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Innovation and clinical specialities: burns
In children, maintenance requirements must be added to the
resuscitation formula, and should be provide as a dextrose
containing solution for infants due to the risk of hypoglycemia if
they are not drinking. The addition of maintenance is less
important in adults due to the large volumes and low risk of
hypoglycemia. One formula that accounts for the maintenance
requirements is the Shiners Burns Hospital SBH-Galveston
Formula, which calls for initial resuscitation with 5000 mL/m 2 BSA
burn/d + 2000 mL/m2 BSA/d of Lactated Ringers solution. 18 See
http://www.halls.md/body-surface-area/bsa.htm to express BSA
in M2. Again, the first half is administered within the first 8 hours
post-burn, and the remaining is given over the next 16 hours.
Another option to intravenous fluids, in cases of less severe
burns or where intravenous solutions are at a premium, includes
oral rehydration solution. The WHO describes a method for
preparation of an electrolyte-balanced solution 62 . Although very
time consuming, IV fluids may also be prepared on site at low
cost. 63
It is important to remember that these are only guidelines, and
the infusion volumes must be titrated on a regular basis. Urine
output is the usual indicator of adequate resuscitation. Urine
output in a child should be maintained at 1 mL/kg/h. In an adult,
0.5 mL/kg/h is sufficient (unless myoglobinuria is suspected in
which case it should be over 2 mL/kg/h). It is essential to avoid
over-aggressive resuscitation, which may lead to increased
extravascular hydrostatic pressure and pulmonary edema. This is
especially important in patients who have a cardiac history, as well
as patients with a concomitant inhalation injury, because they will
also have increased pulmonary vascular permeability.
Administration of colloid or hypertonic solutions decreases the
total amount of fluid requirements in the first 24 hours post-injury;
however, no clear advantages in long-term outcomes over isotonic
crystalloid resuscitations have been clinically documented. In
general, crystalloid resuscitation with isotonic Lactated Ringers is
the best option in the acute phase. 18
If a patient is having increased fluid requirements, it should raise
suspicion of concomitant inhalation injury, a delay in resuscitation,
or another associated injury. It must be reiterated that the most
important thing is to begin resuscitation as soon as possible after
the time of injury. Unfortunately, delays in adequate resuscitation
are common and lead to increased fluid requirements because of
additive perfusion-reperfusion injury, which lead to unnecessary
loss of life. 18
Escharotomy
With circumferential full thickness, or deep partial thickness burns,
there must be a high index of suspicion for compartment
syndrome. The decreased skin compliance does not
accommodate the extreme edema from the inflammatory
response. Swelling increases with fluid resuscitation and it is
much better to release a limb with early escharotomies than to
discover too late that compartment syndrome and myonecrosis
have set in. The diagnosis of compartment syndrome in a burned
patient is challenging. Pallor is difficult to determine because the
eschar often is discolored, soot stained and can be pale and
leathery or red and plastic-like to the touch. Most burn wounds are
painful to the touch, unless an area of pure full thickness exists.
Paresthesia and paralysis are late findings of compartment
syndrome and are impossible to address in a patient that may be
paralyzed or sedated.
The absence of a pulse
is similarly too late
of a finding. Delayed
escharotomies can lead
to muscle necrosis
and limb loss. Sufficient
release can usually be
noted as soon as the
dermis is released,
as the wound opens
and subcutaneous
tissue bulges out.
Escharotomies may need
to be done on any limb.
(Figure 4) Escharotomy
may be done with a
scalpel or diathermy
blade. While it is true that Figure 4: Escharotomy lines
full thickness burns are
usually insensate, it is not true that escharotomy can routinely be
performed without some kind of pain control. Ketamine or
fentanyl and versed are safe and effective. The incision should go
through skin but not into fascia or muscle. The mid-medial and
mid-lateral lines of each limb are incised. A small “T” where the
incision meets normal skin will ease constriction at the end of the
incision.
Thoracic escharotomies are also occasionally required for
improving chest-wall compliance and facilitate ventilation. This
may require multiple incisions across the chest, both longitudinally
and transversely to allow full chest expansion. Figure 4 shows
possible thoracic escharotomy lines, but more lines may be
required for very deep constricting burns.
In electrical injury, the final extent of tissue injury can be difficult
to predict. Frequent assessments and surgical debridements are
required often in the face of progressive myonecrosis. With any
high voltage electrical injury, the index of suspicion for a deep
injury should be high. The skin wound is not a reliable indicator of
the underlying damage. These injuries will require a fasciotomy,
with release of all muscle compartments to minimize muscle
damage. Patients should also be monitored for myoglobinuria
which will require treatment with increasing urine output,
alkalinization of the urine, and sometimes with very cautious use of
diuretics. Untreated myoglobinuria can lead to deposition in the
glomerular tubules and renal failure.
Inhalation injury
Inhalation injuries are associated with severe burns and poor
outcomes. A retrospective review in Cape Town, South Africa
found that inhalation injury was present in 63% of severe burn
patients (>30% TBSA), which resulted in a mortality rate of 76%. 21
However, it is believed that inhalation injuries are more frequently
seen in high income countries due to the high prevalence of house
burns, where victims are confined to enclosed spaces. Alcohol
and smoking account for over half the deaths in developing
countries, so prolonged exposure to smoke may occur as a result
of intoxication. The prevalence of inhalational injury in low to
middle income countries is unknown, but suspected to be lower.
The reason for differences in prevalence is unclear, whether due to
Hospital and Healthcare Innovation Book 2009/2010 57