Monitoring

Goal: Maintain adequate oxygenation and ventilation, avoid hypotension, trend response to resuscitation. Document blood pressure (BP), heart rate (HR), urine output (UO), mental status, pain, pulse oximetry, and temperature, and record data on a flow sheet (Appendix D).

VITAL SIGNS

Best: Portable monitor providing continuous vital-signs display; capnography if intubated; document vital-signs trends frequently (every 15 minutes initially, then every 30–60 minutes once stable for more than 2 hours).

Better: Capnometry in addition to minimum requirements (if intubated).

Minimum: blood-pressure cuff, stethoscope, pulse oximetry, document vital-signs trends frequently.

URINE OUTPUT

Urine output (UO) is the main indicator of resuscitation adequacy in burn shock.

Goal: Adjust IV (or oral/rectal intake) rate to UO goal of 30–50mL/h. For children, titrate infusion rate for a goal UO 0.5–1 mL/kg/hr.

Best: Place Foley catheter

- If UO too low, increase IV rate by 25% every 1–2 hours (e.g., if UO = 20mL/h and IV rate =300mL/h, increase IV rate by 0.25 Å~ 300 =75mL/h. New rate is 375mL/h.)
- If UO too high, decrease IV rate by 25%.

Better: Capture urine in premade or improvised graduated cylinder

- Collect all spontaneously voided urine and carefully measure; >180mL every 6 hours is adequate for adults.
- A Nalgene® (Thermo Fisher Scientific Inc., http://www.nalgene.com/) water bottle is an example of an improvised graduated cylinder)

Minimum: Use other measures

- If unable to measure UO, adjust IV rate to maintain HR less than 140, palpable peripheral pulses, good capillary refill, intact mental status.
- Measure the BP and consider treating hypotension, but remember: BP does not decrease until relatively late in burn shock, because of catecholamine release. On the other hand, BP may be inaccurate (artificially low) in burned extremities.

NOTE: Electric injury

- Patients with high-voltage electric injury causing muscle damage and gross pigment in the urine (and similar patients, such as rhabdomyolysis or crush injury) have a higher target UO of 70–100mL/h in adults. See PFC Crush CPG.
- If this does not cause gradual clearing of the pigment (urine turns lighter on three or four hourly checks), the patient likely needs urgent surgery for decompression/debridement