The key clues here are: - Altered mental status without central acting meds - Cherry red skin - Normal pulse oximetry reading This combination of findings is classic for cyanide poisoning. Cyanide binds cytochrome c oxidase, preventing cellular respiration and causing tissue hypoxia despite normal oxygen saturation. The best initial test to confirm cyanide poisoning is CO-oximetry, as it directly measures carboxyhemoglobin levels. An elevated level would support cyanide toxicity. While an ABG could show metabolic acidosis, CO-oximetry is more specific. A CXR, head CT, and VBG would not directly identify the cyanide poisoning. The diagnostic tool most likely to

1. Burn Resuscitation
Jacob A. Swann, MD, FS
MAJ, MC, USA
R5, PGY
William Beaumont Army Medical Center

2. Burn Resuscitation
• Burn Center Referral Criteria
• Primary Survey
• Fluid Resuscitation
• Escharotomies
• Failed Resuscitation
• Resuscitation Complications

3. Burn Resuscitation Goals
• Resuscitate patient from worst physiologic
insult a patient can suffer
• Stepwise assessment to ensure no pathologic
entities are missed
• Ensure adequate intravascular volume to
support organs
• Bridge patient to early excision

4. Burn Center Referral Criteria
• Large Burn
– >10% TBSA
• Inhalational Injury
• Associated mechanical trauma
• Full thickness burns of any size
– 3⁰ or deeper
• Special burned areas
– Hands, feet, face, perineum, genitals, joints (H1F2J2)
• Special types of burns
– Electrical, chemical
• Special patients

5. Primary Survey
• Airway
• Breathing
• Circulation
• Disability
• Exposure

6. Primary Survey--Airway
• Several patients warrant early intubation
– Large burn size (≥40% TBSA)
• Early resuscitation leads to *MASSIVE* anasarca such that
airway compromise occurs
– Symptomatic inhalational injury
• Upper airway damage, lower airway damage, and toxic gases
• Evidenced by exam (stridor, hoarseness, carbonaceous
sputum)
– Burns of face, oral cavity, oropharynx
• Mucosal damage, singed nose hairs, facial burns

7. Primary Survey--Breathing
• Thoracic Eschar Syndrome
– Epidermis and dermis are burned causing partial
or fully circumferential burns around chest cavity
– As resuscitation occurs, fluid builds up around
burned tissue
– Constrictive band around chest
– Inadequate chest excursion and hypoventilation
– Evidenced by rising peak airway pressures
– Requires escharotomy

9. Escharotomies

10. Primary Survey--Breathing
• Carbonmonoxide: colorless, odorless gas
caused by incomplete combustion of carbon-
containing fuels
– Binds avidly to Hgb -> hypoxia
– Dx: CO-oximeter (NOT pulse ox and NOT PaO2)
– Tx: 100% oxygen until COHb is less than 10%

11. Primary Survey--Breathing
• Cyanide: Incomplete combustion of nitrogen-
contianing compounds (silk, nylon, and plastics)
– Cyanide binds to the terminal cytochrome oxidase of
the electronic transport chain (“cellular asphyxiation”)
– ID’d by lactic acidosis with elevated mixed venous
saturation
• No rapid diagnostic test available; tx based on presumptive
diagnosis
– Tx: High-dose vitamin B12 (MOA: direct chelation of
cyanide)
• Less favorable sodium thiosulfate, amyl nitrite, and sodium
nitrite

12. Primary Survey--Circulation
• Access, access, access
– PIVs, IO, CV access
– Arterial line
• Okay to access through burns
• Fluid resuscitation will be discussed later

13. Primary Survey--Disability
• AVPU, GCS, and motor exam
– Important to get before intubation
• Burn patients—even with extensive burns--
should have a NORMAL mental status exam
– Abnormal GCS concerning for hypoxia 2/2
inhalational gases, concomitant CNS trauma, or
drug intoxication

14. Primary Survey--Exposure
• Assess every square inch of skin
• Remove jewelry
• Active warming!
– Loss of ability to thermoregulate
– Loss of skin
– Unable to shiver

15. Fluid Resuscitation
• Goal is adequate tissue perfusion in the first
24-48 hours post-burn
• Historically, 13% of burn patients died in the
first 48-hours due to inadequate resuscitation
• Now, supratherapeautic IVF resuscitation
leads to abdominal compartment syndrome
(uniformly fatal in burn cohort)
• This has lead to multiple instutitions
developing burn formulas

16. Fluid Resuscitation
• ABA consensus statement reports that burn
resuscitation should be started based on 2-
4cc/kg/TBSA
• Parkland Formula:
– 4cc LR*kg TBW*% TBSA
• Modified Brooke Formula:
– 2cc LR*kg TBW*% TBSA
• ISR Rule of Tens:
– %TBSA x 10cc

17. Fluid Resuscitation
• So, for a 70-kg adult with 40% TBSA…
• Parkland Formula:
– 4cc LR*kg TBW*% TBSA
– 4 * 70 * 40 = 11,200cc over first 24 hours = 5,600 over first
8 hours = 700cc/hr
• Modified Brooke Formula:
– 2cc LR*kg TBW*% TBSA
– 2 * 70 * 40 = 5,600cc over first 24 hours = 2,800cc over
first 8 hours = 350cc/hr
• ISR Rule of Tens:
– %TBSA x 10cc
– 40 * 10 = 400cc/hr

18. Fluid Resuscitation
• Primary marker of resuscitation is UOP
– Other markers important too (lactate, base deficit, et
cetera)
• All patients get a Foley catheter
• Titrate hour-by-hour
– Goal is 30-50cc/hr
– Goal is 70-100cc/hr if electric injury patients due to
myoglobinuria
• BEWARE! >250cc/kg over 24 hours = ACS!!!
– All cause ACS mortality = 30%
– In burn patients = 90+%

19. Fluid Resuscitation

20. Fluid Resuscitation

21. Failed Resuscitation
• Early recognition of failed resuscitation is
critical to avert poor outcomes
– Repeat episodes of low UOP
– Repeat episodes of hypotension/vasopressors
– Worsening base deficit
– Total IVF >200cc/kg (approaching 250cc/kg)

22. Failed Resuscitation
• If failing:
– Reassess ABCs
– Rule out missed injuries (i.e., hemorrhage)
– Monitor bladder pressures
– Assess cardiac function (i.e., echocardiography)
• Interventions:
– Control hemorrhage
– Ionotropic support
– Continuous 5% albumin or plasma
– High-dose vitamin C (66mg/kg/hr -> call pharmacy)
– CRRT
– Plasmapheresis

23. Resuscitation Complications
• Extremity ischemia (extremity eschar syndrome)
– ID’d via Doppler examination
– Tx: Escharotomy
• Extremity compartment syndrome
– Seen in massive resuscitation and high-voltage electric
injury
– Tx: Fasciotomy
• Ocular compartment syndrome
– Massive resuscitation leads to facial edema and IOP
– Tx: Lateral canthotomy

24. Resuscitation Complications
• Burn wound conversion
– Phenomenon where partial-thickness burns
convert to full thickness burns
– Pathophysiologic mechanism is unclear
• Thought to be due to tissue ischemia, inflammation,
edema during resuscitation phase
– Overresuscitation leads to massive wound edema
and exacerbates conversion rates
• Late burn excision

25. Resuscitation Complications
• Abdominal compartment syndrome
– Uniformly fatal
– Due to massive intra-abdominal fluid that causes
intra-abodominal pressures to rise
– Leads to inadequate microscopic tissue perfusion
– Causes tissue ischemia -> organ dysfunction ->
death
– Ongoing inflammatory process (i.e., unexcised
burn)

27. BURN ABSITE QUESTIONS

28. A 100-kg patient is a restrained passenger in an MVC. The
vehicle rolls over, and the patient is unable to self-extract
from the vehicle. As a result, the patient presents to the ER
with 10% TBSA from 1st degree burns, 25% TBSA from 2nd
degree burns, and 25% TBSA from 3rd degree burns. What is
the initial resuscitation rate for this patient?
A. 1250cc/hr NS
B. 1250cc/hr LR
C. 1500cc/hr NS
D. 1500cc/hr LR
E. 2500cc/hr LR

29. A 100-kg patient is a restrained passenger in an MVC. The
vehicle rolls over, and the patient is unable to self-extract
from the vehicle. As a result, the patient presents to the ER
with 10% TBSA from 1st degree burns, 25% TBSA from 2nd
degree burns, and 25% TBSA from 3rd degree burns. What is
the initial resuscitation rate for this patient?
A. 1250cc/hr NS
B. 1250cc/hr LR
C. 1500cc/hr NS
D. 1500cc/hr LR
E. 2500cc/hr LR

30. Only use Parkland formula for ABSITE/boards
4 x 50 x 100 = 20000
20000 ÷ 2 = 10000
10000 ÷ 2 = 1250
LR not NS because NS @ super high volumes causes
hyperchloremia with a resultant metabolic acidosis.
1st degree burns don’t count in your burn resuscitation
formula

31. A patient has suffered a 50% TBSA from a car fire. This patient
is noted to have large eschars that are unable to be debrided
urgently 2/2 significant hemodynamic instability. A topical
antibiotic is placed on these wounds. The next day, the
patient is noted to have a pH = 7.08 on their AM ABG. Which
medication is the most likely cause of this metabolic
derangement?
A. Bacitracin
B. Silver sulfadiazine
C. Silver nitrate
D. Mafenide acetate
E. Azetazolamide

32. A patient has suffered a 50% TBSA from a car fire. This patient
is noted to have large eschars that are unable to be debrided
urgently 2/2 significant hemodynamic instability. A topical
antibiotic is placed on these wounds. The next day, the
patient is noted to have a pH = 7.08 on their AM ABG. Which
medication is the most likely cause of this metabolic
derangement?
A. Bacitracin
B. Silver sulfadiazine
C. Silver nitrate
D. Mafenide acetate
E. Azetazolamide

33. Gotta know the side effects of the topical
antibiotics. 5 star topic, definitely going to be
on the test.
Mafenide acetate (Sulfamylon) is a carbonic
anhydrase inhibitor and has a similar
mechanism of action as acetazolamide. It also
penetrates eschar.

34. A patient has suffered a 50% TBSA in a car fire. The patient was
intubated on presentation, and they are sedated with
propofol/fentanyl drips. The patient has been resuscitated adequately
over the first 24 hours with 20L of LR. At hour 30 after presentation,
the patient’s respiratory therapist says the patient has a pCO2 of 45, is
overbreathing the ventilator with tachypnea to 28, a peak airway
pressure of 28 cm of H20, and a plateau pressure of 25cm of H20.
What is the next best step in management?
A. Thoracic escharotomies
B. BUE/BLE escharotomies
C. Start vecuronium infusion
D. Increase propofol infusion
E. Increase FiO2%

35. A patient has suffered a 50% TBSA in a car fire. The patient was
intubated on presentation, and they are sedated with
propofol/fentanyl drips. The patient has been resuscitated adequately
over the first 24 hours with 20L of LR. At hour 30 after presentation,
the patient’s respiratory therapist says the patient has a pCO2 of 45, is
overbreathing the ventilator with tachypnea to 28, a peak airway
pressure of 28 cm of H20, and a plateau pressure of 25cm of H20.
What is the next best step in management?
A. Thoracic escharotomies
B. BUE/BLE escharotomies
C. Start vecuronium infusion
D. Increase propofol infusion
E. Increase FiO2%

36. The patient has undergone a massive resuscitation. They will have
huge third space requirements. If massive fluids and rising inability to
VENTILATE (not oxygenate), this is 2/2 eschar. Pt needs escharotomies
to open burned skin/subQ.
If only a rise in Paw, then bronchodilators would be indicated.
Increasing sedation/paralyzing wouldn’t effect ability to ventilate
adequately. It may actually cause respiratory collapse.
Lastly, the problem is a ventilation problem; increasing the FiO2% or
PEEP (oxygenation parameters) doesn’t change ventilation parameters
(TV and RR = CO2)

37. A patient presents to the ER after being found down in a
house fire. The patient has suffered 70% TBSA. The patient is
emergently intubated on arrival to the BICU ER. Copious,
carbonaceous secretions are noted coming from the ETT.
Fiberoptic bronchoscopy shows hyperemia and carbonaceous
bronchorrea. What is the pathophysiology of this disease
process?
• A. Inhalation of high temperature dry air
• B. Over resuscitation with LR
• C. Under resuscitation with LR
• D. Direct flame injury to lower airways
• E. Direct toxic effect of aerosolized synthetic compounds

38. A patient presents to the ER after being found down in a
house fire. The patient has suffered 70% TBSA. The patient is
emergently intubated on arrival to the BICU ER. Copious,
carbonaceous secretions are noted coming from the ETT.
Fiberoptic bronchoscopy shows hyperemia and carbonaceous
bronchorrea. What is the pathophysiology of this disease
process?
• A. Inhalation of high temperature dry air
• B. Over resuscitation with LR
• C. Under resuscitation with LR
• D. Direct flame injury to lower airways
• E. Direct toxic effect of aerosolized synthetic compounds

39. The upper airways absorb the majority of heat and spasm
of the epiglottis prevent hot dry air from entering the
upper airways. Moist heat doesn’t cause this spasm.
Inhalational injuries classically require much higher
volumes of resuscitation, but over/under resuscitation
doesn’t—in and of itself—cause inhalational injuries.
The direct toxic effect of synthetic compounds is highly
toxic to the lining of the lower airways.

40. A patient suffers a 50% TBSA from a car fire. The patient is
resuscitated adequately. They are undergoing their first of many serial
debridements of their wounds on HD4. At the end of the case, a topic
antibacterial medication is applied to their wounds. On HD5, their CBC
is noted to show a WBC of 14, their ABG shows a pH of 7.38, and renal
panel shows a sodium of 123. What is the most likely medication
being used on this patient?
A. Bacitracin
B. Silver sulfadiazine
C. Silver nitrate
D. Mafenide acetate
E. Azetazolamide

41. A patient suffers a 50% TBSA from a car fire. The patient is
resuscitated adequately. They are undergoing their first of many serial
debridements of their wounds on HD4. At the end of the case, a topic
antibacterial medication is applied to their wounds. On HD5, their CBC
is noted to show a WBC of 14, their ABG shows a pH of 7.38, and renal
panel shows a sodium of 123. What is the most likely medication
being used on this patient?
A. Bacitracin
B. Silver sulfadiazine
C. Silver nitrate
D. Mafenide acetate
E. Azetazolamide

42. Side effects!!!
Silver nitrate causes hyponatremia.

43. A patient suffers a 50% TBSA from a car fire. The patient
presents with altered mental status. No central acting
medications were given to the patient in transport. The
patient is noted to have cherry red skin diffusely. Initial pulse
oximetry shows 100% on RA. What is the diagnostic tool most
likely to reveal the underlying etiology of the patient’s
pathology?
A. Chest x-ray
B. ABG
C. CO oximetry
D. CT, head
E. VBG

44. A patient suffers a 50% TBSA from a car fire. The patient
presents with altered mental status. No central acting
medications were given to the patient in transport. The
patient is noted to have cherry red skin diffusely. Initial pulse
oximetry shows 100% on RA. What is the diagnostic tool most
likely to reveal the underlying etiology of the patient’s
pathology?
A. Chest x-ray
B. ABG
C. CO oximetry
D. CT, head
E. VBG

45. Cherry red skin + 100% SpO2 = carbon monoxide
poisoning until proven otherwise.
Treatment is 100% FiO2 and follow CO on CO
oximetry. Rarely, you can dive a patient, but this
is never done; don’t put it on the test.

46. A patient suffers a 50% TBSA. His wounds are dressed
with a topical medication. After three days of therapy,
the patient’s CBC is significant for a leukopenia of 1.3.
Which medication is the likely cause of this?
A. Bacitracin
B. Silver sulfadiazine
C. Silver nitrate
D. Mafenide acetate
E. Azetazolamide

47. A patient suffers a 50% TBSA. His wounds are dressed
with a topical medication. After three days of therapy,
the patient’s CBC is significant for a leukopenia of 1.3.
Which medication is the likely cause of this?
A. Bacitracin
B. Silver sulfadiazine
C. Silver nitrate
D. Mafenide acetate
E. Azetazolamide

48. Silver sulfadiazine causes marginalization of
WBC with resultant leukopenia.

49. • A patient suffers a 50% TBSA from a house fire. The
patient’s airway was secured. Initial ABG shows a pH of
7.14 and a lactate of 4.8. The patient is put on A/C, TV =
500, RR = 20, PEEP = 8, FiO2% = 100%. After 10 minutes of
ventilation, a repeat ABG shows a pH of 7.08 and a lactate
of 6.2. What is the next best step in management?
• A. Increase TV
• B. Increase PEEP
• C. Hydroxocobalamin
• D. Start bicarbonate infusion
• E. Start nitroprusside

50. • A patient suffers a 50% TBSA from a house fire. The
patient’s airway was secured. Initial ABG shows a pH of
7.14 and a lactate of 4.8. The patient is put on A/C, TV =
500, RR = 20, PEEP = 8, FiO2% = 100%. After 10 minutes of
ventilation, a repeat ABG shows a pH of 7.08 and a lactate
of 6.2. What is the next best step in management?
• A. Increase TV
• B. Increase PEEP
• C. Hydroxocobalamin
• D. Start bicarbonate infusion
• E. Start nitroprusside

51. • Cyanide toxicity requires RAPID intervention.
• Treat empirically.
• Hydroxocobalamin (cyanokit) is first line
agent.

52. Split-Thickness Skin Graft
Covers more surface area, decreases
seroma/hematoma formation.
Increased contraction after healing (little
contraction after harvest), not good for
joints/bony surfaces, poor cosmetics
Imbibition (days 1-3), inosculation (days 3-5),
and neovascularization (days 5-7)

53. Full-Thickness Skin Graft
• Opposite of STSG
• Good cosmesis, good function, little
contraction when healed (tons of contraction
when initially harvested), used on face, hands,
joints
• Must de-bleb the bullae that form on POD1-2.