ASSESSMENT AND DOCUMENTATION/SUPPORT TOOLS

Calculate the patient’s initial burn size using the Rule of Nines (Appendix A). When wounds have been cleansed, re-calculate using the Lund-Browder chart (Appendix B and Appendix C). Superficial (1st degree) burns are NOT included in the estimation of burn size.

Superficial burns (1st degree) appear red, do not blister, and blanch readily. Partial-thickness burns (2nd degree) are moist and sensate, blister, and blanch. Full-thickness burns (3rd degree) appear leathery, dry, do not blanch, are insensate, and often contain thrombosed vessels.

If TBSA is 20% or greater, patients typically require acute fluid resuscitation for 24 to 48 hours postburn.

NOTE: In 10%-20% TBSA burns, maintenance IV fluids should be initiated, and urine output and other endpoints of resuscitation monitored closely. This is especially important in the setting of pre-existing dehydration, methamphetamine or alcohol intoxication, petroleum-based accelerants, concomitant electrical injury, or multisystem trauma as these may be associated with higher than anticipated fluid requirements.12,13

When performing fluid resuscitation, place a Urinary Catheter (with a calibrated urimeter chamber if available). Burns to the penis are not a contraindication to urinary catheter placement. Suprapubic bladder catheter placement is rarely required.

Hourly urine output (UOP) is the main index of resuscitation adequacy and assists with IV fluid adjustments. In adults, the goal is to achieve an hourly target UOP of 30-50 mL/hr (or 75-100 mL/hr for high-voltage electric injury).

Lactated Ringer’s (LR) or PlasmaLyte A are the preferred resuscitation fluids. Normal saline should be avoided, if possible, but can be used if absolutely necessary. ***Polytrauma patients with a source of hemorrhage should receive whole blood or balanced component therapy until hemorrhage is controlled and the patient is no longer coagulopathic. (Refer to JTS CPGs: Damage Control Resuscitation and Whole Blood Transfusion).

For adults, initiate IV fluid resuscitation using the Rule of 10s:10 mL/hr x %TBSA = initial fluid resuscitation rate.14

For patients weighing more than 80 kg, add 100 mL/hr to IV fluid rate for each 10 kg > 80 kg. Example: For a 100-kg patient with 50% TBSA, the initial rate is (10*50) + 200 = 700 mL/hr.

For children, 3 x TBSA x body weight in kg gives the volume for the first 24 hours. One half is programmed for delivery during the first 8 hours. Further guidance for pediatric management is provided below.

Example: a 30-kg child with 50% TBSA will need an estimated 30*50*3 = 4,500 mL during the first 24 hours. Half of this is 2,250 mL, to be given over the first 8 hours. Thus, the initial hourly rate is 2,250 mL/8 hrs = 281 mL/hr.

Use the Burn Resuscitation Worksheet (Appendix D) to assist initiation and documentation of fluid resuscitation.

If available, use the Burn Navigator for decision support.15 At the top of every hour, follow the prompts and enter the intake and UOP values. The device will provide isotonic fluid rate recommendations for the next hour. For guidance, see Appendix I: Burn Navigator.

Both under- and over-resuscitation can result in serious morbidity and mortality. Patients who receive over 250 mL/kg in the first 24 hours are at increased risk for severe complications including abdominal and extremity compartment syndromes.

In the absence of overt hypotension (MAP < 65 mmHg), avoid fluid boluses, as rapid changes in infusion rates contribute to edema. Instead, adjust IV fluid rates based on urine output (see below).