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CHAPTER11 Fluid resuscitation inburns
Calculation offluid requirement
Parkland formula (1968)
This is the most commonly used and often recommended regimen in
practice today.
Three key pieces of information are needed to commence appropriate
resuscitation uids.
• TBSA (see diagram on inside cover to aid calculation)
• Time of burn injury
• Weight of patient
The Parkland formula for the total uid requirement in 24 hours following
burn injury is as follows:
• 4mL × TBSA (%)× body weight (kg)
• 50% given in rst 8 hours
• 50% given in next 16 hours
• Children receive maintenance uid (4% glucose in one- quarter or
one- fth saline) in addition, at an hourly rate of:
• 4mL/ kg for the rst 10kg of body weight plus
• 2mL/ kg for the second 10kg of body weight plus
• 1mL/ kg for >20kg of body weight
• For accuracy, subtract any amount of uid already given from the
requirements for the rst 8 hours
Beware hyponatraemia in children and use background uids of 5% dextrose in half- normal saline if transfer is delayed >12 hours.
• Fluids should run through two large bore IV cannulae ideally inserted
through non- burnt skin. Intraosseus infusion may be needed in children.
• Worked example:
• 10kg child suers 20% TBSA and arrives in department 2 hours
following injury
• Resuscitation requirement as per Parkland formula
• 4 × 10 × 20=800mL in 24 hours
• Burn was 2 hours ago, therefore uid for rst 8- hour time period
must go through in 6 hours
• Thus 800/ 2=400mL over 6 hours, ie. 66mL per hour for 6 hours
• Followed by 400mL over 16 hours, ie. 25mL per hour for next 16
hours Hartmann’s solution
• PLUS maintenance 4 × 10=1000mL, ie. 40mL per hour 4% glucose
in one- quarter normal saline
Muir and Barclay resuscitation protocol (1962)
Estimates the amount of colloid (5% human albumin solution) that needs to
be administered during the rst 36 hours after a major burn.
It divides up the total time into six periods of varying duration, each re-
quiring the same volume of uid.
• %TBSA × body weight (kg) × 0.5=volume (mL) in each period
• 1st/ 2nd/ 3rd periods— 4 hourly
• 4th/ 5th periods— 6 hourly
• 6th period— 12 hourly
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CALCULATION OFFLUID REQUIREMENT
When using this formula, maintenance uid is also required.
• Combination resuscitation regimes are often used:Hartmann’s for
8hours and switch to albumin for the remaining time
Monitoring response toresuscitation
The most straightforward and reliable technique to assess adequacy is
via urine output (UOP) thus demanding catheterization for patients with
large burns.
• Adults 0.5mL/ kg/ h. This equates to 30– 50mL per hour
• Children <30kg 1.0mL/ kg/ h
This urine output reects adequate renal perfusion and will alert the clinician to over resuscitation if UOP is excessive, and poor tissue perfusion
with associated consequences if UOP is low.
Developing acidosis can reect hypoperfusion of tissues and under resus-
citation, but may also indicate the need for, or inadequacy of, escharotomy.
It is essential to monitor serum electrolytes following resuscitation.
Adilutional hyponatraemia is common and hyperkalaemia seen following
electrocution.
Myoglobinuria
Tissue injury associated with electrocution, blunt trauma, or ischaemia
results in the release of myoglobin and haemoglobin into the circulation.
Deposition in the proximal tubules of the kidney will cause acute renal
failure. The urine is typically coloured brown or orange.
Treatment
• Increase UOP to 1– 2mL/ kg/ h
• Mannitol 12.5g/ L resuscitation uid
• Sodium bicarbonate 25meq/ L resuscitation uid
Important points
• Do not put too much emphasis on uid calculation and instead prioritize
(1)transfer of patients to burns services, (2)keeping the patient warm,
which is critical, (3)analgesia
• Patients are often over- resuscitated. Aim for an accurate assessment of
burn and sensible uids until they reach specialist care
• Various technological solutions exist to facilitate calculation of burn
surface area and uid resuscitation such as the Mersey Burns iPhone/
iPad App, which can be accessed and used from any computer or
smart device through the internet if the app is not available via www.
merseyburns.com
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CHAPTER11 Fluid resuscitation inburns
Further reading
Alvarado R, Chung KK, Cancio LC, Wolf SE. Burn resuscitation. Burns 2009;35:41– 4.
Hunter JE, Drew PJ, Potokar TS, etal. Albumin resuscitation in burns:a hybrid regime to mitigate uid
creep. Scars, Burns & Healing 2016;22;2:2059513116642083.
Tricklebank S. Modern trends in uid therapy for burns. Burns 2009;35:7– 67.
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Chapter12
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Escharotomies
Background of escharotomies 96
Indications of escharotomies 96
Principles of escharotomies 96
Specics of escharotomies 98
Fasciotomy 102
Volar 103
Proximal forearm and arm 104
Anterior incision 106
Further reading 108
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CHAPTER12 Escharotomies
Background ofescharotomies
Following a signicant thermal or electrical injury, tissues beneath the skin
swell through uid loss into the interstitial space. The increase in extravascular uid together with the inelastic nature of the overlying burned skin
compound to increase pressure within the aected limb. This increase in
pressure can compromise the vascular supply distally in an aected limb
or increase ventilatory pressures in those with circumferential burns of the
chest and abdomen. This chapter will give guidance on when and how to
perform escharotomies; however, the nal decision is usually based on experience and clinical judgement.
Indications ofescharotomies
• Circumferential burns of extremities that develop signs of inadequate
perfusion (cool to touch, reduced pulse oximetry)
• Circumferential burns of chest and abdomen that develop ventilatory
compromise or abdominal compartment syndrome
• Absence of pulse on Doppler distal to injury (presence of a pulse
doesn’t rule out need for escharotomy
• Compartment pressure >30mmHg or within 30mmHg of systolic BP.
Note— escharotomies will not treat true compartment syndrome, which will
require fasciotomies
Principles ofescharotomies
• Electrocautery may be preferred to scalpel in general although some
prefer scalpel especially for the digits
• Full thickness incisions through burned skin to subcutaneous tissues
• Longitudinal incisions to avoid injury to underlying neurovascular
structures, with the limbs in the anatomical position
• Aim to commence and end incision within normal skin, preferably 1–
2cm from the edge of the burn
• If you are cutting through long lengths of unburned skin, reect on the
necessity or location of the escharotomy
• Experienced surgeons may deviate from ‘traditional’ lines of
escharotomy in preference for the deepest area of burn and incise the
fascia to allow assessment of any need for formal fasciotomy
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PRINCIPLES OFESCHAROTOMIES
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CHAPTER12 Escharotomies
Specifics ofescharotomies
Please see the gures for details of regional escharotomies.
Upper limb
• Longitudinal incision along both radial and ulnar aspect of upper
extremity (Fig. 12.1)
• Pass anterior to the medial epicondyle (avoid ulnar nerve injury)
• Continue incisions into hand overlying hypothenar and thenar eminence
• Dorsal hand escharotomies overlying the 2nd and 4th metacarpals can
be linked to ulnar escharotomy at wrist (Fig. 12.2)
• Digital escharotomies can reduce necrosis and should be made between
the neurovascular bundle and the extensors, avoiding both structures
on the radial border of the thumb and ulnar border of all other digits
(Fig. 12.3)
Lower limb
• Longitudinal incision along both medial and lateral aspect of lower
extremity
• Pass anterior to the bula head (avoid common peroneal nerve injury)
Fig.12.1 Markings for escharotomies of upper limb. Avoid injury to ulnar nerve by
passing anterior to the medial epicondyle.
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SPECIFICS OFESCHAROTOMIES
Fig.12.2 Markings for escharotomies of thumb (continuation of radial forearm
escharotomy), dorsal markings for escharotomy.
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Fig.12.3 Markings for escharotomies of digits— ulnar border of digits 2– 5.
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CHAPTER12 Escharotomies
Chest and abdomen
• Join all incisions to allow a “breast plate” of tissue to move and reduce
ventilatory pressures (Fig. 12.4)
• Superior incision— transverse incision inferior to the clavicles
• Longitudinal incision— along anterior axillary lines bilaterally (allow
continuation along lateral borders of abdomen to decompress, if
necessary)
• Inferior incision— along inferior border of costal margin
• Abdominal compartment syndrome is not infrequent and there should
be a relatively low threshold for release of the abdomen as well. This is
even more important in children as abdominal restriction compromises
ventilation
Fig.12.4 Markings for escharotomies of chest and abdomen. Superior incision
below clavicles, longitudinal incision along anterior axillary line, and inferior incision at
the inferior border of the costal margin. Continuation of longitudinal incision shown
to allow release of abdomen.
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SPECIFICS OFESCHAROTOMIES
Practical points toconsider
• Local anaesthetic if patient not sedated (lignocaine with adrenaline 1%)
• Maximum dose 7mg/ kg
• Maximum dose for 70kg patient=49mL
• Dry the tissues and then use a sterile pen to mark the line that will be
inltrated with local anaesthetic
• Anatomical position
• Cutting diathermy
• Swabs/ gauze ready
• Dressings:alginate dressing to assist haemostasis
• Monitor for postoperative bleeding
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