RESUSCITATION OF

PATIENT WITH ACUTE

BURNS
Corinne Ooi
AST II
 Question

A 25 year old man weighing 70kg with a 30%

flame burn was admitted at 4 pm. His burn
occurred at 3 pm. He received 1L fluid from
emergency services.
Calculate his fluid resuscitation regime for first 24
hours.
 OVERVIEW
z Definition
z Pathophysiology
z Emergency treatment
z Assessment of burn size and depth
z Fluid resuscitation
 Introduction
z Definition of a major burn
- any burn that requires IV fluid resuscitation (>10%BSA
in child, >15%BSA in adult) and/or burn to major airway
z Types of burns
- Contact- damage fm contact with hot materials
- Scald- damage fm contact with hot liquids
- Flame- damage fm superheated air
- Chemical- contact with noxious chemicals
- Electrical- conduction of electrical current through tissues
 Burn Pathology
Local Reaction
z Causes coagulative necrosis of epidermis and underlying
tissues
z Changes in vascular permeability as normal capillary
barrier is disrupted by host of mediators – injured tissues
become ‘leaky’
z Shift of intravascular fluid into surrounding tissues,
replacing the intravascular deficit with fluid resuscitation
drives the continued accumulation of oedema fluid
z Reaction continues for 3 to 36hr after injury
z Classic description of burn wound and surrounding
tissues whereby area of cutaneous injury divided into 3
circumferential zones radiating from primary burned
tissues
1. Zone of coagulation – non-viable tissue at center of burn
2. Zone of stasis – surrounding tissue of coagulated area
with decreased tissue perfusion.
3. Zone of hyperemia – peripheral tissues that undergo
vasodilation from inflammatory mediators released.
Contains viable tissue
 Burn Pathology (cont)

Systemic Changes
z Release of inflammatory mediators, produce vasodilation
and vasoconstriction -> increased capillary permeability
and oedema
z Loss of plasma volume, increased peripheral vascular
resistance ->decreased cardiac output
z Decreased renal blood flow, decreased GFR -> oliguria
z If untreated, develop acute tubular necrosis and renal
failure (development of acute renal failure assoc with
higher mortality)
z Immunosuppression & increased infectious complications
z Increased gut mucosal permeability, mucosal atrophy and
changes in digestive absorption
z Hypermetabolism after severe burn because of release of
inflammatory hormones -> gluconeogenesis, lipolysis and
proteolysis
 Emergency Treatment of Acute
Burns
Immediate Emergency Burn Care

z ABCD assessment
z maintain clear airway
z remove source of injury and/or prevent ongoing thermal
injury
z Use airway and C-spine precautions
 Emergency Burn Management
1. Airway management
z Administer high flow oxygen
z consider early intubation if signs of inhalational injury or
very large burns
z Features associated with inhalational injury
-Hx of fire in enclosed space, Hx of unconsciouness,
carbonaceous sputum, facial burns, singed nasal hairs
2. Intravenous access
z 2 x large bore IV ( away fm burned tissues if possible)
3. Analgesia – opioids, titrated intravenously
4. Insert IDC
 Fluid Resuscitation, Assessment
of Burn Size and Depth
z Fluid resuscitation
- IV fluid required is determined by burn size and weight of
patient in Kg’s
z Careful examination of all body surfaces to determine
percentage of burns
z Use Wallace ‘Rule of Nines’ or standard Lund-Browder
chart
 Estimation of Burn Size

z ‘Rule of Nines’
- differs in children
- child’s head represents a larger proportion and lower
extremities a lesser proportion of TBSA
- palm of patient’s hand represents approximately 1% of
patient’s body surface area (helps estimate irregular burns
area)
z Only include 2nd degree burns or greater in TBSA for burn
fluid calculations
‘Rule of Nines’

z Useful as a practical guide

for evaluation of severe
burns
z Adult body is generally
divided into surface areas
of 9% each and/or
fractions or multiples of
9%
 Depth of Burn
3 standardized categories
1. First degree burns (superficial)
- limited to epidermal layers, characterized by erythema,
pain and absence of blisters (eg sunburn)
2. Second degree burns (partial thickness)
- involves dermal layer, characterized by red or mottled
appearance with associated swelling and blister
formation. May have weeping, wet appearance and
painfully hypersensitive
3. Third degree burns (full thickness)
- extend to subcutaneous tissues. Have dark, leathery
appearance. Surface is painless and generally dry
Assessment of Burn Depth

z Most burns are a mixture of

depths
z Assessment of depth is
important for planning
treatment
z May be difficult to estimate in
acute situation and may change
with resuscitation
z Consider factors such as
mechanism, duration of contact
& anatomic location.
 Obtain Patient History

z Time and nature of incident ( burn/ chemical/

electrical/inside or outside)
z Assume CO exposure in patients burned in enclosed area
z Associated injuries
z Medical/surgical history
z Drug/alcohol history
z Allergies
z Ascertain tetanus immunization status
 Baseline Investigations

z Blood Tests
- FBE, U&E,Type and crossmatch, carboxyhemoglobin,
serum glucose, arterial blood gas and pregnancy test in all
females of childbearing age.
z X-Rays
- CXR, repeat after intubation or insertion of central
lines
- assessment of associated injuries
 Additional Evaluation

z Remove all jewelry

z Assess distal circulation, check for cyanosis, impaired
capillary refilling and progressive neurologic signs
z Evaluate all extremities and chest wall for potential
compartment syndromes. Escharotomy may be required.
z Consider if lost pulses are reflection of under resuscitation,
whether there is associated trauma with potential vascular
injury and lastly if compartment syndrome has developed.
z Nasogastric tube if nausea, vomiting or burns >20%TBSA
z Prophylactic antibiotics not indicated in early postburn
period
 Wound Care

z 2nd degree burns are painful when air currents pass over
burned surface. Cover with clean linen
z Do not break blisters or apply antiseptic cream
z Do not apply cold compresses
z Do not apply cold water to patient with extensive burns
z Maintain body heat
z Elevation of burned limbs
 Special Burn Requirements

1. Chemical Burns
z Tissue damage dependent on chemical nature of agent,
concentration of agent and duration of skin contact
z Alkali burns more serious than acid burns (alkali
penetrates deeper)
z Immediately flush away chemical with copious amounts
of water (min 15-20L of tap water)
z Care to drain away from uninjured areas
z If dry powder present, brush away before irrigation
z Neutralizing agents should not be used
2. Electrical Burns
z Often have large underlying tissue damage, may be more
progressive and deeper than apparent
z Muscle sustains most damage
z Institute therapy for myoglobinuria if urine is dark
z High voltage injury may cause cardiac arrythmias
z Often require large volume fluid resuscitation (as most
of wounds is deep, can’t rely on values predicted based
on wound area)
 Fluid Resuscitation

z Plays a fundamental role in early period of burns

resuscitation
z Worldwide practices differ between institutions
z Several resuscitation formula for calculation of fluid
requirement used worldwide (eg. Parkland, Evans, Brooke)
z Parkland formula is the ‘gold standard’- introduced by
Charles Baxter at Parkland Hosp in 1960’s, college
recommendation
z No one formula has been proven to be superior
z IV fluid therapy should be instituted in
Burns >5-10% TBSA in children
Burns >15-20% TBSA in adults
High voltage electrical injury
Burns associated with smoke inhalation
z Parklands :Crystalloid resuscitation eg. Hartmanns
24 hr fluid requirement = 4ml x %TBSA x
wt(kg)
Give half over the first 8 hrs, and the remainder
over the next 16 hrs
z In children: add maintenance fluid of ½ normal saline with
5% dex in a volume calculated by
100ml/kg for the first 10 kg
50ml/kg for the next 10kg
20ml/kg for the next 10kg
z Monitor adequacy of fluid resuscitation by urine output
measurement and adjust accordingly.
z Ideal UO : Children: 1.0ml/kg/hr
Adult (>30kg): 0.5ml/kg/hr
z Smoke inhalation injury may increase fluid requirements
by 50%
 Controversies in Fluid
Management
z Other formulas in use include Evans and Brooke(colloid
formulas) and Monafo (hypertonic saline formulas)
z Hypertonic saline thought to be useful because of it’s fluid
– sparing effects and reduction of volume load in early
phase of burn injury. However ?associated with increased
mortality in one study.
z Colloids (mainly albumin and FFP) are used to elevate the
intravascular osmolality and stop extravasation of
crystalloids and overall reduce oedema.
z As capillary barrier gains its integrity 12-24hrs after burn,
fluid requirements reduced. ? Benefits of using colloid to
reduce fluid load
z Disadvantages of colloid are ?higher costs, not always
available, increased febrile incidence and ?viral
transmission with FFP.
z Cochrane Injuries Group – 2 systematic reviews on use of
albumin and hypertonic versus near isotonic crystalloid for
fluid resuscitation in critically ill patients
z Insufficient data to conclude if hypertonic saline or
albumin use are better.
z Some studies have demonstrated harmful effects secondary
to pulmonary oedema and some evidence of renal
dysfunction
 Answer

25 yo weighing 70kg with 30% flame burn 1hr ago. 1L

fluid already given.
1. Total fluid requirements in 1st 24hrs
4mlx(30%TBSA)x(70kg) = 8400ml in 24hrs
2. Half given in 1st 8 hrs, half over 16hrs
4200mls during 0-8hrs and 4200mls during 8-16hrs
Already received 1L, 3200mls in 1st 8hrs
3. Infusion rate
3200/7hrs = 457ml/hr for next 7hrs
4200/16hrs = 262.5ml/hr for last 16hrs
 Summary
z ABCD
z Airway management
z Intravenous access
z Fluid resuscitation
- Parkland formula is ‘gold standard’ but any one formula
have been proven successful
- Aim is to replace volume deficit to support tissue
perfusion
- may need to be adjusted according to urine output and
other physiological parameters. Overresuscitation can lead
to major morbidity eg pulmonary complications, oedema
and tissue hypoxia
 - periodically increasing fluid rate is better than boluses
for low urine output (worsens oedema)
- regular assessment important
- use of colloids and blood products may be beneficial
z Correct estimation of burn size is important
z Burn depth may be difficult to estimate and changes with
resuscitation
z Be aware of the need for escharotomies
z Check tetanus toxoid immunization status