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Chapter 4. Initial Management andResuscitation
125
undefined. The 2008 U.S.Joint Theater Trauma System guidelines for burn resuscitation described a stepwise approach to
the hypotensive burn patient, as follows:
1. Vasopressin
2. Volume infusion to achieve central venous pressure (CVP)
or pulmonary arterial wedge pressure (PAWP) targets
3. Norepinephrine up to 20mcg/min
4. Epinephrine or phenylephrine. Meanwhile, these patients
should be evaluated for missed injury, adrenal insufciency,
hypocalcemia, or other issues [35]
Our practice has evolved since that publication.
Vasopressors are used more routinely. CVP is rarely monitored in the critically ill burn patient. Pulmonary artery
catheters are placed less frequently, and use of predetermined CVP or PAWP targets is unusual. On the other hand,
it is important to understand that the cavalier up-titration
of alpha agonists during burn shock is potentially hazardous. An increasing requirement for such agents should
prompt a comprehensive reevaluation of volume status,
cardiac function, end-organ perfusion, and acid–base status.
The risk/benefit ratio of volume vs. vasopressor infusions
must be assessed.
Maintaining situational awareness of all the data that need
to be monitored during a complicated burn resuscitation is
challenging and starts with effective documentation. The
Joint Trauma System flowsheet is one paper-based format,
developed for the battlefield, that can be used to record the
basic data [35]. Furthermore, decision support tools such as
Burn Navigator (Arcos Medical, Houston, TX) can be used to
document and display these data in a manner which was
developed specifically for burn resuscitation. This system also
makes recommendations on fluid infusion rates based on
analysis of trends in the UO [36].
During hours 24–48 postburn, we routinely infuse 5%
albumin in normal saline in accordance with the modified
Brooke formula. The dose for this infusion is weight based,
according to a sliding scale:
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• 0.3mL/kg/TBSA for burn size 30–49%
• 0.4mL/kg/TBSA for burn size 50–69%
• 0.5mL/kg/TBSA for burn size 70–100%
Thus, an 80kg patient with a 70% burn would receive (80
*70*0.5mL)/24h=2800mL/24h=117mL/h. This infusion is
given over 24h and is normally not titrated. Meanwhile, the
LR infusion used during the first 24 h is weaned to off. As
described below, initiation of an albumin infusion before the
24th postburn hour is sometimes used to rescue patients who
are failing resuscitation.
Typically, burn patients spontaneously diurese their
resuscitation volume over days 3–10 postburn. Increasingly,
we have recognized the value of active “de-resuscitation” to
offload this volume more quickly [37]. Beneficial effects of
this strategy may include earlier extubation and, in patients
who require excision of the burn wound, more successful
healing of skin grafts [38]. De-resuscitation can be performed
either pharmacologically using diuretics or by means of continuous renal replacement therapy.
Complicated Resuscitation
Not all patients respond to resuscitation successfully;
historically, about 12% of burn patients who died, did so
during the first 48 h despite full resuscitative efforts [39].
Indications of resuscitation failure, in patients who have
already received a substantial volume of fluids, include the
following:
• Progressive metabolic acidosis
• Acute kidney injury
• Refractory oliguria or anuria
• Escalating vasoactive pressor doses
In this setting, it is tempting to respond with a further
escalation in crystalloid resuscitation volume. This may be
reasonable at first, but as the cumulative infusion volume
nears 250mL/kg during the first 24h (the “Ivy Index”), the
Chapter 4. Initial Management andResuscitation
127
risk of abdominal and other compartment syndromes mounts
[31]. In our experience, abdominal compartment syndrome
(ACS) in burn patients is associated with a mortality risk of
nearly 100% if it requires decompressive laparotomy [40].
The group at UC Davis reported a 40% survival rate after
decompressive laparotomy for ACS, but many of those
patients were children who developed ACS in the setting of
sepsis rather than burn shock [41]. Although a decompressive
laparotomy may temporize ACS, it is often impossible to
achieve timely abdominal closure, there is loss of domain, and
the physiologic insult of an open abdomen compounds that
of an extensive burn.
Thus, we aim to keep the resuscitation volume below
250mL/kg/24 h. This requires ongoing awareness of the current infusion rate, the cumulative volume, and the projected
24-h volume. As a rule of thumb, an hourly infusion of
2000mL or more is cause for concern, as is a sustained infusion rate of 1500mL/h or more for several hours. By about
8–10 h postburn, it should be possible to extrapolate: the
cumulative volume to the 24-h point, and to begin to make an
assessment of the risk of exceeding 250mL/kg/24h (Fig.4.3).
Interventions to salvage patients who are headed toward
resuscitation failure include:
• Reassess volume and cardiac status via enhanced
monitoring (see above)
• Look for a missed injury, such as non-thermal trauma
• Measure bladder pressure; assess for ACS
• Initiate early albumin
• Initiate continuous renal replacement therapy (CRRT) or
therapeutic plasma exchange (TPE)
• Initiate high-dose ascorbic acid therapy
Measurement of bladder pressure should be done routinely
in patients whose predicted or actual infused volume exceeds
250 mL/kg. WSACS—the World Society of Abdominal
Compartment Syndrome—defines ACS as a bladder pressure
of 20 mmHg with new onset organ failure [42]. In burn
patients, others have recommended decompressive laparot-
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L. C. Cancio and J. M. Cancio
F . Screen shot from the Burn Navigator burn resuscitation
decision support system. This graph shows the cumulative fluid volume. Extrapolation of the cumulative fluid volume curve to the 24th
postburn hour allows an estimation of the risk of exceeding the Ivy
index of 250 mL/kg by that hour. Reproduced with permission of
Arcos Medical, Inc., Houston, TX
omy at a bladder pressure of 30mmHg and signs of physiologic compromise [41]. Thus, a bladder pressure of
20–30mmHg could be defined as a “warning zone.” Short of
decompressive laparotomy, burn patients with ACS may benefit from several interventions to include abdominal escharotomy, neuromuscular blockade, and paracentesis [43].
Placement of a diagnostic peritoneal lavage catheter into the
abdomen may allow ongoing drainage to occur as resuscitation proceeds.
We routinely infuse 5% albumin in normal saline during
hours 24–48 postburn, in accordance with the modified
Brooke formula (see above). In light of evidence suggesting
that microvascular permeability, at least in unburned tissues,
begins to resolve around hours 8–12 postburn [11], we insti-
Chapter 4. Initial Management andResuscitation
tute albumin before the 24th postburn hour in patients whose
trajectory indicates that they are headed toward exceeding
the Ivy Index. We have observed that it is possible to decrease
the fluid infusion rate within about 3h in many patients who
receive early albumin [18].
At the US Army Burn Center, CRRT for the treatment of
burn patients with sepsis-induced acute kidney injury (AKI)
was associated with decreased 28-day and hospital mortality,
in comparison with matched case controls [44]. Although that
study did not examine the use of CRRT during burn shock,
we now routinely provide CRRT to patients during burn
shock resuscitation who develop AKI, to include hyperkalemia or metabolic acidosis refractory to medical management.
CRRT also facilitates the off-loading of edema fluid during
de-resuscitation. Another extracorporeal rescue strategy is
TPE [45].
Finally, high-dose IV ascorbic acid (vitamin C) was studied
by Tanaka and colleagues in Tokyo. In their randomized controlled single-center trial, patients were considered for enrollment if they were admitted within 2h of injury. Vitamin C at
a dose of 66 mg/kg/h was started as soon as possible after
admission and was continued for the first 24h postburn. It
was associated with a decrease in resuscitation fluid requirements, weight gain, wound edema, serum malondialdehyde
levels, and ventilator days [46]. Since the proposed mechanism of action of vitamin C in burn shock is its anti-oxidant
properties, it makes sense to begin it as soon as possible after
admission, rather than as a later rescue therapy.
129
Management of theBurned Extremity
One of the most challenging aspects of early burn care is the
management of the burned extremity. Extremities with deep
circumferential burns are at risk of ischemic injury via a process we term “extremity eschar syndrome.” Whereas normal
skin is elastic, full-thickness burns are inelastic. Furthermore,
edema beneath the inelastic burn wound progressively
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squeezes the extremity, acting like a tourniquet, and impeding
venous outflow, capillary blood flow, and ultimately arterial
inflow. To decrease edema formation, burned extremities
(especially upper extremities) should be elevated by any
available means at a level above the heart throughout resuscitation; see below for more information on the role of the
rehabilitation team in positioning.
Doppler flowmetry of circumferentially burned extremities
is performed hourly during resuscitation. The arteries to be
monitored are the radial and ulnar arteries at the wrist; the
superficial palmar arch of the hand; and the dorsalis pedis
and posterior tibial arteries at the ankle/foot. Loss or progressive diminution in the audible Doppler signal is an indication for escharotomy.
Escharotomy is an incision through the full thickness of
the burn eschar and into the underlying subcutaneous tissue.
Escharotomies of the extremities are performed along the
mid-medial and/or mid-lateral joint lines (Fig.4.2). Structures
to avoid include the ulnar nerve at the elbow (place the incision anterior to the medial epicondyle) and the superficial
radial nerve at the wrist (which becomes subcutaneous about
9 cm proximal to the radial styloid) [47]. Successful escharotomy results in restoration of the distal Doppler signal.
Doppler flow must be rechecked after the procedure, and
hourly thereafter till resuscitation is complete.
The deeply burned hand is a problem of great concern.
The following procedures should be performed by qualified
surgeons. In a patient with deep dorsal hand burns, loss of
the palmar arch Doppler signal despite the presence of
radial and ulnar flow is an indication for dorsal hand escharotomies via incisions over the second and fourth metacarpals, with care not to injure the extensor tendons. In
addition, some authors recommend that interosseous
(intrinsic) muscle fasciotomies should routinely accompany
dorsal hand escharotomies [48, 49], although this has not
been our usual practice.
Patients with deeply burned but still viable fingers who
lose Doppler signal in the digital arteries may benefit from
Chapter 4. Initial Management andResuscitation
131
digital escharotomies. This is a matter of ongoing controversy
in the burn literature with some advocating for digital escharotomies [49, 50], and some questioning the benefit [51].
There are limited studies, with one small prospective trial
showing an improvement in the number of necrotic phalanges with digital escharotomies [52]. The incision for a digital
escharotomy is performed along one side of the involved
finger, between the neurovascular bundle (which lies at the
level of the digital flexion crease) and the extensor tendon
apparatus. This procedure can be bloody, and pinpoint electrocautery will likely be needed.
The advent of Nexobrid (MediWound Ltd, Industrial
Zone Yavne, Israel), a rapidly acting, enzymatic debriding
agent, may facilitate the prevention and treatment of extremity eschar syndromes, especially of the hands. At present,
NexoBrid is recommended for use by trained specialists [53].
FDA approval for marketing in the US has been obtained.
The extremity eschar syndrome should not be confused
with a true intramuscular compartment syndrome. In the former situation, the problem is edema beneath the burn eschar,
and the remedy is an incision through the skin. In the latter
situation, the problem is edema (or bleeding) beneath the
investing fascia, and the treatment is a fasciotomy. To be sure,
compartment syndrome does occur in burn patients, for
example:
• With massive resuscitation, in either burned or unburned
extremities
• Following delayed escharotomy, via an ischemia-
reperfusion mechanism
• In the setting of concomitant mechanical trauma (e.g.,
crush, fracture, vascular ischemia-reperfusion)
• With burns that extend into the muscle
• Following high-voltage electrical injury
Thus, even patients who undergo apparently successful
escharotomies must continue to receive monitoring of the
Doppler signal and of the physical examination throughout
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the resuscitation period. In patients diagnosed with
compartment syndrome, operative fasciotomy is required.
Wound Care andPain Management
During first aid at the scene, immediate cooling of a burn
wound with cool running water appears to be beneficial if it
can be performed without causing hypothermia or delaying
lifesaving interventions [54]. Any toxic chemicals must be
rapidly decontaminated. Wound debridement is not an early
priority in the management of a critically ill burn patient, but
it should be completed during the first 24h postburn. At the
US Army Burn Center and many other centers, a special
room is dedicated to showering burn patients while they are
recumbent on a shower cart. In other settings, it may be
advantageous to use the operating room for initial debridement. Burn wound debridement is often an aggressive process intended to remove all sloughed epidermis, debris, dirt,
and other material. An antiseptic such as chlorhexidine gluconate is used. Once debridement has been completed, a
topical antimicrobial or other burn dressing is applied as
described in the Burn Wound Management chapter.
Adequate debridement requires adequate analgesia.
Conscious sedation may be helpful, but general anesthesia is
rarely needed. Analgesia may consist of intermittent IV
boluses or a continuous rate infusion of narcotics and/or ketamine. Intravenous sedatives with a sympatholytic effect such
as propofol may be poorly tolerated during burn shock.
Intermittent low-dose lorazepam or an infusion of midazolam
may be better tolerated during this phase of care.
Supportive Care
Because of increased blood flow to the injured surface of the
body, impaired thermoregulation, and loss of the cutaneous
barrier to evaporative water loss, burn patients are at high
Chapter 4. Initial Management andResuscitation
risk of hypothermia. During debridement and indeed
throughout the resuscitation period, prevention of hypothermia is essential, and the primary method for accomplishing
this is a warm environment.
Patients with burn size of 20% or greater, and those who
are mechanically ventilated, require prophylaxis against
stress gastroduodenal ulceration (Curling’s ulcer). We use a
proton-pump inhibitor for this purpose. We provide deepvenous- thrombosis prophylaxis with subcutaneous lowmolecular weight or unfractionated heparin.
We aim to provide enteral nutrition within 24h of injury,
via a nasogastric or nasoduodenal tube [55]. Reasons for
delay during the burn shock period may include a high vasopressor dose (e.g., norepinephrine >10 mcg/min) or lactic
acidosis (e.g., lactate >3mmol/L).
Care of the eyes during burn resuscitation includes evaluation
upon admission for corneal injury and measurement of
intraocular pressures. If undiagnosed and untreated, corneal
injuries in burn patients may become infected, ulcerate, and
perforate, leading to blindness. Like abdominal and extremity
compartment syndromes, orbital compartment syndrome
(OCS) is more likely in patients who receive >250mL/kg during the first 24h postburn. However, it can also occur in patients
with facial burns who receive no fluid resuscitation at all [56].
OCS, another vision-threatening complication, is easily treated
with lateral canthotomy and cantholysis. This speaks to the
value of early and ongoing evaluation of patients with extensive
burns and those with facial burns by an ophthalmologist.
133
Role oftheRehabilitation Team
Rehabilitation was traditionally viewed as a separate “phase”
in the care of injured patients, but today we recognize the
long-term functional impact of interventions made by therapists during the immediate postburn hours. Accordingly,
assessment by the rehabilitation team (occupational and/or
physical therapists) should take place on the day of admis-
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L. C. Cancio and J. M. Cancio
sion. A comprehensive burn evaluation should include the
following elements [57, 58]:
• History of how injury occurred
• Patient’s preinjury functional and activity level
• Location and depth of burn injury, to include TBSA burn
and calculation of cutaneous functional units (CFUs)
• Associated injuries such as fractures, inhalation injury,
exposed tendon/bone
• Edema, range of motion, strength, sensation measurements
• Activities of daily living assessment
• Functional mobility status
• Positioning needs
• Short-term and long-term goals
• Treatment plan
Since the hands are involved in more than 80% of patients
with severe burns [59], monitoring hand edema is of significant importance during initial resuscitation. Use of a figureof- eight hand edema measurement technique has been
shown to be reliable and valid in the burn population [60].
This is a practical technique that can be performed rapidly
and can be used to examine the efficacy of initial edema management techniques during resuscitation.
Positioning programs should be initiated immediately
upon admission, as edema generally peaks within 12–48 h
postburn [61]. The focus should be on reduction of edema,
minimizing the risk of peripheral neuropathy, and promoting
joint alignment [57]. This is especially prudent in burns of
extremities that are deep-partial to full-thickness in depth, as
well as in burns involving over 20% TBSA. In larger burns,
edema formation is more severe and lasts longer, due to
increased capillary permeability and the massive fluid volumes required for resuscitation [62].
Positioning programs should be individualized, closely
monitored, and adjusted depending on the patient’s medical
status [57]. Generally speaking, elevation of the extremities
includes placement of the involved hand or foot above the
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