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BURN RESUSCITATION

These pages are excerpted from the Trauma Resident Handbook, Rhode Island Hospital Department of Surgery, Division of Trauma - updated 2001. The policies herein are intended to serve as guidelines only. Individual circumstances need to be considered as there may be times when it is appropriate or desirable to deviate from these guidelines. These educational guidelines will be reviewed and updated routinely.

Burn resuscitation is characterized by the formation of tissue edema and intravascular hypovolemia. Hydrostatic and oncotic forces play a significant role in the formation of edema during the first 24 hours, most notably in the first 8 hours. Widening of the basement membrane gap junctions at 6-12 hours post-burn results in increased permeability, which further drives fluid losses. Due to the release of circulating cytokines and other inflammatory products, the effects of burn injury are both local and systemic. During the period of increased edema formation (the first 24 hours after burn), maintenance of normovolemia with aggressive fluid resuscitation and fluid boluses only exacerbates the severity of edema formation. Maintenance of end organ perfusion - not the rapid achievement of normovolemia - is the goal of burn resuscitation. The end organ monitored during resuscitation is the kidney, with urine output guiding fluid rates. By 24 hours after burn, the endothelial leak has sealed and albumin infusions can safely be started. Insensible fluid losses through the burn wound begin in the second 24 hours following burn and continue to be significant until the burn wound is closed.

Success of resuscitation depends on ability to meet the patient's physiologic demands. Identifying patient populations at risk for failure directs resuscitative measures and possibly affects outcome. Risk factors for failure include age + burn size >100, thrombocytopenia, blood transfusions, and excessive fluid requirements (6 cc/kg/% burn, normal averages 3.7 cc/kg/% burn). These patients may benefit from invasive monitoring and the attainment of supranormal physiologic resuscitation parameters. The use of Vitamin C and hypertonic saline, though not found to affect outcome in the general population, may have a role in populations predicted to fail therapy.

Due to the difference in body surface area, children <30 kg require a maintenance IV fluid of D5 1/2 NS in addition to a resuscitation equation of 3 cc/kg/% burn. Other special thermal injury populations include the electrical injury patient who has sustained a current injury greater than 1,000 volts. The surface area burned often greatly underestimates edema formation and, therefore, volume needs due to underlying muscle and soft tissue injury. These patients should be closely measured by urine output and for the appearance of pigmenturia.

1. References:
   Kramer GC, Nguyen TT: Pathophysiology of burn shock and burn edema. In Total Burn Care (Herndon DN, ed.). Philadelphia: WB Saunders, 1996.
2. Warden GD: Fluid resuscitation and early management. In Total Burn Care (Herndon DN, ed.). Philadelphia: WB Saunders, 1996.

Burn - The First 24 Hours

>20% TBSA		<20% TBSA
Start at 2 cc/kg/% burn (1/2 of volume given in first 8 hrs) Measure urine output hourly		Oral hydration
If urine output < 0.5-1 cc/kg/hr IVF 10-20%	If urine output > 0.5-1 cc/kg/hr IVF 10-20%	If nausea/vomiting or poor urine output
Assess volume infusion @ 6 hrs*
>6 cc/kg/% burn Invasive monitoring	<6 cc/kg/% burn Continue current resuscitation	Start IV resuscitation

* IV rate at 6o post-burn - multiply by 24o. Determine what this rate is equivalent to in terms of cc/kg/TBSA.

Burn - The Second 24 Hours

Start 5% albumin infusion for TBSA >30%:

For 30-50% burns 0.3 cc/kg/TBSA/24 = _____ cc/hr
For 50-70% burns 0.4 cc/kg/TBSA/24 = _____ cc/hr
For >70% burns 0.5 cc/kg/TBSA/24 = _____ cc/hr

Continue to wean LR as dictated by the 1st 24 hour protocol. When LR rate <200 cc/hr, stop LR and start D5W at 1 cc/kg/TBSA/24 (to replace insensible water losses).

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