Management of Moderate to Severe Burns


                       Initial Fluid Resuscitation - The Parkland Formula




Initiation of fluid resuscitation should precede initial wound care. In adults, IV fluid resuscitation is usually necessary in second- or third-degree burns involving greater than 20% TBSA. In pediatric patients, fluid resuscitation should be initiated in all infants with burns of 10% or greater TBSA and in older children with burns greater than 15% or greater TBSA.
Two large-bore IV lines should be placed. Lactated Ringer's solution is the most commonly used fluid for burn resuscitation.
The Parkland formula is used to guide initial fluid resuscitation during the first 24 hours.

The formula calls for 4 cc/kg/TBSA burn (second and third degree)

 of lactated Ringer's solution over the fast 24 hours.

Half of the fluid should be administered over the first eight hours post burn, and
the remaining half should be administered over the next 16 hours.
Formula:

Adults / Adolescent : mL LR = 2 * Weight(kg) * %Burn
Children : mL LR = 3 * Weight (kg) * %Burn


 The volume of fluid given is based on the time elapsed since the burn.
Urine output should be used as a measure of renal perfusion and to assess fluid balance. In adults, a urine output of 0.5-1.0 mL/kg/h should be maintained. Patients with significant burns should have a Foley catheter inserted in order to monitor urine output.
A nasogastric (NG) tube should be placed in patients with burns involving 20% or more TBSA in order to prevent gastric distention and emesis associated.

Remember that this fluid management formula is only a guideline.   Furthermore, this fluid regimen does not include normal maintenance fluids.   Fluid management must be individualized.  Additional parameters for fluid management include urine output & systemic blood pressure. 

The 24 hour formula is
fluids for 24 hours = (4 х kg х  %burn) [2^nd & 3^rd added together]
with 1^st 50% of that total in the first 8 hours and the 2^nd 50% over the following 16 hours.

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Basics

Intravenous fluids may be used for:

Maintenance

 provide daily fluid requirement in patients unable to take in adequate fluids or losing increased amounts and correct dehydration

Use crystalloids to maintain volume.

A common regime (for an average 70kg man) to give 3 L fluid with 150 mmol sodium and 60 mmol potassium is:

·         1L normal saline with 20 mmol potassium over 8 hr

·         1L 5% dextrose with 20 mmol potassium over 8 hr

·         1L 5% dextrose with 20 mmol potassium over 8 hr

Other common regimes are:

·         1L normal saline with 20mmol potassium over 8hrs each and 1L of 5% dextrose with 20mmol potassium for patients with surgical problems (such as bowel obstruction) that may lead to excessive Na loss. Always check U+Es before prescribing

·         3x 1L of Hartmann’s solution over 8hrs each.  Hartmann's is physiologically close to plasma but has a lower osmolality. Continuous therapy can therefore reduce plasma osmolality and it should be avoided in patients with head injury to avoid exacerbating cerebral oedema.

A common regime to replace fluid loss requires several adjustments and close monitoring is:

·         250 ml colloid (Gelofusine) or 5% dextrose fluid challenge to maintain CVP at 8-12 cmH2O and BP >120 mmHg (repeat if necessary)

·         1 ml/kg/hr normal saline as adjunct fluid therapy

·         Additional potassium in 5% dextrose if K+ <3 mmol/L

Severe hemorrhage requires packed red blood cell infusion.

Hartmann’s solution at 20-30 ml/kg/hr can also be used for fluid resuscitation

Fluid and electrolyte balance

Daily requirements

·         Water: 40 ml/kg/day (rough estimation, see below for exact calculation)

·         Sodium ~ 100 mmol

·         Potassium ~60 mmol

Maintenance fluid requirement for healthy nil-by-mouth patient:

·         4 ml/kg/hr for first 10 kg of patient’s weight

·         2 ml/kg/hr for second 10 kg of patient’s weight

·         1 ml/kg/hr for every kg after that

·         + 100 mM sodium and 60 mM potassium

·         Fluid requirements in resuscitation depends on stages of hypovolemic shock:

·          

·         Stage 1 (< 15% or <750ml loss):  Normal blood pressure as compensated by increased systemic vascular resistance --> give Crystalloid

·         Stage 2 (15-30% or 750-1500ml):  Tachycardia, postural hypotension, +/- sweating and anxiety – partially compensated by increased systemic vascular resistance --> give Colloid

·         Stage 3 (30-40% or 1500-2000ml):  Systolic blood pressure <100 mmHg, tachycardia, tachypnoea, altered mental state (confusion) --> give Colloid + Blood

·         Stage 4 (>40% or >2000ml):  Very low blood pressure, bradycardia, weak pulse pressure, depressed mental state, urine output

·         negligible --> give Colloid + Blood