1. For 2014

2. Objectives for Today’s Class
 Basics on Burn Resuscitation
 ICU Interventions to prevent Burn Complications
 ICU Standards to Advocate for Burn Patients
 Labs and Markers to Note
 Adjunct Care Practices specific for Burn Patients
 Plan of Care for ICU Burn Patient
 Inhalation Injury
 Dressings and Burn Netting

3. Resuscitation – It’s Good
 Goal is to anticipate and prevent burn shock, not to
play catch up and treat it. Cell death is not an event
that is eligible for resurrection.
 Everyone agrees fluid resuscitation is the primary
factor in determining survivability of burns with
TBSA >20%. [Holm C: Resuscitation in shock associated with burns: Tradition or evidence-based
medicine? Resuscitation 2000; 44:157–164]
 Consensus formula is not set in stone – it is a
guideline. The two consensus formulas endorsed by
the ABA are: Parkland & Modified Brooke

4. Resuscitation – It’s Good
 Delay in fluid resuscitation beyond 2 hours of the
burn injury complicates resuscitation and increases
mortality. [Klein MB, Hayden D, Elson C, et al: The association between fluid administration and outcome following
major burn: A multicenter study. Ann Surg 2007; 245:622–628]
 High dose ascorbic acid in first 24 hours leads to 40%
reduced fluid volume requirement, 50% reduced
burn tissue water content and decreased vent days.
(but not standard practice or in ABA guideline)[Dubick MA,
Williams C, Elgjo GI, et al: High-dose vitamin c infusion reduces fluid requirements in the resuscitation of burn-injured
sheep. Shock 2005; 24:139–144; Tanaka H, Matsuda T, Miyagantani Y, et al: Reduction of resuscitation fluid volumes in severely
burned patients using ascorbic acid administration. Arch Surg 2000; 135:326–331]

5. Resuscitation – It’s Bad
 Over-resuscitation leads to pulmonary edema,
myocardial edema, conversion of superficial into deep
burns, the need for fasciotomies in unburned limbs,
and abdominal compartment syndrome.[Fodor L, Fodor A, Ramon Y, et al:
Controversies in fluid resuscitation for burn management: Literature review and our experience. Injury, Int J Care Injured 2006; 37:374–379]
 Initial rates are based on accurate calculation of TBSA
and most first responders and providers not
specialized in burns inaccurately calculate TBSA.[Bhat S,
Humphries YM, Gulati S, et al: The problems of burn resuscitation formulas: A need for a simplified guideline. Available
at: http://www.journalofburnsandwounds.com. Accessed February 8, 2009]
 Aggressive fluid resuscitation potentiates edema and
decreases tissue perfusion. [Saffle JR: The phenomenon of "fluid creep" in acute burn resuscitation. J Burn
Care Res 2007; 28:382–392]

6. Resuscitation – It’s Ugly
 No “agreed upon standards” exist for the approach
to resuscitation of burn patients from current
data. Review American Burn Association practice guidelines burn shock resuscitation.Pham TN, Cancio LC, Gibran
NS, American Burn Association J Burn Care Res. 2008 Jan-Feb; 29(1):257-66.
 ABA Guidelines have not been updated since 2001.
 Over-resuscitation vs. under-resuscitation studies
are mixed. Blumetti J, Hunt JL, Arnoldo BD, et al. The Parkland formula under fire: Is the criticism
justified? J Burn Care Res. 2008;29:180–186. [PubMed]

7. Resuscitation – It’s Ugly
 Resuscitation failure increases with co-morbidities of
inhalation injury, electrical burns, those in whom
resuscitation is delayed, and those using alcohol or
illicit drugs.[Cancio LC, Reifenberg L, Barillo DJ, et al: Standard variables fail to identify patients who will not respond to
fluid resuscitation following thermal injury: Brief report. Burns 2005; 31:358–365]
 Meth lab burns require 2-3x more fluid than standard
resuscitation due to depth, size and mechanism of
burn.[Burke BA, Lewis RW, Latenser BA, et al: Methamphetamine-related burns in the cornbelt. J Burn Care Res 2008; 29:574–579]
 Studies indicate that the gold standard of
measuring urine output for adequate fluid
resuscitation is not a good indicator. [Klein MB, Hayden D, Elson C, et al:
The association between fluid administration and outcome following major burn: A multicenter study. Ann Surg 2007; 245:622–628]

8. ICU Interventions that Lead to
Successful Resuscitation
 Think fluids first: vascular access and foley insertion
for TBSA >20%. Under 20% TBSA burns with no
airway involvement can be orally resuscitated.
 Measure UO. The American Burn Association Practice
Guidelines for Burn Shock Resuscitation recommend
0.5 mL/kg/hr urine output in adults.
You have a 100 kg patient. How much urine per
hour should you expect for adequate resuscitation?
0.5 ml * 100 kg = ___________
 Decreased UO in first 48 hours indicates inadequate
reperfusion.

9. ICU Interventions that Lead to
Successful Resuscitation
 A-line is more accurate than cuff for pressures
 Other measurements to consider for adequate
resuscitation are:
 HR <120. 110s are ideal. HR >120 indicative of hypo-
resuscitation.

10. ICU Interventions that Lead to
Successful Resuscitation
 MAP > 70. MAP <60 requires immediate action
and increase in fluid volume;
 Crystalloid of preference is LR; NS in large
quantities in large burns has increased risk for
abdominal compartment syndrome
 Arterial Pressure (systolic – diastolic) of 30-40.
(Narrow arterial pressure indicative of hypo-
resuscitation and poor outcome)

11. ICU Interventions that Lead to
Successful Resuscitation
 Avoid pressors; use of pressors within first 12 hours
of resuscitation yielded an independent factor of
80% higher risk of mortality with a 2-fold increased
risk if used in first 24 hours. [Sperry JL, Minei JP, Frankel HL et al. Early use of
vasopressors after injury: caution before constriction. J Trauma. 2008 Jan;64(1):9-14. doi:
10.1097/TA.0b013e31815dd029]
 Avoid hypothermia. Keep room at 29○C (85○F) or
greater; keep patient temperature between 37○C
and 38○C ideally; start warming when 37.5

12. ICU Interventions that Lead to
Successful Resuscitation
 Monitor for ACS in abdomen, limbs and chest.
 Bladder pressure is current indicator for
determining abdominal acute compartment
syndrome.
 Cap refill is best indicator for limb perfusion.

13. ICU Interventions that Lead to
Successful Resuscitation
 Monitor bladder pressure for TBSA >30% and
prepare for abdominal decompression. Patients who
get more than 250ml/kg of crystolloids in first 24
hours will likely require abdominal decompression
[Klein MB, Hayden D, Elson C, et al: The association between fluid administration and outcome
following major burn: A multicenter study. Ann Surg 2007; 245:622–628]
 On admission: Ensure DVT prophylaxis is started.
Burn patients are more susceptible to HIT; usually
placed on LMWH weight-based therapy BID unless
contraindicated
 On admission: Ensure Stress-Ulcer prophylaxis is
started.

14. Labs and Markers to Note
 On admission:
 CMP, CBC with diff, Lactate, ABG
 Every 6 hours during active resuscitation
 Electrolyte replacement protocol should be
standard
 Values to pay attention to -
 BE/BD in ABG (Low BD values indicate poorer
outcomes)
 Serum lactate (values that are high on initial
admission indicate poorer outcomes)
 HCT of 55-66 is not uncommon in early post-
burn resuscitation

15. Labs and Markers to Note
 Values to pay attention to -
 Thrombocytopenia in early post-burn is
expected.
 WBCs that trend down for 3 days post
admission and then increase suddenly are
normal for a burn patient – called transient
neutropenia. Monitor when above 12 and
consider cultures above 14.
 Sudden decrease in WBCs may indicate AgSd
induced neutropenia
 Higher cortisol levels are normal for burn
patients with large TBSAs

16. Adjunct Care Practices Specific to
Burn Patients
 Nutritional support via enteral tube feeding and
protein supplements; insert NJ (tiger stripe) for
feeding tube; consider OG for abdominal
decompression; metabolic impact of burns
 Nutritional consult on admission (assesses need for
ascorbic acid, zinc, oxandralone, juven, tube feed
formula and caloric needs, etc.)
 Splints for hand burns within 24 hours – OT/PT
evaluation orders on admission
 Curos caps on ALL IV ports, including foley

17. Adjunct Care Practices Specific to
Burn Patients
 Foot drop splints (PRAFO type boots) within 7 days if
ICU LOS is expected to be more than 1 weeks
 GI Motility prophylaxis and consideration of fecal
management tube for burns on buttocks and perineal
areas
 Elevate testicles and reposition frequently
 Increased perineal care for burns in that area
(alternate every 2 hours with oral care schedule)
 Pillows! (NO under head; YES under arms/legs)

18. Adjunct Care Practices Specific to
Burn Patients
 Facial Burns
 Daily shaving
 Face care every 4 hours
 Increased frequency of oral suctioning
 Oral care every 2 hours
 Elevate limbs and perform passive ROM every 2
hours, along with hand and finger manipulation
every 4 hours if uninjured (combine with face care
schedule)

19. Typical Plan of Care for ICU Burn
Patient
 Fluid resuscitation x72 hours
 Initial burn dressing will be bacitracin/adaptic for
superficial burns and superficial partial-thickness
(BID).
 Deep partial thickness burns will be dressed with
collagenase + bacitracin & adaptic (if Dr. Pharaon)
or AgSd (Schulz/Cho). (BID)
 Expect patient to be scheduled for OR within 5-7
days of initial burn injury. Longer delays result in
higher risk for burn wound sepsis.

20. Typical Plan of Care for ICU Burn
Patient
 Surgery will usually be TED with allo/auto graft
placement
 Post allo/autograft, patient will remain occluded
between 3 and 7 days
 Post surgical surveillance of CBC (platelets, Hgb,
Hct, WBCs) and discoloration or sweet smell of
dressings for post-surgical site infection is important
 Continued burn dressings for non allo-autografted
areas are maintained

21. Typical Plan of Care for ICU Burn
Patient
Patient ICU criteria include:
 Vent-dependent
 S/S sepsis requiring higher level of care
 Acuity
 Multiple drips and sedation
Vital Sign Normal values are redistributed in the burn patient.
 HR is typically tachycardic
 Temp is elevated (38.5 is normal for TBSA 40% or more)
 Low BP and MAP are expected (within range. 80/60 is concerning but
not alarming; MAP of 65 is concerning but not alarming)

22. Inhalation Injury
 Increases mortality risk
 Requires more fluids in resuscitation (up to 44%
more)[Navar PD, Saffle JR, Warden GD. Effect of inhalation injury on fluid resuscitation requirements after thermal injury. Am J Surg 1985;
150:716–720]
 Early intubation indicated for patients with hx of
being in enclosed space, facial burns, stridor,
carbonaceous sputum, vocal change
 Obtain carboxyhemoglobin on admission if inhalation
injury is remotely suspected
 Obtain bronchoscopy within 24 hours of admission

23. Questions?