Accepted Manuscript

Early Resuscitation and Management of Severe Pediatric Burns

Mary K. Arbuthnot DO , Alejandro V. Garcia MD

PII: S1055-8586(19)30013-7
DOI: https://doi.org/10.1053/j.sempedsurg.2019.01.013
Reference: YSPSU 50794

To appear in: Seminars in Pediatric Surgery

Please cite this article as: Mary K. Arbuthnot DO , Alejandro V. Garcia MD , Early Resuscita-
tion and Management of Severe Pediatric Burns, Seminars in Pediatric Surgery (2019), doi:
https://doi.org/10.1053/j.sempedsurg.2019.01.013

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 ACCEPTED MANUSCRIPT

Pediatric Burn Management

Early Resuscitation and Management of Severe Pediatric Burns

Mary K. Arbuthnot, DOa

Alejandro V. Garcia, MDb
a
Naval Medical Center Camp Lejeune
Department of General Surgery
100 Brewster Blvd.
Camp Lejeune, NC 28547

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Johns Hopkins Hospital
Department of Pediatric Surgery
1800 Orleans St. Bloomberg Bldg 7313

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Baltimore, MD 21287

Mary.kathleen.arbuthnot@gmail.com

Correspondence:
Dr. Mary Arbuthnot
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Alg2014@gmail.com
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Naval Medical Center Camp Lejeune
Department of General Surgery
100 Brewster Blvd.
Camp Lejeune, NC 28547
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Phone: 813-482-5824
mary.kathleen.arbuthnot@gmail.com
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ABSTRACT: Pediatric burns are a leading cause of injury and mortality in children in the

United States. Prompt resuscitation and management is vital to survival in severe

pediatric burns. Although management principles are similar to their adult counterparts,

children have unique pathophysiologic responses to burn injury thus an understanding of

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the differences in fluid resuscitation requirements, airway management, burn and wound

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care is essential to optimize their outcomes.

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KEYWORDS: Pediatric burns, Resuscitation, Inhalational injury, Wound coverage

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INTRODUCTION

Pediatric burns are a leading cause of injury and accidental death in children. In

the United States, it is the third most common cause of unintentional injury or death in

children between 5 and 9 years of age and a leading cause of death in children aged 1 to

14.1 In the toddler age group, scald burns from hot liquid or grease predominate, although

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contact burns from objects such as hot stoves or grills are also common.2 Younger

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children tend to suffer thermal burns from matches or lighters, while older, school-age

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children tend to suffer burns from risk-taking activities such as the use of fireworks or the

reckless use of flammable substances.2 Many of these thermal injuries are minor and can

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be treated on an outpatient basis. However, nearly 5% are considered to be moderate or
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severe, necessitating hospitalization.3 Notably, 16-20% of children admitted with burns

are the victims of abuse and this should be considered when the history of the burn does
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not match the pattern of the injury, or if there is a delayed presentation.2

Historically, severe burns > 80% of the total body surface area (TBSA) in
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children were deemed uniformly fatal. Advancements in fluid resuscitation, nutritional

support, airway injury management and burn care have improved overall burn survival.4
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Although the principles of resuscitation are similar between children and adults, there are
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marked differences in their physiologic response to burns, their fluid resuscitation

requirements, their airway management and burn care; a critical understanding of these
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differences is essential to improve short-term and long-term outcomes in burned children.

INITIAL RESUSCITATION IN BURNS

Why do burns require prompt intravenous resuscitation?

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Unlike other traumatic injuries, thermal injury uniquely results in plasma loss

from injured tissues, thereby affecting not only the integumentary system but also the

cardiovascular, renal, gastrointestinal and pulmonary systems.5 In addition to the loss of

the evaporative protection of the skin, burns > 15% TBSA activate a systemic

inflammatory response that results in diffuse capillary leak and massive fluid shifts.6-8

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The resultant intravascular fluid depletion may rapidly lead to hypovolemia and shock.3, 5

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Further, delayed fluid administration to the volume-contracted patient may contribute to a

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perfusion-reperfusion injury when they are finally resuscitated, resulting in the release of

free radicals which, in turn, potentiates the systemic inflammatory response.4 Due to

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smaller circulating blood volumes in children, delays in initiating adequate volume
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resuscitation must be avoided.3 Postponing proper resuscitation in children for as little as

30-minutes is associated with the development of acute renal failure, increased hospital
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length of stay and increased mortality.3-5

Partial thickness and full thickness burns are used to calculate the TBSA. While
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smaller burns can often be treated with oral hydration, infants and children with >10%

TBSA burns or teenagers with >15% TBSA burns require prompt intravenous access and
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volume resuscitation.6, 7, 9, 10 Peripheral large-bore intravenous access should be obtained

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either percutaneously or by cut-down, preferably into unburned skin.9 Intraosseous lines

may be necessary for access in infants but should be replaced within 24 hours. Central
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venous catheters may be necessary in children with sizeable burns.9 The first 48 hours

post-burn are the most critical to avoid renal failure, sepsis and mortality. As such, the

goals of resuscitation should be aimed at achieving optimal organ and tissue perfusion

while attempting to minimize tissue edema from widespread capillary leak.7

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Pediatric Burn Management

What is the ideal estimated fluid resuscitation rate?

Physical examination will assist in determining the severity of the burn, which is

based on body surface area affected and the depth of the burn. In children, the body

surface area of the head and neck is much larger compared to adults, and similarly, the

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body surface area of the lower extremities is much less.11 The Lund and Browder chart is

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the most commonly used and is the most precise method for estimating TBSA in children

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(Figure 1).11 It accounts for the variation in body shape with age to allow for a more

accurate assessment of body surface area affected.10 If not available, the palm of the

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individual, regardless of age, can be used to estimate 1% of the body surface area.9
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It is critical to not underestimate the TBSA in children. Their overall baseline

body surface area to mass ratio in children is increased compared to adults, thus the
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volume of fluid required per percentage of body surface area burned is greater.3, 9

Furthermore, due to their limited glycogen stores, infants and children are at risk of
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developing hypoglycemia if this is not accounted for.3 To address these differences,

several pediatric-specific formulas have been developed which calculate age and weight-
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based estimated fluid resuscitation (EFR) volumes which include the provision of
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dextrose-containing maintenance fluids (MF).3

Ringer’s Lactate solution (LR) should be started in children regardless of age

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combined with dextrose-containing maintenance fluids in children <30 kg.3, 8, 9 The

Cincinnati Formula and the Galveston Formula are the two main pediatric-specific tools

utilized in current practice (Table 1).3 These formulas account for EFR and MR based on

the TBSA of the burn. They also include the use of colloid in resuscitation (see later

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description). Unfortunately, there are no direct comparisons between the two formulas to

determine superiority. In older children and teenagers, the two most widely used

formulas are the Parkland and the modified Brooke formulae, neither of which includes

the use of colloid (Table 2).3, 12 These formulas are intended for use in the initial 48-hour

period post-burn.13

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Endpoints of resuscitation, such as the urinary output (UO), should be used to

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guide fluid resuscitation and be monitored hourly. In children < 30 kg, the goal UO is 1

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mL/kg/hr, and in children >30 kg, the goal UO is 0.5 mL/kg/hr.3, 9 In addition to urinary

output, physical examination findings such as peripheral perfusion, sensorium, and

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normalizing hemodynamics are cues to adequate resuscitation.3, 14 Trending biomarkers,
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such as plasma lactate levels and base deficit, may be useful to estimate burn severity and

predict survival.15, 16 Kraft et al. evaluated the use of a transcardiopulmonary thermo-

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dilution monitoring device (PiCCO) to guide resuscitation in children with > 30% TBSA

burns and compared this cohort to children resuscitated with conventional monitoring
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systems. Children monitored with the PiCCO system received significantly less fluid

with improved diuresis; Kaplan-Meier curve analysis revealed a lower mortality in the
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initial post-burn phase. These findings suggest that vital, parameter-based fluid
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resuscitation in severe pediatric burns may improve outcomes.17 Further analysis with

prospective randomized trials investigating the use of biomarkers and fluid-adjusted

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algorithms may be useful to provide additional guidance for resuscitation in the severely

burned child.

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What is the role of albumin in reducing "fluid creep"?

First described by Pruitt in 2000, “fluid creep” is a phenomenon where patients

receive significantly more fluids than predicted thus leading to fluid overload and

potentially other deleterious complications (Table 3).13, 18, 19

While historically controversial, colloid-assisted resuscitation decreases fluid

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requirements. Faraklas et al. retrospectively reviewed the use of crystalloid resuscitation

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to crystalloid plus colloid supplementation in children with >15% TBSA burns. They

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found that a subset of patients with deeper, more severe burns, and those with inhalation

injuries who failed to maintain target UO, had it restored with the addition of colloid.20 A

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randomized controlled trial by Dittrich et al. in 2016 investigated the addition of early (8-
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12 hours post-burn) and late (24 hours post-burn) albumin administration and its effect on

fluid creep in children with >15-45% TBSA burns. The early albumin group had
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statistically significant decreased overall crystalloid administration, shorter hospital

lengths of stay and a reduced incidence of fluid creep.19 Mechanistically, increasing

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oncotic pressure and decreasing capillary leakage with colloid restores intravascular

blood volume and minimizes fluid creep, particularly in children who may require
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significantly more volume than would an adult counterpart.19, 20 Albumin-assisted

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resuscitation is currently included in both the Galveston and the Cincinnati burn fluid

resuscitation formulas (Table 1).

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MANAGEMENT OF INHALATIONAL INJURIES

What is the pathophysiology behind inhalational injuries and who is at risk?

Twenty to 30% of patients who suffer major burns will have an associated

inhalation injury.21, 22 Smoke, which is composed of both a gas and particle phase, is

often inhaled through the mouth during a fire.23 Bypassing the nasopharynx facilitates

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the inhalation of particles that would have otherwise been cleared, resulting in particle

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deposition in the upper airway, sloughing of the tracheobronchial tree, fibrin deposition

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in lung parenchyma and subsequently atelectasis.23 Smoke inhalation releases

thromboxane which increases pulmonary arterial pressure and releases chemotactic

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factors and cytokines, such as TNF-alpha and IL-6.22, 24 Protein-rich fluid then enters the
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lung secondary to the disruption of endothelial junctions leading to pulmonary edema,

surfactant dysfunction, copious exudates and progressive cellular injury.22, 23 In addition

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to the chemical irritation of the airways, inhalation injuries may result in direct thermal

damage producing airway erythema, ulceration and edema. Systemic toxicity may also
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result from impaired mitochondrial metabolism due to carbon monoxide and hydrogen

cyanide inhalation.21, 23
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Although less likely to be affected than adults, inhalational injuries still pose a
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significant risk to children.21 Indeed, concomitant inhalational injuries reduce the lethal

burn area from 73% TBSA to 50% TBSA.25 The diagnosis of an inhalational injury is
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based on history and clinical exam. Patients found in enclosed fires are at risk for smoke

inhalation.26 In children, agitation or confusion may be related to smoke inhalation, fear,

or other injury.26 Facial burns, singed nasal or facial hairs, soot in or around the airway,

stridor, hoarseness, dyspnea or wheezing are worrisome findings.21, 26, 27 Chest

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radiographs are usually normal and oxygen saturation, as detected by pulse oximetry, is

unaffected initially and thus is not helpful in the initial diagnosis of inhalation injury.21, 27

How should inhalational injuries be evaluated and graded?

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A variety of adjuncts are utilized to confirm inhalational injury, including

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carboxyhemoglobin measurements, chest computed tomography, pulmonary function

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tests, and xenon ventilation-perfusion scans.28 While the computed tomography findings

of ground glass opacities, atelectasis, and interstitial markings may assist in the diagnosis

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of inhalational injury, fiberoptic bronchoscopy (FOB) is the most helpful adjunct.21, 28
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Fiberoptic bronchoscopy allows for the severity grading of inhalational injury, the

prognostication of acute lung injury, the need for resuscitation and overall mortality.27
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The Abbreviated Injury Score (AIS), initially published by Endorf et al., is now

the most widely used approach for grading the severity of inhalational injuries. The
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classification scheme stratifies injuries into 5 categories based on FOB (Table 4).27-30

More severe injuries have been demonstrated to be associated with impaired gas
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exchange and worse survival rates.28, 29 Curiously, the AIS grade of injury scale itself has
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not been found to be associated with fluid resuscitation requirements.27, 28 Despite this,

the presence of inhalational injury has been demonstrated to be associated with fluid
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requirements in excess of what most burn fluid resuscitation formulas predict, and this

must be carefully monitored.6

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What are other considerations for patients with inhalational injuries?

Pediatric burn patients with inhalation injuries have a mortality that exceeds

15%.31 Early management of these injuries is critical to decrease long-term morbidity.32

Injury severity dictates the complexity of management which may involve simple

supportive care in the context of minor injuries or advanced ventilation or extracorporeal

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life support for significant injury.33 Indeed, inhalational injury in conjunction with

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cutaneous injuries typically requires early critical care support.34 Five-year follow-up

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studies suggest that patients with inhalational burns do not have an impaired quality of

life further emphasizing the need for appropriate early care.35

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The initial management of all burn patients follows the Advanced Trauma Life
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Support guidelines for trauma. If respiratory distress is significant, intubation or a

surgical airway may be required. Following the assessment and grading of injury via
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bronchoscopy, early management includes strategies to minimize bronchospasm and

airway occlusion. This includes the use of oxygen supplementation, bronchodilators,

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racemic epinephrine, frequent suctioning and aggressive pulmonary toilet. Adjunct

measures include heparin inhalation and N-acetylcysteine which help to clear secretions
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and decrease cast formation within the airways. Recent studies have demonstrated that
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these adjuncts may decrease reintubation rates and overall mortality amongst those with

severe burns and inhalational injuries.36-39 Hypertonic saline can be used to induce
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effective cough in an attempt to clear the airways. In patients with severe respiratory

failure, high frequency percussive ventilation has been shown to reduce the development

of pneumonia by facilitating the clearance of bronchial secretions. The need for

mechanical ventilation and severe inhalation injury noted on bronchoscopy were both

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found to be independent predictors of mortality.40 Extracorporeal membrane oxygenation

using venovenous support has been shown to be safe in burn patients who fail maximal

respiratory support.33

All patients with inhalational injury require special consideration for carbon

monoxide (CO) and cyanide toxicity. Both CO and cyanide are highly toxic compounds

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that can cause significant morbidity and mortality.41 Poisoning should be suspected when

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the history suggests entrapment in an enclosed space. Symptoms can vary from mild

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neurological symptoms to unexplained metabolic collapse, but any suspicion should

prompt urgent investigation and treatment.

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Carbon monoxide is one of the most frequent causes of immediate death
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following an inhalational injury. Carbon monoxide is a colorless, odorless gas with an

affinity for hemoglobin 200 times greater than oxygen. Binding of CO leads to a shift of
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the oxyhemoglobin disassociation curve to the left. Carbon monoxide levels can be

measured from a blood gas sample by obtaining a carboxyhemoglobin level. Symptoms

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of CO poisoning such as disorientation and obtundation typically occur when levels are

above 10%. Carbon monoxide levels greater than 25% typically lead to loss of
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consciousness and death.

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Since CO has a higher affinity for hemoglobin then oxygen, elevated levels of CO

will lead to hypoxia. Routine pulse oximetry data is not reliable in the detection of CO
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poisoning. Carbon monoxide has a half-life of 4-6 hours at room air. Oxygen

supplementation using 100% oxygen will decrease the half-life of CO to 80 minutes.

While hyperbaric oxygen decreases the half-life of CO to 22 minutes, a recent

metanalysis suggests there may be no added benefit with this therapy.42

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Cyanide toxicity occurs from the combustion of household items and may lead to

unexplained metabolic collapse. Symptoms are typically non-specific and levels cannot

be measured soon enough to be clinically helpful. Cyanide toxicity remains a clinical

diagnosis and patients with soot in their mouth, altered mental status and metabolic

acidosis with high lactate levels suggests cyanide poisoning. Treatment consists of

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hydration and the immediate administration of hydroxycobalamin or sodium thiosulfate.

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CYANOKIT® (hydroxocobalamin for injection) is a commonly available cyanide

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antidote with a rapid onset of action.43

BURN MANAGEMENT US
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Who requires debridement and grafting?

Following proper resuscitation, attention should be directed to the management of

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the burn wounds. The initial surgical management of burns involves debridement of

necrotic tissue and cleaning the wound base. First-degree burns typically require no
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treatment. All patients with partial and full thickness burns should be surgically debrided

to remove devitalized tissue. This allows for optimal wound healing and minimizes the
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risk of infection. Burn wounds that are infected or nonhealing also require surgical
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management. The goals of surgical intervention are to provide an optimal wound healing

environment and to prevent infection. Wounds of indeterminate depth may be observed

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with daily dressing changes to assess for changes over time. Most wounds will declare

themselves within the first few days. Large areas of full thickness burn require early

excision within the first week. Small areas of full thickness injury can be managed as an

outpatient with close follow up for signs of infection and contracture. Studies have

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shown that early debridement helps decrease the hypermetabolic state and reduce the risk

of subsequent burn wound infection.44

It is imperative that the operating room be kept warm to prevent hypothermia.

Wounds can be treated with sharp debridement or excision with grafting. Newer

techniques using the VERSAJET™ Hydrosurgery system have been described. This

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system utilizes a high-powered stream of sterile saline for debridement. The reported

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benefits of this new technology include the ability to perform small-scale incremental

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debridement which preserves the dermis when compared to standard sharp excisional

techniques. This technique has been shown to reduce bleeding and healing times as well

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as biological dressing adherence to the burn site.45
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Skin grafting has many benefits including minimizing pain, allowing faster

recovery, and minimizing the risk of infection. Typically, a tangential excision of full
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thickness burns is performed using a dermatome, electrocautery, VERSAJET™ or knife

blades until a viable tissue plane is obtained. The use of epinephrine-soaked gauze and
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tourniquets for extremity burns can help decrease blood loss. Skin grafting can be

performed at the time of excision provided there are adequate donor sites and the patient
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is hemodynamically stable. If there is concern regarding a patient’s physiologic status,

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the extent of the burn or the quality of the graft site, alternative dressings such as

cadaveric skin may be used prior to autografting. Allografts are typically used for short-
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term wound coverage (i.e. a few days to a few weeks) and permit rapid coverage which

will minimize pain and infection while also preparing the wound bed for subsequent

autografting. Autografts can then be utilized once the allograft has sloughed from the

wound as long as there is no infection and the patient is stable.

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What are options for wound coverage?

Wound care following debridement varies depending on the depth of the burn.

Many partial or full thickness burns can be initially managed with salves, soaks, or

dressings. Salves are topical ointments and creams that are applied to provide moisture

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to the wound bed. Many salves have antimicrobial properties that help control bacteria in

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the wound and minimize the risk of infection. Salves typically require multiple

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applications per day to prevent the wound from desiccating. Soaks can be used similarly

for wound care. There are many available soak solutions including silver nitrate and

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sodium hypochlorite (Dakin’s solution) solutions. These solutions are generally poured
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onto gauze dressings and applied to the wound. They may be poured repeatedly over

dressings to minimize the frequency of dressing changes, which could lead to graft loss
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and impair wound healing. These soaked dressings can also be used in cases where a

wound infection is suspected.

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Commonly used salves include silver sulfadiazine and bacitracin. Bacitracin

provides antimicrobial properties against gram-positive bacteria. Silver sulfadiazine

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(SILVADENE®) provides added coverage for gram-negative and enteric bacteria.

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Prolonged use of silver sulfadiazine requires monitoring for leukopenia. More complex

burns may require mafenide acetate (Sulfamylon®) which can penetrate an eschar while
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also providing Pseudomonas coverage. Mafenide acetate is typically used for third degree

burns and areas of exposed cartilage such as the ear and nose. Patients who require

mafenide acetate need to be monitored for metabolic acidosis and pain.46 Due to these

side effects, its use should be limited to burns less than 20% TBSA.

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Most wounds can be covered after placement of a salve. Typical dressings include

petroleum gauze or iodine impregnated gauze. The exception to this are burns to the face

for which the salve is typically applied without dressing coverage. Salves should be

replaced at least daily and the wound should be assessed for progression or signs of

infection.

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Silver impregnated dressings have facilitated the outpatient management of

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burns.47 They have the ability to absorb excess wound exudate and may remain in place

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for several days to weeks prior to replacement. They also contain biologically active

silver ions, which provides antibacterial properties. Studies have demonstrated that

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patients experience less pain with the use of silver impregnated dressings compared to
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standard gauze dressings.48 These silver impregnated dressings can be used to cover

donor sites as well. In addition, studies indicate that calcium alginate is superior to
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standard wound care for pediatric donor sites.49 Negative wound pressure therapy has

also been found to be safe and effective in children without causing excessive bleeding or
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pain.50
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What are other novel synthetic and biological dressings available?

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Many novel alternative dressings are now available for use in burn wound care.

Biologic options include xenografts, cadaveric skin, and placenta-derived tissue.

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Bioengineered products are also available which help prepare a wound bed prior to

grafting. Importantly, cost is a consideration with many of the synthetic dressings. The

benefits of synthetic dressings are that they eliminate the need for frequent dressing

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changes and reduce potential fluid loss. These attributes make them particularly

appealing to younger patients.

Acellular human dermal allograft, which is devoid of epidermis, may be used to

replace the dermis as an alternative for skin coverage (AlloDerm®). Another dermal

substitute made of bovine collagen and shark chondroitin sulfate together with a silicone

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surface layer (Integra™) is also available. Both of these products can be placed on a

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clean and well-vascularized wound bed. Cultured epidermal autografts (CEA) such as

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Epicel®, are also available as an alternative to harvesting large skin grafts. These CEAs

can be placed directly on a clean wound bed; they are particularly useful for sensitive

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areas, smaller burns as well as use in small children. A new product derived from
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dehydrated human placenta (EpiFix®) is composed of a layer of epithelial cells, a

basement membrane and an avascular connective tissue matrix and has been successfully
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used in several case series as a permanent alternative to skin grafting for chronic wounds.

The reported benefit is that it protects the wound while promoting vascular angiogenesis
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and healing. 51 Few randomized controlled trials exist to comparing these products to

standard wound care.

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CONCLUSION

Outcomes following severe burn injury in children have improved with specific
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attention to prompt and goal-directed resuscitation, the recognition and management of

inhalational injuries, and novel wound care techniques. Still, the challenge remains in

ensuring that providers managing pediatric burns account for the acute physiologic

differences in children as they proceed with resuscitation management. Further research

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is necessary, particularly with respect to the ideal burn dressing and coverage. Most

importantly, ongoing education to care providers is essential to ensure the highest level of

care to this vulnerable population.

Figure 1: Lund and Browder Chart11

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Age (years) 0–1 1-4 5-9 10-14 15

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A – ½ of head 9.5% 8.5% 6.5% 5.5% 4.5%

B – ½ of one thigh 2.75% 3.25% 4% 4.25% 4.55%

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C – ½ of one leg 2.5% 2.5% 2.75% 3% 3.75%

Adapted from Sharma RK, Parashar A. Special considerations in paediatric burn

patients. Indian Journal of Plastic Surgery : Official Publication of the Association of
Plastic Surgeons of India. 2010;43(Suppl):S43-S50. doi:10.4103/0970-0358.70719, Open
Access Article.

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Table 1: Common pediatric burn fluid resuscitation formulas3

Formula Galveston Cincinnati (young Cincinnati (older

children) children)
Crystalloid 5000 ml/m2 burn + 4 ml/kg/%TBSA 4 ml/kg/%TBSA
2 2
2000 ml/m total burn + 1500 ml/m burn + 1500 ml/m2
BSA of LR total BSA of LR total BSA of LR

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Colloid 12.5 g of 25% 12.5 g of 25% None
albumin per liter of albumin per 1 liter

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crystalloid of crystalloid in the
last 8 hours of the

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initial first 24 hour
post-burn period
Glucose 5% dextrose as 5% dextrose as 5% dextrose as
needed needed needed
Administration
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½ over first 8 hours, To be administered
then ½ over next 16 ½ over the first 8
hours hours and the
½ over first 8 hours,
then ½ over next 16
hours
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second ½ over the
next 16 hours. Fluid
composition
changes each 8
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hoursperiod. 1) 1st 8
hours, add 50 meq/L
sodium bicarbonate
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2) 2nd 8 hours, only

LR without additive
3) 3rd 8 hours, add
albumin
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Body surface area (BSA), percent total body surface area (%TBSA), Ringer’s lactate
solution (LR)
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Adapted from Romanowski KS, Palmieri TL. Pediatric burn resuscitation: past, present,
and future. Burns & Trauma. 2017;5:26. doi:10.1186/s41038-017-0091-y, Open Access
Article.
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Table 2: Common adult burn fluid resuscitation formulas3

Formula Parkland Modified Brooke

Crystalloid 4 ml/kg/%TBSA 3 ml/kg/%TBSA
burn of LR burn of LR
Colloid None None
Glucose None None
Administration ½ over first 8 hours, ½ over first 8 hours,

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then ½ over next 16 then ½ over next 16

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hours hours

Adapted from Romanowski KS, Palmieri TL. Pediatric burn resuscitation: past, present,

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and future. Burns & Trauma. 2017;5:26. doi:10.1186/s41038-017-0091-y, Open Access
Article.

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Table 3: Potential complications of “fluid creep” resulting from over resuscitation19

Cerebral edema
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Pulmonary edema
Upper airway edema
Pleural effusions
Pericardial effusions
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Anasarca
Wound deepening
Extremity compartment syndrome
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Abdominal compartment syndrome

Orbital compartment syndrome
Pneumonia
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Acute respiratory distress syndrome

Multiorgan dysfunction syndrome
Death
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Table 4: Abbreviated Injury Score (AIS) grading scale based on fiberoptic

bronchoscopy30

Grade 0 1 2 3 4
Classification None Mild Moderate Severe Massive
of Injury
Description Absence of Minor or Moderate Severe Evidence of
carbonaceous patchy areas of degree of inflammation mucosal
deposits, erythema, erythema, with friability, sloughing,

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erythema, carbonaceous carbonaceous copious necrosis, or
edema, deposits in deposits, carbonaceous endoluminal

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bronchorrhea, proximal or bronchorrhea, deposits, obliteration
or obstruction distal bronchi or bronchial bronchorrhea,
obstruction or obstruction

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Adapted from Albright JM, Davis CS, Bird MD, Ramirez L, Kim H, Burnham EL,
Gamelli RL, Kovacs EJ
Crit Care Med. 2012 Apr; 40(4):1113-21.

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