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Burns Treatment

Fluid resuscitation

Authors: Rami Mossad Ibrahim, MD, Elisabeth Lauritzen, MD, Frederik Gulmark, Hansen Med. Stud., Anne Mosebo, Med. Stud., Magnus Balslev Avnstorp, MD and Rikke Holmgaard, MD, PhD

Fluid resuscitation during the first 24 hours after a 2nd or 3rd degree burn can be calculated using the modified Parkland formula:  

Fluid resuscitation during the first 24 hours =
3 ml x weight in kg x burned percentage of TBSA*

*Total Body Surface Area

Indications for fluid resuscitation

Indications for fluid resuscitation depend on the age of the patient:

Adults ≥ 15 yearsTBSA ≥ 20%
Children < 15 yearsTBSA ≥ 10%
Table 1 | Indications for fluid resuscitation

Administration of fluids

Intravenous input

50% of the fluids are given within the first 8 hours and the remaining 50% is administrated within the next 16 hours. Fluid therapy should be calculated from the time of the injury and not from the patient is admitted to the hospital. Patients can eat and drink without restrictions.

Figure 1 | The Parkland formula for calculating fluid resuscitation during the first 24 hours after a 2nd or 3rd degree burn.

Urine output

The input has to balance the output and must be adjusted according to the hourly urine output. A bladder catheter is indicated to measure the urine hourly output.

Urine output should be

Adults 0,5-1 ml/kg/hr
Children1-2 ml/kg/hr
Table 2 | Urine output

Reassess fluid administration if

The hourly diuresis is too high

  • This can lead to oedema in the lungs, brain etc.
  • This can reduce peripheral circulation and thus increase ischemia in the tissue

The hourly diuresis is small or decreasing

  • Make sure of adequate administration and a well-functioning bladder catheter
  • Reassess burn size and if inadequate make a new calculation of fluid treatment

The hourly diuresis remains small or decreasing

  • Administer extra fluid as a bolus of 5-10ml/kg over 1 hour or by increasing the fluid administration to 150% for 1 hour
  • If continued low urine output, albumin can be given on the second day after injury. This increases the osmotic gradient across the vessel wall when the capillaries are no longer permeable to colloids and thus increases the kidney filtration pressure resulting in greater diuresis
  • Albumin 5% is given according to the formula: 0.5 ml x kg x TBSA

The 4:2:1 principle

Children (<9 years of age) should also receive maintenance fluid therapy during the first 24 hours after the burn injury. This is calculated using the 4:2:1 principle. Children have lower physiological reserves and therefore a higher risk of developing hypoglycaemia. The supplemental fluids consist of 0.9% NaCl with 5% dextrose. 

The dose is calculated according to weight:

Up to 10 kg4 ml per kg
From 10-20 kg2 ml per kg
>20 kg1 ml per kg
Table 3 | The 4:2:1 principle

Summary

The table below is a summary of the practice of fluid resuscitation during the first 24 hours after a burn injury according to age.

Formula1. period (8 hours)2. period (16 hours)
Adults ≥ 15 yearsParkland: 3 ml x weight in kg x % TBSA50% of the calculated fluid 50% of the calculated fluid
Children < 15 years Parkland: 3 ml x weight in kg x % TBSA + Maintenance fluid (4:2:1 principle)50% of the calculated fluid 50% of the calculated fluid
Table 4 | Summary of fluid resuscitation practice

Example

Child with a 2nd degree burn

  • Weight: 25 kg
  • Burned percentage of TBSA: 10%

Fluid is given according to the modified Parkland formula and maintenance fluid according to the 4:2:1 principle:

The Parkland formula

  • 3 ml x 10 kg x 10 % = 300 ml/hour

The 4:2:1 principle:

  • 4 ml x 10 kg = 40 ml/hour
  • 2 ml x 10 kg = 20 ml/hour
  • 1 ml x 5 kg = 5 ml/hour

The child should be given 365 ml/hour for the first 24 hours after the burn injury.

Pearls

  • To measure input and output all patients must have a fluid schedule and bladder catheter

Pitfalls

  • Be aware of signs such as confusion, restlessness or anxiety as this may be due to hypovolemia. These patients should have reassessed their fluid therapy and urine output

Acknowledgements

Illustrators: Anne Mosebo, Med. Stud.

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