The Critically Burned Patient Part 2- What You learned About Fluids Was Wrong, A Simpler Approach

This is Part 2. Derek, an experienced clinician in burn care, joins us to delve into the intricacies and challenges of treating burn patients. This discussion provides valuable insights into the unique aspects of burn injuries, the importance of a comprehensive assessment, and the latest trends in burn treatment.

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Blog post- The Critically Burned Patient

Key Topics Covered

• Complexity of Burn Injuries: Derek begins by explaining why burn patients require a unique approach compared to other trauma patients. He highlights the potential for burns to mask other critical injuries, underscoring the necessity of a thorough and trauma-informed initial assessment.

• The 'Big Three' Considerations: The conversation shifts to what Derek refers to as the "big three" — polytrauma, airway loss, and inhalation injuries — which are crucial early considerations in burn care. He stresses the importance of recognizing these potentially life-threatening conditions alongside the burn injury itself.

• Fluid Resuscitation: A significant portion of the discussion is dedicated to fluid resuscitation, a critical aspect of burn care. Derek talks about the Parkland formula for calculating fluid needs based on the total body surface area affected by burns but a better simpler method is-

  • 500 ml/hr for an adult (<13 yo)
  • 250 ml/hr for a young kid (6-13 yo)
  • 125 ml/hr for a child (<5 yo)

• Pain Management and Ethical Concerns: Derek addresses the ethical and practical aspects of pain management in burn victims. Effective pain control not only improves patient comfort but also aids in overall patient management and long term healing, making it a critical component of the initial response.

• Assessment Tools and Techniques: Various assessment tools such as the Rule of Nines and the Palmer Method are discussed. Derek explains their applications and limitations, emphasizing that while these tools are helpful for initial assessments, more detailed evaluations are typically conducted at specialized burn centers. A link from ABA that may be helpful: https://ameriburn.org/resources/burnreferral/ Includes brief overview of severity/depth (with diagrams, not pictures), Rule of Nines & Palmar Method, plus a link for ABA referral criteria.

  Here is another great article for a deeper dive into pros & cons of different methods of estimating TBSA, although not exhaustive, per se.

  Gretchen C., Burn size estimation: A remarkable history with clinical practice implications,Burns Open, Volume 8, Issue 2, 2024, Pages 47-52, ISSN 2468-9122

  Evaluation and Optimization of the Wallace Rule of Nines for the Estimation of Total Body Surface Area in Obese and Nonobese Populations, The Journal of Emergency Medicine, Volume 65, Issue 4, 2023, Pages e320-e327.
• Burn depth estimates: There are free diagrams out there, but for actual real wound pictures, very little is open-license. UpToDate has a decent starting place, with four pictures embedded, and likely accessible for most.

https://www.uptodate.com/contents/assessment-and-classification-of-burn-injury?search=burn%20depth&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1

Other Scientific papers mentioned-

Burn resuscitation

First article is an overview of evolution of burn fluid resuscitation formulas & philosophy – although again, not exhaustive, per se.

Bacomo, F. K., & Chung, K. K. (2011). A primer on burn resuscitation. Journal of emergencies, trauma, and shock, 4(1), 109–113.  

Next article underscores the risks of fluid creep. Starting too high, being reluctant to titrate down, and the fact that giving too much fluid can actually CAUSE an increased need for fluids (vicious cycle).

Chung KK, Wolf SE, Cancio LC, Alvarado R, Jones JA, McCorcle J, King BT, Barillo DJ, Renz EM, Blackbourne LH. Resuscitation of severely burned military casualties: fluid begets more fluid. J Trauma. 2009 Aug;67(2):231-7; discussion 237. doi: 10.1097/TA.0b013e3181ac68cf. PMID: 19667873.