complete information about the fluid resuscitation in burn patients, types of care given to the patient in the hospital after burning accidents, fluid replacement therapy, medical management, nursing management.

1. F L U I D
R E S U S C I TAT I O N
I N B U R N
PAT I E N T S

2. Submited to :
Mrs.Mamta toppo
[subject
coordinator,
medical surgical
nursing]
Submited by :
Priya kumari
Roll no.:22
Basic Bsc
nursing 3rd year

3. CONTENT
1. Introduction
2. Host response to burn injury
3. Goals of resuscitation
4. Choice of resuscitation fluids
5. Resuscitation methodology
6. Monitoring of resuscitation
7. Complications of over resuscitation
8. Complication of under resuscitation
9. Failure of resuscitation
10. Innovations
11. Research
12. Summary
13. Resources
14. Bibliography

4. INTRODUCTION
• Burns greater than 20% TBSA are associated with increased
permeability and intravascular volume deficits that are most
severe in the first 24 hours post injury .
• Optimal fluid resuscitation aims to support organ perfusion with
the least amount of fluid .
• Proper fluid management is critical to the survival of patients with
extensive burns.
• Fluid resuscitation of any burn patient should be aimed at
maintaining tissue perfusion and organ function while avoiding the
complications of inadequate or excessive fluid therapy .
• The damaging effect of burn shock may be mitigated or prevented
by physiologically based early management of patients with major
burn injury.

5. HOST RESPONSE TO BURN
INJURY
• Massive tissue injury from burns often elicits a
profound host response , resulting in a number of
physiologic and cellular changes which are as
follows:
• A marked decrease in cardiac output , accompanied
by an increase in peripheral vascular resistance.
• An intravascular hypovolemia ensues which is slow
and progressive.It is characterized by massive fluid
shifts from capillary leak and resultant tissue edema
formation .
• The combined hypovolemic and distributive burn
shock requires sustained replacement to avoid organ
hypoperfusion and cell death.

6. GOALS OF RESUSCITATION
• Prevention of hypovolemic shock
• Maintenance of adequate tissue
perfusion and organ function while
avoiding complication of over
resuscitation and under resuscitation.

8. CHOICE OF FLUID

9. RESUSCITATION FLUIDS
Colloids :
Albumin , dextran ,
hexastarch
Crystalloids :
NS , RL , D5%
,Hypertonic saline

10. Crystalloids Colloids
Half life of 30-60 minutes Half life of several hours or days
Three times the volume needed for
replacement
Replaces fluid volume for volume
Excessive can cause peripheral and
pulmonary edema
Excessive use can precipitate
cardiac failure
Molecules are small enough to freely
cross capillary walls , so less fluid
remains in the intravascular spaces
Molecules too large to cross
capillary walls,so fluid remains in
intravascular spaces longer
Inexpensive Expensive than crystalloids
Non – allergic Risk of anaphylactic reactions

11. RESUSCITATION
METHODOLGY
B E G I N S W I T H T H E A R R I VA L
O F T H E PAT I E N T

12. STEP 1 : SECURE AN I.V
LINE

13. PERIPHERAL
VENOUS
CATHETER
A peripheral venous
catheter ( PVC ),
peripheral venous line or
peripheral venous access
catheter is a catheter
(small, flexible tube)
placed into a peripheral
vein for venous access to
administer intravenous
therapy such as
medication fluids.

14. PER IPH ER A LLY
IN SER TED
C EN TR A L
C ATH ETER
Peripherally inserted central
catheter , less commonly called
a percutaneous indwelling
central catheter, is a form
of intravenous access that can
be used for a prolonged period
of time .
It is a catheter that enters the
body through the skin
(percutaneously) at a peripheral
site, extends to the superior
vena cava (a central venous
trunk), and stays in place (dwells
within the veins) for days or
weeks.

15. C E N T R A L
V E N O U S L I N E
A central venous catheter
(CVC), also known as a
central line, central venous
line,is a catheter placed into a
large vein It is a form of
venous access
These catheters are
commonly placed in veins
in the neck(internal jugular
vein), chest (subclavian
vein or axillary vein)

16. V E N O U S C U T
D O W N
Venous cutdown is an
emergency procedure in
which the vein is exposed
surgically and then
a cannula is inserted into the
vein under direct vision. It is
used to get vascular
access in trauma and hypov
olemic shock patients when
peripheral cannulation is
difficult or impossible.
The saphenous vein is most
commonly used.

18. STEP 2 :NOTE WEIGHT OF
THE PATIENT

19. STEP 3 : ESTIMATION OF
BURN

20. R U L E O F
N I N E
 The most common
method used to
estimate the extent
of burns.
• The system is
based on anatomic
regions ,each
representing
approxmiately 9%
of the TBSA
(total body surface
area)

21. L U N D A N D
B R O W D E R
M E T H O D
It recognizes the
surface area of
various anatomic
parts, especially the
head and leg as it is
according to the age
of the patient.
It divides the body
into very small area
and provide an
estimate proportion
of TBSA burned.

22. PA L M E R
M E T H O D
In patients with
scattered burns, the
palmer method may be
used to estimate the
extent of burns.
The size of the
patient’s hand,
including the fingers is
approxmiately 1%of
that patient’s TBSA.

23. STEP 4 : CALCULATE
RESUSCITATION FLUID

24. RESUSCITATION
FORMUL AS

25. 1.PARKLAND FORMULA
Resuscitation fluid needs : first 24 hours
4 ml R L x kg body weight x % burn
• First half of volume over first 8 hours , second half following
16 hours
Resuscitation fluid needs : second 24 hours
• Colloid are added
• No crystalloids
• Glucose in water is added in amounts required to maintain a
urinary output of 0.5-1ml /hour in adults and 1ml/hour in
children.

26. FORMULA FIRST 24 HOURS NEXT 24 HOURS
1. EVANS
FORMULA[1952]
CRYSTALLOIDS : 1ml
/kg/% burn
+
Colloids : 1ml /kg/%
burn
+
2000ml glucose in
water
Crystalloids : 0.5 ml/kg
/%burn
Colloids : 0.5ml/kg/%
burn
+2000ml of glucose in
water
2.BROOKE FORMULA RL : 1.5ml /kg/%burn
Colloids : 0.5 ml /kg
/%burn
+
2000ml glucose in
water
RL : 0.5ml/kg/% burn
Colloids : 0.25 ml/kg/%
burn
+
2000 ml glucose in water
3. MODIFIED BROOKE NO COLLOIDS
RL : 2ml / kg /% burn in
adults &
3ml /kg /% burn in
children
Colloids : 0.3-0.5 ml/kg/%
burn and no crystalloids
.
Glucose in water is
added in the amounts

27. FORMULAS DEVELOPED FOR
CHILDREN
Galveston • Initial 24 hours : RL
5000ml/m2 burn +2000ml /m2
total
[1/2 of total fluid to be given over
8hours and rest in next 16 hours.
Shriner’s
cincinnati
• 4ml RL / Kg / % burn + 1.5 L /
m2 BSA for first 8 hours
• 50m Eq NaHCO3+RL solution
in next 8 hrs
• 5% albumin in LR solution in

28. STEP 5 : START
RESUSCITATION

29. MONITORING OF
RESUSCITATION

30. 1. URINARY OUTPUT
• The hourly urinary output obtained by use of an
indwelling bladder catheter is the most readily
available and generally reliable guide to resuscitation
adequacy in patients with normal renal function
Adults : 0.5 ml /kg /hour[or 30-50 ml/hour]
Young children[weighing <30 kg] :1ml /kg/hour
Pediatric [weighing > 30 kg , upto age 17] : 0.5 ml /
kg / hour
Adult patients with high voltage electrical injuries with
evidence of myoglobinuria :75-100 ml / hour until
urine clears.

31. • The expected output should be based on
ideal body weight , not actual pre – burn
weight [I . e the patient who weighs 200 kg
does not need to have urinary output of 100
ml per hour ]
• Fluid infusion rate should be increased or
decreased by up to one – third , if the urinary
output falls below or exceeds the desired
level by more than one –third every hour.

32. A . MANAGEMENT OF
OLIGURIA
• Verify that the catheter is functioning well , Oliguria
can be caused by mechanical obstruction , such as
intermittent urinary catheter kinking or dislodgement
from the bladder .
• Oliguria in association with inadequate fluid
adminsteration. The rate of resuscitation fluid infusion
should be increased to achieve target urine output .
• Older patients with chronic hypertension may become
oligouric if blood pressure falls below their usual range.

33. B . MANAGEMENT OF
MYOGLOBINURIA AND DARK ,
RED TINGED URINE
• Administration of fluids at a rate sufficient to maintain a
urinary output of 1.0-1.5 ml /kg /hour in the adult will
often produce clearing of the heme pigments with
significant rapidity to eliminate the need of diuretic.
• Persistence of dark red tinged urine may indicate
compartment syndrome.
• Administration of a diuretic or the osmotic effect of
glycosuria precludes the subsequent use of hourly
urinary output as a guide to fluid therapy ; other indices
of volume replacement adequacy must be relied upon.

34. 2.BLOOD PRESSURE
• Early hypovolemia and hypotension can be a
manifestation of associated hemorrhage due to
trauma.It is important to recognize and treat
hemorrhage in cases of combined burn /trauma
injuries.
• Blood pressure cuff measurement in can be misleading
in the burned limb where progressive edema is present.
• Intra arterial monitoring of blood pressure may be
unreliable in patients with massive burns because of
peripheral vasoconstriction and hemoconcentration.
• In patient with massive burns ,it is important to place
more emphasis on markers of organ perfusion such as
urine output.

35. 3.HEART RATE
• A rate of 110-120 beats per minute is common
in adult patients who , appear to be adequately
resuscitated.
• A persistent severe tachycardia [>140 beats
per minute]is often a sign of treated pain
,agitation, severe hypovolemia or a
combination of all.
• The levels of tachycardia in pediatric patients
should be assessed on the basis of age related
normal heart rate.

36. 4.HEMATOCRIT AND
HEMOGLOBIN
• In massive burns , hemoglobin and hematocrit levels may
rise as high as 20g/dl and 60% respectively during
resuscitation .This typically corrects ,as intravascular volume
is restored over time ,When these values do not correct, it
suggests that the patient remains under-resuscitated.
• Whole blood or packed red cells should not be used for
resuscitation unless the patient is anemic due to pre-existing
disease or blood loss from associated mechanical trauma at
the time of injury. In that case , transfusion of blood products
should be individualized.

37. 5.SERUM CHEMISTRIES
• Baseline serum chemistries should be
obtained in patient with serious burns.
• The treatment of hyperkalemia and other
electrolyte abnormalities should be
coordinated with the burn center physicians.

38. COMPLICATION OF OVER
RESUSCITATION
• Edema
• Extremity , orbital and abdominal compartment
syndromes
• Pulmonary and cerebral edema.

39. COMPLICATION OF UNDER
RESUSCITATION
• Shock and organ failure
• Acute kidney injury.
• GI ulcers

40. FAILURE OF RESUSCITATION
• EXTREME AGE
• EXTREME BURNS
• MAJOR ELECTRICAL BURNS
• MAJOR ELECTRICAL INJURY
• MAJOR INHALATIONAL INJURY
• INTIAL DELAY IN INITIALIZING FLUID
• UNDERLYING DISEASE THAT LIMITS METABOLIC OR
CARDIAC RESERVE

41. INNOVATIONS
• Burns fluid resuscitation calculator : A dedicated
calculator for determining correct burns fluid resuscitation which
improves speed ,reduces human error and provides an audit trail.
• Developed by : E2L limited in collaboration with the dept. of
anesthetics & welsh centre for burns ,Morriston hospital,ABM UHB
,Swansea.
FEATURES :
 PARKLAND AND MUR &
BARCLAY formula
support
 Touch screen input with
input error validation.
 Adminstered fluid error
correction
 Printed output for patient
notes

42. RECENT RESEARCH

47. S
U
M
M
A
R
Y
• In burns greater than 20%
TBSA, fluid resuscitation
should be initiated using
estimates based on body size
and surface area burned.
• The goal of resuscitation is to
maintain tissue perfusion and
organ function while avoiding
the complications of
inadequate or excessive
therapy.
• Excessive volumes of
resuscitation fluid can
exaggerate edema formation ,
thereby compromising the
local blood supply.

48. • Inadequate fluid resuscitation may lead to
shock and organ failure.
• Promptly initiated , adequate resuscitation
permits a modest decrease in plasma volume
to predicted normal levels by the end of
second post –burn day.
• In the event that plasma transfer must be
delayed beyond the first 24 hours , close
consultation with nearest burn center is
recommended regarding ongoing fluid
requirements.

49. EVALUATION
1.Which type of fluid is administered in the first 24 hours of burn
resuscitation?
A.Colloids
B.Crystalloids
C.FFP
D.Packed RBC
2.Most accepted formula for calculating burn resuscitation fluid is
A.Parkland
B.Modified Brooke
C.Evans
D.galveston

50. 3.In patient with severe burns hemotocrit value
A.Increases initially
B.Decreases initially
C.Has no effect
D.may increase or decrease
4.which of the following health history should be considered while
calculating fluid resuscitation in burn patients
A.MI 1 year ago
B.Seasonal asthma
C.Hepatitis 10 years ago
D.Kidney stone removal last year

51. BIBLIOGRAPHY
1.Javed ansari;A textbook of medical surgical nursing-II;PV
publication;page no.-609-625.
2.Bunner and suddarth’s;textbook of medical surgical nursing;13th
edition;page no.-1703-1739.
3.www.nurseslab.com
4.www.slideshare.com
5.www.researchgate.net
6.www.academia.apu