Burns injury - PACT - ESICM

3/ ONGOING FLUID AND SURGICAL MANAGEMENT
Fluids (24–72 hrs)
After primary fluid resuscitation (0–24 hrs), the patients have oedema and are loaded
with salt. At this stage, standard crystalloid solutions are replaced by hypotonic
solutions (glucosaline, dextrose 5% or N/2 saline) and colloids are added (0.5 mL x
BW (kg) x %TBSA Burned= mL colloid/24 hrs) while aiming for 0.5 mL/kg/hr of urine
output (1 mL/kg/hr in children). After 48 hrs, the goal is a negative salt and fluid
balance and an intravascular volume that is adequate. The ambition is to bring the
patient back to his/her usual weight within 7-10 days after the injury.
Hypernatraemia is frequently observed during this fluid reversal phase and the use of
thiazide diuretics may be considered. Due to evaporation it is important to give
enough water e.g. as intravenous glucose 5% (glucose 50 mg/mL in water or as
enteral water, usually via an NG tube). Other electrolyte disorders such as low
potassium, phosphate and magnesium are common. The complication of most
concern however is fluid overload due to ‘fluid creep’ – see below.
Pruitt BA Jr. Protection from excessive resuscitation: ‘pushing the pendulum
back’. J Trauma 2000; 49(3): 567–568. PMID 11003341
Holm C, Melcer B, Hörbrand F, Wörl H, von Donnersmarck GH, Mühlbauer W.
Intrathoracic blood volume as an end point in resuscitation of the
severely burned: an observational study of 24 patients. J Trauma 2000;
48(4): 728–734. PMID 10780609
Bacomo FK, Chung KK. (2011) A primer on burn resuscitation. J Emerg Trauma
Shock 2011; 4(1): 109–113. PMID 21633578
Greenhalgh DG. Burn resuscitation: the results of the ISBI/ABA survey. Burns
2010; 36(2): 176–182. PMID 20018451
Lund T, Wiig H, Reed RK. Acute postburn edema: role of strongly negative
interstitial fluid pressure. Am J Physiol 1988; 255(5 Pt 2): H1069–1074.
PMID 3189570
Baxter CR, Shires T. Physiological response to crystalloid resuscitation of severe
burns. Ann N Y Acad Sci 1968; 150(3): 874–894. PMID 4973463
Surgical procedures 0–24 hrs and beyond
Excision of the burn wound
Assessment of burn depth is often difficult and it may delay surgery as spontaneous
healing is preferable in all cases where the healing is finalised before day 10-14 post
burn. In cases of clear full-thickness burns, early excision is the state of the art
recommendation.
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