TFC 012: EPICC Review Week 6: Simplifying Fluid Resuscitation in the Burn Patient

Background:  When I started my career in EMS in 2001 the way we managed fluid resuscitation in the burn patient was to follow the Parkland Formula which had been the cornerstone of fluid resuscitation for the burn patient since the late 1960’s. Over the years it was observed that most patients receiving the standards 4ml/kg x TBSA burned experienced significant complications from fluid overload which complicated their long term care. Along came the Modified Brooks Formula (2ml/kg x TBSA) which left some patients under resuscitated. Finally, we were taught the Consensus Formula 2-4ml/kg x TBSA) which sought to strike a balance between the two previous formulas. Today, the ABA recommends a more simplified approach to the initial resuscitation of all burn.


Fluid Resuscitation - The Past

Parkland Formula

  • 4ml/kg x TBSA burned (2nd / 3rd Degree)

Modified Brooks Formula

  • Adults - 2ml/kg x TBSA burned (2nd / 3rd Degree)

  • Children - 3ml/kg x TBSA burned (2nd / 3rd Degree)

Fluid Resuscitation - Today

Consensus Formula for Initial Fluid Resuscitation

  • Adults (15 years old and older & >40kg)

    • 2ml/kg x TBSA

  • Peds (14 years old and younger & <40kg)

    • 3ml/kg x TBSA

  • Adult High Voltage Electrical Injury w/ myoglobinuria

    • 4ml/kg x TBSA until urine clears.

  • Peds High Voltage Electrical Injuries w/ myoglobinuria

    • Consult Pediatric Burn Center

In each case, the total amount of fluid determined for the initial 24 hours post injury was to be administered…

  • 50% over first 8 Hours

  • 50% 1/2 over next 16 Hours

NOTE: If initial fluid resuscitation is delayed from the time in injury, the time for the 1st half of the initial fluid resuscitation should be shortened so that by 8 hours post injury the patient has received the proper amount of initial fluid.

Outcomes:

  • With 4ml/kg, many patients were experiencing significant fluid overload.

  • Confusion over the proper amount of fluid to administer leading to many patients either being over or under resuscitated.

  • When fluid resuscitation was delayed from the time of initial injury, EMS providers were bolusing IV fluids to “catch the patient up” which resulted in significant myocardial strain, fluid overload, and third spacing.

Current American Burn Association Recommendations

Initial Fluid Resuscitation - Prehospital and Early Hospital

  • Fluid Resuscitation Only Necessary for Burns >20% (2nd & 3rd Degree)

  • Ringers Lactate is preferred resuscitation fluid

    • LR produces less acidosis than NS

      • Hyperchloremic Metabolic Acidosis

    • Normal Saline acceptable, but should be exchanged for LR as soon as possible

  • Adults (14 years and older)

    • 500ml/hr

  • Peds (6 years to 13 years old)

    • 250ml/hr

  • Infants (5 years and younger)

    • 125ml/hr

Once accurate TBSA burned is determined, Consensus Formula is used for Fluid Resuscitation.

Calculating Total Body Surface Area (TBSA) Burned

  • Initial

    • Rule of Palms for small / Irregular burns

      • Splash burns

    • Rule of 9’s

  • Lund and Browder Chart

    • Considers Pt’s Age

    • More accurate

    • Typically only used by tertiary burn centers

Comparison of Rule of 9’s vs. Lund and Browder for Determining TBSA Burned

Comparison of Rule of 9’s vs. Lund and Browder for Determining TBSA Burned


Additional Fluid Requirements

  • Maintenance Fluid (4,2,1) for pts <30kg in addition to Burn Resuscitation

    • 4cc/kg/hr for first 10kg PLUS

    • 2cc/kg/hr for next 10kg PLUS

    • 1cc/kg/hr for everything over 20kg

    30kg kid gets 70cc/hr

  • Fluid Bolus for Hypotension

    • 20cc/kg


Goals

  • Protect kidneys

    • Urine Output

      • Adults - 0.5cc/kg/hr (30-50cc/hr)

      • Children up to 17 YOA (>30kg) - 0.5cc/kg/hr

      • Young Children (≤ 30kg) - 1cc/kg/hr

      • Adult w/ high voltage electrical injuries and myoglobinuria - 1-1.5cc/kg/hr (75 – 100 ml/hr) until urine clears.

  • Maintain Circulating Volume

  • Prevent Hypothermia

  • Prevent Electrolyte Imbalances

  • Maintain Euglycemia


TIPS and Take Home Points

  • Burn Resuscitation Only Necessary with 2nd and 3rd Degree Burns >20% TBSA

  • <20%TBSA, just give maintenance fluid

  • An easier way to remember initial fluid resuscitation rates is to just remember 5 & 15. This will get you in the ballpark.

    • 5 and under = 125cc/hr

    • 15 and over = 500cc/hr

    • In between gets 250cc/hr

  • Use Ringers Lactate if available. If not, NS is just fine but switch out for LR ASAP. LR causes less acidosis than NS in large volumes.

  • All patients swell. Don’t make it worse by over hydrating them.

  • Once the patient reaches the Burn Center their fluid will be titrated based on their urine output.

    • Make sure IFT patients have foley cath in place, and monitor their U/O.

  • If monitoring U/O, increase or decrease IFV by 1/3 q hour for proper urine output.

  • For the FP-C and CCP-C Exam you will still need to know how to calculate TBSA Burned and Calculate Fluid Resuscitation Rates.

    • Use Rule of 9’s and Parkland


References:


For More Thoughts on This Topic Checkout:

Mary Ellen Billington, MD at EMDocs: Modern-Day Burn Resuscitation: Moving Beyond the Parkland Formula


Resources:

Burn Center Referral Criteria

Locate Center Finder


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