APPENDIX D: BURN RESUSCITATION PROTOCOL, WORKSHEET & FLOW SHEET

THE BURN RESUSCITATION PROTOCOL

The JTS Burn Resuscitation Flow Sheet provides clinicians with a tool to track burn resuscitation over a 72-hour period. Conceptually, the flow sheet creates a continuum between clinicians during the resuscitation phase. This format allows clinicians to accurately trend intake and output, hemodynamics and vasoactive medications, and promotes optimal outcomes through precise patient management.

1. The clinicians at the first medical facility where the patient receives treatment will initiate the JTS Burn Resuscitation Flow Sheet. This treatment facility will be listed in the “Initial Treatment Facility” block. Clinicians at any role of care (R1, R2, R3, R4) may initiate the flow sheet.
2. Record today’s date in the “Date” block according to the current date where the recorder is located. (Do not adjust this date based on the patient’s origin or destination; use the local date).
3. Record the patient’s full name and DoD ID number or social security number in the “Name” and “SSN” blocks. Document name and DoDID/SSN on all three pages of the flow sheet.
4. Record the patient’s weight in the “Pre-burn est. wt (kg)” block. In theater, record the estimated weight based on the patient’s weight prior to injury or “dry weight.” If a patient presents prior to initiating resuscitation and an accurate weight can be easily obtained without delaying care, providers are urged to weigh the patient and record the result.
5. Record the total body surface area burned in the “%TBSA” block (do not include superficial injury in this calculation). Clinicians will assess the burn size and use this value to determine fluid resuscitation requirements. Following the patient’s transfer to another facility, the receiving clinicians are required to “re-map” the burn, considering the burn wound may “convert” (or become deeper) between assessments or during transport between two facilities.
6. Burn Fluid Resuscitation Calculations: Use the Rule of Tens to determine fluid requirements for the first 24 hours post-burn. (Rule of Tens: 10 x % TBSA > 40 kg and < 80 kg; if > 80 kg, add 100 ml/hr for every 10 kg > 80 kg). At 8-12 hours post-burn, reevaluate resuscitation efforts and assess for potential over resuscitation. If fluid resuscitation needs exceed 6 ml/kg/%TBSA in 24 hours, consider the guidelines established in the Emergency War Surgery Handbook and the addendum to the handbook, “Recommendations for Level IV Burn Care.” [LRMC specific: USAISR/BAMC Burn Unit Guidelines can also be found in the LRMC Burn Care Guide.]
   - Clinicians at the first medical facility to treat the patient will calculate the fluid requirements for the first 24 hours post-burn and record the amount in the block on page 1 labeled “Estimated fluid volume patients is administered.”
   - Clinicians will record the “fluid volume ACTUALLY received” during the first 24 hours of resuscitation in the block labeled as such at the top of page 2. This amount will equal the actual volume delivered during the first 24 hours (as recorded on page 1).
   - Clinicians will transcribe the 24-hour fluid volume totals recorded on pages 1 and 2 of the flow sheets onto page 3 in the block labeled “fluid volume ACTUALLY received.” This allows clinicians to see the first 48-hour totals as the patient enters into the last 24 hours of the 72-hour period.
7. Record the local date and time that the patient was injured in the “Date & Time of Injury” block. This date and time IS NOT the time that the patient arrived at the medical facility, but rather the date and time of INJURY.
8. Record the facility name and/or treatment team in the “Tx Site/Team” block. The facility name/team name is the team of clinicians who managed the patient during each specified hour on the flow sheet. This team may reside within a facility, in which case the facility name is recorded, or be a transport team (e.g., MEDEVAC, CCATT, AEROVAC).
9. “Hr from burn” is defined as the number of hours after the burn injury occurred. If a patient does not arrive at a medical facility until 3 hours after the burn occurred, clinicians do not record hourly values for hours 1-3 but begin recording the row marked “4th” hour post-burn. To the extent possible, clinicians should confer with level I and II clinicians to determine fluid intake and urine output. These totals may be record in the 3rd hour row.
10. Record the current local time of the recorder in the “Local Time” block. As with date do not adjust time based on the patient’s origin or destination; use the local time.
11. Record the total volume of crystalloids and colloids administered in the “crystalloid/colloid” column, not the specific fluids delivered. Clinicians should refer to the critical care flow sheet to determine the fluid types and volumes. This burn flow sheet is designed to track total volumes. Examples of crystalloid solutions are LR, 0.45% NS, 0.9% NS, D5W, and D5LR. Examples of colloids are Albumin (5% or 25%) and blood products. The use of hydroxyl ethyl starch (hextend) as a resuscitation fluid is no longer recommended.
12. Document the name, dosage, and rate of vasoactive agents in the “Pressors” block. Patients who receive vasoactive agents may also have invasive pressure monitoring devices (e.g., arterial line, central venous line, pulmonary artery catheter), in which case significant values should be recorded in the “BP” and MAP (>65)/CVP” columns.

For additional guidelines refer to the Emergency War Surgery Handbook and the Recommendations for Level IV Burn Care.