Burn Resuscitation

How should you start evaluating a burn patient?

ABCs: Assess airway, breathing, circulation

Be sure to rule out life threatening injuries including open pneumothorax, tension pneumothorax, hemothorax, and cardiac tamponade. The patient may have burns as well as other injuries related to a blast injury, MVC, fall, or other trauma.

What will give you a high index of suspicion for early intubation?

Any sign of inhalation injury:
oropharyngeal swelling, edema
facial burns or soot
singed nasal hairs
hoarseness, stridor, wheezing, rhonchi
mucus, carbonaceous sputum
elevated carboxyhemoglobin level

What is the half-life of carbon monoxide in the blood?

At room air (21% O2) - 4hrs
At 100% O2 - 45-60 minutes

How do you estimate burn severity in total body surface area?

The Rule of Nines
Include only second and third degree burns:
each upper extremity = 9%
each lower extremity = 18%
anterior trunk = 18%
posterior trunk = 18%
head and neck = 9% (20% in infants!)
perineum = 1%

Another good measure is the palmar hand surface = 1%TBSA

What is the Parkland Formula?

A method for burn resuscitation. After assessing the extent of burns, calculate total volume as follows:

4 ml/kg/%TBSA Lactated Ringers over 24h
Give half in the first 8hrs and the remainder in the following 16hrs.

What is the Modified Brooke Formula?

Another method for burn resuscitation
2 ml/kg/%TBSA LR over 24h

What are good endpoints for resuscitation?

Adequate end-organ perfusion...
Urine output > 0.5 ml/kg/hr (adults)
> 1.0 ml/kg/hr (children)
> 1-2 ml/kg/hr (infants)

Why so much fluid?

Local injury leads to histamine release from mast cells, disrupting endothelial tight junctions.
Local and systemic cytokine release leads to SIRS (systemic inflammatory response syndrome) and increased vascular permeability.
Vascular leak leads to third spacing (plasma volume decreases while total extracellular fluid compartment increases).

What is Starling's Law?

Plasma proteins create an inward oncotic force that counteracts an outward hydrostatic pressure.

So, what about colloid resuscitation?

Controversial, but are generally seen to not have an advantage over crystalloid resuscitation, and may be detrimental, at a higher cost. Nice in theory...
Some advocate colloids after 24hrs in burn patients, but not in the initial resuscitation phase because of the large fluid shifts.

What is a potential consequence of overresuscitation?

Abdominal compartment syndrome

What happens with large volume resuscitation with normal saline?

Hyperchloremic metabolic acidosis

Lactated Ringer's is generally recommended to avoid this...

Late...SG

Source:
Schwartz' Principles of Surgery, 8th ed.