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
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:
Advanced Burn Life Support Providers Manual (2016)
https://www.aliem.com/2013/01/trick-of-trade-rule-of-10s-for-burn/
For More Thoughts on This Topic Checkout:
Mary Ellen Billington, MD at EMDocs: Modern-Day Burn Resuscitation: Moving Beyond the Parkland Formula
Resources:
THANKS FOR LISTENING!
To share your thoughts:
To help out the show:
Leave an honest review on iTunes. Your ratings and reviews really help and I do actually read each one.
Subscribe on iTunes.
I hope you enjoy this episode! Until next time remember...
"Education is good, but excellence through collaboration is much better!"
Stay Safe, and Live Well!
Sean
Right-click here to download this episode to your computer.
