FLUID

MANAGEMENT IN
BURN INJURY
DELA ROSA, JAMEE LORRAINE M.
FUMC-SURGERY ‘18
OBJECTIVES
■ GENERAL OBJECTIVE
– To present a case of a 24yo male burn patient

■ SPECIFIC OBJECTIVES
– To know the important factors in burn care
– To know what is the appropriate fluid management for a burn patient
– To discuss the different intravenous fluids and its indications
CASE
■ H.O.
■ 24 years old
■ Male
■ Roman Catholic
■ Filipino
■ Marilao, Bulacan
■ DOA: May 24, 2017.
CHIEF COMPLAINT:
■ Burns
HISTORY OF PRESENT TRAUMA
NOI: SCALD BURNS
POI: CALOOCAN CITY
DOI: 10:45 PM
TOI: 05-24-17

PRIMARY SURVEY SECONDARY SURVEY

A – IRWAY PATENT A – LLERGIES NO ALLERGIES

B – REATHING SPONTANEOUS M – EDICATIONS NO MEDICATIONS

C – IRCULATION BP 140/90 P – AST ILLNESSES (-) HTN (-) DM (-) PTB

D – ISABILITY GCS 15 L – AST MEAL 7:00pm

E – XPOSURE WITH E – VENTS/ Patient suddenly slipped then fell in a basin of boiling water
SCALDED BURN
ENVIRONMENTAL CONTROL ENVIRONMENT RELATED involving right suprascapular area, right lumbar area, right &
TO INJURY left gluteal area, right & left lower extremities, ventral part
 PERSONAL AND SOCIAL
PAST MEDICAL HISTORY FAMILY HISTORY
HISTORY

• (-) DM • Hypertension: none • Smoker = 1.5 pack

• (-) HPN • CAD: none years
• (-) PREVIOUS HOSP • Asthma: none • Occasional alcoholic
• (-) PREVIOUS OR drinker
• Diabetes: none
• (-) ASTHMA • (+) illicit drug use
• (-) PTB • TB: none
• Cancer: none
REVIEW OF SYSTEMS
■ Skin: (-) Pruritus, (-) Rashes
Head: (-) dizziness (-) headache
Neck: (-) neck pain
Neurological: (-) tremors
Pulmonary: (-) DOB (-) SOB
Cardiovascular: (-) Palpitation
Gastrointestinal: (-) diarrhea
Genitourinary: (-) dysuria
Muskulosketal: (-) atrophy
Endocrine: (-) heat and cold intolerance (-) polydipsia
PHYSICAL EXAMINATION
■ GENERAL: Awake, alert, not in cardio respiratory distress, ambulatory, in
visible discomfort/pain and irritable
VITAL SIGNS: BP: 140/90 CR: 89 RR: 24 TEMP: 36.8 O2SAT: 97% WT: 55kg
■ HEENT: anicteric sclera, no burns around buccal region, no
tonsilophyaryngeal congestion
■ CHEST AND LUNGS Scald burn at right suprascapular area, right lumbar
area (+)symmetrical chest expansion, no retractions, no crackles, no
wheezing, broncho-vesicular breath sounds
■ HEART: Adynamic precordium, normal rate, regular rhythm, no murmurs
■ ABDOMEN: Flat, soft, non tender, normoactive bowel sounds
■ EXTREMITIES: Scald burn at right & left gluteal area, right & left lower
extremities, ventral part ( Erythematous, painful, with blisters)
TBSA: </= 12%
DIAGNOSIS
■ Partial thickness burn secondary to boiling liquid, right buttocks,
left buttocks lateral half, right upper extremities (forearm and
upper arm), right scapular region, area of the gastrocnemius
muscle bilateral
PROCEDURE AND ANCILLARY TESTS
Clinical Chemistry (05/25/17)
System International
05/25/2017 Conventional
Normal Values
WBC 11.9 (H) 5.00-10.00 109/L
Result Normal Value Result Normal Value
Neutrophils 0.32 (L) 0.40-0.60
Potassium Lymphocytes
5.50 (H) 3.50 – 5.10
0.51 (H)
5.50 (H) 3.50 – 5.10
0.20-0.40
Sodium Monocytes 129.00 (L) 136.000.07
– 145.00 129.00 (L) 136.00
0.02-0.08 – 145.00
Eosinophils
Chloride 99.70 98.000.09
– (H)
107.00 99.70 0.01-0.03
98.00 – 107.00
Basophils 0.01 0.00-0.02
Hgb 156 (H) 123.00-152.00 g/L
Hct 0.46 (H) 0.37-0.42
RBC 5.4 4.50-5.50 1012/L
MCV 85.0 88.00-96.00 fL
MCH 28.9 27.00-33.00 pg
MCHC 340 330.00-360.00 g/L
RDW 12.3 12.70-22.70%
Platelet 255 150.00-450.00 10^9/L
MPV 8.1 4.50-7.50 fL
 COURSE IN THE WARD
Day 1 Day 2 Day 3 Day 4 Day 5
• Admitted • DAT • Fluid by mouth • Present • May go home
• DAT • PLR 1L q12 was encouraged management • Continue
• PLR 1L q12 • Tramadol • Ascorbic acid continued Ascorbic acid OD
• Meds: continued 500mg/tab OD • DAT • Proper aseptic
• Co-amoxiclav • Advised to • IVF TF: PLR 1L dressing of scald
1.2g q12 TIV ambulate if q12
• Tramadol 50mg tolerable • Ascorbic acid
q8 TIV • Ketorolac 30mg continued
• Ketorolac 30mg IV was given
IV
• Change of
dressing wet to
dry with
Flamazine
cream OD
• VS q4
DISCUSSION
TOTAL BODY WATER
■ 50 – 60% of the total body weight.
■ Male: 60% of the total body weight.
■ Female: 50% of the total body weight.

■ THREE FUNCTIONAL FLUID COMPARTMENTS:

1. PLASMA
2. EXTRAVASCULAR INTERSTITIAL FLUID
3. INTRACELLULAR FLUID
FLUID COMPARTMENTS
■ Extracellular compartment (1/3 of TBW; 20% of total body weight)
– Plasma (5% of body weight)
– Extravascular interstitial fluid (15% of body weight)
■ Intracellular compartment (2/3 of TBW; 40% of total body weight)
COMPOSITION OF FLUID COMPARTMENTS
DISCUSSION
Loss in the integrity of the skin destroys the barrier that balanced humans inner
environment and that of the external world leading to:
■ Loss of body
 Temperature
 Fluids
 Proteins
 Electrolytes
■ Ingress of foreign bodies
■ Invasion by Microbes
 Most common cause of burn from hot water

IMPORTANT FACTORS IN BURN CARE > 140 0F or > 60 0C in 3 secs.

> 156 0F or > 69 0C in 1 sec

■ ETIOLOGY
■ BURN SIZE ETIOLOGY
■ BURN DEPTH
FLAME – damage from superheated oxidized air

SCALD: Damage from contact with hot liquids

CONTACT: damage from contact with hot or cold solid materials

CHEMICALS: contact with noxious chemical

ELECTRICITY: conduction of electrical current through tissues

 • Estimates the burn injury
• Most important factor predicting burn related
IMPORTANT FACTORS IN BURN CARE
mortality
■ ETIOLOGY
■ BURN SIZE
■ BURN DEPTH

TBSA: </= 12%

 • Varies depending on the degree of tissue damage
IMPORTANT FACTORS IN BURN CARE • Dependent on temperature and duration of contact
with the skin.
■ ETIOLOGY • Classified into degree of injury in the epidermis,
dermis, subcutaneous fat, and underlying structures
■ BURN SIZE
■ BURN DEPTH

PARTIAL THICKNESS DEPTH ETIOLOGY CLINICAL FINDING

Superficial scalds, flash Erythematous, painful,
SUPERFICIAL (papillary) burn blanch to touch, often
dermis without blisters
Deep (reticular) contact, Mottled, do not blanch to
DEEP dermis weak touch, more pale, painful
chemical to prick
MANAGEMENT
BASIC TREATMENT
■ PREHOSPITAL MANAGEMENT  INITIAL ASSESSMENT  INITIAL WOUND CARE 
TRANSPORT  RESUSCITATION
RESUSCITATION
■ One of the cornerstones of modern burn treatment
■ Appropriate fluid management directly improves the survival rates
– Suboptimal resuscitation: Increases burn depth and longer shock period
■ Required for a patient that has sustained a burn >10% for children, >15% for
adults.
■ GOAL: maintain tissue perfusion in the early phase of burn shock
BURN SHOCK PATHOPHYSIOLOGY
RESUSCITATION
PARKLAND FORMULA
4ml x TBSA% x Kg = ml/24hrs
4 x 12% x 55 =2,640 ml/24 hours
■ ½ total in 8 hours post injury
2,640 /2 = 1,320 ml to run for 8 hours
1,320 /8= 433.125cc/hr x 8 hours
■ ½ total in 16 hours post injury
1,320 ml to run for 16 hours
1,320/16= 82.50cc/hr x 16 hours
Basic types of Intravenous Fluids
IV FLUIDS DESCRIPTIONS EXAMPLES
• Balanced salt/ electrolyte solutions
• PNSS
Crystalloids which may be isotonic, hypertonic or
• LR
hypotonic

• High molecular weight solutions which

• Albumin
draw fluid into the intravascular
Colloids • Plasma
component via oncotic pressure
• dextran
• Effective plasma expanders

Provide water that is not bound by

Free H20
macromolecules or organelles, thus is free • D5W, D10W, D20W
solution
to pass through membranes

Whole blood, pRBC, FFP,

Blood
Essentially are also considered colloids platelet concentrate,
products
cryoprecipitate
FLUID MANAGEMENT
INDICATIONS
Incorporation of medication, initial IVF for MI, CVA,
D5W RF on admission where electrolyte levels are not
yet known
Isotonic volume loss, like bleeding, cholera, AGE-
PLR for most surgical cases, not for jaundice, cirrhotic
patients, blood transfusion due to calcium content
Maybe use for blood transfusion, replaces chloride
PNSS
loss, NGT drainage
Promote osmotic diuresis, hence defeats the
D5LR
purpose of resuscitating the ECF
RESUSCITATION
■ FIRST 24 HOURS
– CRYSTALLOID FLUIDS
■ Fluid of choice
■ Advantage:
– Readily available and cheaper
■ Colloids have no sufficient influence on maintaining intravascular volume
■ Between 18 to 24 hours the capillary leak begins to seal sufficiently
– Colloid replacement at this time may be estimated at 0.5cc/kg/%burn.
– Either Albumin or Fresh Frozen Plasma is used
RESUSCITATION
■ SECOND 24 HOURS
– Capillary permeability approaches normal during the latter half of
the first burn day with restoration of functional capillary integrity by
the second post burn day.
■ MONITORING
– REMEMBER: the infusion rate is guided by the urine output, not by
formula
– The urine output should be maintained at a rate
■ Adult 0.5 – 1ml/kg/hr
■ Children 0.5-2ml/kg/hr - *aim for 1 ml/kg/hr
CONCLUSION
■ Fluid resuscitation in each patient must be individualized, because each
person has varied reactions and responses to burn injury and fluid
resuscitation.
■ The optimal resuscitation regimen is that which decreases volume and salt
loading, prevents acute renal failure and has low incidence of pulmonary
and cerebral edema.
■ Initial resuscitation should be a balanced crystalloid. Ringer’s acetate
protect the electrolytic balance on large replacements – Crystalloid of
choice
■ Acute Burn Management. (n.d.). Philippine Society for Burn Injuries.
■ Bartel, B., & Gau, E. (n.d.). Fluid and Electrolyte Management.
■ Dries, D. J., & Marini, J. J. (2017). Management of Critical Burn Injuries: Recent
Developments. Korean J Crit Care Med, 13.
■ Tricklebank, S. (2009). Modern Trends for Fluid Therapy for Burns. Science Direct, 12.
THE END 