Burns 

 

 

Considerations 

 

  • Trauma patient, ATLS approach

  • Difficult/threatened airway: edema, secretions, bleeding 

  • Potential inhalational injury & carbon monoxide/cyanide poisoning

  • Hypovolemia & need for goal-directed volume resuscitation (e.g., Parkland, see below) 

  • Multisystem dysfunction:

    • Acute:

      • Hypovolemic/cardiogenic shock/low cardiac output state → septic shock/high cardiac output state

      • Pulmonary edema/aspiration/restrictive lung

      • Hyperkalemia/myoglobinuria/AKI

      • DIC, anemia of burns

      • Impaired thermal regulation

      • Difficult monitoring/IV access (ECG patches, BP cuffs, etc)

    • Delayed:

      • Sepsis

      • DVT/PE

      • Stress ulcers, adynamic ileus, hypermetabolic/catabolic state

  • Pharmacologic changes: succinylcholine contraindication (>24 hours to 1year)/NDMR resistance (>60 days)

  • Complications of resuscitation:

    • Abdominal compartment syndrome

    • Fluid creep (pulmonary edema, venous congestion, graft dysfunction)

  • Frequent ORs (debridement/grafting):

    • Blood loss

    • Pain, opioid tolerance

    • Possible remote location

 

 

Goals 

 

  • ATLS approach

  • Secure definitive airway (facial/neck/inhalational or major burn) 

  • Assess burn severity/extent

  • Volume resuscitation (formula driven, goal directed)

  • Measure CO levels with co-oximetry 

  • Prevent end-organ dysfunction (lung protective strategy if ARDS, urine output >1ml/kg/hr)

  • Adequate analgesia (multimodal approach +/- antidepressants)

 

 

Parkland Formula

 

  • 4cc X %BSA X weight (kg)

    • E.g. 70kg patient with 20% burn

      • 4cc X 20 X 70 = 5600cc

  • Total fluid for 24 hrs: 1/2 in first 8 hrs, 1/2 in next 16 hrs 

  • Clinical end points: 

    • Urine output >0.5cc/kg/hr

    • Follow HR/BP, goal MAP >60 

    • Follow lactate/mixed venous