Acute Resuscitation
1. Calculate the patient’s initial burn size using the Rule of Nines (Appendix A). When wounds are cleaned, re-calculate using the Lund-Browder charts (Appendix B and Appendix C). Superficial (1st degree) burn is NOT included in the estimation of TBSA used for fluid resuscitation.
2. 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, non-blanching, are insensate, and often contain thrombosed vessels.
3. If TBSA is 20% or greater, patients typically require acute fluid resuscitation for the next 24 to 48 hours with close observation until hour 72 post-burn.
4. Place a Foley catheter with calibrated urometer chamber. Burns to the penis are not a contraindication to urinary catheter placement. Suprapubic bladder catheter placement is rarely, if ever, required in burn patients and should be avoided in the presence of abdominal burns.
5.If available, for patients weighing 40 kg or more, use the Burn Navigator, a burn resuscitation decision support fluid calculator.2 At the top of every hour, follow the prompts and enter the intake and urine output (UOP) values. The device will provide isotonic fluid rate recommendations for the next hour. For guidance, see the Burn Navigator Training and Resources.
6. The device uses feedback algorithms and the principles listed below to make fluid rate recommendations. The goal is to achieve an hourly target UOP of 30-50mL/hr.
7. Intake and output tables and graphs display how much fluid a patient received. Graph colors change as the patient approaches over-resuscitation danger zones of >200mL/kg and then >250mL/kg.
8. The system seeks to encourage communication between physicians and bedside nurse by displaying an assessment checklist, alert, and minimum and maximum rate recommendations.
9. Each Burn Navigator device allows resuscitation of only one patient at a time.
CAUTION: The Burn Navigator is NOT intended to be used for electrical burn injuries resulting in rhabdomyolysis with pigmenturia (red-brown urine). Resuscitation fluid needs in these patients often outpace the system’s recommendations. Use clinical judgment and consider the entire scenario when interpreting recommendations, especially when patients have conditions that artificially alter UOP.
10. For adults, if the Burn Navigator system is not available, initiate manual intravenous (IV) fluid resuscitation using the Rule of 10s (10 mL/hr x %TBSA)3 Use the Burn Resuscitation Worksheet (Appendix D) 4 to assist initiation of fluid resuscitation.
1. For patients weighing more than 80 kg, add 100 mL/hr to IV fluid rate for each 10 kg >80 kg.
12. For children, 3 x TBSA x body weight in kg gives the volume for the first 24 hrs. One half is programmed for delivery during the first 8 hours. Further guidance for pediatric management is provided below.
13. Lactated Ringer’s (LR), PlasmaLyte A (Baxter International, Deerfield, Il) or other isotonic solution is the preferred resuscitation fluid; other solutions (normal saline) should be used with caution as electrolyte imbalances may result. In the absence of overt hypotension (MAP <55), avoid fluid boluses as additional volume contributes to edema. Instead, increase the rate of IV fluids to maintain adequate organ perfusion, as reflected by urine output (UOP).3
14. The use of blood products in major burn resuscitation due to coagulopathy, anemia, and bleeding from escharotomy sites or other traumatic injuries is common. Refer to the Joint Trauma System Damage Control CPG for transfusion guidelines and resuscitation of patients with other significant injuries.
15. Monitor UOP closely and decrease or increase the isotonic fluid rate by approximately 20-25% per hour to maintain a UOP of 30-50 mL/hour in adults, or 0.5 to 1 ml/kg /hr in children. Every attempt should be made to minimize fluid administration while maintaining organ perfusion. If UOP> 50 mL/hr, then decrease the fluid rate by 20% for two consecutive hours and reassess. Increase rate of LR by 20% if UOP is less than 30 mL/hr (adults) or pediatric target UOP for 2 consecutive hours. Over-resuscitation can lead to many life threatening complications in the burn patient - so close monitoring of UOP and end organ perfusion is imperative.
16. Both under- and over-resuscitation can result in serious morbidity and even mortality; patients who receive over 250 mL/kg in the first 24 hours are at increased risk for severe complications including acute respiratory distress syndrome and both abdominal and extremity compartment syndromes.
17. Hour-to-hour fluid management is critical, particularly during the first 24 hours. Use the Burn Resuscitation Flow Sheet (Appendix D) to record both fluid intake and UOP.
18. At 8-12 hours post-burn, if the hourly IV fluid rate exceeds 1500 mL/hr or if the projected 24 hr total fluid volume approaches 250 mL/kg, initiate 5% albumin infusion using Table 1 (Adults only); for children, infuse 4-7 mL/kg at the rate of 0.5 mL per minute. Continue the 5% albumin infusion until the 48-hour mark. Fresh frozen plasma may be substituted. In children, consider colloid infusion at calculated maintenance rate, reducing the calculated isotonic infusion by at equal volume.
19. If possible, measure bladder pressures every 4 hours in intubated patients with >20% TBSA burns.5 Ensure the patient is in the supine position and follow the manufacturer's instructions for commercial kits; otherwise, use between 25 and 50 ml, being consistent in whatever volume is used, for serial measurements using a transducer located at the level of the symphysis pubis. Sustained bladder pressure >12 mmHg indicates early intra-abdominal hypertension and adjuncts such as colloid fluid should be considered. If the measured pressure is >20mmHg, the patient should be paralyzed and the measurement repeated. Persistent bladder pressures >20mmHg may indicate abdominal compartment syndrome (See Abdominal Compartment Syndrome below).
20. Combat casualties with burns often present with multi-system injury, to include inhalation injury, hemorrhage, and soft tissue trauma. Associated injuries may increase fluid needs above and beyond standard burn resuscitation formulas.
21. After approximately 24-72 hours, completion of resuscitation is marked by stabilizing hemodynamic parameters and reduction of IV fluid rate to a maintenance level. A well-resuscitated adult burn patient should follow commands, be hemodynamically stable, be tachycardic in the range of 110-130 beats per minute, and have UOP between 30-50 mL/hr. Acid-base balance should normalize, hematocrit should reveal a dilutional anemia, and pulses should be present in all extremities.