Evolution of burn resuscitation in operation Iraqi freedom.

Burns are common in all military conflicts, comprising approximately 10% of all casualties. Of these, nearly 20% are categorized as severe, or involving greater than 20% TBSA, and require significant intravenous resuscitation. A unique set of challenges have emerged during the present conflict associated with global evacuation of burned soldiers, adding a new dimension to the alreadycomplex and often-controversial topic of the burn resuscitation. Critical advances in air evacuation of the war wounded, thorough prewar planning, and sustained burn care education of deployed personnel have proven vital in the optimal care of our injured soldiers. During the Vietnam conflict, burned soldiers were evacuated to an Army Hospital in Japan (Camp Zama) and were treated for up to 6 months before they were evacuated to the United States. Since that time, the transfer of the patient to the burn center for definitive care has been expedited by the Army Burn Flight Team’s ability to transport the most severely burned patients within the first several days after injury. With the emergence of the U.S. Air Force Critical Care Air Transport Team (CCATT) program in the 1990s, global air evacuation of burn patients became even more rapid, maximizing available U.S. Air Force aircraft for patient evacuation. The doctrine has shifted from aeromedical transport of the stable to aeromedical transport of the stabilized. In burn patients, evacuation presents a unique problem because it usually takes place while resuscitation in the first 24 to 48 hours after burn injury is ongoing. In addition to the innate complexity involved in global evacuation, war burn patients often exhibit multisystem traumatic injuries further complicating and augmenting resuscitation fluid needs above and beyond standard burn resuscitation formulas. The presence of smoke inhalation injury, occurring in 5% to 15% of patients with severe burns, also increases fluid requirements. In most cases, the critical first days of burn resuscitation of the war wounded lies on the shoulders of physicians and nurses who do not specialize in burn care with priorities focused on stabilization and evacuation to the place of definitive care. Providing guidance and “standardizing” practice based on current available knowledge applied in this setting has been our greatest challenge. In this article, we aim to review the evolution of initial burn care of the war wounded during the current conflict and provide some insight into future directions.