This document provides guidance on transport considerations for burned patients. It discusses burn classification, initial resuscitation, and fluid management. Burns are classified based on depth and percentage of total body surface area affected. The Parkland formula is commonly used to calculate initial fluid resuscitation, with 4 ml of lactated Ringer's solution per kg of body weight per percentage of burn over 24 hours. Accurate assessment of burn size and depth is important for determining fluid needs. Complications like edema formation, systemic inflammatory response, and hypothermia are also addressed.

2. Transport Considerations of
the Burned Patient
Gustavo E. Flores, MD EMT-P

3. Objectives
• Classification of burns
• Initial resuscitation
• Transport considerations

4. Etiologies
• Based on the mechanism of injury:
• scalds,
• contact burns,
• fire,
• chemical,
• electrical, and
• radiation.

5. Classification
• 1st Degree (superficial)
• 2nd Degree (partial thickness)
• 3rd Degree (full thickness)
• 4th Degree (subdermal)
• Routinely underestimated during the initial examination.
• Devitalized tissue may appear viable for some time after injury
• Some degree of progressive microvascular thrombosis is observed on the
wound periphery.

6. 1st Degree / Superficial
• Usually red, dry, and painful.
• Burns initially termed first-degree are often actually superficial
second-degree burns, with sloughing occurring the next day.

7. 2nd Degree / Partial Thickness
• Second-degree burns are often red, wet, and very painful.

8. 3rd Degree / Full Thickness

9. 4th Degree / Subcutaneous
• Fourth-degree burns involve underlying subcutaneous tissue, tendon,
or bone.

10. Estimating Burn Size
• Accurate estimate is important.
• (Size does matter.)
• Lund-Browder diagram (age-specific)
• Rule of 9
• Palm of patient’s hand

11. Initial Burn Size and Depth
• Outside reports are notoriously unreliable.
• Correctly estimated only 1/3 of times.
• Leads to over-resuscitation.

12. Systemic inflammatory response (1/4)
• When TBSA > 30%, cytokines and other mediators are released into
the systemic circulation, causing a systemic inflammatory response.
• Because vessels in burned tissue exhibit increased vascular
permeability, an extravasation of fluids into the burned tissues occurs.
• Hypovolemia is the immediate consequence of this fluid loss, which
accounts for decreased perfusion and oxygen delivery.
• In patients with serious burns, release of catecholamines,
vasopressin, and angiotensin causes peripheral and splanchnic bed
vasoconstriction that can compromise in-organ perfusion.
• Myocardial contractility also may be reduced by the release of
inflammatory cytokine tumor necrosis factor-alpha.

13. Edema Formation (2/4)
• At the peak of edema formation, essentially all whole blood elements up to the
size of RBCs are able to transmigrate through the vessel wall in burned tissue.
• As a result of this capillary leak, replacing the intravascular
deficits drives the continued accumulation of edema.
• Nearly 50% of infused crystalloid volume lost to the interstitium.
• As the burn size approaches 15-20% total body surface area (TBSA), shock sets in
if the patient does not undergo appropriate fluid resuscitation.

14. Edema Formation (3/4)
• The peak of this third-spacing occurs at some point 6-12 hours postburn as
the capillary barrier begins to regain its integrity.
• Hence the reduction in fluid requirements observed in resuscitation formulas around
this point.
• At this point, the theoretic benefits of adjuvant colloid therapy during the
resuscitation allow the careful downward titration of fluid administration to
reduce the obligatory edema.

15. Systemic inflammatory response (4/4)
• Hemolysis may occur in deep 3rd deg burns.
• PRBC to HCT of 30-35
• Decrease in pulmonary function can occur in severely burned patients
without evidence of inhalation injury from the bronchoconstriction
caused by humoral actors, such as histamine, serotonin, and
thromboxane A2.
• Burned skin  increased evaporative water loss  heat loss 
hypothermia.

16. Patient Evaluation
• Primary Survey: ABCDE
• Secondary Survey: Hx and Physical Exam (burn-
specific)
• Determination of mechanism of injury,
• Presence or absence of inhalation injury and carbon
monoxide intoxication,
• Examination for corneal burns,
• Consideration of the possibility of abuse, and
• Detailed assessment of the burn wound
• Imaging studies
• Laboratory studies

17. Vital Signs
• Very difficult to interpret in patients with large burns.
• BP ok due to catecholamine release despite extensive intravascular
depletion.
• Edema limits usefulness of NIBP.
• Arterial line measurements limited by peripheral vasospasm from
high-cathecolamine state.
• Tachycardic due to pain and high adrenergic state, not just
hypovolemia.
• Following a trend is much more useful than any single reading.

18. Fluid Resuscitation
Parkland Formula
mL in 24 hrs

19. Caution
• Not all burns require use of the Parkland formula for resuscitation.
• Adult with < 15-20% TBSA without inhalation injury does not require
Parkland Formula.
• Not enough to initiate the systemic inflammatory response.
• These patients can be rehydrated successfully primarily via the oral route with
modest IV fluid supplementation.

20. Parkland Formula
4 mL x BSA x kg
• 50% in first 8 hrs
• 50% in remaining 16 hrs
• Example: 4 x 45 BSA x 100 kg = 18,000 mL (24 hrs)
• 9,000 mL in 1st 8 hrs
• 1,125 mL per hour (1st 8 hrs)

21. Adequate Fluid Resuscitation
• Urine output
• Adults 0.5 – 1 mL / kg / hr
• Peds 1 mL / kg / hr
• If myoglobinuria and/or rhabdomyolysis
suspected?
• 1 – 1.5 mL / kg / hr

22. Ringer Lactate
• NaCl
• Ringer Lactate 130 mEq/L
• Normal Saline 154 mEq/L
• pH
• Ringer Lactate 6.5
• Normal Saline 5.0
• Plasmalyte?

23. Hypoperfused?
• Failure to meet these goals should be addressed with gentle upward
corrections in the rate of fluid administration by approximately 25%.
• Frequent boluses result in transient elevations in hydrostatic pressure
gradients that further increase the shift of fluids to the interstitium and
worsen the edema.
• However, do not hesitate to administer a bolus to patients as appropriate early
in the resuscitation for hypotensive shock.

24. Hyperperfused?
• Avoid urine output at rates > 0.5 - 1 mL / kg / h.
• Fluid overload in the critical hours of early burn management leads to unnecessary
edema and pulmonary dysfunction.
• It can necessitate morbid escharotomies and extend the time required for ventilator
support.

25. Even More Fluids
• Inhalation injuries sometimes as much as 30-40% higher (close to 5.7 mL/kg
x BSA)
• Delays in initiating resuscitation promptly have also been shown to increase
fluid requirements by as much as 30%, presumably by permitting the
occurrence of an increased inflammatory cascade.
• Home diuretic therapy frequently have preexisting free-water deficits in
addition to burn shock.
• Escharotomy or fasciotomy can substantially increase free water loss from
the wound.
• Electrical burns, associated with large and underappreciated tissue insult

26. Formula Fluid in First 24 Hours Crystalloid in Second 24-Hours Colloid in Second 24-Hours
Parkland RL at 4 mL/kg per percentage burn 20-60% estimated plasma volume Titrated to urinary output of 30 mL/h
Evans[2]
NS at 1 mL/kg per percentage burn, 2000 mL
D5W*, and colloid at 1 mL/kg per percentage
burn
50% of first 24-hour volume plus 2000 mL D5W 50% of first 24-hour volume
Slater[2] RL at 2 L/24 h plus fresh frozen plasma at 75
mL/kg/24 h
Brooke[2]
RL at 1.5 mL/kg per percentage burn, colloid at
0.5 mL/kg per percentage burn, and 2000 mL
D5W
50% of first 24-hour volume plus 2000 mL D5W 50% of first 24-hour volume
Modified Brooke RL at 2 mL/kg per percentage burn
MetroHealth
(Cleveland)
RL solution with 50 mEq sodium bicarbonate per
liter at 4 mL/kg per percentage burn
Half NS titrated to urine output
1 U fresh frozen plasma for each liter of half NS
used plus D5W as needed for hypoglycemia
Monafo hypertonic
Demling[22, 23]
250 mEq/L saline titrated to urine output at 30
mL/h, dextran 40 in NS at 2 mL/kg/h for 8 hours,
RL titrated to urine output at 30 mL/h, and fresh
frozen plasma 0.5 mL/h for 18 hours beginning 8
hours postburn
One-third NS titrated to urine output
*D5W is dextrose 5% in water solution
Table 2. Resuscitation Formulas

27. Pediatrics
• Burns < 15% BSA are not associated with an
extensive capillary leak.
• Fluid resuscitation = 150% maintenance rate
• And continuous monitoring of fluid status.
• In smaller children, low hepatic glycogen reserves
can be exhausted quickly:
• Hypoglycemia is a threat. Monitor every 4-6 hrs.
• Ringer lactate solution with 5% dextrose should be
added at a maintenance rate.

28. Pain Control
1. Morphine @ 2mg increments up to 20 mg max;
2. Ativan @ 1-2 mg increments up to 4 mg max.;
3. Fentanyl @ 1-3mcg/kg or 50-200 mcg IV q 30-40 minutes;
4. Propofol (Diprivan) @ 5 mcg/kg/min
• Increase 5-10 mcg/kg/min to max of 80 mcg/kg/min.
• Maintenance rate @ minimum 25-50 mcg/kg/min;
5. If patient is wheezing administer: Albuterol 2.5/3 cc with repeat
prn and if pt. is intubated administer in-line;

29. Circunferential Burns
• Neck = INTUBATE NOW.
• Chest
• Interferes with ventilation.
• Extremity
• Progressive edema leads to poor chest wall compliance.
• Extremity escharotomies
• As soon as peripheral perfusion is threatened.
• Do not wait until the extremity is overtly ischemic.
• Torso escharotomies
• As soon as ventilation appears compromised.

30. Monitor Electrolytes
• Hyponatremia can lead to cerebral edema and seizures.
• Rapid correction of hyponatremia may result in central pontine
demyelinating lesions.

31. Take-home
•Airway deteriorates over time. Consider early intubation.
•Breathing may become difficult if patient is awake and has low
chest wall compliance. Manage pain aggressively.
•Circulation is very labile. 4 mL x BSA x kg. Keep an eye on BP and
urine output if using multiple analgesics and sedation.
•Disability is due to low perfusion unless TBI is also suspected.
•Exposure is critical to re-evaluate extent. Prevent hypothermia.

32. References
• Initial Evaluation and Management of the Burn Patient
• http://emedicine.medscape.com/article/435402-overview#showall
• Burn Resuscitation and Early Management
• http://emedicine.medscape.com/article/1277360-overview#showall

34. Thank you!