Emergency Care of The Burn Patient

Now it is time to start treating the burn wound. This part of the information is left towards the middle for a good reason. You don't want to start treating the burn wound until you have:

1. Stopped the burning process
2. Assessed Airway, Breathing and Circulation
3. Evaluated the extent and depth of the bu

4. Assessed the criteria for referral to a burn center
5. Have observed for and treated associated injuries.

Fluid replacement is the prime object of initial burn treatment. When someone gets burned, to put it very simply, their capillaries begin to leak. Instead of sticking together, keeping blood inside of the vessel, the endothelial cells separate and become very porous. Huge amounts of fluid pour out into the tissue. In small burns this fluid accumulates only in the burned areas but in very large burns fluid can accumulate everywhere in the body. These patients can develop a significant amount of edema at the expense of your vascular volume. The blood volume goes down as you become more edematous, or rather, they develop hypovolemic shock.

Who gets resuscitated? Any burn greater than 10%, but this is dependent on the age and health of the patient. For instance if you are treating a healthy 20 year old with a 15 % burn, they can probably resuscitate themselves with oral fluids but nonetheless, they should be observed to make sure they take in enough fluids, is not vomiting and that they produce a satisfactory amount of urine. Anyone with an inhalation injury, associated trauma or electrical injury gets fluid resuscitation. When in doubt, over treat. Make sure they get through the first 24 hours.

There are many formulas for fluid resuscitation. These are not aimed at treating burn shock because burn shock will reverse itself. The goal in resuscitation is to maintain the volume of the patient during the period of hypovolemia. The formula that we use at the Burn Center is the Parkland Formula. It is a good formula for two reasons:

1. It calls for a large amount of fluid
2. It is easy to remember.
The criteria to judge whether or not fluid resuscitation is adequate is measured by urine volume.

Why do we use lactated ringers? Because lactated ringers is most like normal extracellular fluid. If you must give a couple liters of normal saline to a burn patient, you will not harm them but remember that normal saline contains a large amount of chloride. If you give very much chloride to a burn patient there is a potential for metabolic acidosis. Fluid which contains dextrose is not used for two reasons:

1. Does not contain any electrolytes,

2. There is potentially a large amount of adrenaline in the bloodstream which makes these patients glucose intolerant. Their blood glucose levels will increase which will cause their urine output to increase, therefore they will not be getting resuscitated appropriately.

Per fusing the kidneys is one of the goals of therapy. If the kidneys are perusing adequately, the patient will make enough urine. If the patient does not make enough urine they are not getting enough fluid. Even if you are following the Parkland Formula guidelines correctly, some people require more fluid. Turn the rate of the IV fluid up, DO NOT GIVE DIURETICS!

Patients with electrical injuries or very deep tissue damage may have myoglobin in their urine; therefore they will require double the urine output to flush the kidneys of the large myoglobin cells. The amount of fluid resuscitation required is difficult to assess because you can't go by the size of the burn.
All of these criteria are important, but this doesn't help you very much if you are in the field. If there is only one criterion which you can assess, it must be urine output.