Burn Assess airway breathing and circulation Treat the

Burn: • Assess airway, breathing and circulation • Treat the burn wound • In patients with large burns, do not initially spend much time carefully calculating fluids. • Instead, start an IV and start giving fluids rather rapidly while exam is being performed. • DO NOT BOLUS! 500 cc/hr is a good rule. • Later do the calculations.

Fluid resuscitation • Goal: Maintain perfusion to vital organs • Based on the TBSA(Total Body Surface Area), body weight and whether patient • is adult/child Fluid overload

• Lactated Ringers ﺍﺩﺍﻣﻪ • Contains Na+ • Free of glucose : high levels of circulating stress hormones may cause glucose intolerance

• Have large insensible fluid losses • Fluid volumes may increase in patients with co-existing trauma • Vascular access: Two large bore peripheral lines (if possible) or central line. • Fluid requirement calculations for infusion rates are based on the time from injury, not from the time fluid

Assessing adequacy of resuscitation • Peripheral blood pressure • Urine Output: Best indicator unless ARF occurs (mucous membranes, skin turgor, tears, pulse rate, capillary refill) • CVP: Better indicator of fluid status • Heart rate: Valuable in early post burn period – should be around 120/min. • Invasive cardiac monitoring: Indicated in a minority of patients (elderly or pre-existing cardiac disease)

R/L

Parkland Formula • Maintain urine output at 0. 5 cc/kg/hr. • ARF may result from myoglobinuria • Increased fluid volume, mannitol bolus and Na. HCO 3 into each liter of LR to alkalinize the urine may be indicated

This formula recommends no colloid in the initial 24

Galveston Formula • Used for pediatric patients • Based on body surface area rather than weight • L/R is used at 5000 cc/m 2 x % BSA burn plus 2000 cc/M 2/24 hours maintenance. • ½ of total fluid is given in the first 8 hrs and balance over 16 hrs. • Urine output be maintained at 1 cc/kg/hr.

Fluid requirements in children • Use same formula for fluids to replace loss from burns. • In children, add this amount to normal maintenance rate: 10 kg - about 40 cc / hr maintenance fluids 20 kg - about 60 cc / hr 30 kg - about 70 cc / hr • Expected urine output for child: 1 cc / kg /hr for infant: 2 cc/ kg / hr

Fluids requirements in children 20 kg child with 30% burn: 20 (kg) x 30(%) x 2 (cc/kg/%) = 1200 cc in 24 hr Half of this in first 8 hr = 600 cc in 8 hr = 75 cc / hr initially 75 cc / hr for burn loss + normal 60 cc / hr maintenance =135 cc / hr initially

How do you know if the patient is getting too much fluid, or too little? Check Urine Output, Urine Specific Gravity, HCT

Fluid resuscitation regimen ( adapted from Mount Vernon formula) • Divide first 36 h from the time of burn into six consecutive periods of 4 , 4, 6 and 12 h. For each period give 0. 5 ml 4. 5– 5% albumin × body wt [ k g ] × %burn • Give blood as necessary to maintain haemoglobin > 10 g / dl • Commence enteral nutrition as soon as possible • Give 1. 5– 2 ml / kg / h 5 % glucose • Reassess cardiorespiratory variables and urine output

Fluid management in major burn injuries(2010): Several studies have supported that patients who receive larger volumes of resuscitation fluid are at higher risk for injury complications and death. In the light of this prediction, the chosen types and rates of the fluid administration in major burns are at the focus of controversy.