will heal uneventfully and can be managed in the field, but patients with more severe burns require evacuation. The goal of this practice guideline is to reduce the morbidity of burn injuries sustained in the wilderness and other low-resource settings. It focuses on unique aspects of care of burned patients in the remote settings and is not intended to replace general knowledge about care of burned patients.
Methods
A series of literature reviews was conducted in PubMed on topics including initial stabilization, burn first aid, estimating size and depth of burns, management of blisters, fluid resuscitation, burn dressings, pain management, evacuation, and use of telemedicine. Articles were reviewed by a panel of experts and prioritized based on applicability in the austere setting and then graded on the strength of evidence. The American College of Chest Physicians classification scheme was used to grade the strength of the evidence.12 The expertise of wilderness and burn practitioners was used to supplement recommendations for topics where the evidence was weak or nonexistent.
Field Assessment
Initial Evaluation
After ensuring that the scene is safe, the initial evaluation of the burn patient follows the typical priorities of trauma resuscitation.13,14 Burns are often visually impressive, and other serious pathology may be missed if a methodical evaluation of the patient is not completed. This evaluation should follow the ABCDE format of airway, breathing, circulation, disability, and exposure and environmental control.14
Traditional indications for airway management in burn patients include singed nasal hair, soot in the mouth or sputum, hoarse voice, stridor, or significant dyspnea.15 Recognition that many patients intubated prior to arrival at a burn center may not have required intubation led to stricter criteria being proposed by the American Burn Association: Intubation should be performed for patients with signs of airway obstruction such as hoarseness or stridor, full-thickness facial burns, respiratory distress, upper airway trauma, inability to clear secretions, altered mentation, hypoxia, hypercarbia, or hemodynamic instability.14,16,17 There is little evidence to guide the use of nasopharyngeal or supraglottic airways in burn patients, but they may fail if the indication for airway management is upper airway edema.18 Successful field cricothyroidotomy was described for a patient who sustained a lightning strike.19 Patients with indications for airway management in the field should be intubated if appropriate medications and equipment are available, including sedation and, potentially, paralytics. A surgical airway may be required if patients have indications for intubation and equipment is not available to perform oral or nasal endotracheal intubation. Field airway management is fraught with difficulty and may require awaiting rescue personnel with advanced airway skills, equipment, and medication.
Altered mental status is not an expected finding in burn injuries, and its presence should prompt further evaluation for its etiology, such as hypotension, head injury, or toxic inhalation. Inhalation injury and toxic inhalations are considered rare in open-space fires, although a recent case report has challenged this dogma. It describes a lethal level of carbon monoxide and measurable cyanide in a burn fatality patient who was burning brush and household debris in his yard.20 Inhalation injuries are caused by heat from exposure to flame or superheated gas, particulate matter, and chemical irritants inhaled with smoke and local hypoxia in the pulmonary tissue.21 Heat and smoke tend to dissipate in open-space fires.
Carbon monoxide and cyanide are specific inhalation toxins that may be present in fires and cause patients to have altered mental status. Carbon monoxide toxicity presents with altered mental status, with the classic cherry red lips seen in a minority of patients.22,23 Treatment is moving the patient to open air with oxygen administration, if available. In house fires, cyanide is released from burning of synthetic materials such as furniture cushions and carpet, but cyanide is also released from combustion of outdoor recreation supplies such as plastics, vinyl, paper, and wool.24 Supplemental oxygen is helpful in cyanide poisoning, and definitive treatment is administration of cyanocobalamin or sodium thiosulfate with sodium nitrite.
Hypotension in burn patients is secondary to extravasation of intravascular fluid into the extracellular or third-space compartment and does not typically result until 6 to 12 h after the initial injury, so hypotension during the initial evaluation requires evaluation for other traumatic injuries.25,26
Recommendations
We recommend that the initial evaluation of a burn patient follow general principles of trauma care. Grade: Strong recommendation, high-quality evidence.
We recommend that patients with altered mental status or hypotension in the immediate postburn period be evaluated for other etiologies of these findings. Grade: Strong recommendation, moderate-quality evidence.
First Aid
Clothing may continue to smolder, so any ongoing fire should be extinguished and burned material should be removed from patients. Jewelry and any items that may tighten or constrict over time should be removed from all extremities, and a careful vascular exam should be performed.
Cooling of burn wounds has been used for centuries.27 Burns of <10% total body surface area (TBSA) should be irrigated with water that is 12 to 18°C (53–64°F) for 20 to 30 min, starting as soon as possible after the burn occurs.28–31 Immersion in cool water is acceptable if no running water is available. Cool water therapy remains effective if initiated within 60 min of injury.28,32 Potable water is preferred to untreated surface water, but there is little evidence regarding the risk of infection using untreated water. Ice should not be use because reepithelialization occurred more rapidly in a porcine model with cool water compared with ice.29 We found no evidence regarding use of snow but recommend against direct application of snow to burn wounds because its properties are similar to those of ice. However, snow may be used to cool water for treatment. Use of cool water therapy is associated with reduced burn depth, lower TBSA, less need for skin grafting, and shorter time to healing.33–43 Use of cool water therapy also may aid in pain control.44 Hypothermia is more common in patients with larger TBSA burns and is associated with increased mortality.45 Other risk factors for hypothermia include prolonged scene time, older age, need for airway management, and altered mental status.46 There is little evidence to support a maximum TBSA that can be safely cooled in the field. Rescue personnel should weigh the risk of hypothermia given environmental conditions and expected time to definitive care against the risk of increased morbidity from larger or deeper wounds if not treated with cool water therapy.
Recommendations
We recommend that burn wounds of <10% TBSA be irrigated with cool running water for 20 min. Grade: Strong recommendation, moderate-quality evidence.
We suggest that burns not be cooled in the field if there is a risk of hypothermia. Grade: Weak recommendation, low-quality evidence
Classification of Burn Depth
The shallowest burns are classified as superficial. These burns involve only the top layers of the epidermis. The skin will appear reddened and warm to the touch. There is no blister formation, and the skin is dry. These wounds tend to be very painful because there is no damage to the underlying neurovascular structures. Healing of superficial burns is expected within 1 wk of injury, and scarring is absent.
Classification of partial-thickness burns is divided into 2 separate categories based on their infection risk and expected healing.
Superficial partial-thickness burns form blisters between the dermis and epidermis within the first 12 to 24 h after the burn occurs. Superficial partial-thickness burns tend to have thin-roofed blisters that rupture spontaneously. When these blisters rupture, the underlying area will be wet and weeping and will blanch easily with pressure. Because the underlying structures are uninjured, these are intensely painful wounds. Superficial partial-thickness burns are expected to heal in 7 to 21 d and rarely cause significant scarring. Because blisters can be expected to form over the first few days after injury, it is important to periodically reassess wounds as the burn evolves and to recalculate your burn surface area based on conversion of the wound.47,48
Deep partial-thickness burns involve the deeper dermis, causing damage to the hair follicles and glandular tissue. The wound will appear wet or waxy with a mottled color and overlying eschar. These deeper wounds present a much higher infection risk than the more superficial burns discussed earlier. Spontaneous healing is expected to take 3 to 9 wk, and hypertrophic scarring is common. These wounds benefit from specialized burn center management.
Full-thickness burns involve all layers of the epidermis and dermis and extend into the subcutaneous tissues. These wounds result in damage to the neurovascular structures of the underlying tissue, and the areas of full-thickness burn are often insensate. On initial evaluation, the burn eschar is often still intact, presenting as a blackened or leathery covering. These wounds do not heal spontaneously and require excision and management by a burn specialist to minimize contracture formation and scarring.
Fourth-degree burns are characterized by injury involving the fascia, muscle, tendon, and bone. These often result in amputation of the extremity and, again, require specialized burn care.
Burn Size Estimation
Estimation of the burn size is a crucial step in the initial care of burn patients. %TBSA is estimated based on the amount of superficial partial-thickness, deep partial-thickness, and full-thickness burns. Areas of intact skin must be monitored carefully for conversion but are added to the TBSA only if the wound transforms into a partial-thickness burn, as evidenced by blister formation.
Several different methods of burn size estimation exist. The rule of 9’s is commonly used for adults, and a modified version is available for children and infants. (Figure 1). The Lund-Browder chart provides a graphical representation of burns. The rule of palms states that the patient's palm (including digits) is ∼1% of their body surface area.49 This method is expedient for field use but tends to overestimate burns, particularly if the burn is >10% TBSA.50
Figure 1. Rule of 9’s for burn size estimation in adults and infants. Used with permission of the American Burn Association.
Several smartphone-based calculators exist to assist in the calculation of burn size. These are based on the rule of 9’s and are adult specific. These calculators also may provide burn fluid resuscitation recommendations based on the %TBSA calculated and the patient's weight.
Careful estimation of the %TBSA is crucial in burn patients because it guides the initial resuscitation fluid rate and decisions regarding evacuation. Field estimation of burn size is not entirely reliable because providers often overestimate the %TBSA, especially in children.51–53
Recommendation
We recommend %TBSA burn be calculated using a validated method to guide resuscitation and evacuation decisions. Grade: Strong recommendation, moderate-quality evidence.
Blister Management
Evidence to guide management of blisters in the field is lacking. The biggest source of controversy is whether to leave the blister intact or to drain the fluid from the blister with or without removing the roof of the blister. The fluid within a blister is sterile, providing a moist environment that promotes wound healing and epithelialization. Conversely, blister fluid contains thromboxanes and other inflammatory mediators that cause vasoconstriction and may interfere with wound healing. A head-to-head comparison in 1987 showed decreased bacterial colonization and better pain control with intact blisters compared with debridement.54 Evidence for and against debridement during early hospital management was presented in a “Clinical Controversies” presentation in the Annals of Emergency Medicine in 2020.55,56 The concerns for both infection and pain control are of the utmost importance when in the wilderness or other resource-limited settings.
An alternative method of blister treatment is aspiration of the fluid. Ro et al57 compared aspiration with deroofing and found neither treatment to be superior, but some aspects of wound healing did favor the aspiration group. Aspiration allows for easier dressing of blisters and may prevent spontaneous rupture with potential contamination.
Recommendations
We suggest that blisters should be left intact in most situations. Grade: Weak recommendation, low-quality evidence.
We suggest debridement of ruptured blisters and large blisters that may rupture spontaneously. Grade: Weak recommendation, moderate-quality evidence.
We suggest aspiration or drainage of a blister through a small window if the blister is limiting movement of a joint or is in a location that would impede self-evacuation. Grade: Weak recommendation, low-quality evidence.
Fluid Resuscitation
Burns of 20% TBSA or greater can cause shock, and fluid resuscitation is a lifesaving intervention. Multiple formulas for burn resuscitation exist, and there is no universally accepted formula. Fluid resuscitation is a dynamic process that depends on frequent evaluation of the patient for signs of inadequate end-organ perfusion and careful titration of fluids.58 If fluid resuscitation is inadequate or delayed, increased tissue loss, shock, multiorgan system failure, and death may ensue. If fluid resuscitation is excessive, capillary leak leads to edema and may cause adult respiratory distress syndrome, compartment syndrome, and other complications.59,60 Any isotonic fluid is acceptable for prehospital fluid resuscitation, but a balanced solution such as lactated Ringer's solution is preferred.61 Avoidance of these complications starts with accurate burn size estimation. There are several smartphone applications that also may aid in estimation of fluid requirements for burn patients.62
The American Burn Association recommends the following63:
•
Oral resuscitation is appropriate for burns of <20% TBSA because these burns are not associated with severe systemic inflammation, rapid formation of edema, or vasodilation in unburned tissues.
•
Adults and children with burns of 20% TBSA or greater should undergo volume resuscitation with intravenous fluids.
•
Many of the common formulas estimate a crystalloid need in the first 24 h of 2 to 4 mL·kg–1 of body weight/%TBSA.
•
Fluid resuscitation should be titrated to maintain a urine output of 0.5 to 1.0 mL·kg–1·h–1 in adults and 1 to 1.5 mL·kg–1·h–1 in children.
•
Certain populations are expected to have increased fluid requirements, such as patients with full-thickness burns, inhalation injuries, or rhabdomyolysis and patients with delays in resuscitation.
•
For prehospital providers without pumps, drip rates of 20 drops/min for infants (60 mL·h–1), 40 drops/min for pediatric patients (∼125 mL·h–1), and 80 drops/min for adults are reasonable.
Oral fluid resuscitation has been used for burns up to 40% TBSA in low-resource settings.64–68 Oral rehydration solution may be prepared with commercial products or improvised (Table 1). When unavailable, “safe” local beverages with added salt or supplementation with salt tablets may be adequate as long as the total sodium content does not exceed oral rehydration solution recommendations.64 Excessive sodium may contribute to nausea and vomiting. The rate of oral fluid intake should match the predicted intravenous fluid resuscitation rate. If patients do not tolerate the necessary volumes of fluid by mouth, a nasogastric tube may be inserted to assist in fluid resuscitation. Under extreme circumstances, when fluids may not be administered via other routes, fluids may be instilled into the subcutaneous tissues or delivered by rectal infusion, known as proctoclysis.69 If it is not possible to formally measure urine output and evacuation is delayed, rescuers should titrate fluids so that the victim produces copious pale-yellow urine.
Table 1. Recipes for oral rehydration solution.
World Health Organization formulaSimple formula1 L clean water 1 L clean water
6 tsp sugar 6 tsp sugar
3/8 tsp salt ½ tsp salt
¼ tsp salt substitute (potassium chloride)
½ tsp baking soda
Recommendations
We recommend oral rehydration for resuscitation of burn injuries of <20% TBSA. Grade: Strong recommendation, moderate-quality evidence.
We recommend that intravenous fluid resuscitation be started, if available, for burns of >20% TBSA. Grade: Strong recommendation, high-quality evidence.
We suggest that starting with a rate of 2 mL·kg–1/%TBSA is reasonable given the constraints of field care. Grade: Weak recommendation, moderate-quality evidence.
We suggest that oral rehydration may be sufficient for burns of up to 40% TBSA. Grade: Weak recommendation, moderate-quality evidence.
We suggest that fluid resuscitation may proceed by alternate routes in extreme circumstances, including nasogastric tube, subcutaneous infiltration, and proctoclysis. Grade: Weak recommendation, moderate-quality evidence.
We recommend that the patient’s volume status should be monitored with titration of fluids as needed. Grade: Strong recommendation, moderate-quality evidence.
Burn Dressings
Silver sulfadiazine was long the standard of care for burn dressings but has largely been replaced by antibiotic ointment, which provides equivalent or better healing and is more likely to be included in a first aid kit.70,71 No antibiotic ointment or specialized dressing is required if time to definitive care is less than 12 to 24 h. Absorbent foam dressings such as Mepilex™ (Mölnlycke Health Care, Peachtree Corners, GA) are useful for superficial partial-thickness burns and may be left in place for up to 1 wk, minimizing the pain of dressing changes. Hydrogel dressings show promise in burn healing and are available over the counter.72 There is a significant body of literature to support the use of honey as an improvised burn dressing.73 Other agents with animal or in vitro evidence of efficacy that might be available in resource-limited settings include green tea, papaya paste, kiwifruit, turmeric, and coconut oil.74–76 These could be used under gauze or a nonstick dressing. Other dressings suggested for use in remote settings include biodegradable temporizing matrix, polylactic acid skin substitute, hyaluronic acid ester matrix, and decellularized fish skin graft.77 If specialized dressing materials are unavailable, any clean, dry cloth may be used to cover the wound.
Although topical antibiotics can reduce colonization and risk of infection, prophylactic oral or systemic antibiotics should not be used.78 Prophylactic antibiotics may increase the risk of later infection with resistant organisms.79
Recommendations
We recommend using absorbent foam dressings on superficial partial-thickness burns. Grade: Weak recommendation, moderate-quality evidence.
We recommend using antibiotic ointment or honey on deep partial-thickness burns if attempting field management or evacuation will be delayed. Grade: Strong recommendation, moderate-quality evidence.
We suggest that absorbent foam dressings may be easier to manage in the field than other types of dressings. Grade: Weak recommendation, moderate-quality evidence.
Analgesia
Over-the-counter analgesics such as acetaminophen and nonsteroidal anti-inflammatory drugs may be sufficient for small or superficial burns and should be used as part of multimodal pain relief in all patients without contraindications. However, burn injuries are incredibly painful, and patients may require prescription analgesics.80 Adequate control of pain has been associated with lower rates of psychological sequelae.81,82 Cooling the wound aids in pain control in the hyperacute phase.83 Use of topical lidocaine is controversial due to concern for toxicity owing to systemic absorption, but it may be useful in small burns.84 Adjuncts such as hypnosis, music therapy, and virtual reality have been used in the inpatient setting, but there are no data on effectiveness of these interventions in the prehospital setting.85–87 Opioids are the mainstay of pain control in hospitalized patients, and ketamine is widely used for procedural pain and opioid-sparing effects.80 The Wilderness Medical Society clinical practice guideline for the treatment of acute pain in remote environments provides a comprehensive review of analgesic medications and adjuncts for pain control in the field.88
Recommendations
We recommend over-the-counter analgesics as the initial treatment for pain. Grade: Strong recommendation, moderate quality evidence.
We recommend opioids or adjuncts such as ketamine to control pain, if available. Grade: Strong recommendation, moderate-quality evidence.
First Aid Kit
Many items included in a general wilderness first aid kit will be helpful in the treatment of burn injuries, including antibiotic ointment, sterile dressings, rehydration salts, and analgesics. Expeditions with an elevated risk of burn injuries may consider additional items such as intravenous fluids, hydrogel dressings, and narcotics or other advanced analgesics.
Evacuation of Burn Patients
There is little evidence to guide what types of burn injuries require evacuation. The Wilderness Medical Society wound management guidelines cite Level 1C evidence for evacuation of patients with the following burns that require higher levels of care not available in the wilderness setting89:
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Airway or inhalational injury
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Burns to the thorax that impair ventilation
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Significant burns to hands, feet, genitals, mucous membranes, or face
•
Circumferential burns that are partial or full thickness
•
Full-thickness burns of >5% TBSA
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Partial-thickness burns of >10 to 20% TBSA
•
Infected burns
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Burns with uncontrolled pain
•
Lightning injuries
•
Electrical burns
•
Chemical burns
Additionally, we suggest evacuation be expedited if there are
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burns to the eye that compromise vision or result in foreign-body sensation;
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any burn that required advanced airway management in the field;
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any burn that requires field escharotomy or fasciotomy;
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signs of impending compartment syndrome;
•
burns associated with significant trauma;
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decreased urine output in the setting of burns (<30–50 mL·h–1);
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other signs of decreased perfusion (eg, change in mentation, inactivity, decreased skin turgor, sunken eyes, etc);
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burns with associated hypothermia;
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deep partial- or full-thickness burns of >5% TBSA;
•
superficial partial-thickness burns of >10 to 20% TBSA;
•
partial- or full-thickness burns over joints;
•
burns of >5% TBSA in infants (<2 y);
•
burns with suspicion of carbon monoxide or cyanide toxicity; and
•
burns that impair the victim's ability to remain active in the field.
This means that most burn patients will require evacuation, with only minor burns being appropriate for a trial of field management.
Adequate stabilization should occur prior to transport, including initiation of fluid resuscitation, securing the airway (if indicated), and splinting of fractures. Treatment should continue during evacuation, including monitoring of vital signs and mental status, analgesia, and titration of fluid resuscitation. A hypothermia wrap may be used to prevent hypothermia.90,91 If time to definitive care is <24 h, burn dressings should be left intact. Wounds may need to be rechecked for progression of burn depth or signs of infection if evacuation is delayed.
Telemedicine
Telemedicine has been shown to improve estimation of burn size, resulting in lower rates of over- and undertriage of burn patients. Telemedicine also improves resource utilization for burn care.92–96
Recommendation
We recommend use of telemedicine to facilitate field care. Grade: Strong recommendation, moderate-quality evidence.
Conclusion
These guidelines are evidence-based recommendations for providing care for burn patients in the wilderness and other austere settings. Care of burned patients in the field must consider severity of injury, available resources, environmental conditions, and time/distance to definitive care.
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