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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Burn Resuscitation and Management

Timothy J. Schaefer ; Omar Nunez Lopez .

Authors

Affiliations

Last Update: January 23, 2023 .

Continuing Education Activity

Severe burns cause not only significant injury at the local burn site but also a systemic response throughout the body. Inflammatory and vasoactive mediators such as histamines, prostaglandins, and cytokines are released, causing a systemic capillary leak, intravascular fluid loss, and large fluid shifts. These responses occur mostly over the first 24 hours, peaking around 6 to 8 hours after injury. This response, along with decreased cardiac output and increased vascular resistance, can lead to marked hypovolemia and hypoperfusion, called burn shock. This can be managed with aggressive fluid resuscitation and close monitoring for adequate, but not excessive, IV fluids. This activity reviews the importance of burn fluid resuscitation and highlights the role of the interprofessional team in managing burn patients.

Communicate the importance of improving care coordination among interprofessional team members to improve outcomes for patients affected by burns.

Introduction

Most small burns are treated at home or by local providers as outpatients. This topic focuses on the initial resuscitation and management of severe burns. (Also see Burns, Evaluation and Management and Burns, Thermal).[1][2][3] The patient's age determines burn severity classification, the percentage of total body surface area burned (%TBSA), depth of burn, type of burn, and whether specific body parts are involved. Patients are classified as having severe burns if they have any of the following;

Other factors that should be considered and increase the patient’s morbidity and mortality include associated inhalation injury, associated traumatic injury, and the patient’s baseline medical conditions like heart disease or lung disease. Several factors may predispose the specific group of patients to more complicated injuries.[4][5] Severe burns cause not only significant injury at the local burn site but also a systemic response throughout the body. Inflammatory and vasoactive mediators such as histamines, prostaglandins, and cytokines are released, causing a systemic capillary leak, intravascular fluid loss, and large fluid shifts. These responses occur mostly over the first 24 hours, peaking around 6 to 8 hours after injury. This response, along with decreased cardiac output and increased vascular resistance, can lead to marked hypovolemia and hypoperfusion, called “burn shock.” This can be managed with aggressive fluid resuscitation and close monitoring for adequate, but not excessive, IV fluids.[6][7]It is important to remember that burns alone do not cause significant hypotension initially, and “burn shock” develops over the first few hours. If the patient is profoundly hypotensive initially, other causes of hypotension should be sought.

Anatomy and Physiology

Burns to the face, eyes, ears, joints, hands, or genitalia are genitalia are generally considered more significant and require transfer to a burn center.

Indications

Adults and children with burns greater than 20% TBSA should undergo fluid resuscitation using estimates of body size and surface area burned. Common formulas used to initiate resuscitation estimate a crystalloid need for 2–4 ml/kg body weight/% TBSA during the first 24 hours.[8][9][10]

Contraindications

Excessive fluids are contraindicated in the hemodynamically stable burn patient, which likely contributes to edema.

Preparation

If a trauma with extensive burns is suspected, the team should prepare for burn resuscitation, which includes fluids, sterile sheets, and having pain medications quickly available.

Technique or Treatment

Resuscitation for Major Burns

Burns are dramatic injuries that can draw healthcare providers’ attention away from more immediate life or limb-threatening problems. The initial assessment and management of severely burned patients should be similar to the approach of a major trauma patient. However, for the burn patient, the very first step is to immediately stop the burning process and remove burning or hot items from skin contact. Providers should obtain an initial A.M.P.L.E. history (allergies, medications, past medical history, last oral intake, events of injury). The primary survey assesses the A.B.C.s for life threats. In the burn patient, attention should focus on the airway, looking for oral burns that might cause swelling and obstruction, breathing problems from smoke inhalation or lung injury, and bleeding or circulation problems by looking for life-threatening bleeding and checking blood pressure, heart rate, and pulses. The next step would be resuscitation and immediate intervention for life threats. A secondary survey with a complete physical exam follows this.

Evaluating and treating the burns are part of the secondary survey. The fundamental physical exam findings to record in burns are the extent of the burns, expressed as a percentage of total body surface area burned (% TBSA), and the depth of the burns, expressed as superficial (or first-degree), partial-thickness (or second-degree) or full-thickness (or third-degree).[11][12] See Image. Burn Degrees. Patients with burns of more than 20% - 25% of their body surface should be managed with aggressive IV fluid resuscitation to prevent “burn shock." Various formulas exist, like Brooke, Galveston, Rule of Ten, etc, but the Parkland Formula is the most common. This formula estimates the amount of fluid given in the first 24 hours, starting from the time of the burn.[13][14][15]

The Formula

Four mL lactated ringers solution × %TBSA burned × patient's weight in kilograms = total amount of fluid given in the first 24 hours. One-half of this fluid should be given in the first 8 hours. For example, a 75 kg patient with 55% total body surface area burn would need 4 mL LR × 75kg × 55% TBSA = 16,500 mL in the first 24 hours, with 8,250 mL in the first 8 hours or approximately 1 liter/hr for the first 8 hours. The Parkland Formula can be used for pediatric patients, plus normal maintenance fluids can be added.[16][17][18][19]

Whichever formula is used, the critical point to remember is the fluid amount calculated is just a guideline. The patient’s vital signs, mental status, capillary refill, and urine output must be monitored and fluid rates adjusted accordingly. Urine output of 0.5 mL/kg or about 30 – 50 mL/hr in adults and 0.5-1.0 mL/kg/hr in children under 30kg is a good target for adequate fluid resuscitation. Recent literature has raised concerns about complications from over-resuscitation, described as "fluid creep." Again, adequate fluid resuscitation is the goal.

Other management for severe burns includes nasal gastric tube placement, as most patients develop ileus. Foley catheters should be placed to monitor urine output. Cardiac and pulse oximetry monitoring is indicated. Pain control is best managed with IV medication.[20]Finally, burns are considered tetanus-prone wounds; tetanus prophylaxis is implied if not given in the past 5 years.[21]In any severe flame burn, you should always consider possible associated inhalation injury, carbon monoxide, or cyanide poisoning (see Inhalation Injury chapter).[22][23][24] Severe burn wound management should be directed to your local burn center. The burns should be gently cleansed and covered with clean dressings. Extensive debridement and application of topical antimicrobial creams or ointment are not needed if the patient is urgently transferred to a burn center because they need to do their burn assessment once the patient arrives.[25]

In certain situations, an emergent escharotomy may be necessary before transfer. An escharotomy is a surgical procedure performed to relieve the constricting effect of full-thickness burns. Because full-thickness burns are firm, leathery, and nonpliable, they can limit the typical swelling. This can create a compartment syndrome effect if the burns surround an extremity or an abdominal compartment syndrome effect if the burns surround the abdomen. If the burn involves extensive chest areas, then adequate ventilation may be impossible. In such cases, escharotomy should relieve the constriction effects and allow for adequate circulation or ventilation. An escharotomy is done by incision through the firm burn eschar, deep enough into the fat layer to enable the eschar to split open. This can be done at the bedside without an anesthetic because the burn has destroyed the nerve fibers, and the skin has lost sensation. Incisions are made on the medial and lateral sides of extremities and digits, along with the axillary lines and parallel to the clavicles on the upper chest and along the lateral abdominal walls on the abdomen.[26][27]

Complications

Deep or Extensive Burns Complications