Overview
Definition:
Burn resuscitation is the immediate management of a patient with significant thermal injury, focusing on restoring fluid balance and preventing hypovolemic shock
The Parkland formula is a cornerstone of this process, providing a guideline for intravenous fluid administration in the initial 24 hours post-burn.
Epidemiology:
Burns are a significant cause of injury worldwide, with thermal burns being the most common
The incidence varies by region and socioeconomic factors
Major burns requiring aggressive resuscitation are less common but carry high morbidity and mortality.
Clinical Significance:
Inadequate or excessive fluid resuscitation in burn patients can lead to severe complications, including hypovolemic shock, organ ischemia, compartment syndrome, and increased mortality
Correct application of formulas like Parkland is crucial for optimizing outcomes and guiding clinical decision-making for DNB and NEET SS aspirants.
Parkland Formula
Formula Statement:
Total fluid requirement in the first 24 hours = 4 mL x Body Weight (kg) x % Total Body Surface Area (TBSA) burned.
Fluid Administration Schedule:
Administer half of the calculated total volume in the first 8 hours post-burn (from the time of injury, not admission)
Administer the remaining half over the subsequent 16 hours.
Crystalloid Type:
Lactated Ringer's solution is typically the preferred crystalloid for initial resuscitation due to its electrolyte composition and buffering capacity, aiming to counteract burn-induced acidosis
Isotonic saline can also be used.
Adjustment Criteria:
Urine output is the most critical indicator of adequate resuscitation
Target urine output is 0.5-1 mL/kg/hr in adults and 1-2 mL/kg/hr in children
Other indicators include heart rate, blood pressure, mental status, and peripheral perfusion.
Limitations:
The Parkland formula is a guideline and requires continuous clinical reassessment
It may need adjustment in specific scenarios such as inhalation injuries, electrical burns, patients with pre-existing renal or cardiac disease, and very large or small burns.
Burn Assessment
Tbsa Estimation:
Accurate estimation of TBSA burned is paramount
The Rule of Nines is commonly used in adults
In children, the Lund-Browder chart is more accurate
Specific areas like palms and soles are considered 1% TBSA.
Depth Of Burn:
Classification into superficial (first-degree), partial-thickness (second-degree), and full-thickness (third-degree) burns is important for guiding management and predicting fluid needs, though fluid resuscitation primarily addresses the systemic inflammatory response to partial and full-thickness burns.
Inhalation Injury Assessment:
Suspect inhalation injury in patients with facial burns, singed nasal hairs, soot in oropharynx, hoarseness, or symptoms of airway obstruction
Inhalation injury significantly increases fluid requirements and complicates resuscitation.
Associated Injuries:
Always assess for and manage associated trauma, especially in cases of explosions or falls associated with burns
A rapid trauma survey is essential.
Resuscitation Monitoring
Urine Output:
Continuous Foley catheterization is essential to monitor urine output accurately
This is the primary determinant of fluid resuscitation adequacy.
Vital Signs:
Close monitoring of heart rate, blood pressure (including invasive monitoring for large burns), respiratory rate, and oxygen saturation is vital to assess hemodynamic stability.
Central Venous Pressure:
CVP monitoring may be considered in patients with very large burns or underlying cardiac comorbidities to guide fluid management.
Laboratory Investigations:
Serial electrolytes, arterial blood gases (ABGs), lactate levels, complete blood count (CBC), and renal function tests are crucial for assessing metabolic status, acid-base balance, and organ perfusion.
Fluid Management Beyond 24 Hours
Colloid Administration:
After the initial 24 hours, fluid management shifts focus
Albumin or other colloids may be considered to maintain oncotic pressure and help mobilize fluid back into the intravascular space, particularly when plasma proteins are depleted.
Maintenance Fluids:
Continue intravenous fluids to meet maintenance requirements, adjusted based on ongoing losses, urine output, and clinical status
Basal metabolic rate increases with burn size, influencing fluid needs.
Monitoring For Overhydration:
Be vigilant for signs of fluid overload, such as pulmonary edema, peripheral edema, and weight gain, especially in patients with pre-existing cardiac or renal issues, or those with inhalation injury.
Weaning From Fluids:
Gradual reduction in IV fluid rates as the patient stabilizes, intake improves, and edema resolves
Transition to oral fluids as tolerated.
Complications Of Burn Resuscitation
Fluid Overload:
Pulmonary edema, cerebral edema, compartment syndrome, acute kidney injury
This is more common with incorrect calculation or poor monitoring.
Under Resuscitation:
Hypovolemic shock, ischemic injury to organs, increased metabolic rate, delayed wound healing, higher risk of infection, and increased mortality.
Electrolyte Imbalances:
Hyponatremia, hyperkalemia, or hypokalemia can occur and require careful correction
Hyperchloremic acidosis can be seen with excessive saline administration.
Compartment Syndrome:
Can occur in extremities due to circumferential burns and edema, requiring escharotomy or fasciotomy
It can also occur in the trunk (abdominal compartment syndrome).
Renal Failure:
A consequence of prolonged hypoperfusion or rhabdomyolysis (from muscle damage in severe burns or electrical injuries).
Key Points
Exam Focus:
Parkland formula calculation: 4mL x Kg x %TBSA
First 8 hours: 1/2 total
Next 16 hours: 1/2 remaining
Urine output is the GOLD STANDARD for resuscitation adequacy (0.5-1 mL/kg/hr)
Rule of Nines for TBSA estimation in adults.
Clinical Pearls:
Always re-evaluate fluid needs based on clinical parameters, not just the formula
Consider inhalation injury and other co-morbidities that will increase fluid requirements
Early escharotomy may be needed for circumferential burns to prevent compartment syndrome.
Common Mistakes:
Using incorrect TBSA estimation
Starting resuscitation clock from admission instead of time of injury
Relying solely on formulas without clinical monitoring
Underestimating fluid needs in inhalation injury
Incorrectly calculating fluid rates for boluses vs
continuous infusion.