Burn Management

Dr. M. AbdelmoneimICU-Fellow

PSMMC

Major strides in understanding the principles of burn care have resulted in improvement in

– Survival rate– Hospital stay– Morbidity and mortality rates

Introduction

Resuscitation• Effective fluid resuscitation is one of the cornerstones of modern burn

care and perhaps the advance that has most directly improved patient survival

• Proper fluid resuscitation aims to anticipate and prevent rather than to treat burn shock

• Resuscitation of burn shock cannot hope to achieve complete normalization of physiologic variables because the burn injury leads to ongoing cellular and hormonal responses

Resuscitation

• Without effective and rapid intervention, hypovolemia/shock will develop if the burns involve > 15% to 20% total body surface area (TBSA)

• Delay in fluid resuscitation beyond 2 hrs of the burn injury complicates resuscitation and increases mortality

Resuscitation Goals• The obvious challenge is to provide enough fluid replacement to maintain

perfusion without causing fluid overload

• The consequences of fluid overload are as deleterious as those of under-resuscitation: – pulmonary edema– conversion of superficial into deep burns– the need for fasciotomies in unburned limbs– abdominal compartment syndrome

• A Lund-Browder chart should be completed at the time of admission to calculate the TBSA burn

Resuscitation Formulas• Adequate resuscitation from burn shock is the single most important

therapeutic intervention in burn treatment

• Each patient will react uniquely to burn injury depending on age, depth of burn, concurrent

• Inhalation injury, preexisting comorbidities, and associated injuries

• The Parkland formula has been renamed the Consensus formula as it is the most widely used resuscitation guidelines

• 4 mL/kg per percentage TBSA, describing the amount of lactated Ringer's solution required in the first 24 hrs after burn injury

• Starting from the time of burn injury, half of the fluid is given in the first 8 hrs and the remaining half is given over the next 16 hrs

Resuscitation Formulas

• REMEMBER: The infusion rate is guided by the urine output, not by formulaThe urine output should be maintained at a rate

Adult 0.5 / kg / hrChildren 1 ml / kg / hr

• If urine output <0.5mls/kg/hr increase IV fluids by 1/3 of current IV fluid amount

• If urine output >1ml/hr for adults or >2ml/kg/hr for children decrease IV fluids by 1/3 of current IV fluid amount

• Eg: Last hrs urine = 20mls, received 1200mls/hr, increase IV to 1600mls/hrLast hrs urine = 100mls, received 1600mls/hr, decrease IV to 1065mls

Resuscitation Formulas

• More IV fluids are required in (Resuscitation nonresponders):

1. Haemochromogenuria (dark red, black urine) is evident, like in thermal damage to muscle eg electrical injury. Mannitol may be ordered if haemochromogenuria evident

2. Inhalation Injury

3. Electrical injury

4. Delayed resuscitation

5. Fluid loss prior to burn eg fire fighter, diuretics, alcohol etc

Resuscitation Formulas

Colloids?• Due to the capillary leak, most burn centres advise not to use colloids and

other blood products within the first 24 hours

• If used in the early phase (up to 12 h), it can lead to a prolonged tissue oedema and consecutive lung complications

Vascular Access/Other Tubes and Catheters

• No factor other than airway protection is as critical in the early post-burn period as vascular access

• Ideally, obtain peripheral intravenous access away from burned tissue

• Intraosseous catheters may safely be placed in patients of any age

• A patient undergoing resuscitation should have a Foley catheter placed • Nasogastric tubes should be considered in patients with > 20% TBSA

burns, as they will experience gastroparesis and probable emesis, also for early feeding

Bronchoscopy• Subjected to inhalation injury

• Burns occurring in closed areas and all burns that are affecting the head

• Carbon monoxide (CO) intoxication

Infection/Inflammation/Sepsis• 75 % of mortality following thermal injury is directly related to infection

• Sepsis and infection have many criteria routinely found in patients with extensive burns without infection/sepsis

• Fever, Tachycardia, Tachypnea, Leukocytosis

• Patients with large burns have a baseline temperature reset to 38.5°C, and tachycardia and tachypnea may persist for months

Use other clues as signs of infection or sepsis such as:

– Increased fluid requirements– Decreasing platelet counts > 3 days after burn injury– Altered mental status– Worsening pulmonary status– Impaired renal function

Infection/Inflammation/Sepsis

• Any infection in a burn patient should be considered to be from the central venous catheter until proven otherwise

• Central catheters should be changed to a new site every 3 days to minimize bloodstream infections

Infection/Inflammation/Sepsis

Central venous catheter

• The optimum frequency for changing central venous catheters has not been definitively determined in burn patients

• Some centers change catheters to a new site every 3 days, whereas others perform less frequent replacement protocols

• Some centers change catheters to a new site every 3

• At SBH, Boston catheters are changed approximately every 7 days, either to a new site or over a guide wire with a low rate of catheter associated infection

Infection/Inflammation/Sepsis

Central venous catheter