Severe Burn Management
Initial Assessment and Management of Burns
Primary Survey
Secondary Survey
Fluid Resuscitation in Burns
In the first 48 hours, severe burn patients have extreme and sustained distributive shock which is directly proportional to the extent (TBSA) and the depth (partial vs full-thickness) of tissue damage secondary to the burn injury. This is in addition to possible trauma, smoke inhalation injury, infectious injuries etc.
Various formulae (see below) are derived over the past half-century to guide fluid resuscitation in severe burns over the first 24-48 hours. There is no clear superior strategy but generally, the crystalloid requirement is 2-4 mL/kg/% TBSA in the first 24 hours. However, it is important to have an individualized strategy to optimize end-organ perfusion (lactate, UOP, mentation, blood pressure, coagulopathy, etc).
| Strategy/Formula | First 24h | Second 24h |
|---|---|---|
| Evan Formula (1952) | ||
| Brooke Formula (1953) | ||
| Parkland Formula (1974) | ||
| Rule of 10 |
Resuscitative Adjuncts
A resuscitation volume greater than 250 mL/kg in a 24-hour period is often used as a benchmark and is otherwise known as the Ivy index. Exceeding this volume is associated with intra-abdominal compartment syndrome and may be an indication for adjunctive therapy. Assessment/projection of this benchmark is typically done in the first 8-12 hours.
Optimizing Burn Wound Coverage
- Surgical management has the greatest impact on burn survival. Consider it equivalent to "source control for sepsis". Patients need early surgical excision of the burn wounds and definite coverage with autografts. This reduces the hypermetabolic state of burns, decreases the infectious risk period, and improves functional recovery among survivors.
- Definite coverage can be achieved for burns <30-40% TBSA
- MUST try to prevent graft loss
- Pig skin or artificial skin substitutes may be used for larger area burns, or the surgeries may be done as staged procedures.