Practice Guidelines for Burn Care Preface and Acknowledgements Jeflivey Saffle The present version of these Guidelines represents the work ofa committee that met tirelessly (at times, it seemed, endlessly) during 1998-1999 in an at~ tempt to bring some objectivity to the practice of initial burn care. The process and rules we followed during this effort are outlined in the Introduction, That the product which follows is—more than any- thing—a testimony to the dearth of “evidence: based” clnial practice in burn eare was not regarded by us a a fllure; rather, we fele the most important consequence of this work would be to stimulate fr ture efforts to conduct the randomized, controlled trials so clearly needed to prove thatthe tenets of our clinical care are indeed valid, and ifproven otherwise, co change them. This work will bea fulure only itis not improved upon and surpassed in the future. Throughout this project Ihave been amazed at the willingness of our many authors and advisers to int rupt their hectic schedules and endure a series of te- dious and frustrating meetings, amend—again and again—theie chapters, and listen and respond to erit- icism. Our initial decision not to list individual au- thors for specific chapters has deprived many partici pants of academic credit they deserve, but we believe it will strengthen this document in the long run. Ifit somchow adds to our participants’ prestige as well, so much the better. They deserve it Several other people, who will be denied even the dubious distinction of authorship, also helped greatly with this project. We could not have proceeded with- out them, and I extend to them my sincerest thanks. First and foremost is Ms. Pam Cardin at Paradigm ‘Medical, who arranged and rearranged flight sched: ules and hotel reservations flawlessly. My secretaries, Stephanie Miya and Lou Theurer, helped with end: less details efficiently, and endeared themselves to all concerned in the process, Lastly, we thank all of our families, who watched us depart for yet another round of mysterious meetings, and stay late to work. on yet another mysterious project. We know you're used to it, but your tolerance and support is as appre ciated and necessary to us as it appears to be endless, ‘Thanks,PRACTICE GUIDELINES FOR BURN CARE Developed by the Evidence-Based Guidelines Group, American Burn Association, with the assistance of Paradigm Health Corporation Participating Authors Davi i Arenhol, MD Gary F.Purae, MD nD or parton ops er sco ‘as eee ‘Jeffrey R. Saffle, MD Gprereee Cnr ef ih ar Cor Concord, ‘Salt Lake City, UT ‘Alan R, Dimick, MD . Se Robert Sheridan, MD oe Sint Be ea Test Richard L. Gamelli, MD dept i Bani paula Sundance, MD Mopovod, Ie Parudigm Health Corporation Cina Robert W. Gillespie, MD Omeha, NB Stewart Sweetser, MD Richard J. Kagan, MD Paraiigm Heath Corporation Onversity of Cicinmat Brn Center Gomcord Cincinnat, OF Ronald G. Tompkins, MD G. Patrick Kealey, MD Massachusats Gonoal Hospital Burn Center ‘versity Towa Bur Center Boston MA wa City 1A David J. Wainwright, MD —— Le Oniversity of Teras School of Medicine ‘North Cavana Jaye Bir Centr (Chapel, NC el Lawrence H. Pitts, MD Glenn D. Warden, MD Onersty of California, San Francisco ‘Shriners Burs Hopital ‘So rons, CA Cincinnati, OffPRACTICE GUIDELINES FOR BURN CARE Contents Preface and Acknowledgments Introduction Chapter One: Organization and Delivery of Burn Care Is Chapter Two: Initial Assessment of the Burn Patient .........-.-+ses+ .. BS Chapter Three: Outpatient Management of Bur Patients ... . 108 Chapter Four: Management of Carbon Monoxide and Cyanide Exposure ......... us Chapter Five: Inhalation Injury: Diagnosis Chapter Six: Inhalation Injury: Initial Management Chapter Seven: Burn Shock Resuscitation: Initial Management and Overview Chapter Eight: Hypertonic Fluid Resuscitation Chapter Nine: Fluid Resuscitation: Colloid Resuscitation ... Chapter Ten: Fluid Resuscitation: Monitoring ... Chapter Eleven: Escharotomy Chapter Twelve: ial Nutritional Support of Burn Patients ... Chapter Thirteen: Deep Venous Thrombosis Prophylaxis in Burns ..Introduction THE EVOLUTION OF PRACTICE GUIDELINES ‘An important recent change in medical practice has been the development and use of practice guidelines. ‘Simply defined, practice guidelines are recommenda tions for management of specific medical problems, supported by objective and comprehensive reviews of literature, that seck to define the current best and most cost-effective methods of treatment. Properly, applied practice guidelines have been shown to im: prove patient care and reduce costs? Practice Guidelines are recommendations for management of ‘specific medical problems, supported by objective and comprehensive reviews of the literature, which seek to define the current best and most cost-effective methods of treatment. Practice guidelines are the product ofa more wide- spread movement in medicine, called evidence-based ‘medicine. This movement has been driven, at least in part, by three factors: the explosion of technology and information in health care; altered perceptions of the role of health care in society; and recognition that health care costs must be reduced. Health care providers must now deal with an over whelming volume of new technology and seemingly endless published literature in every field. This infor ‘ation overload has far outstripped the ability of tra ditional medicine-which relied heavily on the judg ment of experienced observers-to guide decision ‘making, In addition, when this tradition is scrutinized ‘with the scientific rigor that has permitted such ex: traordinary recent advancements, it is sometimes found to be inefficient, inaccurate, and expensive. ‘The same ready access to information, coupled with growing concems about the impersonal nature of technology and the insurance industry, has prompted consumers, often as well-informed as their providers, to demand an active role in determining. both their own treatment and the future direction of health care as a whole Perhaps most importantly, realization that society cannot afford unrestricted medical care has led to widespread attempts at cost-containment by the health care industry. Even the best-intentioned of ‘these efforts sometimes have contributed to.an adver- sarial relationship among providers, payers, and pa- tients, and validated the public’ impression of a de humanized medical system; at their worst, such efforts have-often subjectively and eapriciously-in- creased inequities in access to care. ‘These factors have stimulated shift toward objec: tivity in medicine, as a means of keeping pace with technological progress and of applying limited health care resources in the most beneficial way. Evidence- based medicine (a term coined in 1990” uses the scientific method to evaluate medical practice. Some observers have described evidence-based medicine as a “paradigm shif”,* representing a split from a cen: turies-old tradition of empiric medicine, whereas oth 15 view it as the evolutionary culmination of the de sire to define the best methods of care.° Regardless, there is little doubt that evidence-based medicine is changing the way in which medicine is practiced, and that ithas been embraced both inside and outside the health care community. Evidence-based Medicine stresses critical reading and interpretation of ‘medical literature according to levels of scientific certainty. Evidence-based medical practice stresses the criti cal reading and interpretation of medical literature according to the strength of medical evidence, The “gold standard” of evidence isthe randomized con trolled clinical tial (RCT), in which a new treatment ‘or tests compared to existing standard therapy (the “control”) and evaluated using carefully defined end- points, including cost, risks, and benefits. (Multiple ‘or contradictory RCTS often are evaluated jointly,vi Practice guidelines for burn care Inerdction using the technique of meta-analysis.®) Asa product, of the evidence-based medicine movement, practice guidelines ideally are based entirely on such scientif- ically valid evidence. Few areas in medicine, however, have had enough RCTs to permit such rigor. Many guidelines, therefore, also rely heavily on more tradi tional medical resources, including reviews, case re ports, and expert opinion. That is not a problem, 2s Jong as the level of evidence that supports each guide. line is carefully defined. In fact by illuminating the deficiencies in knowledge about a particular disease process, practice guidelines can stimulate additional investigation in the form of well-designed trials. Evidenced-based medicine has the potential to re solve many of the conflicts generated by pressures to deliver efficient and cost-effective care. For practitio. ners, practice guidelines provide convenient distila tion of a great deal of information into a clear and useful summary, and reduce problems caused by un: familiarity or differing interpretations of literature, and by the habits that come from experience. For consumers, guidelines provide ready access to current knowledge about disease treatment. For payers, guidelines provide consensus.as to most effective (and cost-effective) care, stating what does not need to be done as well as what does. Such guidelines may help reduce unexplained variations in the delivery of med ical eare. In addition, proper use of practice guidelines can obviate irksome “utilization reviews” and go far toward eliminating the antagonism sometimes felt between providers and insurers. Practice Guidelines help reduce unexplained variations in the delivery of medical care, which are a major source of both high costs and poor outcomes in clinical medicine. ‘The growth of practice guidelines was stimulated in. part by a mandate from the US Congress to develop {guidelines to improve clinical effectiveness and qual ity of care,” As Walters® points out, the practice guidelines movement has grown exponentially since its inception in the early 1990s (Table 1). Many spe cialty societies have hurried to produce practice guidelines dealing with a host of medical problems,” and some evidence already exists that practice guide lines ean produce improvements in patient care and reductions in costs.? The Canadian Medical Associa: tion web site on the Internet (www.cma.ca/epgs) Journal of Buon Care & Rehabilitation ‘Apel 2001, (edline citations for “practice guidelines” by y No. Year citations 1988 2 1989 u 1990 41 1991 34 192 163 1998 422 1994 1995 1996 1232 1997 1992 1998 740 provides access to over 650 current guidelines for use by practitioners. Practice guidelines must be distinguished from srisical pathways, another recently developed tool for regulating medical practice. Critical pathways, which may be based on practice guidelines, are more de tailed, disease- and institution-specific protocols for ‘managing specific disease states. Critical Pathways are detailed disease- and institution-specific protocols for managing specific disease states. Properly designed practice guidelines, especially ‘when endorsed by professional societies, can have te mendous influence in affecting, medical practice, and sometimes are viewed as too authoritative to defy ‘without pesil2° Precisely because of their potential impact, therefore, practice guidelines must be con: structed and implemented with great care. A poorly drafted or misleading practice guideline can do far more haem than any single clinical study. As a result, detailed and explicit instructions have evolved for the reading and interpretation of medical literature, and. for creation of practice guidelines (Tables 2 and 3). PRACTICE GUIDELINES FOR BURN CARE ‘There may be no area in medicine that has relied as heavily on subjective and empiric observations as bbum care. ‘There are several reasons for this. Serious burns are a relatively uncommon medical problem,Toural of Burn Care & Rehabilitation which tends to make bum centers geographically and. culturally isolated. ? The lack of accepted standards for training bur practitioners encourages perpetua- tion of an apprenticeship system in which novices emulate their mentors In addition, few rigorous mul- ticenter trials exist in the burn literature. Not surpris- ingly, this has led to divergent methods of practice among institutions, methods that sometimes advo cate opposing techniques and philosophies. In a number of areas in medicine, improved out comes have been shown to correlate with physician experience and institutional volume in handling spe- cific diseases,'? providing support for referral of com- plex medical problems to “centers of excellence.” ‘There are no such data for burns. This dearth of de- ‘monstrable evidence of the benefits of burn center treatment, plus the lack of uniform practice pattems, has raised serious questions about the ftture of buen centers in @ managed care economy." In his 1994 Presidential address to the American Burn. Associa- tion, Dr. David Hemdon'* emphasized that these traditions, caught in the pincers of health care reform, threaten the continued existence of burn care as a specialty, and underscore the need to “take a proac- tive approach in demonstrating through prospective studies the benefits of our interventions.” This prob- Jem was aso pointed out by Childs," who systemat- ically reviewed the bum literature and found few RCTs; she questioned whether an evidence-based practice for many aspects of bum care existed at al THE PROCESS OF GUIDELINES DEVELOPMENT In May of 1998, 2 tsk force was formed for the purpose of developing evidence-based guidelines for the management of acute burn injury. This task force ‘was supported by the American Burn Association (ABA), The National Coalition of Burn Center Hos- pitas, and Pazadigm Health Corporation, a private disease management company specializing in cata- strophic injury. Members of the task force were s¢- lected based on their academic and practical expertise in burn injury, evidence-based medicine, or both (sce Appendix I) ‘The tsk force selected the topics to be addressed in the first edition of these guidelines. Each person on. the taskforce was assigned a topic 0 research and draft. Initial topic drafts were based on a comprehen- sive literature search, followed by review and grading of clinical articles pertinent to the topic. These drafts were reviewed and critiqued by the entire task forcein September of 1998 and resulted in the first draft of | the guidelines. Practice guideline for bur cove: Introduction vii Subsequent meetings held in January 1999, May 1999, and October 1999 resulted in this final version. At each meeting the entire document was reviewed and critiqued by the taskforce. This process included the participation and contributions of representatives of various medical societies, individuals from associ- ated specialties with expertise in burn injury care, and. ‘members of the ABA’s Committee on the Organiza: tion for the Delivery of Burn Care. ‘The purpose of our initial effort was to design guidelines that summarize clearly the current scien- tific basis of the clinical practice for the management of acute burn injury. ‘These guidelines are by no ‘meanis an exhaustive treatise on burn care. Because of the enormous effort required to develop evidence: based guidelines, we restricted this initial effort 10 topics dealing with the emergency and initial care of bur patients; other important aspects of patient management that were not covered in the present effort will be considered for study in subsequent edi- tions. Examples of topics for frture consideration include bun rehabilitation, psychological manage- ment, wound management and grafting, manage- ment and protection of recovering skin, post-acute burn rehabilitation, indications for reconstructive in- terventions, prognosis and predictors of outcome, prevention and management of contractures, and heterotopic ossification. Our purpose was to design guidelines which summarize the current scientific basis of the clinical practice for the ‘management of acute bum injury. Although the lack of objective evidence in the form. ‘of RCT for burn care posed a problem for us, we also felt that it was a good reason to begin. Summarizing, existing evidence in the form of practice guidelines might underscore the need for further research, and stimulate such research on a multi-insttutional level. ‘We also wish to emphasize that these guidelines should not be taken as a “cookbook” to help the novice manage patients with serious burn injuries. Rather, we hope they will serve as summaries of ex- isting knowledge for experienced practitioners al- ready familiar with the literature in this field, and provide an expression of consensus about the current knowledge of some controversial topicsPrucis guidelines for burn sare: Introduction KEY DEFINITIONS As stated previously, practice guidelines can have tre- mendous influence on the way medical cae is deliv- ‘ered. It is imperative, therefore, for guidelines t0 be constructed as carefull, as objectively, and as compre- hensively as possible. As Eddy'” has stated, the objec- tives of practice guidelines are accuracy, accountability, predictability, defensibilty, and usability Recently, Shaneyfelt et al reviewed 279 practice {guidelines published from a number of sources from 1985-1997. They developed a checklist of 25 items dealing with guideline format and development, identification and summary of evidence, and formu’ Iation of recommendations. They found that these guidelines containeda mean of 10.77 ofthe 25 items, and that only 51% of the guidelines adhered to meth- odological standards for guidelines development. ‘These data illustrate that not all practice guidelines are equally rigorous or valid. In beginning the task of creating practice guidelines for burn care, we fe it ‘was important to avoid the mistakes previous groups have made, and to follow the highest published stan- dards for guideline development. In addition to wanting the best quality guidelines possible, we real- ized that opinions of experts in burn care often are far from uniform; only guidelines with clearly docu- mented methodology and carefully constructed rec- ‘ommendations would be sufficiently authoritative to gain widespread acceptance. Secondly, the dearth of truly objective information in the form of random- ized, controlled trials mandated that we describe our dlata-gathering process in detail, and summarize ex- isting evidence completely. Finally, we recognized that bum care is uniquely a team effort, and that our guidelines must be capable of being read and under- stood by every member of the burn care team. ‘We have tried to tailor these guidelines to fit these objectives, Numerous publications have outlined the rales and process of guideline development. In con- structing these guidelines for bur care, we attempted, to adhere to recommendations developed and pub- ‘Table 2, Classes of evidence Journal of Burn Care & Rehabilitation ‘April 2001 lished by the American Medical Association,” using widely accepted terminology. Classification of Evidence When evaluating the value of therapies or interven- tions, available data are assessed for their strength and categorized according to the criteria outlined in Ta- int out that a number of publica- vided the broad classes listed in Table 2 into as many as nine levels of evidence (eg, 2a, 2b), including modifiers to indicate the assessed ‘quality Ofeach reference." ??9 We elected to retain the more straightforward classification listed, however, partially because we felt that the evaluable studies available in burn care did not lend themselves to fur- ther subdivision. For each of the guidelines that fol- low, our group has inciuded comments, where nec- essary, regarding the quality or shortcomings of individual studies. ‘These comments are intended to help the reader evaluate the real value of the evidence summarized. Correlation Between Evidence and Recommendations Practice guidelinesare assigned an appropriate degree of certainty based on the level of evidence. In assess- ing the degree of certainty associated with a particular recommendation, the terminology addressed in Ta- ble 3 is the most widely accepted and is used in this document.??#? ‘A Comment on Terminology ‘Note that the term “guidelines” is used both in a ‘global sense, eg, clinical practice “guidelines,” and in a more specific sense, The fact that this word is used. ‘with two different meanings is unfortunate, but both, "usages have become too widespread for us to attempt to change the terminology now. It is imperative that the reader understand the use ofthis terminology asit pertains to the level of evidence available for each topic. Because few objective studies exist that support las T “The “gold standard” of evidence-based medicine: evidence provided by prospective, andomized, ‘controlled tials that ince approprite design and methodology and suficent patient numbers Chas 1 ‘Clinical soaies in which the data are coleced prospectively o sewospecively and rewospectve analyses that ate bated om clealy reliable dats, Types of tudes so cased include observational sues, cohort seudies, prevalence seodies, and ease contol studies, Chas “Technology assessment evidence provided by clinical series, ompacsive sti, ake reviews, case reports, and expert opinion ‘The asesment of technology dos not lend ise. classification inthe indicated format. Thus, for ‘chology asetsmene che devices were evaluated in terms of thei accuracy, reliability, therapesic potential, and cost effectiveness.Journal of Barn Cate & Rebabiltation ‘Table 3. Levels of recommendations in practice guidelines Srandands Practice guideline for burn cae: Introduction ‘Standards represen accepted principles of patent management that elect high degree of linc] certainty. Standards usual are bused on Clas T evidence; however, srong Clas If evidence may form the bass for 3 sandr, especialy if the issue doesnot lend itself to testing in a randomized format, Conversely, weak or contradictory Clas T evidence ‘may not suppor 2 standard. Standards are intended tobe applied rigidly, Standards are rues. Guidlines (Guidelines presenta particular strategy or range of management stzategis that elects a moderate clinical certain. Guidelines are based on sigaficant Cas It evdence anda preponderance of Clas II evidence. Guidelines shout be followed in most cases, Guidelines can snd should be walored to fitindvidual patent needs Options (Options represent strategies for patient management that lack strong scent evidence bat represent the panels? current state of eae secommendations. Options are bated on song Clas III evidenes. Options have value a5 credible recommendations, stools for educational purpose, and for sein guiding furure rues, They are reasonable and avaiable erategies to be considered by the physician in the care ofthe patient even the most widely practiced principles in burn care, our group was forced to offer many recommen: dations as “options.” For example, the use of high: flow oxygen (FiO, = 1.0) in treating carbon monox- ide poisoning is undisputed in clinical practice; many physicians would consider withholding such treat- ‘ment to be unethical. However, because the efficacy of such treatment has never been proven in an RCT, its use is listed as a practice option in our guidelines, Readers should remember that all of the recommen: dations listed in the guidelines that follow represeat our consensus as to the best clinical practice currently available; their division into standards, guidelines, and options is meant to reflect the quality of evidence available to support them rather than the degree of support they should receive in clinical practice. Ed- dy" has suggested that options can be further mod- ified by indicating where expressed. preferences are unknown, indifferent, or split among experts. In con- structing these guidelines, however, we elected to leave our options explicit to optimize theie clarity. In the future, the upgrading of therapeutic options to guidelines to standards will require carefully de- signed, cooperative trials with appropriate scientific igor. Division of recommendations into standards, guidelines, and options is meant to reflect the quality of evidence available to support them, rather than the degree of support they should receive in clinical practice. ATTRIBUTES OF GUIDELINES DEVELOPMENT To ensure the development of scientifically sound, clinically relevant guidelines that are applicable to the day-to-day practice of medicine, the American Med. ical Association*? developed a list of attributes, which are listed here in an abbreviated form. Our group followed these recommendations in drafting practice guidelines for buen care. A more step-by-step outline is provided by Walters.® We have attempted to follow both groups of recommendations as much as possi ble. The following paragraphs list the actions of our Practice Guidelines group in response to the sug: gested AMA guidelines. 1. The first AMA attribute is that practice guide- lines should be developed by or ia conjunc tion with physician organizations and should take into consideration the following: A, Scientific and clinical expertise in the con- tent areas of the parameters must be considered. B. There must be a broad-based representa tion of physicians likely to be affected by the parameters. ©. The specialty affiliations and other cre dentials of the physician organization ‘groups and individuals conducting the re- view should be listed. D. The process for selection of clinical ex- perts and reviewers is noted or available on request B, At least two thirds of the clinical experts who acted as reviewers were actively in- volved in clinical practice in relevant clin- ical areas Our group's response to attribute #1 is as follows: A large group of practicing burn care2X Practice puielins for burn car: Introduction physicians was selected for our initial group, representing key institutions active in burn care, and including representatives of the ABA Board of Trustees, the ABA’s Commit tec on Organization and Delivery of Burn Care, the Shriners’ Burns Institutes, and oth- ers (see Appendix I). Two physicians with ex tensive experience in successful guideline cre- ation also were included. Approval from the American Burn Association was obtained cariyin the process, and draft guidelines were shown to the ABA’s Board of Trustees for approval. These Practice Guidelines were pre- sented at the 2000 meeting of the American Bum Association. In addition, the input and approval of im- portant related professional societies also was sought, and representatives were invited to review our guidelines. ‘These societies are listed in Appendix I ‘The second attribute required by the AMA is that relevant scientific literature and expert clinical opinion should be reviewed, as evi- enced bp ‘A description of the process ofthe review BA description of the evidence reviewed C. Adescription ofthe methods used to eval- uate the scientific literature and other ap- propriate research findings D. Notation of the rationale for including or excluding studies E, The clinical expert reviewers thoroughly reviewed and assessed the scientific literature For each of the guidelines that follow, a section entitled “process” describes in detail the system we used in searching the existing literature and compiling data. All relevant publications are summarized in the eviden- tiary tables, and are classified as to the level oF evidence they contain, Where appropriate, editorial comments on the quality and con- tents of these references are included, ‘The third attribute specified by the MA is that practice parameters should be as comprehen- sive and specific as possible. ‘As mentioned previously, the guidelines chosen for inclusion in ths initial effort were selected to cover the initial (12-48 hours) care of the acutely burned patient. Wherever possible, we have tried to make specific state- Journal of Burn Care & Rehabilitation ‘April 2001 _ments regarding the best practice choices for the clinician. 4. The fourth AMA attribute states that practice parameters should be based on current infor- mation and that there should be provisions for periodic reviews and revisions when appropriate. In response, the Practice Guidelines group has recommended that the ABA’s Commit- twee on Organization and Delivery of Burn ‘Care take over the creation of addition prac- tice guidelines, and the periodic revision and updating of existing guidelines. 5. The fifth AMA attribute is that the guidelines should be widely disseminated. ‘Three efforts to disseminate our guidelines are planned: (1) a number of related profes- sional organizations with an interest in burn ‘are have been asked to review and comment ‘on the guidelines (Appendix 2); (2) the guidelines will be presented to che member- ship of the ABA at the annual meeting 2001; and (3) these guidelines will be pub- lished in the Journal of Burn Care & Rehabilitation GUIDELINE FORMAT Published guidelines typically follow a defined for- ‘mat, which is intended to maximize clarity and allow the reader to follow every step of the process used in creating the guideline. Although these formats differ somewhat, most follow the recommendations pub- lished by Eddy.” The format for the burn care guide- lines that follow were adapted from these and similar recommendations, and consist of the following, sections: Recommendations: the conclusions of the reviewers are summarized as standards, guidelines, or op- tions, as discussed previously Background: information is provided to put the clin- ical problem in perspective, and provide a brief re- view of current practices Health Problem: this section defines the clinical ques: tions addressed by the guideline, and the patient population to whom the guideline should be applied. “Health and Economic Outcomes: thissection lst the ‘outcomes that could be affected by application of the guideline. Possibilities might be as obvious as survival, in the case of guidelines for treating car- ‘bon monoxide poisoning.Journal of Burn Care & Rehabilitation Process: the methods used for gathering literature dealing with the guideline topic are described in detail. Scientific Foundation: ‘The scientific background “supporting evolution of current medical practicesis presented, including the literature reviewed. ‘Summary: A brief synopsis ofthe results of the review is given, Key Issues for Further Investigation: the authors list areas that would be important to address in future prospective trials. ‘Evidentiary Tables: important publications that con- stitute the evidence for the recommendations are d in detail. Evidence is classified as described previously, and comments are included regarding the strengths and weaknesses of specific articles, References: All references are listed. FLEXIBILITY OF PRACTICE GUIDELINES ‘The primary purpose of practice guidelines is to pro- vide physicians with the availabe, credible scientific evidence they need for the delivery of optimal patient care. Established guidelines also are used as instru- ments for quality assessment, for accreditation, and to judge appropriateness of care. For these reasons, the American Medical Association instigated a study of the legal aspects of practice guidelines.>* This study establishes that not all treatments can oF should be applied to all patients and that the law allows for variability. Practice guidelines provide a reference from which the physician considers treatment strate- gies. The physician remains accountable to establish the most appropriate treatment strategy for hisor her patient. Should the physician choose not to follow published practice guidelines because of doubts about the applicability of the guideline to a particular patient, the guideline would then not be considered “standard of are.” The terminology suggested by the AMA, and adopted by this panel, establishes level of certitude relative t0 the supporting scientific evi- dence, as reflected in the designation of standards, guidelines, or options, ‘This statement contains both good and bad news for the practicing physician. On one hand, slavish, compliance with practice guidelines is not mandated; the physician is free to choose the care which in his oF her opinion is best for the patient. On the other hand, practice guidelines in no way abrogate the physician's personal responsibility for decision-making in medi- cal practice. We hope that physicians will see practice ‘guidelines as what they are intended to be: aids for the rational practice of patient care Practice gules fir burn care: Toersdction xi PRIVACY AND CONFIDENTIALITY ISSUES RELATED TO PRACTICE GUIDELINES To beas accurate as possible, practice guidelines must be based on the best medical evidence available. This is only one example of the increased need for timely and complete data to drive the process of evidence based medicine. Clinical information must be readily available to health care providers for quality patient management. The expanding scope of information technology systems in the field of medicine has en- hanced access to patient information for payers as well as providers, raising real concerns regarding confi- ddentialty of sensitive patient information. The collec~ tion of meaningful data can happen only if both pro- viders and patients willingly participate in such a system, and this requires that the integrity of both the data and the record keeping system are guaranteed. ‘The American Health Security Act of 1993 recog- nizes thatall participants in the health care system (con- ‘sumers and patients, physicians, health plans, health al- liances, purchasers of health care, and health policy makers) need access to high-quality information for in formed decision making, At the same time, everyone must have confidence that information of a private na- ‘ture is adequately protected. Therefore, information and data systems must address the accuracy, correctness, and trustworthiness ofthe information and the privacy rights ofindividuals to control the disclosure of personal information, inctuding:*°° 1. The integrity of health care data so that infor: mation is accurate, complete, and trustworthy; 2, The availability ofhealth data so that authorized persons who need the information for legiti- rate health purposes have ready access to the datas 3. The privacy of patients so that they can be as- sured that personal information remains private and will not be disclosed without their know!- edge and permission Similar concerns have been reflected in the 1997-98 updates to the Comprehensive Accreditation ‘Manual for Hospitals, which likewise identifies crite- tia established by the Joint Accreditation Commis- sion for Health Organizations.” REFERENCES 1. dy D. Practice policies and guidelines: What are they? JAMA 1990;265877-8, 2. WoolfS. Practice guidelines: 2 new realsyin medicine. Arch Int Med 1993;183:2545-2685, 3. Grimshaw J, Russel I fect of lnc! guidlines on medical practice: systematic review of rigorous evaluations. Lancet, 1995;342:1817-22,10. n 12, 13. 4 16. 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JAMA 1999,281:1950-1, Roche N, DurieusP Clinical practice guideline rom meth ldological to practise, Inensive Care Medicine 1994 20,598-601 Brigham P, McLoughlin F. Buen incidence and medical care tse in che United States: eximates, reals, and data sources, J Baar Cace Rehabil 1996;17: 95-105, Biskmeyer),Fislsyson, Torteson A etal ect of hospital ‘volume on in-hoepital more with pancreticoduodeee- tomy, Surgery 1999:125250~6, Rees J, Dimick A. Washington buen watch wil bura center hospits survive PPS} Bara Care Rehabil 1989,9:314-5. Hendon D. Accepting the challenge. J Burn Care Rehabil 1994:15:463-9. Childs C. Ty there an evidence-based practice for burns? Bums 1998;24:29-33, v. 18. 21 23, 2s. 26. 2, Journal of Bum Care & Rehabilitation Apri 2001 Eddy D. Recommendations for guidlines: the explice a: ‘proach, JAMA 1990;263:2239 40. ‘Shaneyfle T, Mayo-Smith M, Rothwangl J. Are guidelines following guideline The methodologial quality of eine practice guidelines in the peereviewed medics! iterate. JAMA 1999;281:1900-08, ‘American Medical Assocation, Office of Quality Ineurtace ad Health Care Organizations Abutesto Guidelines De ‘lopment of Pace Parameters Chicago: American Met fea Awocttions1990, Cooper dy Doig, Sibbald W. Pulmonary arec catheters in the criti il an overview using the methodology of ev ‘dence-besed meicine. Crtcal Cae Clinies 1996:13.777- on Eady D. Designing a practice policy standards, guidelines, and opsions JAMA 1990,263:3081-4 Rosenbesg J, Gecenberg M. Practice parameters: strategies for survival ieo the nineties, Neurology 1992342:1110-15. ‘Ausbutes foe guideline development of practice paramere. Chicago: Ametian Medical Anociaton, Office of Qualy ‘Assurance and Health Cate Ozpanizatons; 1990, Johnson K, HishfeldB, Li, M. Legal implications of prac: tice parameters. Chicago: American Medical Association, 1990, Gostin 1, Tasek-Beesna J, Powers M, et al. Privacy and secuty of persnal information ina new health ace system JAMA 1998;270:2487-98. Protecting privacy of medical records. Health policy: The legislative agenda. Congressioual Quarterly 1980:137— 140, Joint Commission of Accreditation of Health Organizations. Comprehensive acceditation manu for hospitals. One brook, TL: Joint Commission of Accreditation of Health Organizations; 1997. pp. IM-1, 1M2-2.2.Chapter 1 Organization and Delivery of Burn Care RECOMMENDATIONS Standards ‘There are insufficient data to support a treatment standard for organization and delivery of burn care. Guidelines. All regions should ave an organized system of care for injured persons. Options ‘There should be an organized system of acute and long-term care for patients with buen injury. The following injuries generally require referral toa buen unie ‘+ Partial thickness burns greater than 10% total body susface area (TBSA) ‘+ Bums that involve the face, hands, feet, genita- lia, perineum, oF major joints ‘Third-degree bums in any age group Blectrical burns, including lightning injury Chemical burns Inhalation injury Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality ‘+ Bums in any patients with concomitant trauma (suchas fractures) in which the burn injury poses the greatest risk of morbidity or mortality. In such cases, ifthe trauma poses a greater imme- date risk than the burns, it may be necessary to stabilize the patient in a trauma center before being transferred to a burn unit. Physician judg- ‘ment is necessary in such situations and should be in concert with the regional medical control plan and triage protocols, ‘© Burns in children being cared for in hospitals without qualified personnel or equipment for the care of children # Burn injury in patients who will require special social, emotional, or long-term rehabilitative intervention. OVERVIEW Purpose ‘The purpose ofthis guideline i to review the history of the development of trauma and burn care systems, and to present both a rationale and a reasonable approach forthe treatment of burn patients within such systems, Users ‘This guideline is designed to aid those physicians who are responsible forthe triage and intial management of burn patients Clinical Problem ‘More than 1 million people are burned in the United States each year; approximately 40,000 require in-hos- pital care, and 5500 die as a result of their injuries. ‘Hospitals with dedicated burn care programs have dem- onstrated progressive improvement in burn care over the past several decades, This experience has led to the development of the concept of burn centers.2* PROCESS ‘A MEDLINE search from 1966 to 1998 that in- cluded only English language publications was done with key words “burn care,” “trauma system,” “pre- ventable deaths,” and “outcome.” That literature was used asa basis to assess the value of burn care systems. ‘The guidelines and options listed are derived from studies and the opinions of many experts in burn care from a variety of peer-reviewed and other articles. ‘The American College of Surgeons’ publication Op- timal Resources for Care of the Injured Patient pro- vides the basis for most recommendations regarding the organization of a burn care system as well as key criteria for definition of a burn center.” SCIENTIFIC FOUNDATION Various investigators since the late 1970s have tried to demonstrate the efficacy of trauma systems.°-° Some early studies demonstrated that preventable deaths occurred in regions without organized care. McDermott et al” established that most preventable as2S Practice guidelines for burn care: Chapter | deaths are the result ofa lack of practitioner or system amiliarty with critical procedures or situations. Coo- per et alé found that treatment of victims of motor vehicle trauma at designated trauma centers reduced preventable deaths, and Acosta et al? showed that early (within 24 hours), proper management of trauma patientsis essential in minimizing preventable deaths. Campbell et al!? demonstrated that trauma patients moved ftom trauma hospitals to general hos- pitals had longer lengths of tay. A retrospective study. of surgeon trauma volume and patient outcomes showed that there was a critical level of experience required of surgeons to achieve optimal outcomes ‘when caring for trauma patients."' Smith etal? also demonstrated that increasing experience is rellected in improved patient outcomes in trauma, Young et al’? demonstrated that direct transport from the scene to an organized trauma center, bypassing closer facilities with less trauma expertise, improved patient ‘outcome and reduced costs. large review from Ken- tucky demonstrated that injured children had higher mortality if they did not have prompt access to an organized trauma system. Significant cost savings also have been suggested for trauma patients man- aged in an organized way.® A 1975 study of motor vehicle trauma deaths suggested that survival rates for major trauma could be improved by an organized system of trauma care that includes the resources of trauma center.!® “Although most patients with severe burns are now managed in self designated or verified burn centers,!® burn care system development has lagged behind ‘trauma care system development; fewer data on out- come and cost impact of burn centers are, therefore, currently available.!” One negative study of the sig. nificance of burn center development has been pub- lished. A 1977 retrospective study by Linn et al!®-2° evaluated Florida bum patients treated at hospitals with self designated burn centers, compared to pa tients treated at hospitals without such facilities. Bum. ‘are was no more effective at burn centers than in general hospitals, and mortality rates (adjusted for burn size) were higher. The authors concluded that “The crucial question, is whether mortality and com- plications were lower in special facilities. Although there was no evidence in this survey that they were, the final answer must come from a prospective study of outcome. If these survey results are confirmed, burns might be identified as an illness for which cur” rent limits in management abilities limit the ultimate proportion of successful outcomes.” This controversial study has been criticized for sev- ‘ral shortcomings. Fist, it relied on retrospective sel reporting of bum size data, a category that is known, Journal of Burn Care & Rehabilitation ‘Apel 2001 to be dependent on observer experience. This raises the concern that inexperienced physicians may have been significantly overestimating the size of bur in- juries. Secondly, the study was performed in the early 1970s, witen early excision of burns was not widely practiced. This clearly speaks to the routine poor out- comes seen in the presurgical era of burn care, and emphasizes the enhanced outcomes that are seen ‘when serious bums receive optimal surgical care. Sur- vival of bum patients has been demonstrated to have improved dramatically since early excision and closure of deep wounds have become standard.?-? More recent data have demonstrated that its less expensive ‘to manage patients with serious burns in a burn cen- ter, and that long-term outcomes are enhanced by participation in a burn center aftercare program 2° Ideally, a randomized prospective trial could be done comparing outcome and cost of burn care in ‘general hospitals and burn centers. However, avail- able data and the weight of expert opinion hold that bburn center care is more effective and less costly. Eth- ical considerations make such studies impossible, therefore. Awealth of reliable (class land IT) data has accumulated recently, which demonstrates that the ‘outcomes of patients with a variety of complex med- ical and surgical problems are improved if they are ‘managed in ficilities and by providers with a critical volume of regular experience with such problems.** Extrapolating from experience with trauma ss tems, the American Burn Association and the Amer ican College of Surgeons have developed a verifica- tion process for bum centers patterned after the ACSCOT Trauma Center Verification Program, which has been in existence for over 20 years. From 1995 to the present, over 50 burn care facilities in the United States have been verified as Burn Centers us- ing the criteria listed in the ACSCOT Optimum Care document? In addition, cooperative, multicenter ‘outcome studies of burn patients treated at these cen- ters have already begun," and more comprehensive data should be available soon. SUMMARY Available data and weight of expert opinion support the contention that patients with serious burns will have better outcomes and be less costly to manage if they are in a dedicated burn center KEY ISSUES FOR FUTURE INVESTIGATION Development of tools for evaluating long-term out- come will be necessary to assess the true “costs” ofJournal of Bum Care & Rehabilitation ‘Table 1, Evidentiary Table: Burn care systems Practice guidlines for burm cave: Chageer 1. 38 Description class ‘Conelusion/Comaments ‘Svenson etal Statewide evaleation of 1024 TE Survival ofinjredchiléren in Kentucky was sigaificandly 1996 pediatric trauma deaths poorer if they lived in area with es acces to organized Smith etl, 1990! Revospective statistical evatuaton HE ‘of 1643 trauma patents ‘admited to low and high volome rau facies -Resrospectvessady of 16 a ‘consecutive children with serious tourns whose transfer toa buen cae fciity was delayed for 5 oF more day, compared with a ‘oncurently managed matched «control group of children said tothe bum center ‘within 24 houre of injury ‘Sheridan et 19998 ACS-COT Manual, Guidelines of tem of case for om 19997 seriou injured patients Campbell etal, Matched comparison of trauma um 1995! patents managed at Level ‘wauma faity or wansered 10 2 general hospital based a coverage pan requirements ‘Cooper etal, 1998" Eraluaton for preventable dewths TT ‘0 257 consecutive tematic fualdes in Victoria, Australia Acosta etal, 1998? Review of 900 consecutive trauma ‘IL deaths Dimick etal, 1993 Documentation of development of LIE ‘bum centers ia North Americe Kogvolinka etal, Study ofsurgeon trauma volume IIL 1995! snd patient outcomes Young etal, 1998!* Compared seiouly injured om patients taken directly to the ‘esuma center to those taken Sst to nears flit for initial sstbization 41977 review of 1222 patients m managed in Florida at el designated burn centers, ‘compared to bum patients managed in general oil ‘inn ecal, 197" Increasing experience (program case volume) predicts decreased mortality “The delayed transfer group had satisically more complications, required more time to attain wound clowur, had loaget lengths of horital stay, and had more rehabilitation dae, “Euler wansler of children with serious burs to a burn center reduced complications and shortened hospital and eubiltation day, and this reduced costs, ‘Comment: Toe apparent reason for these ndings was that the ‘window of opportunity for ealy Wound evaluation and ‘restmens by an experienced team with early excision and closire of deep bur wenunds was missed when transfer was delayed Increasing experience (program case volume) predices decreased mortality Lengths of say were extended when patients were moved 19 ‘the general hospital A auma system in Vitor, including bypas of major trauma patents to designated hospitals with 24-hour trauma services, decreases the fequency of preventable deaths. Early (within 24 5) proper management of trauma patens is ‘sendl to minimizing death ates Descption of concentration of cae foe seriously burned individuals Increasing experience (surgeon case volume) is reflected in Jmproved patient outcomes in tauma, Hospital stays were shorter and morality deceased if seriously ‘injured patients were ransfered directly to sauma center from sene of ini Pavents managed in ficities with burn centers had larger injries, and longer lengths of stay, When patients wih comparable size buras were compared, patients treated a bum units had increased morality. Authers concluded that bums might he identified sean iines for which there 0 soccesfl therapy. Therefore, burn care in general ospitals ray bea effective a that in burn centers Comment: This controversial study can be cited for several ‘shortcomings data collection was done without quality ‘control, and relied on selfeporting, which may have factated significant inaccuracies in burn ie estimation, au are from 1977, and survival statistics do noe begin 0 approach chose avalable from moder bum centers ‘ACS COT, Antica Calley of Sueocr—Commitec on Tama.AS. Pracsie guidelines fr burn care: Chapter 1 burn injury and the potential advantages of a coordi- nated system of burn treatment in improving long. term results. Studies are needed to evaluate the effect of facility and physician experience on outcomes of treatment for bur injury. The level of experience (program volume) requized to develop and maintain the capa- bility to deliver high-quality outcomes to seriously burned individuals should be defined. The specific clements of burn care systems that are most effective in optimizing outcomes should be dlearly defined. EVIDENTIARY TABLES Table 1 summarizes publications on bum care systems. REFERENCES: 1. Brigham PA, MeLoughlin E. Bum incidence and medical caceinthe United States estimates, rends, and datasources J Buin Care Rehabil 1996,17.95-107. 2. Amerian College ofSurgeons—Committe on Traum Re ‘sources of optimal care of the injured patient. Chicago: “Amercan Collegeof Surgeons; 1999. 3. Dimick AR, Brigham PA, Shechy EM, The development of bur ceatersin Nom Areriea. | Burn Care Rehabil 1993; 14:284-99, 4. Champion HIR, Teter H. Trauma care stems: the federal role see comments). J Trauma 1988,28877-9, 5. Hackey RB. The polis of tauma system development. | Traum 1995;39 1085-53. 6. Moore BE. Trauma systems, trauma centers, and trauma surgeon: opportunity ia managed competion. J Teaumd 1995,39:1-11 7. MeDermott FE, Cordnee SM, Tremayme AB, Management deficiencies and death preven'ablity in 120 Victorian oad farlites (1993-1994) ‘The Consultative Committee on ‘Road Tilfic Fatalities in Victoria, Aust NZJ Surg 1997367: outs. 8. Cooper DJ, MeDeimott FP, Cordaer $M, Tremayne AB. ‘Quulty assessment ofthe management of road tafe fal thes evel trauma center compared with other hosptalsin ‘Vitoria, Australia. Consultative Committee on Road Trafic Parle in Victoria. J Trauma 1998:45:772-99, 9. Acosta TA, Yang JC, Winchell RJ, e al. Leta injres and 20. LL. 12, 13 14. 1s. 16, 17. 18, 18. 20, 2. 22, 28 m4, 25. Journal of Bum Cate 8 Rehabilitation ‘Apil 2001 time to death in a level I trauma center. J Am Coll Surg 1998;186:828-83. Campbell AR, Vitinghoff E, Morabito D, et al. Trauma centers in a managed eare envionment.) Testa 1998, 246-51 Konwolinks CW, Copes WS, Sacco WJ Institution and per- surgeon volume versus survival outcome in. Pennsyvanis's tenuma centers. Am J Surg, 199551703330, Smith RE, Fateh L, Sloan EP, eta. The impact of volume ‘on outcome in seriou injured aura patents two years ‘experience ofthe Chieago Trsuma System (see comment) 1 Frauma 1990,30:1066-75, ‘Young 8, Bassam, Cephas GA, Brady WJ, BuverK, Pom prey M, inerhonptl versus dizect scene trans of major ‘rau pasents ina rual aura jem. Am Surg 199864 381 ‘Svenson JE, Spuslock C, Nypaver M. Factors associated with the higher tsumase death rate among rural chideen. Ann Emerg Mes 1996;27:625-32. DE, West J. Systems of trauma care, Arch Surg 1979;114455-60. Safle JR, Davi B, Willams P. Recent outcomes in the eeat= ‘ment of um inary in the United State 8 report ftom the ‘American Bum Assocation Patent Registry. | Burm Care Rehabil 1995;15219~2. Childs C15 there an evidence-based practice for buens? Burns 1998:2429-33, ‘Lina BS, Stephenson SE Je, Smith J Evaluation of burn care Jn lords. Ng] Med 1977:206:311-5, Linn BS, Seepenson SE Ir, Bergstresser PR, Smith J. Are ‘Dur units the best places to zeat burn patients? Surg Res 19772815, Lina BS, Stephenson SE Je, BergstesserP, Smith J. Dado: lags spent ela to outcomes in burn cate! Med Caze 1979 T7835—43, WolfSE, Rove JK, Desai MH, Miles JP, Barrow RE, Hers don DN. Moray determinants in massive pedi bans ‘As analysis of 103 caldren wth > or =80% TRSA bums (Cor 970% fal thickness) Ann Surg 1997:225:554~65. ‘Tompkins RG, Burke JP, Schoenfeld DA, ex al. Prompt es char excision: a weatment system conshibution ro reduced burn monly. A statstcal evaluation of burn care atthe Massachusetss General Hospital (1974-1984). Ann Surg 1986:204272-81, Sheridan Ri, Weber JM, Pets M, Lydon M, Tompkins RG Early urn cater transfer shortens the length of hospi sion and redces complications in cicen with vrous burn injures. } Burn Care Rehabil 1999:20:347-50, Stevidan RL, Hinson MM, Lisng MM, Tompkin RG, Long. teem outcome of chien surviving massive burs. JAMA, 2000;283:69~73 ‘Thiemann DR, Coresh J, Octgen WI, Pome NR. The aso cation besween hospital volume and survival after acute ‘myocardial infarction in elderly patents, Ng] Med 1999, 540:1640-8Chapter 2 Initial Assessment of the Burn Patient RECOMMENDATIONS Standards There are insufficient data to support a treatment standard for this topic. Guidelines ‘There are insufficient data to support a treatment guideline for this topic Options 1. All burn victims should be evaluated frst as tcauma patients, using the approach advised by the Advanced ‘Trauma Life Support program of the American College of Surgeons Committee on ‘Trauma. This consists of a primary and secondary survey and a definitive care phase. 2. Burn-specific components ofthe secondary sur- vey that have implications for immediate manage ment oF for transfer decisions should be sought ‘These include: approximate wound size; approximate buen depth; presence of inhalation injury; presence of circumferential burn wound components ofthe torso or extremities; volvement of face, eyes, eas, hands, genitals, of feet; determination of the presence of electrical or chemical injury; and determination of suspicion of abusive injury. 3. Percentage body surface area bum is best esti- ‘mated using the Lund-Browder chart supplemented. by the use ofthe patient's palm to represent 0.5% of their body surface area 4. The depth of the wound is best estimated ini tally by examination by experienced clinicians 5. The diagnosis of inhalation injury is supported by one or more specifi points of history (closed space exposure to hot gases, steam, or products of combus: tion); physical examination (singed vibrissae and car bonaceous sputum); bronchoscopy (carbonaceous endobronehial debris, mucosa ulceration); or abo: ratory findings (abnormal xenon of technetium sean, elevated carboxyhemoglobin or cyanide level. 6. Tetanus immunization status should be assessed and supplemented ifindicated 7. The presence of circumferential burns; involve- ment of fae, eyes, eats, hand, genitals or fet; pres- ence of electrical or chemical injury; and suspicion of abusive injury is determined by history and physical OVERVIEW Purpose ‘The purpose of this guideline is to outline a rational approach to the initial assessment of burn patients, with emphasis on key issues in both diagnosis and Users ‘This guideline is designed to aid those physicians who are responsible for the triage and initial management of buen patients, Clinical Problem ‘The initial evaluation and support of the trauma patient requires a systematic approach that has been developed by the American College of Surgeons Committee on ‘Trauma! and has been promulgated in the Advanced ‘Trauma Life Support (ATLS) course. The structure of this evaluation includes a primary survey, a secondary survey, and a definitive care and transport phase. There is substantial evidence that adherence to an organized approach to these complex patients has improved both physician response™* and trauma patient outcomes.** Burn injury often is accompanied by nonthermal trau- ‘ma; burn patients should be evaluated initially following ATLS protocols. Several unique clements of the inital evaluation of burn patients may affect early management or transfer decisions. These elements should be sought and acted upon during the secondary survey. They include es- timation of wound size; estimation of buen depth; determination of the possibility of inhalation injury; determination of circumferential burn wound com” ponents of the torso or extremities; documentation of involvement of face, eyes, ears, hands, genitals, oF feet; determination of the presence of electrical or chemical injury; tetanus immune status; and determi: nation of suspicion of abusive injury. These important points of information have an impact on immediate patient management or transfer decisions, or both. 5868. Practice guidelines fr burn care Chapter 2 Journal of Burn Care & Rehabilitation ‘Apel 2001, [ACD K.Towbin, venison, vaca enon adore wanton, Fay ‘Ban ipa sop Say t Bains aso a Brae da pam 03 Wn woe East Soph oom eal sano foam q Baa Hide Be Chag 61 enema Yee Denia ome oem) |} _{ "See Gir ov alin we Yes (Deis sent ofcbeumtaratabar Bee Che Tom acy re Yes ialonioe of pects avons aa eat We Eealaon rope BS loci aba dip, oan eben wo Daksa whee ary wabaae ve Yeu Nai opera Figure 1, Algorithm Initial assessment of bum injury PROCESS A Mailine search of the categories “traumatic injury diagnosis,” “burn injury diagnoses,” and “assess- ment” was conducted for the years 1968-1998. All English-language publications were reviewed. The following keywords were used to perform the litera- ture search: “trauma injury assessment,” “burn injury assessment,” “body surface atea measurement,” “depth of bum injury,” “inhalation injury,” and “air- way burn.” Only articles discussing the assessment of traumatic injury, assessment of bur injury, estimate of the percentage body surface area burned, and es- timate of burn depth were referenced in the eviden- tiary tablesand used asthe source forthe conclusions. ‘The methodology, results, and conclusions of each of these references were studied, ‘SCIENTIFIC FOUNDATION ‘Adherence to an organized approach to seriously in- jured. patients has improved trauma patient out- comes.* Burns are traumatic injuries, and a similar organized approaci is likely to be beneficial. Burn- specific elements ofthe secondary survey include es- timation of wound size; estimation of burn depth; determination of the possibility of inhalation injury; determination of circumferential burn wound com- ponents ofthe torso or extremities; documentation of involvement of fice, eyes, ears, hand, genitals of fect; determination of the presence of electrical or chemi cal injury; and determination of suspicion of abusive injury. These points of information help determine immediate patient management, transfer decisions, ‘or both.Journal of Bure Cae & Rehabilitation ‘Table 1. Evidentiary Table: Initial assessment of burn injury Practice guidelines for burn care: Chapter 2. 7 Conctasion Reference Description of Study __Data Class Jabboureeal 1996" Analy of iererare 1 West etal, 1979 Retrowectve stay of role of 1 ‘aura gsters Ryan etal, 19987 —-Rewospective study ofthe 1 determinants of death rom burs Saffe etal, 1995" Resospectve arasis of che causes ‘of dest in burn victims A review and collation of preceding work to determine tual body surfice area and relative percent ofindivdual exes ‘Measurement ofthe body surice a Lund and Browder, 1944? a DuBois and Dubois, 0 1916" rain adult humans using planimetry ‘Sheridan etal, Anatomic etude 1 1995 Hieimbach etl, Comparison of lineal wound. W 1992 depth exit with imaging techniques Maranes ctl, Prospective controled study of 1 1994 clinical rte and ‘aroachoscopy in diagnosis of Inlation ines ‘Concladed that adherence to ATES protocols has decreased trauma patient moral. Demonstrated the efécr of trauma systems on preventable srsume-related mortal Showed the prime determinants of death from bums 0 be age 60 y, BSA burned > 40%, and inhalation injury. ‘Show the most important fatorsin survivorship to be age, percent body sufice bumed, and inhalation injuy. “Esblished tables of BSA, size, and percent of the whole that account for growth and development. Results bated on measurement of surfice ofS humans. Not vali sample; tables developed, Demonstrates thatthe human palm is 0.5% of the body surice Demonstrated use offimaging device to achieve estimate of ‘wound depth, Results similar to clinical evaluation by experienced ciniins ‘Showed tha bronchoscopy and bronchi biopsy are the most accurate meuns of diagnosing infalation ijury. ‘The physician should be able to estimate percent- age body surface area burn in a reliable manner. Burn size is a prime determinant of survival of bum injury,’# is essential in determination of inital resus citation infusion rates (sce fluid resuscitation guide- line), and is an important component of transfer decisions. Currently, the preferred tool is the Lund- Browder chart, which is based on human anatomic studies relating the proportion ofa specific body area to the body as a whole.” The Lund-Browder chart should be used to determine percentage body surface area of the burn wound. If there are irregular or seat- tered burn components, the chart can be supple- mented by using the palm of the patient’s hand to estimate 0.5% of the body surface.!4 The “rile, of nines,” developed by Pulaski and ‘Tennison’2* based on work by DuBois and DuBois,}° has been ‘widely taught, but is less accurate than the Lund: Browder diagram, which should be used preferentially. Although not generally essential to immediate ‘management, burn depth is an important element, of transfer decisions. The most accurate tool avail- able is inspection of the wound by an experienced physician. A number of studies have reported the use of various technologic aids in the determina- tion of wound depth, but none of them has been demonstrated to allow definition of the depth of the wound any sooner or with more sensitivity then clinical evaluation by an experienced physician. Burns are potentially tetanus-prone wounds, so tet- anus immune status should be obtained and pa- tients appropriately treated if immunization status, is unknown or inadequate. ‘The presence of inhalation injury impacts both im- ‘mediate airway management and transfer decisions. ‘The diagnosis of inhalation injury (see guideline on diagnosis of inhalation injury) is supported by one or more specific points of history (closed space exposure tohotgases, steam or products of combustion); phys- ical examination (singed vibrissae and carbonaceous sputum); bronchoscopy (carbonaceous endobron- chial debris, mucosal ulceration); or laboratory find- ings (abnormal xenon or technetium scan, elevated carboxyhemoglobin or cyanide level). Circumferential bums require specific monitoring. and, often, decompression during the initial evalua- tion (see escharotomy guideline) and may impact transfer decisions, These should be specifically sought and documented during the initial evaluation. In-BS Practice guidelines for bur car: Chapter 2 volvement of face, eyes, cars, hand, genitals or feet; presence of electrical or chemical injury; and suspi- ion of abusive injury may impactimmediate manage- ‘ment and transfer decisions and is obtained by phys- ical examination, SUMMARY All burn victims should be evaluated first as trauma patients, using the approach advised by the Advanced ‘Trauma Life Support program of the American Col- lege of Surgeons Committee on Trauma. Burn-spe- cific components of the secondary survey that have implications for immediate management or for trans- fer decisions should be sought. These include approx- mate wound size; approximate burn depth; presence of inhalation injury; presence of circumferential burn, wound components of the torso or extremities; in- volvement of fice, eyes, cars, hand, genitals of feet; determination of the presence of electrical or chemi cal injury; status of tetanus immunization; and deter- mination of suspicion of abusive injury. Figure 1 pre- sents an algorithm for initial assessment of the burn patient, KEY ISSUES FOR FUTURE INVESTIGATION Accurate ways of determining burn size and bum depth that are independent of examiner experience are ripe areas for investigation. As important as this, information is, objective methods of deriving the in- formation are very limited. With the exception of pal- mar surface area,!? bum sizing schemes have not be verified in large numbers of patients,” and chis work should be undertaken. Early estimation fbr depth also remains largely subjective. Light reflectance,!*"” helium neon laser Doppler flowmeters,}® thermographic assessment!” temperature measurement,*°* high-resolution ul- trasound,™* intravenously administered fluorescein dye with ultraviolet excitation,”** nonfluorescent intravenous dyes,?* bum wound biopsy,?* nuclear magnetic resonance,?”* and fluorescence of intrave- nously administered indocyanine green dye’? have all been explored. However, at present, the eye of an ‘experienced examiner remains the standard of burn depth evaluation, EVIDENTIARY TABLE. Initial assessment of bur injury is presented in Ta- ble 1 Journal of Burn Caze & Rehabilitation ‘pil 2001, REFERENCES 1 10. un. n. 13, M4 1s, 18. 18. American Collegeof Surgeons-Committee om Trauma. Re- Sources for optimal cae ofthe injured Patient. Chicago: American Collegeof Surgeons, 1993. ‘Al'J, Cohen 3, Gans Ty, AFBedah KE. Ecc ofthe Ad ‘anced Trauma Efe Suppor program on media student performance in simulated trauma patent management TTrauma 1998;44:588-91. Wiliams MJ, Lockey AS, Culshaw MC. Improved trauma management with advanced trauma Lie suppore (ATLS) teining. J Acc Fmerg Med 1997;14-81-3, Ali J, Adare, Stedman M, Howard M, Willams Jl. Ad ‘vanced Trauma Life Support program increases emergency ‘room application of wauima renscttive procedures in de veloping count. J Trauma 1994;36:391—4. Jabbour M, Osmond ME, Kiasen TP. Life suppoet counes: are hey eflerive? Ann Emerg Med 1996;28:690-8, West JG, Trunkey DD, Tim RC. Systems of trauma care. A seady of two counties. Arch Surg, 19793114:485~60. ‘yan CM, Schoenfeld DA, Thorpe WP, Shesidan RL, Ca sem EH, Tompkins RG. Objective esimates ofthe probabil Jgy of death ffom bur ijusies. N Engl J Med 1998338: 1362-6, Safle FR, Davis B, Willams P. Recent outcomes inthe teat- ‘ment of bum injy in the United States a repor fom the ‘American Burn Assocston Patient Registry) Bun Care Rehabil 1995;16:219-32, Lund , Browder N. The estimation ofareas of burns. Sng {Gynecol Obstet 1944;79:282-8, DuBois, DuBoisE. A formula o estimate the approximate ‘surficeareaifheightand weight be known. Arch Inte Med 191631786371, ‘Sheridan RL, Petras L, Basha Geta. Panimetey smdy of te percent of body surice represeaed by the hand and palm Szingiegular burns is more accurately done with te pa, J Burn Care Rehabi! 1995;16:05-6. Knaysi GA, Crkelair GE, Cosman B, The rue of nines: is history and accuracy. Past Recoast Surg 1968;41:560-3. Berkow 5. A method of esimating the extensiveness of le- sons (bums and scald) based on suefice area proportions ‘Arch Surg 1924;8:138-48. Heeimbach D, Engrav L, Grube B, Marvin J. Burn depth: a eview. World J Surg 1992;16:10°5, ‘Anselmo VI, Zawacli BE, Multipectral photographic an ‘is A new quantitative tool to asst nthe early dsc of ‘thermal bum depth. Ann Biomed Eng 19775-17993, Alromowitz MA, Vas Liew GS, Hembsch DM. Clinal ‘valuation of bur injuries using an optical relectance teh nique. IEEE Trans Biomed Eng 1987;34:1 14-27. Afromowitz MA, Calls JB, Heimbach DM, DeSoto LA, Norton MK. Mulispecua! imaging of bn wounds a 200 lic instrument for evaluating burs depth, TEEE ‘Tans ‘Biomed Eng 1988;35:842-50. Green M, Holloway GA, Heimbach DM, Laser Dopoer monitoring of mictociculatory changes in acute Burn ‘wounds. J firm Cate Rehabil 1988;9:57-62, Cole RP, Skespeare PG, Chissell HG, Jones SG. Thermo- graphic asessment of bums using a oapermesble mem- brane as wound covering. Buens 199117:117-22 ‘Wylie J, Sutherland AB. Measurement of surfce tempera- ‘ure a5 an ad to che lagnoss of bur depth. Burns 1991; vas? Cole RP, Jones SG, Shakespeare PG. Thermographic asses sent of and burs. Burns 1990516:60-3, ‘Wachtel TL, Leopold GR Prank HA, Frank DE. Baie ultrasonic echo determination of depth of thecal injury ‘Burns, Including Theemal Injury 1986:12:432-7, Gat JE, LaRosa D, Silverman DG, Hartford CP. Evalua tion of the burs wound with perfusion Muoromety J Trauma 1983,28:202-6. ‘Black KS, Hewitt CW, Miler DM, et Burn depth evalua:Journal of Burn Care & Rehabilitation tion with fuoromety i it cell deine? J Bum Cae Rehabil 1986,7:313-7 25, Zawacki BE, Waller HL. An evaluation of patent blue V, bromphenol blue, and tetrcyline forthe diagnosis of burn depth, Plst Reconstr Surg 197015:459-65, 26. Clap M, Speer DP, Owea JA, Chvapl TA. Mensfiation fof che depth of bora injury by colagen stainabliy. Pas ‘Reconst Surg 1984:78:438—4. 27. Korads MJ, Zimbler A, Sete RG, et al. Assessing bum ‘wound depth using in vitro naclear magnetic resonance (NMR).J Surg Res 1986,10:475-81 28. 2. 30, Practice guidelines fir burn care: Chapser 2. 9S. ‘Schwelaer MP, Olsen JI, Selby J, etal Noninvasive ases- ment of metabolism ia wounded shin by 31P-NMR in vo, Trams 1992;33:828 34 Shesidan RL Schomaker KT, Lucehina LC, etal. Bur depth timation by use of indocyanine geen fluorescence: inal Raman tal] Burn Care Rehabil 1995;16:602—4 Matanes MY, Legendre C, Liorex N, Maillard D, Ssixy R, Lebess B, Fiberoptic bronchoscopy for the early diagnosis of subglotal inhalation injury: comparative value inthe assessment of prognosis. Trauma 1994;36:59— 6Chapter 3 Outpatient Management of Burn Patients RECOMMENDATIONS Standards ‘There are insuificient data to support a treatment standard for outpatient bum care, Guidelines ‘The routine administration of prophylactic antibior- ics does not protect against cellulitis or sepsis in the burn wound, and their use is not recommended. Options ‘Outpatient Care, Patients should be considered for outpatient care only ifthe following consider- ations have been addressed: *# Intravenous fluid resuscitation is completed or not necessary. + The patientis able o maintain uid balance with oral intake + Facilities for wound care on an outpatient basis are adequate. + Facilites for physical therapy on an outpatient basis are adequate. ‘+ Pain control is adequate using oral medications. + Family support and follow-up are arranged, and any abuse or neglectissues have been addressed + Follow-up is arranged at a facility with appropri- ate burn expertise for continued evaluation and treatment of infection, function, wound care, and scarring (see Chapter 1, Organization and Delivery). Wound Care. Ice should not be used in direct contact with burn wounds. Cooling of burn wounds bby any meansis effective only when performed within the first 2 minutes of injury, and should not be con: timed longer than 20-30 minutes Wound management should include gentle and periodic cleansing of the burn. Treatment of blisters ay be individualized by the management team. ‘There is no evidence that use of topical antimiero- bial agents in the inital management of minor burns reduces the incidence of'infection. los OVERVIEW Purpose. ‘The purpose of this guideline is to outline a rational and reasonable approach for the treatment of burn patients as outpatients within burn care systems. Users This guideline is designed to aid those physicians who are responsible for the triage and initial management of bum patients. Clinical Problem According to statistics from the national Center for Health Statistics,’ 1.25 million burn injuries occur annually in the United States. It is conservatively es- ‘timated that 90% of these injuries do not require hos- pitalization, Even those patients who do require in- patient treatment are eventually considered for ‘outpatient care, as they recover fom their injuries. Outpatient management of the burn patient is a re sponsibility of the burn team. PROCESS A Medline search of the English-language literature from 1966 to 1998 was performed, using the key- words “minor burns,” “ambulatory burns,” “occupa- tional bums,” “scald burns,” “contact burns,” “lec~ trical burns,” and “chemical burns.” This produced 116 results. Of these, 11 articles were found to be relevant to the evaluation and management of the bum patient in an outpatient environment, Each of the references was reviewed individually for study de: sign and relevance. References are incorporated into the analysis provided in this report. Selected other references were also used. SCIENTIFIC FOUNDATION Evaluation and Eligibility There are no available randomized trials addressing valuation and patient eligibility for outpatient burn management. The medical criteria for outpatient care include absence of complications of thermal injuries,Journal of Bum Care & Rebubltaion inhalation injury or associated trauma; successful, fluid resuscitation; a stable hospital course; adequate nutritional intake; appropriate pain management; and. absence ofinfection. Family participation and willing- ness to participate in patient care, including dressing, changes, range of motion exercises, and the ability to transpor the paientfor outpatient appointments and ‘occupational therapy, is essential ‘Several authors have provided prospective evidence of the effectiveness of outpatient management of ‘burn patients, Patients with moderate and major in- juries have been successfully managed as outpatients after a brief period of hospital stabilization for fluid resuscitation, airway evaluation, and pain manage- ‘ment. Successful ambulatory care depends on the clinical judgment of the medical team at the point of first encounter, using the criteria for referral estab- lished by the American Burn Association (see Chapter 1). The outpatient management of burn injuries has resulted in a decreased length of hospital stay and a reduction in cost of care while maintaining optimal evaluation and management of the burn wound.?*® MANAGEMENT OPTIONS FOR OUTPATIENT BURN CARE. ‘There are numerous retrospective reports covering, the subjects of wound management, cooling, topical antimicrobial therapy, and management of blisters. Cooling Effects Application of ice is contraindicated and may com: pound the thermal injury by the effect of frostbite.” Some evidence supports indirect cooling, which acts by decreasing capillary permeability and peripheral edema, To be effective, cold treatment must be ap- plied and continued through the first 30 minutes post-burn, but no longer. Initial Wound Care Direct mechanical cleansing is accomplished by gently washing the burn with a sponge or soft fabric. ‘This is an effective way to remove bacteria and par- ticulate matter from the burn wound."® Blisters Currently there is no strong evidence supporting a specific protocol for management of blisters. Individ- ualization by the management team regarding exci- sion or retention of blisters is warranted.” Wound Dressings ‘The act of covering a wound should mimic the barrier function of the epithelium. Occlusion reflects the rel~ Pracsce guidlines fir burn care: Chapter 3. 1S. ative ability ofa wound dressing to transmit gases and ‘water vapor from a wound surface to the atmosphere. An occlusive dressing should be simple in appli tion—its conformity to body contours encourages ambulation and patient comfort. As Nance et al! observe, “Cosmetically, the well-dressed and odorless ‘wound provides comfore and confidence to a patient and to the health care team.” Topical Antimicrobial Therapy ‘One Class III prospective study of 145 patients with partial-thickness burns treated in an outpatient envi- ronment was conducted to evaluate methods of man- agement ofthe burn wound. Authors concluded that there is no significant difference in overall wound healing rates between non-antibacterial and antibac- terial-impregnated dressings.! ‘Heinrich et al’? conducted a retrospective Class IT study involving 262 patients with partial-thickness bums treated with either a petrolatum fine-mesh gauze, a topical penetrating antibacterial agent, or a topical non-penetrating antibacterial agent, ‘They concluded that infection is uncommon in patients: ‘with limited, partial-thickness burns managed in an outpatient setting. The infection rate was not influ- enced by the use of topical penetrating antibacterial agents, or by a topical non-penetrating antibacterial agent when compared with fine-mesh gauze. Prophylactic Antibiotic Therapy ‘The role of prophylactic antibiotics in the prevention ofwound sepsis was investigated ina Class II prospec tive study in 51 adult patients with burns of 1% t091% ‘TBSA. Authors concluded that the routine adminis- tration of prophylactic penicillin does not protect against cellulitis or burn wound sepsis.!* Follow-Up Burn Care ‘The burn center hospital must include rehabilitation in both the inpatient and outpatient management of all patients, Follow-up care at discharge is developed. to include physical function, neurologic status, buen, scarring, and potential functional impairment. Assur- ance of patient safety, and evaluation of potential abuse /neglect injuries, isan important component of this process. ISSUES FOR FURTHER INVESTIGATION Selective randomized studies are indicated for the management of all aspects of burn wound care. Spe cific issues that should be addressed include the role of topical antimicrobials and the management of bis2S Practice guidelines for burn car: Chapter 3 Journal of Burn Care & Rehabiltstion ‘Apai 2001 ‘Table 1. Evidentiary Table: Outpatient burn management Reference Description of Study Data Clas ‘Constasion/Commeats Brigham & Reospective review to idenofy dhe “THT There hasbeen significant decline in burn incidence on an McLoughlin, Incidence and ulization of burn smal basis and in morality and morbid. 19964 ‘are in the United Seats, (Comment Based on sass fom the National Cente: for Health Statistics Warden etl, Retrospective snady analyzing the TIT Patients with moderate and even major injusies can be 1987* ‘management of patients wested, in successfily managed as outpztiens provided that they meet the oupatient setting medical criteria and thatthe fly participates inthe eae of the patient. smsnen!: Criteria focus on cardiovascular and pulmonary stably pain conto, and family suppor. Fichandler etl, Clic eview ofthe guidelines for —‘TIT_—_Succesfl ambulatory cre depends on clinical judgment, 1974° management of ambulatory barn ‘denying those individuals who do not qualify for ce ‘outpatient care ‘Comment: The single mostimportnt decision in the ‘management ofl brnsis whether hospitalization oF ‘vspatient cae i indicated, Hartford, 19977 Review ofthe principles ofoutpatient IT_—The advantages of outpatient bum management are: reduction burn management Jn cost, redaction in exposure to ansbioticresistantbactea, and a exly resin to home environment. Comsmont: Burs rypically esl in an injury with low meaty, and most patents cn be teated in an outpatient setting. unter and Chang, Randomized prospective rudy of 80 TL_——_There sno significant diffrence in overall wound healing in 1976" ‘outpatients treated with either patent treated with non-antbacteral wy antibacterial: suibiotcmpeegnated gauze impregnated dresings. dressings or pewlatum mesh gauze without abiotic Demling etal, Study ofthe ect of cold treatment ‘THC exposure immediately folowing burn reduces edema, If 1979" ‘on the degree of wound edema cold exposure is delayed beyond 2 minutes ther is no ‘allowing thermal injury significant reduction in edema. Comment: cold treatment beyond 30 minutes is of no value. Wiseman etal, Review ofthe principles of wound TIL The principle Rinetion of wound dressing isto provide an 1992" desings and avaliable desing ‘optimal healing milieu. The wound must be protected from materi, ‘infection and forther damage. Nance et, Prospective study of 145 patients with T_—There sno significant diference in overall wound healing rates 1972 parl-thickes bums rated on 28 ‘benween nomantlacteval and anubacteria-impregnated ‘outptient basis, to evaluate the resings courputient management ofthe burn ‘wound Heeincch etal, Review of 262 patients with pari TL The infection rates low in patents with small partis thickness, 1988" ‘hickness burns treated wich ‘burns and isnot infuenced by the use of eopical anubactrsl potoatum fine-mesh gauze, agents. topical penetrating antibacterial agent, ora topical nonpenetrating anibscteal agent Durchictal, Prospective study of I adult patients T_——The routine administration of prophylactic peiclin does not 1982" vith burns of 1 091% THSA to rocect against clits or barn wound sep determine the ecacy of ‘prophylactic penicilisin the prevendon of wound cll and sepsis Leman, 1994 Review ofthe role of discharge TIT Follow-up care of buen patient i essential; parculr focus planing and follow-up burn care ‘on sehabltaton in the outpatient sting is essential for Incorporating rehabilitation inthe ‘woud and scar management, preservation of strength, and ‘tpatient setting forthe formeriy restoration of function, hospitalized patientJournal of Burm Cate & Rehabittation ters. Outpatient studies are necessary to clarify and justify the role of specialized burn care facilities in the care of this patient population. SUMMARY Outpatient care isthe primary mode of treatment for the vast majority of burn patients, and an important modality in the treatment of all bun patients. At present, although itis known that a systematic team approach to outpatient care of burn patients is justi- fied, far too litte is known about the best way to treat minor wounds. EVIDENTIARY TABLE ‘Table 1 lists important research on this topic. REFERENCES 1. Brigham PA, McLoughlin E, Bor incidence and medial care use in the United Sites: ertimates, tenis, and data Sources, j Burn Cate Rehabil 1996317:95-107, 2. Gillespie 8. The impact ofthe curcent health care sete on bum patent management, In Te Future of Burn Cate [ABA Postgraduate Coane, Unpbised dita, 1998 3, Nance FC, Lewis VL, eta. Aggressive outpatient care of booms. J Trauma 1973,12:144~7, 10. aL 12, 13. Ms Practice guidelines for burn cave: Chapter 3. 138, Warden GC, Kravite M, Schnebly A. The outpatient man- agement of moderate and major thermal injuries. J Burn Care Rebabi 198132515961, ‘Wardea GD. Outpatient management of thermal juss. In: ‘Borwick JA (ed) The at and science of arn care. Ann A ‘bor, MI: Aspen Publication; 1987, pp 45-81 Fichandler BO, Neinnch JJ, Robson MD. Outpatient man: agement of butns. PA Journal, Fall 1974:30-23, Harford CD. Care of outpatient bums. Ins Herndon DN (a), Total brn care, Philadelphia: WB Saunders; 1997. pp 71-80. Hunter GR, Chang FC. Outpatient buns, A prospective study, J Trauma 197616:191-5, Demling RH, Mazess RB, Woldberg W. The eet ofimme- clte and delyed cold imierson on bum edema formation and reworption, j Trauma 1979419:86~61 ‘Wiseman DM, Pharm, Rovee DT, etal. Wound dressings: design and use Ins Cohen IK, Degelmana RE, Lindblad W) (cds). Wound healing: biochemical and clinical aspects, Dhilaelphis: WB Sauders, 1992. pp 562-80. ‘Nance FC, Lewis VL Jr, Hines JL, Barnett DP, O'Neil JA, Aggrenive outpatient care of bums. J Trauma 1972512: Me. Heinrich J} iend DA, Cuona CR. The role of topical teat- ment as a determinant of infection in outpatient burns Bum Care Retail 1988;9:258-7, Dursehi MB, Organ C, Counts GW, Heimbsch DM. A prospective sty of propiylactcpeniiin in ately burned Dhosptaized patents. Tuma 1982)22:11-14. Leman D], RichsN. Discharge planning and foliow-p burn care. In: Richard RL, Staley J) (eds). Burn care and fchabiltation: principles and practice, Philadephia: 1994, ppai7-72,Chapter 4 Initial Management of Carbon Monoxide and Cyanide Exposure RECOMMENDATIONS Standards There are insufficient data to support a treatment standard for the initial management of carbon mon- oxide and cyanide exposure. Guidelines There are insufficient data to support a treatment guideline for the initial management of carbon mon- oxide and cyanide exposure. Options ‘The first line of treatment for those with suspected serious carbon monoxide exposuce of cyanide poi soningis standard frst aid measures, including airway ‘management and 100% normobaric oxygen. Hyperbaric oxygen treatment should not be con- sidered except in those burn patients with docu- mented orstrongly suspected serious exposure to car- bon monoxide (carboxyhemoglobin level greater than 25% with depressed mental status suspected sec- ondary to carbon monoxide exposure) who are he- ‘modynamicallystabie,not requiring an ongoing burn resuscitation; are not wheezing or air trappings and in whom such treatment does not require interiaiity transport inconsistent with good general burn treatment ‘There are no data to support routine treatment for cyanide exposure in patients with inhalation injury unless persistent acidosis is associated with a docu- mented elevated cyanide level OVERVIEW Purpose The purpose of this guideline is to review the princi- ples of initial diagnosis and treatment of carbon mon- oxide and cyanide poisoning, Users This guideline is designed to aid those physicians who are responsible forthe triage and initial management of burn patients 14s Clinical Problem Carbon monoxide (CO) often is inhaled by those suffering inhalation injury.’ Cyanide is another product of incomplete combustion sometimes in- haled by house fire victims. At high concentration, carbon monoxide interferes with oxygen delivery; both carbon monoxide and cyanide can compromise oxygen utilization, Although the first line of treat- ment for those with suspected serious carbon mon- oxide exposure or cyanide poisoning is standard fist sid measures, including airway management and 100% normobaric oxygen, hyperbaric oxygen treat ments commonly are proposed. However, use of this treatment modality in the critically injured patient may involve substantial risks associated with transport and monitoring that outweigh any possible benefit ‘This guideline is an effort to provide reasonable di rection to those faced with treatment decisions in buen patients with concomitant severe carbon mon- oxide poisoning, PROCESS A Medline search was conducted of all available En- slish-Language literature from 1966 to 1998, using, the key words “carbon monoxide,” “carbon monox- ide poisoning,” “cyanide,” “cyanide poisoning,” “hy- perbaric oxygenation,” “hyperbaric oxygen treatment,” bums,” “inhalation,” “smoke inhalation injury,” and “inhalation injury.” There were 148 relevant papers in English and involving human subjects. References were classified as Level I evidence (large randomized trials), Level II evidence (small randomized trials), Level IIL evidence (nonrandomized controls or case series), OF technology assessment (TA), according to the outline contained in the Introduction SCIENTIFIC FOUNDATION Hyperbaric Oxygen Treatment for Burn Wounds In an animal model* and in clinical series of radio: therapy-associated wounds * hyperbaric oxygen 6sJournal of Bum Cate & Rehabiltason treatments have been demonstrated to enhance an- giogenesis and wound healing. However, these data cannot be extrapolated to burns that are not hypoxic itradiated wounds. Despite limited clinical series sug- gesting benefit from hyperbaric oxygen treatment of burn wounds,”"° the only prospective randomized tial designed to evaluate this claim showed no ben- fit. In this study of 125 acutely burned patients, ‘twice-daily treatment with hyperbaric oxygen for 2 minimum of 10 treatments was not beneficial when compared to no hyperbaric treatments." Hyperbaric Oxygen Treatment for Carbon Monoxide Poisoning Carbon monoxide is commonly inhaled by persons burned in structural fires. Carbon monoxide binds avidly to hemogiobin'? and other iron-containing enzymes, such as intramitochondrial cytochromes, and at high concentrations can interfere with the de- livery and utilization of oxygen. It is generally as- sumed that CO does not itself cause parenchymal Jung injury,** although there are data in animals sug- gesting that it may increase alveolar-capillary perme- ability." Unfortunately, existing data on the man- agement of carbon monoxide poisoning involve patients without surface burns. The only markers of ‘CO exposure are clinical examination, which is non- specifi, and elevation of serum carboxyhemoglobin, percentage, the halF-lif of which is sharply reduced. from approximately 2.5 hours to approximately 40, minutes by breathing 100% oxygen. The principal physiologic result of CO binding to hemoglobin is. decreased oxygen delivery, much like isovolemic he- modilution. The physiologic consequences of CO binding to intramitochondrial cytochromes are less clear, but it is likely to result in impaired oxygen uti- lization. The halflife of this combination is not known, although CO binds more avidly to hemoglo- bin than to these enzymes. Persons suffering signifi cant CO exposure are atrisk of developing both acute and delayed neurologic sequelae, ‘The pathophysiol- ‘ogy of these changes is not known, but serial mag- netic resonance imaging studies suggest a potentially, reversible demyelinating process.*® Data supporting the use of hyperbaric oxygen to prevent and treat these complications are not strong,” but, given the serious nature of these sequelae, cannot be com- pletely discounted. Children and pregnant women and their fetuses are feltto be at increased risk because of their higher metabolicrates,!*" although this too, is contested. ‘The important practical question is whether hyper~ baric treatments will decrease the frequency and se~ Practice guidlines for burn cove: Chaprer 4 15S verity of delayed neurologic sequelae in burn patients ‘with concomitant carbon monoxide poisoning. An- swering this question is problematic from two per- spectives: the unknown incidence of delayed se- uelae, and the difficulty judging the severity of an individual exposure. The incidence of delayed se- quelac (headaches, iritability, personality changes, confusion, loss of memory, and gross motor deficits} is believed to be approximately 10% in persons with serious exposures.”**" Symptoms typically develop within 3 weeks, with amean ofabout 6 days?5*° after the intial, exposure, and a symptom-free interval i 127 When delayed sequelae occur, delayed hyperbaric treatment has been reported to relieve the symptoms.”°*° Spontaneous resolution of the symp toms can be expected in up to 75% of patients within 1 year without hyperbaric oxygen.2?"? The severity ‘fan individual exposure often is difficult to ascertain, because there isa poor correlation of serum carboxy” hemoglobin with severity of exposure.** Neuropsy chiatric testing has been proposed asa more accurate way to determine this,** but these examinations are routinely compromised in burn patients secondary to alcohol and other drugs, pain medications, and he- modynamic instability. Many authors feel that a his- tory of unconsciousness indicates that an exposure has been severe enough to warrant treatment.*¥*!*8 However, other factors, including hypoxia, drugs, alcohol, trauma, and shock, rather than’ carbon monoxide poisoning may ‘be the etiology of “unconsciousness. ‘What constitutes proper treatment of significant exposures is also controversial; options are normo- batic or various depths and durations of hyperbaric 100% oxygen. One randomized prospective study de- scribed a 23% incidence of delayed neuropsychiatric symptoms (discernible by special testing) in 30 pa tients with relatively mild carbon monoxide poison- ing treated with 100% oxygen, whereas there were no such symptoms in 30 similarly injured patients who were treated with hyperbaric oxygen Using more overt symptoms as an endpoint, the value of hyper- baric oxygen in the treatment of acute carbon mon- oxide intoxication was examined in a group of 629 adults. In those without initial impairment of eon- sciousness there was no difference between outcomes ‘with 6 hours of normobaric 100% oxygen and 2 hours of hyperbaric oxygen (2 atmospheres). In those with impairment of consciousness, there was no difference in outcome between those treated with one session and those treated with two sessions of hyperbaric ox- yygen at2 atmospheres.*® A recent single-center, pro- spective trial comparing 3 to 6 days of normobarie high-flow oxygen with 3 co 6 days of normobaricLOS Pracsice guidelines fr burn care: Chapter 4 Journal of Bura Care 8 Rehabiltsson ‘Apa 2001 ‘Table 1. Evidentiary Table: Management of carbon monoxide poisoning Reference Description of Study __Data Class ‘Conclusion /Comments Bramen etal, Randomized study of hyperbaric TI Nobenefit of HBO testment on wound healing vor ‘eeatment of burn woundsin Comment Treatment arm consisted of twice-daily treatments 125 pasents {or 2 minimum of 10 weatmenss. This seems adequate to have demonstrated any eff. Silverman etal, Prospective evaluation of 144 HII Clinically important cyanide poisoning s common in thove with i988"? tients; 12 of 14 wit high serious CO exposires. syaide levels died despite (Comments 1s 20t cleat that cyanide was che lethal event, given sublethal carboryhemoglohin ‘the wansient nrureofcarboxyhemoglobin elevations levels Baril et, Review of cyanide and TIT Clinically important cyanide poisoning it not common in those 19948" ‘arboxyhemoglobin levels in 438 with serious CO exposues fire feaiies Comment: Those who died wich lethal levels of eyanie also had creme high loves ofearboryemaglobin, Raphael etal, _-‘Twoarmyrandomized prospective —‘T_——=-Nocoutcome difecence in either arm ofthe study: 1989 aloe (1) in those without LOC, normobarc versus hypesbatic (1) normobric versus byperbaric therapy (2 atmospheres) oxygen in those (2) in those with LOC, one verus two bypesbarie treatments with no los of consciousness ‘Comments There was no weatmnent am cat compared 1008 (Loc) ‘oxygen at sea level to hyperbaric oxygen in unconscious (2) one vers nwo sessions of patiens HBO in hose with LOC Weaver etal, (Case series of patients with TIT Recovery without hyperbaric therapy i possible in selected 1996" serious CO poisoning who patients recovered without hyperbaric Comment Tiss very small lineal series, but shows that a serpy least some patent an recover Withoue hyperbari Oxygen therapy. ‘Thom etl, 1995% Randomized prospective study of «‘T—=—_“Higher incidence of delayed neurologic symptoms discernible 60 non burn pens with moderate CO exposures Prospective tial F191 paienrs a ‘exposed to CO eandomly assigned ro 3-6 daye of rormobaci high-flow oxygen of 3-6 days of noemobaric high flow axygen pls dally HBO tucaments a 2.8 atmorphres Retrospective review of inca or ‘experience with HIBO-related ‘ueumment complications in 297 _non-bu patient Scheinkestel et, 19997" Sloan eral, 1989" ‘by neuropsychitrie testing in nonbyperbacie group [HBO srestment did not improve outcome over prolonged. high-low oxygen Conaent Seay ercized for odd randomization scheme, inclusion of large sumbers of patients weih mild exposures, and casifcaon a severe patients who would not be s0 lasted elsewhere. Howver, hiss a randomized study Complication ste of ess than 5% ‘Cominont Teason preumothorax occured in 3 patient, arhon monoxies HB iypebari ype L0G, los of conscouses. high-flow oxygen plus daily hyperbaric oxygen treat ments at 2.8 atmospheres in patients with CO poi- soning found no benefit to treatment,” although the trial has been criticized for methodological flaws.°® ‘Bum patients were excluded from the study. Sponta- neous recovery from serious carbon monoxide poi soning is possible, as demonstrated by several case series and case reports. Hyperbaric oxygen treat ‘ment is not without expense, inconvenience, and po- tential risk, however.*? One study described compli- cations seen during treatment of a heterogeneous sroup of patients: emesis (6%); seizures (5%); agita- tion requiring restraints or sedation (2%); cardiacdys- shythmias or arrests (25), areal hypotension (2%); and tension pneumothorax (1%). Complications ‘may be expected more frequent in critically il pa- tients. Furthermore, bum patients have other poten- tial causes of neurologic injury including hypoxia, shock, head trauma, cyanide exposure, and drugs, none of which are responsive to this therapy. Risks and potential benefits must be weighed in each individual.Jounal of Buen Care & Retabiltstion Specific Treatment for Cyanide Exposure Cyanide is another product of incomplete combus- tion that may be inhaled by house fie victims. Ele- vated cyanide levels are commonly detected in those suffering inhalation injury in structural fires.® Al though some reports have suggested that clinically important cyanide intoxication is common in those ‘with significane inhalation injury.*? the levels seen usualy are stich that well-resuscitated patients can be rapidly detoxified; routine therapy is not therefore generally advised. Therapy can be provided without undo risk using a commercially available cyaniee an- tidote kit containing sodium nitrite.*® Although eya- ride occasionally can be clinically important, there usualy are other reasons, ineluding drugs, hypoxia, carbon monoxide, and shock, contributing to the ob- tunded state in such patients.“ SUMMARY Breathing 100% oxygen for 6 to 12 hours remains the standard of care for burn patients with concomitant carbon monoxide exposure. Hyperbaric oxygen ‘treatment may be appropriate for those with docu- mented or strongly suspected serious exposure to car- ‘bon monoxide (carboxyhemoglobin level >25% with depressed mental status suspected secondary to car- bon monoxide exposure) who are hemodynamically stable, not requiring an ongoing burn resuscitation; are not wheezing or air trapping; and in whom such, treatment does not require imterfcility transport in- consistent with good general burn treatment. There are significant practical limitations to the provision of this therapy that must enter into treatment decisions. Routine specific treatment for cyanide exposure is not warranted unless toxic levels of eyanide are doc- tumented in acidotic patients. KEY ISSUES FOR FUTURE INVESTIGATIONS. Controversy lingers over the value of hyperbaric ther- apy in burn patients with associated severe carbon ‘monoxide poisoning, A prospective clinical trial this patient population would be of value Controversy also lingers over the role of specific treatment of cyanide poisoning in those with con- comitant carbon monoxide poisoning and inhalation injury.4** A prospective clinical trial would be of value. Practice guidelines for burn care: Chapter 4 V78 EVIDENTIARY TABLE ‘Table 1 presents findings on the management of car- bon monoxide poisoning. REFERENCES 1, Grim PS, Got LI, Boddie A, Beton E. Hyperbaric ony keen therapy, JAMA 1990,268:2216-20, 2, Rein A, LeltA, Hopewell PC. Pashophysiology and manage ‘ment ofthe complications sesulking from fire and the inhaled ‘roducss of combustion: review ofthe literature, Crit Care Med 1980;894-8 3. Baro DJ, Goode R, Rash BF Jr, Lin RL, Freda A, Andetson } Je. Lack ofconslaton between earboxyhemoglobin snd ‘yanide in smoke inhalation injury. Carr Surg 1986435 ors 4. Knighton DR, Silber JA, Hunt TK. Regulation of wound healing angiogenesis—eect of oxygen gradients and in ‘spiced onypen concentration. Surgery 1981;90:262-70. 5. Marx RE, Hhlee W), Tayapongsak?, Pierce LW. Relaonship| ‘ofoygen dose roan deson in iracted sie. ‘Am Surg 1990;1605519-24 6. Myers RA, Mane RE, Use of hyperbaric nygen in postadiae tom head und neck surgery. NCI Monographs 1990:181-7. 7. Mare RE, Johnson RP, Kline SN. Prevention of ‘osteoradionecrosis-a randomized prospective clinic sl of hyperbaric oxygen vers pencil. J Am Dent Assoc 1985; N95, 8. Marc RE, Ames JR The use of hyperbaric oxygen therpy ia bony reconstruction of the bradated and dare-defcent pa tiat. J Oral Maillofacial Surg 1982340:412-20. 9. GianciP, Willams O, Lueders 1, etal. Adjunctive hyperbaric ‘orygenin the weatment of thermal burs. An economic na sie Burn Care Rebabil 1990311:140-3, 10, Hat GR, O'Reily RK, Broosand ND, Cave RH, Goodman DB, Yanda RL. Treatment of bums with byperbae oxygen ‘Surg Gynecol Obmet 1974)139:693 6, 11, Branaen AL, Sul J, Haynes M, eral. A randomized prospec tive lof hyperbari oxygen in a referral burs center pop lation. Am Surg 1997:68:208-8. 12, Buehler JH, Berns AS, Webster JR, Addington WW, Cagell DW. Lactic acidosis ftom carboxyhemoglobinemia alter smoke intalation. Ann Int Med 1975;82°803-5. 13, Tibbles PM, Bdelsberg JS. Hyperbaric-oxygen therpy. 1N Engl J Med 1996;338:1642- 14. Shimazu T,Theuchi H, Hubbard GB, Langlinas PC, Mason AD Jr, Prat BA Je, Smoke inhastionijiny and the eee of farbon mononide inthe sheep model. } Trauma 1990;30: 70-8. 15, Fein A, Grossman RF, Jones JG, Hof J, MeKay D. Car ‘bon monoxide efect on alveolar epithelial pecmeabliy. Chest 1980,78:726-31., 16. Chang KH, Han MH, Kim HS, Wie BA, Han MC, Delayed encephalopathy afer acute carbon mosoxide intoxiction (MIR imaging features and cittrbution of ceretral white mat ter lesions, Ragology 1992)186:117-22. 17. Seger D, Welch L Carbon monoxide controversies: near paychologic testing, mechanism of toxichy, and hyperbaric bxygen. Aan Emerg Med 1994:24:242-8 18, Van Hoesen KB, Camporesi EM, Moon RE, Hage ML, Di sntados CA. Should hyperbaric oxygen be used to crest the ‘pregnant patient for ace cazbon monoxide poisoning? A ‘se report and literature review [published eratum appears in JAMA 1990 May 23-30;273(20}2780)- JAMA 1989; 261103943, 19. Woody RC, Brewster MA. Telencephalic dysgenesis ato sted with presumptive maternal carbon monoxide intone ‘oni chefs trimester of pregnancy. J Texicot Cin Toricol 1980;28:467-75.8S Practise guidelines fr burn care: Chapter 4 20, 21 22, 28, 24 2s, 26 2. 28 2. 30. 22. 33. Zienmecman SS, Tewal B. Catboo monoxide poisoning, Pe lates 1981,68:218-24 Binder JW, Roberts NJ. Carbon monoxide intoxication in childea, Clin Toxicol 1980,16:287-95, “Meert KI, Heldemann SM, Samaik AP. Outcome of el ‘ren with carbon monoxide posoning eated with normo- base oxygen.) Trauma 19984414954 ‘Thom Sty Keim LW. Carbon monoxide poisoning: review epidemiology, pathophysiology, clinica! Radiags, and weat mest options including hyperbaric oxygen therpy.J Toxicol Gin Toxicol 1989:27"141-56. Ginsberg MD. Carbon monoxide intoxication: clinical fea tures, aeuropathology and mechasisms of injury. Toxicol Clin Tovieo! 19853252818, Myers RA, Snyder SK, Emhoff TA, Subacute sequelae of ‘arbon monoxide potioning. Ann Emerg Med 1985;L4 nes-7. ‘Thom SR, Taber RL, Mendiguren I, Ck JM, Hardy KR, Eisher AB. Delayed neuropsychologic sequelae afer cabon ‘moon possoning: prevention by tentment wth hyper Dari oxygen, Ann Emerg Med 1995,25:474~80 Werner 8, BackW, Akerblom H, Bar PO. Two caesof acute carbon monoxide poison with delayed newologial se (Guele after a "fee" itera. J Toxical Clin Tosco! 1985; Fnio-es. Sehwara: A, Henaerci M, Wegenee OH. Delayed choreo: stheros following aate carbon monoxide poisoning New ology 1985;35:98-9, Lacey Dj. Neurologic sequelae of acute carbon monoxide ‘ntolcaion. Am J Dis Chld 1981.135:145-7. ‘Myers RA, Sayer SK, LinbergS, Cow RA. Value of hy: perbasic angen in sspected carbon monoxide posonin. JAMA 1981:246:2478"-0. Mathieu D, NolPM, Durocher A, eta. Acute carbon mon oxide poisoning, Rik oflate sequelae and teatnent by hy. perbane oxygen. J Toxicol Clin Toxicol 1985;23'315-24. ‘Choi IS. Delayed neurologic sequela in carbon monoside fatoxication. Arch Neurol 1983 40:433-5, ‘Myers RA, Batten JS. Are arterial blood gases oF value in treatment decitions for eatbon monoxide poisoning? Cnt (Care Med 1989,17:139--42. 34 3. 36, 2 2%. 40 a 2. rn 45 ‘Journal of Burn Care & Rehabilitation ‘April 2001 Jerson JW. Subtle neuropsychiatric sequelae of carbon ‘monoide intoxication two eave reports. Am J Bayh 1976, T9614 Noskoo! DM, Kiskpatick JN, Treatment of cute cabon ‘monoxide poisoning with hyperbaric oxygen areview of 115, ‘aves, Ann Emerg Med 1985;14:1168-71 Repbae JC, Flkbarat D, Jare-Gaincestre MC, eta. Tal of ‘normobarie and hyperbaic onyge for acute cibon monor- {de inoaleaion, Lance: 1989;2:414-9, Scheinkestel CD, Baley M, Miles PS, Jones K, Cooper DJ, Millar IL eal. Hyperbaric or sormobarc oxygen for acu ‘carbon monoxide poitning:2 randomised costed cin fal wal Med J Aust 1999;170:208-10. ‘Moon RE, DeLong B. Hyperbui oxygen for carbon mon- oxide potsoning. Med J Aust 1999; 170:197-9, ‘Weaver LX, Hopkins RO, Larson-Lohr V. Neuropsycho- logic and funcional recovery kom severe carbon monoxide ‘posoning withoue hyperburc oxygen therapy. Ann Emery Med 1996;27:736-40. Grube BJ, Marvin JA, Heimbach DM. Therapeutic hyper- ‘bari oxygen: help orindrance in bur patients with carbon monoxide poisoning? J Burn Care Rebabil 1988:9-249 82, ‘Sloan EP, Murphy DG, Hare R, etal. Compliations and ‘protocol considerations in earbon monoxide poisoned pe tents who requiehypecbaric oxygen therapy: fepart froma ten-year experience. Ann Emerg Med 1989;18:629~84 ‘Sheridan RL, Shank #5. Hypetbasc oxygen treatment: a boe overview of contoversial topic. J Trauma 1999, 47 46.55, Slvesman SH, Purdue GE, Hunt JL, Bost RO. Cyanide tox ict in burned patients. ] Trauma 1988:28:171-6, Batllo DJ, Goode R, Fach V. Cyanide posoningin victims of fire: analy of 364 Cases and review ofthe literature hm Care Retail 1994;15:46-57. Kuk MA, Gerace Kulg KW. Cyanide and methemoglobin Kinetics in smoke ihalation vet tested with the eyanide antdote lit. Ann Emerg Med 1993:22:1413-8, Yoshida M, Adachi J, Warabiki T, Tasuno Y, Ishida N. A study on house fire victims: age, caiboxyhemogiobin, hydzo- fgen cyanide and hemolysis, Forensic Sei Int 1991382; T3-20)Chapter 5 Inhalation Injury: Diagnosis RECOMMENDATIONS Standards There are insufficient data to support a treatment standard for the diagnosis of inhalation injury. Guidelines There are insufficient data to support a treatment guideline for the diagnosis of inhalation injury. Options Early diagnosis of inhalation injury is an important clement in transfer decisions, Normal oxygenation or chest radiographs do not exclude the diagnosis, Inhalation injury is suspected in the presence of ‘one or more specific points of history (closed space ‘exposure to hot gasses, steam or products of combus: tion), physical examination (singed vibrissae and car bonaceous sputum), or laboratory findings (elevated carboxyhemoglobin or cyanide level), Currently, bronchoscopic examination (revealing carbonaceous endobronchial debris, and/or mucosal, ulceration) isthe standard definitive diagnostic mea- sure. When available, the diagnosis is strongly sup- ported by the presence of abnormal radioisotope (xe- non or technetium) scans. If inhalation injury is suspected based on clinical criteria, transfer decisions do not require bronchos: copy or radioisotope scanning, OVERVIEW Purpose ‘The purpose of this guideline is to review the diag, nosis of inhalation injury, and to present a reasonable approach for the care of patients with suspected in. halation injury. Users ‘This guideline is designed to aid those physicians who are responsible for the triage and initial management, cof burn patients, and those with suspected inhalation injury. Clinical Problem Patients with inhalation injury commonly have litle ‘or no lung dysfunction at the time of initial presen tation. However, pulmonary dysfunction and infec tion may develop subsequently. Inhalation injury is 8 predictor of prolonged ventilator dependence! and death? The frequency of inhalation injury varies with the characteristics of studied populations, but approximately 20% of those requiring admission to regional burn centers cary this diagnosis. The diag, nosis of inhalation injury is an important marker of injury severity, predictor of clinical problems, and fac- tor in transfer decisions. Therefore, the diagnosis should be sought early during evaluation of burn- injured patients PROCESS A Medline search was conducted of all available liter ature from 1966 to 1998, using the key words burns, inhalation, smoke inhalation injury, and inhalation injury. There were 282 relevant papers in English and involving human subjects reviewed, References were classified as Level I evidence (large randomized tr als), Level TI evidence (small randomized tials), Level IIT evidence (nonrandomized controls or ease series), oF as Technology Assessment (TA) according to the outline contained in the Introduction, SCIENTIFIC FOUNDATION Inhalation injury is defined as aspiration of superheated. gasses, steam, hot liquids, or noxious products of in- complete combustion.® To a degree that varies unpre- dictably among individual patents itcanses a number of physiologic derangements including: 1) loss of airway patency secondary to mucosal edema, 2) bronchospasm secondary to inhaled irritants, 3) intrapulmonary shunt ing from small airway occlusion caused. by mucosal edema and sloughed endobronchial debris, 4) dimin- ished compliance secondary to alveolar flooding and. collapse with mismatching of ventilation and perfusion, 5) pneumonia and tracheobronchitis secondary to loss of ciliary clearance and tracheobronchial epithelium, and 6) respiratory fillure secondary to a combination of 19s20S Practice guidelines fir bur care: Chapter 5 the above factors. The injuries evolve over time and parenchymal lung dysfunction is often minimal for 24t0, 72 hours.” A number of tests have been proposed for diagnosis and stratification of inhalation injury: history, physical examination, chest x-ray, bronchoscopy, ,0,/FiO, ratio, xenon and technetium scanning, and ‘tracheobronchial biopsy and cytology. As there are no specific preemptive therapies for inhalation injury and current diagnostic measures only loosely predict the de- agree of subsequent pulmonary dysfunction, the role of diagnostic tests has been primarily to facilitate general evaluation, prognosis formulation, and transfer deci sions.®? The underlying difficulty with diagnosisis that inhalation injuries evolve over time and involve the en: ‘ire respiratory system ffom the upper away to the al- veolus to a variable degree. The composition of smokeis very complex"® and itis not generally possible to know all of the noxious substances to which an individual pa- tient has been exposed.” Routine diagnostic measures, are not able to identify those with significant parenchy- ‘mal injury.1? Therefore, the emphasis to date has been to classify patients as having or not having sustained. inhalation injury; there has been litle effort to quantify the severity of injury. "Noninvasive methods are used by most authors to increase the suspicion ofinhalation injury primarily his- tory and physical examination. Bums sustained in a closed space, or aspiration of hot steam or liquid have constituted the pertinent points of history. Physical findings suggesting the diagnosis have included the presence of carbonaceous debris in the month or the sputum, singed nasal hairs, and facial burns. Although evaluation of serial chest x-ray changes is of value," particulary if they are carefully examined for the pres- ence of bronchial wall thickening,!* admission chest x- ray has been found by mostauthors to be normal.°The P,0;/FiO, ratio has been shown to be a valuable de- scriptor ofthe degree of intrapulmonary shunt and pre- dlictor ofthe development of respiratory failure in criti- cally il nonburn patieats."” When applied to those with inhalation injury, 2 P,O;/FIO, ratio after resuscitation ofless than 300 has been associated with the subsequent development of respiratory failure™®; combining, this, value with peak inspiratory pressure, chest x-ray and bronchoscopy results may permit comparison among, patients with inhalation injury"® Although also nonspe- cific measures of pulmonary function, the alveolar-arte- rial oxygen gradient,” compliance,*” and pulmonary function studies* have been used in efforts to quantify the severity of inhalation injury in small clinical series. Invasive diagnostic measures have included bron- choscopy with or without tracheobronchial biopsy and cytology, xenon and technetium scanning, and deter- ination of serum carboxyhemoglobin percentage. Al- Journal of Burs Care & Rehabilitation ‘pil 2001 though logistically more complicitedin young children, ‘many investigators have used bronchoscopy asthe ‘gold standard? for diagnosis of inhalation injury, reponting carbonaceous endobronchial debris, mucosal pallor, and mucosal uleeration to be consistent with the diag” nosis 27 In most patients, transfer decisions are appro- priately made without bronchoscopy or other invasive diagnostic measures. History and clinical examination sulice for the large majority of situations. ‘Radionuclide imaging has been used to diagnose inhalation injury in two forms: xenon-133 (adminis- tered intravenously) oF technicium-99 (administered by inhalation). Both radioisotopes are rapidly cleared or absorbed respectively by normal Iungs."* Asym- metric or delayed clearance or absorption may be caused by small airway obstruction secondary to sloughed endobronchial debris, bronchospasm, alve- olar flooding, or small airway mucosal edema.”* Ina clinical seting consistent with inhalation injury, these tests, when performed before the development of other types of burn related respiratory failure, are felt tobe diagnostic ofinhalation injury®#5” and to have some predictive value in terms of subsequent gas ex change derangements.”® The results of these exami- nations correlate well with other signs of inhalation injury? Although physiologically sound in principle, xenon and technetium scanning have not been widely used, because of logistic difficulty and expense. Other potential diagnostic adjuncts include trax cheobronchial cytology” and tracheobronchial bi- copsy.*! Both have been reported to facilitate the di- agnosis of inhalation injury in small clinical series but, because of logistic difficulties and potential compli- cations, have not been widely employed. Support for these diagnostic modalities remains inadequate t0 recommend their general use. In most clinical pro- ‘grams, history, physical examination and selected use Of bronchoscopy are the favored diagnostic modali- ties in those suspected of having inhalation inju- sy As the injuries evolve in an unpeedictable way over time," it is important to follow patients clini- cally and provide individualized support (see Guide- line on Initial Management of Inhalation Injury). SUMMARY A diagnosis of inhalation injury s supported by one ot _more specific points of history (closed space exposure to hot gases, steam or products of combustion), physical ‘examination (singed vibrisae and carbonaceous sp ttm), bronchoscopy (carbonaceous endobronchial debris, mucosal ulceration), or laboratory findings (ab- ‘normal xenon or technetium scan, elevated carboxyhe- moglobin or cyanide lve), Ealy chest radiographs areJournal of Burn Cate & Rehabilitation Practice guidelines for burn care: Chapter §- 218, ‘Table 1, Evidentiary Table: Diagnosis of inhalation injury Reference Description of Study __Data Clas Conclusion Comments ‘Ryan etal, 1998" Retrospective review of year TE Diagnosis of inhalation injury hae major influence on morality ‘eaperence with 1668 barn patients ata single regional unit Masanes etal, [Experience with bronchoscopy and TT_——_Prognoss lootely predictable by bronchoscopy, supplemented 199481995! biopsy in 130 bum patients, ‘with endobronchial biopsy demonstrating ability to predict development of rspirscory Sire Liner al, 19979 99-Te scanning ofinhalationinjury TIT_—_99-Te sexing has diagnostic an predictive value in ‘of 17 patients and 10 controls ‘inhalation injuy ‘Comment: Nurivers of sabjects very small and injury severity vil Khoo eral, 19979 Tracheobronchialeytology for TIL Cytology scoring system facitates diagnosis of inhalation agnosis ofinhalation injury injury 20 patients andl 20 controls Comment: Numbers are smal and wotk is preiminary. Hollingsed etal, Review of 529 burn patents TIT Inhalation injury dagnosisis predictive ofthe development of 1993" ‘spinor fre Comment: 27% of those with inhalation injury didnot develop respiratory filure—in these patients inhalation injury dd not pret increased morcliy Brown ctl, 1996°* Evaluation of P0,/Fio, rato after ‘IT Confirmed value of Pa0,/80, ato in prognostication and ‘resuscitation in 120 patients and suggested use of Pa0;/Pio; ratio, chest ray, PIP, and segarat evtion of scoring ‘bronchoscopy results to develop predictive scoring system system involving Pa0,/Fi0, Comment: Deeliinary work with small mambere ratio, eet x-1ay, PIP, and ‘bronchoscopy in 20 survivors snd 6 nonsinrvors Peitzman etal, “Evaluation oferil chest xrayin—‘TIT——_Sesal valuation has better predictive value than initial lm ious 29 patients with inhalation injury Common elirsinary work with small nsmbecs| ‘Texidor etal, Review of seal ches xzys in 62 ‘T—_Caef serial evaluations cary diagnostic information i983" patients with smoke inhalation Commons: Preliminary work with sll amber; technique requires skied radiology support Schall etal, 1978 Teil of anon scansing in 67 TIT Comelates well with other sgn of inhalation injury Patient Comment: Scan alone did not appea to add vale to routine agnostic measures Pewoffer al, 1976 Tris ofpulmonary function studies TA —_Corclation was good between PTs and subjective seveity of ‘ely afc inhalation injury in 7 Injury hy bronchoscopy and xenon seaming tou patients with and 8 without Comment: Preliminary work with soll numbers inhalation inary Agee etal, 1976 Xenon scans in 86 patients, 43% TL BK ilse-postive and 5X fulbe negative compared to sandasd posive; comparison to clinical agnostic citeia and bronchoscopic examination ‘Comsnont Sean alone did not appese to add value t routine diagnostic measures. PFT, puimonary Seton et FIP, pes npn press routinely normal. Inthe setting ofthe initial evaluation vidual patents and comparison of results of and management of patients with suspected inhalation _various studies and new interventions. Serum procaki- injury, transfer decisions are appropriately made without tonin® and human placental alkaline phosphatase lev- bronchoscopy or other invasive diagnostic measures. cls,*® multifactorial scoring systems'® tracheobronchial History and clinical examination suffice for the large cytology” and changes in alveolar cell populations,>” majority of situations, clearance of aerosolized 99mTe-diethylenetriamine- pentacetate,** P,O,/FiO, ratio afier resuscitation, * KEY ISSUES FOR FUTURE the alveolar-arterial oxygen gradient,” compli pulmonary function studies?" and asymmetric or de- ES enon: layed clearance of technicium-9928 have been used t0 ‘An ability to quantify the severity of inhalation injury is stratify the severity of inhalation injury in small lacking. This hinders prognosis development for indi- trials, Refinement ofthese techniques and development22S Practice guidelines for burn cave: Chapter 5 ‘of ways to stratify the severity of inhalation injury would bbe of practical value, particulary if earlier introduction ‘of new therapies is found to be beneficial, ‘The earlier introduction of new modes of ventila- tion and other therapies in those with inhalation in- jury is an area in which useful work may be done, particularly ifa method of injury severity prediction is developed and validated. EVIDENTIARY TABLE Table 1 summarizes rescarch on the diagnosis of in- hakation injury. REFERENCES 1, Seller BJ, Davie BL, Larkin PW, Morris SE, Safe JR. Esl predicon of prolonged venlatue dependence in thea {njared pasients.J Trauma 1997%43:899-908, 2, Safle IR Davis B, Wilams P. Recent outcomes in the teat: ‘mest of bun injury in the United States: a repor: fom the ‘American Burn Astcation Patient Regity.) Burn Care Rehabil 1995;16:219-32. 8, Tredget BE, Shankowsky HA, Tacum TV, Moysa GL, Alton JD. The ol ofinhalation injry in burn zuma. A Cazadian cexperince. Aan Surg 1990,212:720-7. 4. Herndon DN, Gore D, Cole Me]. Determinants of mor calityin pediattc patients with greater than 70% Fll-hickness tora body surfce aca thermal injury treated by early total excision and grating] Trauma 1987:27:208-12. 5. Shira! XZ, Brite BA Jf, Maton AD Je, The iniluence of inhalation injury and pneumonia on burn moray. Ann Sarg 1987;208:82-7, 6, Davies JW. Toric chemicals vermu lng tisue—an aspect of Inhalation injury revsted: The Everet Idris Evans mpemocal lecture—1986. J Burn Care Rehabil 1986,7:213-22, 7. Prat BA Jr, Esckon DR, Mors A, Progressive pulmonary Insufficiency and other pulmonary complieaions of thermal injury, J Trauma 1975,15:369 79 8. Ryan CM, Schoenfeld DA, Thorpe WD, Shesidan RL, Cas sem EH, Tompkins RG. Objective estimates ofthe probabil lny of death fom burn injures. N Engl J Med 1998;338: 302-6. 9. Hollingsed TC, Safle JR, Barton RG, Craft WB, Mortis SE, Exjlogy and consequences of respiratory failure in thermally injred patients. Ar J Surg 1993,166:592-6 10, Prien Ty Traber DL- Toxic smoke compounds and inhalation Jnjary- review. Buns Inluing Thermal Injury 1988;14 451-60, 11, Pryor WA. Biological effects of ciguette smoke, wood smoke, and the smoke fom plas: the use of electro spin ‘esonahce, Free Radic Biol Med 1992;18:659-76,, 12, Peiszman AB, Shires GT 3d, Corbeet WA, Curreti PW, Shires (GT. Measurement oflung water in inhalation jury. Surgery 1981:90:305-12. 13. Tenidor HS, Rubin E, Noviek GS, Alonso DR, Smoke Inalation: radiologic manifestations. Radiology 19835149: 3837 14. Pelszan AB, Shices GT 3d, Tesidor HS, Cure PW, Shires GT Smoke inhalation injury: evaluation of radiographic ‘manifestations and pulmonary dysfunction. J Trauma 19895, 29112328 15. Lee MJ, O'Consell DJ. The pin chest radiograph afer cate smoke inhalation, Clin Radiol 1988;39:33-7, 16. ‘Wirtam C, Kenay JB, The admision chest radiograph after vy. 18 18. 20, 21. 22, 23, %, 25, 26, 27, 28, 29, 20. 31 2, 33. M 3. 4, 2, 2 Journal of Burn Care & Rehabilitation ‘pil 2001 cote inhaon injury and burns. Be J Radiol 199467 rina Bone RC, Masader R, Slotman G, eal. An cay tt of sural it pens with che al espratory direst syn rome. The Ps02/Plod ai an serena responsto conventional therapy rostaghanin El Study Group Chest 1989396849-81 Brown DL, Archer SB, Greenhalgh DG, Washam MA, James [EE Warden GD. fahalton injury sevety scoring stems (guntave metod J Bum Cae Rehabil 19961 7552-7 {ce EA, Su CT, Hoopes JE, Atveolracteal oxygen gr stent in che burn patente Traume 1976;16:212-7 Jones WC, Bare S, Madden M, Finkelstein, Goodwin GW. The ie ofcomptanein predic ealy moliy ser intalaton injry. Cu Surg 198845:309 12 Pewof PA, Harder BW, Cayton WH, Prite BA. Pulmonary function edie ser smoke sabato. Amn } Sars 1976, 132:36-S1 Moyias JA, Ab K,Binbaum M. Ferptic bronchoscopy folowing thermal ius. Surg Gynecol Obstet 1975; 140: Sales Masancs M), Legendee C, Lote N, Mallard D, iy Ry {hea B. Hberopibroachoeopy rte xy igroasof subglotaliahaltion nur: compare vale inte suse sent of progress. ] Tea 1994;3689 67 TR, Anerson JH, Teepak RJ Brown JM, UezTA.Re- dlonuclide aging in the seamen of unin. Sein ‘Necl Med 1980:10:302-10, all, Tatum FL, Sugemin B, Harshorse ME, Boll DA, Kiplan KA Redouucide eration oflung usu. Semin Nec ed 1983:13223-37. ‘Agee RN, Long JM 3, Hunt J etl Uz of "enon inary dingo of inalton injury] Trans 1976,16318-24, MoslanJA J, Wilmore DW, Mouton DE, Prt DA J-Eaty diagnosis of halon injury using "eon lung scan. Ana Surg 1972317647798. {is WY, Kio CH, Wang SJ, Detection of aut intlaton injry in Bre viens by means of tennetiom. 99m DTPA ‘ndloscrosl ination ling scintigraphy. Eu J Nucl Med Ip97aenas-9 Scull GE, MeDonaid HD, Caer LB, Capozzi A. Xenon ves: tation persion lang sears. The cry agnosis of inal tion injury JAMA 1978:240:2441-8 hoo AK, Le St, Poh WT. Tescheobroncial tology in inhalation jy Trauma 1997428105 Masanes MI, Legenire G, Loree N, Sey B, Leben B. Using bronchoscopy and bop to diagnose cy ination injury, Macroncopie and hiologie Sndings, Chest 1998, 17.3655 Gare Cy, Reid WH, Teler AB, Campbell D, Repizztory injury in the bared patent. The role of exble bonchos. Copy, Ansestheas 1983,38:35-9, (Cabalane M, Deming RE. Early resistor sboommalitie fiom smoke ntlaion TAMA 1984:351:771-3 Fein, Lea, Hopewell PC. Pethophyology and manage ‘ent ofthe completions rung fom freandehe hai Products of combustion: rovew ofthe itera. Ct Care Nes 198033:94-8 Nylen ES, O'Neil W, Jordan MH, etal. Serum procatonin {san ind of iba nary in burs. Horm Me Res 1993,24:439-43. anaes B, Boece W, Van Aken H, Grower JA. Curent concep ofinhalaon injury in bara coms Act Anaesthe= Sol Beg 196940:107-11 ‘iyami BM, Tiee R, Kise J, el, Changes in aeoar sacophage, monose, and nestophl call profes afer Spoke inhaliton jr.) Clinical Path 1990:43:43-5. (Gu WR, Grosman 2D, Riser-Hrnit C, Warr ‘Gearance of aerontned 99m Te-dietylenecaminepeta: rate before snd afer smoke inbaation. Chest 1988,98 we,Chapter 6 Inhalation Injury: Initial Management RECOMMENDATIONS Standards ‘There are insufficient data to support a treatment standard for the initial management of inhalation injury. Standards ‘There are insuificient data to support 2 treatment standard for the initial management of inhalation injury. Guidelines ‘There are insufficient data to support a treatment guideline for the initial management of inhalation injury. Options, primal initial management requires directed assess- ment and assurance of airway patency (see initial as sessment guideline). Prophylactic intubation is not indicated for a diagnosis of inhalation injury alone. However, if there is concer over progressive edema ‘occurring during transport to the burn unit, intuba- tion should be strongly considered. Intubation is indicated if upper airway patency is threatened, gas exchange or compliance mandate me- chanical ventilatory support, or mental status is inad: equate for airway protection, Prophylactic steroids are not indicated in the initial ‘management of inhalation injury. Prophylactic antibiotics are not indicated in the initial management of inhalation injury In those requiring mechanical ventilatory support, transpulmonary inflating pressures over 40 emFO should be avoided except in exceptional circum: stances (when pH would otherwise fall below 7.2 and P,O, below 60 mm Hig), or if impaired chest wall compliance suggests that inflating pressures mea- sured at the endotracheal tube do notreflecttranspul- ‘monary pressures, Any mode of mechanical ventila- ‘on that is consistent with these limits is appropriate. OVERVIEW Purpose ‘The purpose of this guideline is to review the initial _management of patients with suspected inhalation in- jury, and to present a system for the treatment of such patients Users ‘This guideline is designed ro aid those physicians who are responsible for the triage and initial management of patients with burns and /or inhalation injury. Clinical Problem Inhalation injury has adverse effects on upper airway patency, gas exchange,” distant microvascular integ. rity and resuscitative volume requirements," hemody namics,* and extravascular lung water.® Inhalation in. jury isa predictor of prolonged ventilator dependence and death.® Survivors may have permanent pulmo: nary dysfunction,” late endobronchial bleeding from granulation tissue,* and upper airway stenosis.” Al though there is no specific therapy for inhalation in- jusy, Proper initial management can have a favorable influence on outcome. The goals of management during the first 24 hours are to prevent suffocation by ensuring airway patency, to ensure adequate oxygen- ation and ventilation, to forgo the use of agents that may complicate subsequent care, and to avoid venti- lator-induced lung injury. PROCESS A Medline search was conducted of all available liter- ature from 1966 to 1998, using the key words burns, inhalation; smoke inhalation injury; and inhalation injury. There were 282 papers in English and involv- ing human subjects reviewed and found to be rele- vant, References were classified as Level I evidence (large randomized trials), Level II evidence (small randomized trials), Level IIT evidence (nonrandom- ized controls or ease series), or Technology Assess- ment (TA) according to the outline contained in the Introduction. 23824S Prete guidelines for burn care: Chapter 6 SCIENTIFIC FOUNDATION Initial Airway Management ‘There are a predictable set of clinical problems as ciated with inhalation injury. These include loss of airway patency secondary to mucosal edema, variable degrees of bronchospasm, intrapulmonary shunting from small airway occlusion secondary to mucosal edema and sloughed endobronchial debris, dimin- ished compliance secondary to alveolar flooding and collapse with mismatching of ventilation and perfu- sion, pneumonia secondary to loss of ciliary clearance, and respiratory failure secondary to a combination of the above factors. Parenchymal dysfunction is typi- «ally minimal for 24 to 72 hours, prior to the devel- ‘opment of overt problems with gas exchange and ‘compliance. Theres an increased risk of pulmonary infection and respiratory failure associated with inha- lation injury." Inhalation injury increases systemic inflammation associated with a surface burn;!? this being consistent with the common clinical observa tions of an increased requirement for resuscitation fluids in patients with burn and concurrent inhalation injury and the increased severity of pulmonary dys function in those with concurrent surface buens.!? ‘The presence of inhalation injury predicts the devel ‘opment of respiratory falure'* and subsequent mul- tiorgan dysfunction.'* Concomitant carbon monox- ide and cyanide exposure is common." All authors agree on the importance of airway eval- uation and security in those suffering inhalation in- jury. Airway edema evolves over time; ongoing mon- itoringisimportant because those with patent aicways early during evaluation can develop significant com- promise a resuscitation proceeds."” Ifairway patency is threatened, immediate intubation is advised (see initial evaluation guideline). Prophylactic intubation isnot indicated for inhalation injury alone; intubation isindicated only if upper airway patency threatened, ‘gis exchange or compliance mandate mechanical ventilatory support, or mental status is inadequate for airway protection, As these injuries evolve over time, itis important to observe patients who are not intubated for the development of airway compromise, indicated by progressive hoarseness, stridor, or retractions. Areas of controversy in the intial management of inhalation in- jury include the role of prophylactic steroids and antbi- ‘ties and the role of specific modes of mechanical ven- tilation in those who require this therapy. Prophylactic Steroids, Antibiotics and Nebulized Agents Anecdotal reports have appeared suggesting a poten: tial role for preemptive steroids. and antibiotics, Journal of Bum Care & Rebabiltation ‘Ape 2001 Although many patients will demonstrate reactive bronchospasm"? and benefit from cadly institution of nebulized beta-agonists, steroids are infrequently re uired to treat bronchospasm. The only large clinical experience available suggests no benefit fzom this po- tentially risky therapeutic maneuver.” A prospective trial involving 60 patients with inhalation injury eval: uating the use of aerosolized steroids showed no ben- efit?" In this same tral, aerosolized gentamicin was examined and also showed no benefit. Although no other randomized trials of prophylactic antibiotics in inhalation injury exist (go the writer's knowledge), consensus opinion holds that this manewver is of no value #8 One report comparing two groups ofchil- dren with inhalation injury, one group given prophy- lactic nebulized heparin and. acetyleysteine and a group of historical controls not so treated, suggested that this therapy may reduce pneumonia, extubation failure, and mortality.* Experience with this tech nigue is not adequate to recommend the general use of this therapy Specific Techniques of Mechanical Ventilation Patients who require intubation because of airway ‘edema, pulmonary dysfunction, or depressed mental status are generally connected to a mechanical venti- lator and given positive pressure ventilation. There are many ways to administer positive pressure venti- lation, and many papers have been written advocating, ‘one method over another in patients with inhalation, injury, It is important that patients with inhalation injury are supported using techniques that do not farther exacerbate respiratory failure. There is ample evidence that limiting transpulmonary inflation pres- sures to below 40 cmH,O and accepting moderate respiratory acidosis (“permissive hypercapnia”), de- fined asa pH greater than 7.2, will enhance survival in animal?® and clinical?*-?* studies. Extensive experi- ence has shown pressure controlled ventilation can be used, effectively in preventing secondary lung in- jury27°9 Circumferential torso eschar or massive accumulation of transudative intraperitoneal fluid or bowel edema can cause torso compartment syn- drome, with decreasing urine output and impaired ventilation, When documented, this may be relieved by escharotomy, placement of peritoneal dialysis catheters, or rarely, abdominal decompression.” There are data to support the use of volumetric diffusive respiration (VDR), a pressure controlled ventilator with a superimposed subtidal oscillation, in those with inhalation injury,*? and the benefit ofthis, technique may accrue from the pressure limited ap- proach, the subtidal oscillation, or possibly both. An-Journal of Bur Care & Rehabilitation Practice guidelines fv bur care: Chapter 6 25S. ‘Table 1. Evidentiary Table: Management of inhalation injury Reference Description of Study __Data Cass Conelusion/Comments ‘Hickling et, (Case series of permissive THE Decreased morality compared ro historic controls 1990" ypercapnia Comment: Historic conzols derese the value ofthese dita Stuesy, 1993 Consensus conference ME Evaluation ofcumrentciicl pracsce suppons permissive ypereapaia| “Hickling etal, Case series of permissive TI Decreased mortality compared 1 predictions based on 1994” Iypercapatain burns APACHE scores Comment: No concurrent controls Desa eral, 1998°* Seis oF 47 children with TIL Decreased mortality, extubation falure, and pneumonia ‘halation injury treated with compared to 43 non-concurent controls managed from ‘ebulized heparin and 1985-1989 sceryleysteine from 1990-1994 Comment: No concree contol, moderate mortality ate Sheridan etal, (Case series of permissive TIE Decreased morality compared 1 historic controls 195% -nypercapni in 54 children Comment: No concurrent contol, but very low moralisy requiring mechanical venation CCiofficeal, 1991? VDRin Sa patient with inhalation _III__Demonstrated improved outcome compared to historic cohort, Injury with histori eons (Comment: No concurrent contcls Levine etal, 19782! Prospective tral involving 60 TH Nobenefc associated with ever therapy atens with inhalation therapy Comment Saal sample sie craluating the use of aerosolized seerids and gentamicin Robinson etal, Review oFouteomes of wo cohorts TIT_—_No dilference in outcome ifteroids are given 1982” ‘of patents with inhalation injury ‘Comments No concurrent controls ‘managed with and without seers YDR, voli dif pation, APACHE, Acs Physiology and Chronic Heals Hlaton imal and human data supporting inflating pressure _ nificant recent progress is aso perceived. ** Two lines limits are compelling. Measures of inflating pressures _of investigation appear potentially fitful. ‘must be interpreted in ight of chest wall compliance; (1) Earlier introduction of novel therapies for se- in the presence of chest wall eschar or edema, higher _vere inhalation injury and respiratory failure, such 5 inflating pressures measured at the endotracheal tube _antiadhesion molecules,” inhaled heparin or muco- may not reflect true ranspulmonary pressures and lytic agents, nitric oxide™ and extracorporeal sup- may be well tolerated. Permissive hypercapnia _ port, ° may enhance their efficacy. Studies comparing should not be practiced in patients with coincident _late versus carly addition of such therapies in patients head injury, as it may increase cerebral blood flow. _with very severe injuries would be of value. ‘Those who continue to fal despite this lung protec- (2) Long term pulmonary functional outcomes tive strategy may benefit from innovative methods of should be better defined and therapies suggested support such as inhaled nitric oxide™ or extracorpo-_for those with permanent impairment secondary to real life support.® inhalation injury. SUMMARY EVIDENTIARY TABLE 5 ‘Table 1 presents findings on the management of in- (Our conclusions for this topic are adequately samma- tized in the Options section, above. hralation injury. KEY ISSUES FOR FUTURE Rerenences INVESTIGATIONS. 1. Gudmote RE, Vor E.Inlation injury to the respiratory tract of den, Prog Pediat Surg 1981 4:175-88 Although most authors describe improved mortality ae erie eat abet ol beatin Re caldeen for those with inhalation injury, a lack of recent sig- ‘ermal iniury.J Burn Care Reb 1997183831426S Practice guidelines for harm care: Chapter 10. n v, 13, 14 1s, 16. v7. 18. 1s. aL ‘Navar PD, Safe JR, Warden GD. Best of nalation iniuy fo fluid exustation requirements fe thermal jury. Am Surg 1985;180.716-20 Roa L, Gomer-Cia T, Cantero A. Pulmonazy cpilary dy amicé and ud dseibuon afer barn adinalaton ify. Burns 199041 6:25-35, Herndon DN, Bartow RE, Traber DL, Rutan TC, Rutan RL, [AbstonS. Ertavascula lung water changes following smoke Inhalation and masive buen injury. Surgery 1987:102: 3419, Ryan CM, Schoenfeld DA, Thorpe WP, Shetidan RL. Cas. sem EH, Tompkins RG. Objective estimates ofthe peobaba- Ity of death ffom buen injures. N Engl} Med 1998;338 382-6. ‘TasakaS, Kanazawa M, Mori M, eta. Long-term course of bronchievass and broncholis obliterans slate complica Hon of soe inhalason. Respiration 1995362:40-2. ‘Wills DO, Vanecko RM, Ghstoth J. Endobronchil pol- sposis folowing smoke inhdlaion. Chest 1983:84:774-6. ‘Timon Cl, MeShane D, MeGovera E, Walsh M. Treatment ‘of combined subglonic and cxtialy low tracheal stenones secondary to buen ination injury. J Laryngol Orel 1989, 103:1088-6, Pruite BA Jr, Pickson DR, Monts A. Progressive pulmonary Insufficiency and other pulmonary complications oF termal injury. | Trauma 1975518:369-79. Sellers BJ, Davs BL, Larkin PW, Mortis SE, Safe JR Early prediction of prolonged veatlator dependence in thera Injured pasients J Tauma 19973433899 903, Deming R, Lalonde C, Youn YK, Piand L. Eifectof graded. increases in smoke inhalation injury on the early sjtemic ‘response oa body bura. Crit Cate Med 1995,28:171-8, ‘Masumoto N, Noda H, Natazaws H, Traber LD, Hemdon DN, Taaber DI. The sequence of injry determines the de {gree oflung damage in boc inhalation end theta nares ‘Shock 1994:1:166-70 Hollingsed TC, Sale JR, Barton RG, Cra WB, Moris SE. Fiology and consequences of respiratory falurein thermally injured patients. Am J Sarg 1993:166:592-6. ‘Aikawa N, Shinozaw ¥,Inhibis K, eal. Clinica analysis of multiple drgas fale in bomed patients, Bums, Including ‘Thermal Injury 1987;13:103-9. Barilo DJ, Goede R, Esch V. Cyanide poisoning in vietins of fire: analysis of 304 Cases and review ofthe tera. J Burs Care Rehabil 1994,1846-87. Sheridan RL. Recognition end management of hot liquid aspiration in children. Ann Emerg Med 1996,27:89-91 ‘Hampton TA. Iabation injury. Proceedings ofthe Royal Society of Medicine 1977.70:487-9. ‘Stenton SC, Kelly CA, Walters EH, Hendrick DJ. Induction ‘of bronchial yperresponsvenes following smoke inhalation Injury Br} Ds Chest 1988;82:436-8, Hobiasoa NB, Huidwoa LD, Rem M, etal. Steroid therapy fallowing isolated smoke inhalstion jury. J Trauma 1982, 2238769. Levine BA, Pewofl PA, Slade CI, Prt BA Jr. Prospective ‘Guls of dexamethasone and aeouolized gentamicin in the treatment of inhalation injury in the burned patent J Frauma 1978;18:188-93 22 23, 24 28. 26, 2, 28 2. 30 a. 33. 3. 4, 36. a, 38, Journal of Burn Care & Rehabilitation ‘Apel 2001 Hiabarchak DR, Prt BA J. Use of systemic anibiocis in ‘he bured paien, Sarg Cin Nores At 1978,581119-22, “Moylan JA, Chan CK Inhalation ajuryan increasing pro lem Ann Sung 1978188367. Desai MH, Mak R, Richardson J, Nichols R, Herndon DN. Reduction in moray in pedire patents With ination injury with aerosolized heparin aceyleysteine therapy. Bua Care Rehabil 1998;19:210-2. (Cosbeidge TC, Wood LD, Cewford GP, Chudoba MJ, Ye ros J, Sznajet JL Adverse fics of large tidal volume and low PEEP in canine aid spirstion. Am Rev Respir Dis 1990; 1311-5 Shenidan RL, Kacmatek RM, McBteick MM, ec al, Penis: sive hypercapnia asa venilatory strategy in burned chide: effect on barotrauma, pneumonia, ané mortality. J Trauma 1995;39:854-9. Hickling KG, Walsh J, Hlenderto S, Jackson R. Low moe ‘aly cate in adul rsiratory estes syndrome using Ion volume, pressure-limited ventilation with permissive hypercapma: a prospective sey. Cait Care Med 199422, 1868-78, Rappapore SH, ShpineeR, Yoshihara G, Wright , Chang P, Abraham E. Randomized, prospective tral of pressure limited versus volume controlled ventilation in severe epi story uae, Cait Care Med 19942-22-32. Slusky AS. Mechanical ventilation. American College of ‘Chest Physicians Consensus Conference. Chest 19935104: 1833-59, icing KG, Hendenon S}, Jackson R. Low mortality a0 ‘ated with low volume presue lited ventilation with pee tasive hypercapnia in severe adv respiratory cies Sy drome, Intensive Care Mee 1990;16:372-7, Greenlalgh DG, Warden GD. The importance of ints abdominal pressure measurements in burned children, [Trauma 1998;36:585-. ‘Cioffi WG Jr, Rue LW II, Graves TA, McManus WR, Mason [AD Je, Pit BA J. Prophylactic use of high-fequency per ‘ussve veatlason i pasents with inkalauon injury. Ann Surg 1991;213:575- 80. Hernandez LA, Peevy KJ, Moise AA, Paker JC. Chest wall restiton limits high aeway pressure induced kung inary i young rabbis. J App Physio! 1989356:2364-8, Sheridan RL, Hluriord WE, Kacmarek RM, etal Inhaled niticoxidein burn patients wit espiratory lure. J Trauma 1997342162934 Goreisky MJ, Greenhalgh DG, Warden GD, Ryckman FC, ‘Wamer BW, ‘The use of extracorporeal Le suppor. in ped atc bum patients wth respitory falure. J Pediate Sarg 1995;30:520-3. Sobel JB, Goldtird TW, Sater H, Hammell BJ Inhalation Injury a decade without progress] Born Care Rchbil 1992: 135735, Hallahan DE, Virudachalam S.frerellular adhesion mole cale 1 knoekout abrogates adiation induced pulmonary i Bammation, Proc Nat Acad Se U'§ A 1997:94:6432~7. Meblroy K, Alvarado MI, Hayward PG, Desai MH, Hem don DN, Rabson MC. Extrise sess esting forthe peitie patent with burns: a preliminary epore. J Burn Care Rehab 1992313:236-8,Chapter 7 Burn Shock Resuscitation: Initial Management and Overview RECOMMENDATIONS Standards ‘There are insuificient data to support a treatment standard at this time Guidelines Patients with burns greater than 15% TBSA should undergo formal fluid resuscitation in which Aid re quirements are based on burn area and body size, Formulas are only a guide to initiate burn shock resuscitation. The most widely used formula for ini- tiation of resuscitation is 2-4 ml of lactated Ringer's solution /kg body weight /% TBSA burn/24 hours. Increased fluid requirements can be anticipated in children with burn injury. Increased fluid requirements can be anticipated in patients with inhalation injury. Other fluid regimens utilized in burn shock resus: citation include hypertonic saline and colloid therapy at various concentrations and at various times post: bbum (see Chapters 8 and 9). Options "There are insuflicient data to support separate treat ‘ment options at ths time. OVERVIEW Purpose “The purpose of this guideline is to review the history and development of fluid resuscitation regiments for bburn patients, and co present a rational and reason- able approach for the treatment of burn patients Users ‘This guideline is designed to aid those physicians who are responsible for the triage and initial management of bum patients. Clinical Problem ‘The goal of fluid resuscitation in the burn patient is ‘the maintenance of vital organ function at the least physiological cost. To optimize fluid resuscitation in severely burned patients, the amount of fluid should be enough to maintain vital organ fiction without producing iatrogenic pathological changes. ‘The composition of the finid given during, the first 24 hours postbuen probably makes litte difference; how- ever, it should be individualized to the particular pa- tient. Use of hypertonic, crystalloid, and colloid so- lutions at various times postburn will minimize the amount of edema formation. Resuscitation fluid should be administered at the rate necessary to main- ‘ain vital organ function with maintenance of hourly tusine outputs between 30 and 50 mlin adults and 1-2 rol/kg/% burn in children. For a child who weighs 30 kg to 80 kg, the urine output should be maintained at the adult level, PROCESS A Medline search of the English-language literature was conducted for the years 1966 to 1998 for all publications involving the key words “burns,” “ther: mal injury,” “burn shock,” “resuscitation,” “col loid,” “dextran,” “albumin,” “fresh frozen plasma, and “hypertonic burn shock resuscitation.” In add tion, selected articles dating back to 1972 were col- lected from Feller’s International Bibliography of Burns Iris of particular interest that there were no cate gory I articles in which a prospective, randomized study was done comparing resuscitation regimes. ‘Most articles were clinical publications of retrospec tive reviews of the individual authors’ experience with a particular resuscitation fluid. Animal models were not used except in elucidation of the pathophysiology of burn injury. SCIENTIFIC FOUNDATION Burn Shock Resuscitation ‘The history of burn resuscitation began over a cen- tury ago; however, complete appreciation of the se- verity of fluid loss in burns was not apparent until the 27828S Practice guideline fir bur care: Chapter 7 enlightening studies of Frank P. Underhill,” who studied the victims of the Rialto Theater fire in New Haven, CT in 1921. His concept that burn shock was due to intravascular Dui loss was further elucidated. by Cope and Moore? who conducted studies on pa- tients from the Coconut Grove disasterin 1942. They developed the conceptof burn edema and introduced. the body-weight burn budget formula for fluid resus- < % TRSA burn per 24 hr + 1500 ml/m? BSA/24 hours. This is the formula used to begin burn shock resuscitation and to compare the amount of fluid needed by a particular peditric bum patient with that needed by an unburmed pediatric patient (Table 2) ‘These results are similar to those reported by Graves and coworkers,*? who found that if maintenance flu- ids were subtracted from the resuscitation fluid re- quirements, the resulting, resuscitation volumes would approach 4 ml/kg/% bum. At the Shriners Burns Institute in Galveston, fluid requirements are estimated according to a formula based on total BSA and BSA bumed in square meters.*? Total fluid re- uirements for the first day are estimated as follows: 5000 ml/m? BSA burned per 24 hours + 2000 ml/m? BSA per 24 hours, Inhalation Injury. The presence of inhalation in- jury increases the fluid requirements for resuscitation from buim shock after thermal injury. Navar, Salle, and Warden have demonstrated that patients with documented inhalation injury require 8.7 ml/kg/% ‘bum, as compared to 3.98 ml /kg/% burnin patients ‘Table 2. Formulas for estimating pediatic resuscitation needs Practise guidelines for burm care: Chapter 7 338 ‘without inhalation injury. These data contiem and quantitate that inhalation injury accompanying ther- rmal trauma increases the magnitude of total body injury and requires inereased volumes of fluid and sodium to achieve resuscitation from early burn shock. Choice of Fluids and Rate of Administration Ikisclearthatall the solutions reviewed are effective in restoring tissue perfusion. However, it makes no more sense to use a single fluid forall patients than it does t0 use one antibiotic for all infections. Most patients with bums of less than 40% TSA and pa- tients with no pulmonary injury can by resuscicared with isotonic crystalloid fluid, In patients with burns ‘of more than 40% TRSA and in patients with pulmo- nary injury, hypertonic saline can be utilized in the first 8 hours postbum, following which lactated Ring- sis infused to complete burn shock resuscitation. In the pediatric and elderly burn patient population, use of a lower but still hypertonic concentration of sodium, eg., 180 mEq/L, still gives the benefits ‘of hypertonic resuscitation without the potential complications of excessive sodium retention and hypernatremia, Tn patients with massive burns, young pediatric pa- tients, and burns complicated by severe inhalation injury, a combination of fluids may be used to achieve the desited goal of tissue perfusion while minimizing edema. In treating such patients, Warden has utilized the regimen of modified hypertonic (lactated Ring: e's + 50 mEq NaHICO,) saline iuid containing 180 mBq Na/L for the first 8 hours. After correction of the metabolic acidosis, which generally requires 8 hours, the patients are given lactated Ringer's alone for the second 8 hours. In the third 8 hours, a 5% albumin in lactated Ringer’ is utilized to complete resuscitation. The resuscitation solution used in Galveston for pediatric patients isan isotonic ghicose- containing solution to which a moderate amount of colloid (human serum albumin) is added. The solu- tion is prepared by mixing $0 ml of 25% human serum ‘Shriners Calculated Volume to Begie Burns Tnstiare Resuscitation Timing Solutions Gincinna “fond 3 kg <8 TBSA burn Tse he Lacared Ringer's + 50 mg NaHCO, ~ 1800 ml/m| BSA 2nd Shr Tactaed Ringer's Bri 8hr — Lacuted Ringe’s +125 g albumin Gaveston 5000 ml/ax? BSA burn + 2000 mi/m? st 24he—Lacated Ringer's + 128 g albumin BSA,34S. Practice guideline for bur care: Chapter? albumin (12.5 gm) with 950 ml of 5% dextrose in a lactated Ringer's solution. “The volume of resuscitation fluid infssed should be adequate for tissue perfusion. The volume of infused. fluid should maintain urine output of 30 ml to 50 ml per hour in adults and 1 ml/kg/hr in children. Te is, important to remember that in children weighing more thanS0 kg, the urine volume should not exceed. 30 t0 50 mi/hr. Heartrateand blood pressure are not necessarily indicative of fluid volume status in the burn patient. Fluid volume status and cardiac output may be measured directly via thermodilution pulmo- nary artery catheterization. However, a low measured. filing pressure with evidence of adequate perfusion is, common. Placement of a Swan-Ganz. eatheter to monitor bum shock resuscitation should be reserved. for burn patients with limited cardiac reserve, such as, the elderly or patients with significant comorbid dis- ‘eases. In addition, bum patients who require ex- tremely large volumes may require monitoring by ‘thermodilutional pulmonary artery catheterization. tis important to emphasize that all ofthe resus: tation formulas are only guidelines for burn shock resuscitation, The Parkland formula, for instance, de- creases the volume administered by 50% at 8 hours postburn. The relationship between the fluid volume required and time postburn depicted by the smooth ‘curve in Figure I represents the influence of temporal changes in microvascular permeability and edema volume on fluid needs, That curve is contrasted with the abrupt changes in fluid infusion rate as prescribed by the formula, The formulas are used as starting, points for volume replacement and to compare the individual patient with the “average” burn patient fo ie he I. “= _ Figure 1. Physiologic curve of fluid requicements com. pated to Parkland formula, emphasizing that formulas are ‘only guidelines for uid therapy during burn shock ** Journal of Bum Care &e Rehabilitation ‘Apel 2001 ‘An interesting question is, “When has bun shock resuscitation been completed successfully?” Ie is ob: vious that resuscitation is completed when there is no further accumulation of edema fluid, which generally ‘occurs between 18 hours and 30 hours postburn. The resuscitation fluids are used until the volume o' fused fluid needed to maintain adequate urine vol ume of 30 to 50 ml per hour in adults and 1 ml/ kg/hr in children equals the maintenance fluid volume. The maintenance fluid requirements follow: ing burn shock resuscitation include the paticnt’s normal maintenance volume plus evaporative water los Fluid Replacement following Burn Shook Resuscitation Although the heat-injured microvessels may continue to manifest inereased vascular permeability for several days, the rate oflossis considerably less than that seen in the first 24 hours, Burn edema by this time is near ‘maximal, and the interstitial space may well be satu rated with sodium, Additional uid requirements will the type of fluid used during the initial ion, If hypertonic salt resuscitation has been used during the entire bum shock period, a hyperos- molar state is produced and the addition of free water will be required to restore the extracellular space toan isoosmolas state If colloid has not been utilized during bum shock and the scrum oncotie pressure is low due to intra- vascular protein depletion, protein repletion often is needed. The amount of protein varies with the type of resuscitation used, Requirements of 0.3-0.5 ml/kg/ TBSA bum of 5% albumin during the second 24 hours are used with the modified Brooke formula. ‘The Parkland formula replaces the plasma volume deficit with colloid, This deficit varies feom 20% to (60% of the circulating plasma volume. Warden et al. have utilized colloid replacement based on a 20% plasma volume deficit during the second 24 hours (circulating plasma volume x 20%) Inaddition to colloid, burn patients should receive ‘maintenance fluids, These maintenance fluids include an additional amount for evaporative water loss. The total daily maintenance fiuid requirements in the adule patient following bum shock can be calculated by the following formula: basal (1500 ml/m?) + ‘evaporative water loss [(25 + % burn) x m? X 24] = total maintenance fluid (m? ~ total body surface area in square meters). This fluid may be given via the intravenous route or with enteral feeding. The solu- tion infused intravenously should be 50% normal sa- line with potassium supplements. With the loss of intracellular potassium during burn shock, the potas-Journal of Burn Care & Rehabilitation Practice guideline for burn care: Chapter 7 358 ‘Table 3. Evidentiary Table: Burn shock resuscitation Overview Reference ‘Description of Study Data Class Conclasion Bauer 1981 Areuospectve view of 954 patients II___-These aides demonstrate a modest bur definite varsity requiring fd esusciation. Of che in hud eequiremens of individual patients; however, 438 adults, 12% required more than most patients required very close 0 4 mi/xg/% bur. the guidelines of4 ml/kg bara and 18% required es than chat. OF the 516 peautric patents only 2% required more than the eleulated rst, 1981" Review ofthe current resuscitation TI nal Guid reusctation should begin at 2 ml/g/% burs formula at NIH census conference 24 be rvitentrodoced the modied Brooke formula OLR a2 mal/kg/ eben 24 he Warden, 19924" Review of bum shock resuscization TIE Many formulas can be scceslly wed in burn shock i he curren formalin use ‘esustaton; however, formals ae only 2 gue 29 inating burn shock resuscitation, Schwan, 19797 Consensus summary on fui TIT The problem ofthe eft of resuitatve regimens onthe ‘resuscitation. The volume of fi 10 postenacsatve phase of buen ines has not be resolved be adminis he Fe 24 ranges from 2 0-4 mi/kg/% burn, "The consensus was that he wlume shouldbe seared athe lower level ofthe sae to minimize hid overload. Mercell etal, 1986" 177 pedi paens were Ti Cihidrea require more lid for esuctation fom burn retrospectively reviewed and thee shock shan do adels wih sila bares. fd recitation characteristics Comment Study sibstasites need for more uid in the were compared. Tn burns >20% pediatsic buen punt and shows that burns >18% BSA BSA, 80% of the cilren required a ‘equi formal fd resuscitation. form of resuscitation. The Sid requirements were neal 2 mi/ig/ Si bun greater than those of ul [Novaret ah 1985% —Revicwaf the burn charctericsof|——‘T_— The combination of ination injury with thermal iniry 171 patients with burns > 25% ‘creases che magitude of total body surfice injury and "TBSA. Inhalation injury was, ‘increases the volume of fuid and sodium needed 0 diagnosed by Xenon sean oF achieve resuscitation from burn shock ‘bronchoscopy. Pasents with inhalation injury required 5.7 ml/ bum, whereas patients ‘without inflation injury required 3:9 mi/ka/% buen sium requirements in adults areabout 120 mEq/day. _perday (burn-related losses) + 1500 ml/m? BSA per In the pediatric patient, increased fluids are required day (maintenance fiuids). due to the differences in BSA to weight ratios com- ‘Once the initial 24- to 48-hour postbuurn period of pared to adults. In addition, children also require rel-__resuscitation has passed, urinary output is an unrel atively larger volumes of urine for excretion of waste _able guide to adequacy of hydration.*® Respiratory products. At the Shriners Bums Hospital, Cincinnati, _water losses, osmotic diuresis secondary to accentu maintenance fluid requirements are calculated by the _ ated glucose intolerance or to high protein, high ca following formula: (35 + % buen) x BSA x 24(evap-_loric feedings, and derangements in the ADH mech: orative water loss) + 1500 ml x BSA per day(main- anism all contribute to increased fluid losses despite tenance fluids). In Galveston, the recommended flu» an adequate urine output. In general, patients wit ids needs are estimated 8 follows: 3750 ml/m? BSA major thermal injures will require a urine output of36S Practice guideline for brn care: Chater 7 1500-2000 ml/24 hours in adults, and 3-4 ml/kg/ hour in children, "The measurement of serum sodium concentration not only is a means of diagnosing dehydration, but also is the best guide for planning and following suc- cessful fluid replacement.** Other useful laboratory indices ofthe state of hydration and guides of therapy include body weight change, serum and urine nitro- ‘gen concentrations, serum and urine glucose concen- trations, the intake and output record, and clinical examination. Continuous colloid replacement may be required to maintain colloid oncotie pressure in very large burns and in the pediatric bur patient. Maintaining, serum albumin levels above 2.0 g/l is desirable. The electrolytes calcium, magnesium and phos- phate must ako be monitored. Although replacement of these electrolytes in burn patients has been studied. in deta, maintaining the values within normal mits is desirable and vary in each patient. SUMMARY ‘The volume of uid necessary to resuscitate burn pa- tients depends on severity ofinjury, age, physiological status, and associated injury. Consequently, the vol- ume predicted by a resuscitation formula commonly must be modified according to the individual's re- sponse to therapy. In optimizing fluid resuscitation in severely bumed patients, the amount of fluid should be just enough to maintain vital organ function with- ‘out producing iatrogenic pathological changes. The composition of the resuscitation fluid, within limita~ tions, in the frst 24 hours postburn probably makes very litle difference; however, it should be individu- alized to the particular patient. Utilization ofthe ben- ficial properties of hypertonic, crystalloid, and col- loid solutions at various times postburn will minimize the amount of edema formation. The rate of admin- istration of resuscitation fluids should maintain urine outputs of 30 mi to 50 ml in adults and 1 to 2 mi/kg, in children. In a child weighing 30 kg to 50 kg, the urine output should be maintained at the adult level. Fluid resuscitation based on our current knowledge of the massive fluid shifts and vascular changes that ceccur following bur injury has markedly decreased mortality related to burn-induced volume loss. The failure rate for adequate resuscitation is less than 5%, even for patients with barns of more than 85% TBSA. ‘These improved statistics, however, ae derived from experience in burn centers where there is substantial knowledge of the pathophysiology of bum injury. Inadequate volume replacement in major bums is, Journal of Burn Care & Rehabilitation ‘Apel 2001 unfortunately, common when clinicians lack suffi- cient knowledge and experience in this area. KEY ISSUES FOR FUTURE INVESTIGATION ‘Areas of bum shock research that need further atten- tion include (1) the definition of the postbum course of capillary permeability changes, and identification of humoral or cellular factors’ influencing these changes; (2) the identification and evaluation of phar macological agents that can significantly alter capil~ lary leakage; (3) elucidation of the relationships be- tween resuscitation fluid composition and pulmonary function changes; and (4) the effect of resuscitation, ‘on late organ dysfunction, such as postresuscitation ‘wound, renal, and pulmonary complications. EVIDENTIARY TABLE ‘Table 3 presents an overview of studies of burn shock resuscitation, REFERENCES 1. Underhill FP. The significance of aniydremia in extensive surface bum, JAMA 1930595:852-7. 2. Moore FD. The body weight bndget: basic Nid therapy for the early bur. Surg Chin North Am 1970550:1249~68, 3. -AruiCP, Moncrief JA. The butn problem. la: Artz CP, Mos: el JA, editors. The weatment of burns, Phladepbias WH Saundets:1969. p. 1-22. 4. rite BA Jr, Mason AD Jr, Moncref JA. Hemodynamic changes in the ety postbarnpaticns he influence of fid sxdistraton and ofa vasoiltor (hydralazine) J Tsuna T971511:36-46, 5, Majno G, Pade GE. Sadie on inlammation, I. The effet ‘of histamine and serotonin on vascular permeabiliy. Cell Biol 1961a1871-8. 46 Maino G, Shea SM, Leventhal M. Endothelial contractures, induced by biseamine type mediators. J Cel Biol 1969.42: 647-72. 7. Anggard E, Jonsson CE. Fux of prostaglandins is ymph fiom scalded tissue. Acta Physio Scand 1971814407, 8, SevteS, Local blood flow in experimental bums. J Pathol Bact 1949;61:427-34, 9. Leape [Inia changes in burns tissue changes in buened snd unburned skins of Rests monkeys.) Trauma 1970510: 485-92, 10. Canal HF, Rrouhard BH, Linaes HA, Fifece of entihisa ‘mine-atiseroronin and ganglionic blocking agers upon i teased capillary permeability following buen trauma J Trauma 1975;15:969~75, LL. Boykin JV Jr, Crate SL, Haynes BW Jt. Cimetidine therapy for buen shock: 2 quantitative assessment. J Trauma 1985; 25:864-70, 12, VanNeuten JM, Janssen PAJ, VanBeck J. Vasclar effects of ‘eranserin (R41 468), a novel antagonist of HIT, sesoto- neg receptors, J Pharmacol Exp Ther 1981;218:317-80 13, Hollman CJ, Meuleman TR, Laren Ki, etal. The eet of etanetin, specific serotonin antagonist, on burn shock ‘hemodynamic parameters ing porcine burn model. J Trauma 1983:28:867-74.Tourna of Burn Care & Rehabilitation 44 45, 16, v7, 18. 2s. 20, 2. 2, 23, 24, 26, 2. 2. 30, 31 Heeger JP, Loy GL, Robson MC, DetBaceao EJ. Histo logical demonstration of prosaglandine and thromoranes in burned tissue. J Surg Res 1980,28:110-17. “Hemdion DN, Abston 5, Stein MD. Inereaied thromboxane B level in the plasma of bummed and septic ued patie Sing Gynecol Obstet 1984;159:210-3, ‘Arsurson G. Microvascular permedbilty to. macromolecaes in thermal injury. Acta Physiol Scand (Suppl) 19793463 11-22 Rocha E Si M, Antonio A, Release of bradykinin andthe mechanism of production of thermic edema (45E C) in the ‘ni'spaw. Med Exp 1960:3:371-8. Hilder IA, Neely AN. Hageman factor-dependent kinia 2c tivation in bums and its theoretical relslonship to postbura Immunosuppresson syndrome and infection. J Bura Care Rehab 1990;11:496~503, ater CR Fluid volume and elecwolye changes inthe early post um period, Cn Dlast Surg 1974:1:695-703. Moyer CA, Margraf HW, Monafo WW. Bar shock and cxtrasculesoditm deficiency: treatment with Ringer's 50 Tuvion with lactate. Arch Surg 1965;90-799 811, [ater CR, Shires GT. Physiological respons v0 crystalloid restactation of severe burns. Ann NY Acad Sei 19685150: 874-94, ‘Moylan TA, Mason AB, Rogers PW, Walker HL Postbum hock: ciel evakiation of resuscitation. J Trauma 1973; 1354-8 Deming RH, Maress RB, Witt RM, Wolbert WH. The sudy ‘of burn wound edema Using dichosmatic absorptiomety, [Trauma 1978;18:124-8. “Hilton JG. Effects of foi resuscitation on total Aud loss following thermal injury. Sure Gynecol Obstet 198)3152: #L7. Schwan SL, Consensus summary on fad resuscitation [Trauma 1979519(L1 Suppl):876~7. Shires GY. Proceedings ofthe second NIET Workshop on ‘Bum Management} Tezuma 1979;19(11 Suppl):862-3. Nedy AN, Nathan P, Highsmith RE. Plasma proteolyc 2c tii following burns, J Trauma 1988,28:3627. “Monafo WW. The treatment of burn shock by the intave- ‘nous and ora adainisuaton of hypertonic lactated saline ‘oltion [Trauma 1970310:575-86. ‘Monafo WW, Halverson JD, Schechtman K. The role of conceatrated sodium solitons inthe resscition of patents with severe buras. Surgery 1984,95:129-35. Demling RH, Gunther RA, Haines B, Kramer G. Burn cedema, Pat Ii: Complications, prevention, and teaumest. Burn Care Rehabil 1982;3:199-206, (Guan ML, Hansbrough JP, Davis JW, Furst SR, Feld TO, Prospective randomized wal of hypereanc sodium lattes. 22 33, a, 35. a6, a. 38 2. 40, a. 42. 4 46 46, a7. Practice guidelines for burn care: Chapter 7. 378 lactated Ringer's solution for buen shock resuscitation [Trauma 1989,29:1261~7. Du G, Sater H, Goldfarb TW. Influence of diferent ress tation regimens on acute weight gan in extensvely bumed patients, Busms 1991;17:147-80, Baxter CR Problems andl complication of burn shock ess: sitation, Surg Cin North Am 1978;88:1313-22. ‘Goodin CW, Dorety J, Lam V, Pit BA Je- Rindomized tol of efficacy of eysalloid and colloid sesusdtation oa Eemodynamic responce and hing water following thermal injury. Ana Surg 1983;197:520-31. Deming RH. Fluid resuscitation, In: Boswick JA J, eto. ‘The arand science of buen cae. Rockville: Aspen; 1987. p. 189-202. Demling RH, Kramer GD, Harms B, Rote of thermalnjury- Induced hypoproteinemia on edema formation in burned and non-burned tissue. Surgery 19849813644 Deming RH, Kramer GC, Gunther &, Nevich M. Bet of ‘son:protein colloid on post-burn edema formation in soft tissues and hang, Surgery 1985;95:593-602. Gels LE, Solvell L, Zederet B. The plasma volume ex: panding efcce of low viscous dextan and Mactodex. Acta (Chir Scand 19613122:809-28. ‘Merrell SW, Safle JR, Selivan JJ, Nevar PD, Krave M, Warden GD. Fluid resusittion sh thermaly inured cl dren, Am J Seg 1986;152:664-9. ‘Graves TA, Giofi WG, MeManos WE, Mason AD Js, Pritt BA], Flidresscittion ofinfans and children with massive thermal injury. J Trauma 1988:28:1656-9. ‘Warden GD. Buen shock resuscitation. Would J Surg 1992; 16:16-23, NavarPD, Safle JR, Warden GD. Eiect of inhalation injury con uid resuscitation requirements after thermalinjury. A Surg 1985;250:716~20, Towser BH, Caldell FI. The eects of resuscintion with byperonic vs, hypotonic colloid on wound and weine Mics and ekctolte losses in severely buted children J Trauma 1983:28:916-28. rut BA Je. Fluid resuscitaon of extensively burned pa sients.J Trauma 1981;21 (Supl):690-2. Baxter CR. Guidelines for fluid resuscitation, J Trauma 1981;21:687-9. Sehnatrs R, Cline C, Goldfeb I, et al. Plasma exchange for fale of ea renusitation in thermal injures. J Buen Care Rehabil 1986;7:230-3, (Carvsl HF. Fuld therapy for the acutely bumed chil Compe Ther 19733(3)17~28 Warden GD, Wilmore D, Rogers P, Mason AD, Pruitt B “Hypematremic state in iypermetabolc bum pants. Arch ‘Sarg 1973;1063420-3,Chapter 8 Hypertonic Fluid Resuscitation RECOMMENDATIONS Standards There are insufficient data to support a treatment standard at this time. Guidelines ‘There are insufficient data to support a treatment guideline at this time. Options Hypovolemia after thermal injuries i a life-threaten- ing complication, requiring immediate correction. Resuscitation with hypertonic saline may be used to maintain a urine output of 0.5 to 1.0 ml/kg/be as a sign of adequate circulating intravascular volume. ‘The physician must monitor the patient to prompily diagnose and treat serum hyperosmolarty ‘or hypernatremia, which may complicate cis therapy. OVERVIEW Purpose ‘The purpose of this guideline is to review the use of hypertonic-based resuscitation regimens for bum. care, and to present a rational and reasonable ap- proach for the treatment of patients using this method. Users ‘This guideline is designed to aid those physicians who are responsible for the triage and initial management of burn patients. Clinical Problem ‘After a thermal injury, ther is rapid release of tissue cytokines, which increase vascular permeabily.!? With small burns, the effec is local, but with major thermal burns (>25% BSA) these changes are system- ic? If fluid resuscitation is nor done, hypovolemia, shock, and death supervene. Rapid advances in un- derstanding the pathophysiology of burn shock inthe 1idportion ofthe 20th century led tothe adoption of. resuscitation with large volumes of isotonic crystal: Joid solutions.* 388 But these regimens (Evans, Brooke, Parkland, and others) have complications as well.°* Patients with major thermal burns who are resuscitated with iso- tonic fluids experience massive weight gain in the first 24 hours, with profound edema of burned and un burned tissue, Many require endotracheal intubation to protect their airway, and escharotomies are r0u: tinely performed for circumferential fall-thickness in juries to prevent distal ischemia as the tissue swells, ‘The sodium administered in the frst day potentiates fluid retention for weeks thereafter. As the extracel lular uid mobilizes, hypervolemia may worsen pul monary function or tigger pulmonary edema.” Tleus also may accompany generalized tissue edlema. In the 1970s, Monafo,° Moylan,* and others proposed us- ing smaller volumes of hypertonic sodium solutions for resuscitation in an attempt 10 limit the massive tissue edema and weight gain. PROCESS [A Medline search for English-language publications fon burn studies in human subjects published since 1966 using combinations of the keywords “hyper tonic,” “resuscitation,” “burns,” and “thermal in jury” yielded 48 articles. Of these, 18 were found to be clinically relevant. These 18 papers were individu: ally reviewed for design content and were used in the analysis presented here SCIENTIFIC FOUNDATION ‘The goal of fluid resuscitation for thermal burns isthe stabilization of plasma volume status to prevent isch- cemic damage at the cellular and organ levels, without fluid overload? After thermal injury there is a rapid accumulation of edema fluid in the region of the in- jury, associated with a local capillary leak, In extensive burns, this leaking occurs throughout the body, and. profound hypovolemia can lead to lactic acidosis, re- nal insufficiency, cardiovascular collapse, and death. The leak allows serum proteins to escape into the extracellular space, and intravascular water follows these proteins. This correlates with an observed drop in serum osmolarity and seram oncotic pressureTournal of Burn Care & Rehabilitation (measured as total protein and albumin). This protein leak decreases within 24 hours, and, in many centers, colloid infusions are limited to the second 24 hours after bums. Hypertonic saline solutions can be used early in the resuscitation phase after thermal burns. Rapid inf sion produces serum hyperosmolarity and hyper- natremia, with two potentially positive effects.°"° ‘The hypertonic serum reduces the shift of intravascu- Jar water into the extracellular space. Proposed ben- efits include decreased tissue edema and fewer atten- dant complications (escharotomies for vascular compromise or endotracheal intubation to protect the airway). Shimazaki et al” resuscitated 46 patients ‘with either lactated Ringer's (LR) or hypertonic sa Jine solution (HSS). The sodium infusions were equivalent, but the free water load was greater with LR; 50% of the latter required endotracheal intuba- tion. The hypertonic serum also delivers a more con- centrated ultrafiltrate within the kidney. This in- creases urine volume and salt clearance without marked increases in the required volume of free water. ‘There is no consensus regarding the type or osmo- larity of hypertonic resuscitation fluid. In 1979, Cald- well et al reported a series of 37 patients with buens greater than 30% treated with either LR or hypertonic lactated saline (HLS), but no colloid. Total sodium, balance was the same, but the HLS gronp received 30% less free water, and the reduced weight gain was maintained for 7 days. Subsequent reports from this, institution reported successful HLS resuscitation in the elderly and children, but no improvement in late mortality 22 Bortolani et al‘ randomized 40 patients with greater than 40% burns to receive LR or HLS. HLS. patients received more sodium, but less total fuid than those in the LR group. The observed higher mortality with HLS was attributed to larger burns in this group. ‘The role of colloid in association with hypertonic sa- line resuscitation alsois unclear. Most physicians reserve colloid for the second 24 hours, if at all, unless the pa- tient remains poorly perfused after large infusions of crystalloid (see Chapter 9). Griswold et al™* reported. resuscitation of 47 patients with HSS, Of these, 29 pa- tients also were given colloid as albumin or fresh frozen, plasma based on bum severity, premorbid state, or poor response to HSS resuscitation. This group had lager ‘burns, greater mean age, and higher incidence of inha- lation injury, but required only 57% of the fuid volume predicted by the Parkland formala, compared to 75% of predicted volume in the group that received HSS alone. Both groups maintained urine volumes of 1 ml/kg/hr Practice guidelines for barn care: Chapser 8 398, with no significant difference in hematocrit or serum sodium levels Jelenko et al? also reported in a small series that patients given HSS and albumin required fewer escharotomies, fewer days of mechanical ventla- tion, and less total uid than patients resuscitated with LR or HSS alone. Gunn etal, ina series of 51 ran- domized patients, found no difference in fluid require- ‘ments or weight gain if they were given LR or HSS, ‘when fiesh frozen plasma was administered to maintain, serum albumin levels above 2 gm/dL. All patients re- ceived hypotonic enteral feedings during, resuscitation, ‘which may have contributed to serum sodium level. ‘Yoshioka et al!” reviewed 53 patients treated with igreater than 30% burns resuscitated with LR, LR and colloid, or HLS. Fluid requirements were 4.8 ml/ kg/STBSA with LR, 3.3 ml/kg/STBSA with LR and colloid, and 2.2 ml/kg/%TBSA with HLS. The total sodium requirements were increased 30% with LR compared to the other groups. Oxygen extrac- tion, measured as A-V Oy difference, was improved ‘with HLS, but reduced with LR plus colloid, perhaps, because of protein leak across the alveoli. ‘Vigorous administration of hypertonic saline solu- tions can produce a serum sodium above 160 mEg/dl or scrum osmolarity greater than 340 mOsm/al, followed by a rapid fallin urine output.* Bowser-Wallace et al!? and Crum et all? have re- ported that 40% to 50% of patients treated with HLS developed hypernatremia with serum sodium greater than 160 mEq/L, requiring a switch to hypotonic fluids. Huang et al reported a series of deaths asso- ciated with hypematremia and. hyperosmolarity fol lowing hypertonic saline resuscitation. Serial determi- nations of serum sodium and serum osmolarity are required to prevent complications including sudden anuria, brain shrinkage with tearing of intracranial vessels, or excessive brain swelling. following rapid correction of serum hyperosmolarity In these studies, hypertonic saline resuscitation, with or without early colloid infusion, did not reduce the long-term mortality of major burns. Because ‘most patients with thermal burns are easily resusc- tated with isotonic crystalloid solutions, and hyper- tonic resuscitation does not improve mortality, the use of hypertonic saline has not gained wide accep- tance in the burn community. It is classed as an op- tion for use by experienced physicians only, because of the attendant risks. SUMMARY ‘Human studies have shown that hypertonic saline, combined with careful monitoring, is one option in the fluid resuscitation of major thermal burns.80S. Practice guidelines for burn eve: Caper 8 Journal of Buen Care & Rehabitaton ‘Apel 2001 ‘Table 1. Evidentiary Table: Hypertonic resuscitation Reference Study Des Dara Class Conclusions Caldwell etal Prospective wil of 37 children with T HLS pants recived more Na but 30% les water though 19755" ‘burns >304 BSA alternately 48 hr and less weight gain through 7 days. At 48 he, no assigned to resuscitation with LR (a liference in Na balance. No wacheoswomnies £20) of HLS (a = 17), combined -Fecharotomies: LR, 4; HIS, 2, Three deaths unrelted 0 with oral Haldane’ solution on day resuscitation. 2, but no albumin®™ BowserWallce etal, Review of 26 patients overage 6O with T= 21/24 aurvved attempted resuscitation >48 hr. 2 not 19857 bums >30% BSA, resscitated with resuscitated for medical reasons, iid was 3.3 ml/eg/% HLS" 10 had 5G catheter, first day, 5.0 ml /eg/% after 2 days 13/26 had hypernatremis. Only 2/26 ded of rena Faure and 3/26 of respiratory faure. Overall, 23/26 die. Gunn ec al, 1989? Prospective randomized tial of S1 1 Nosigniscanecifrences in weight gain, total fide, ral patents (burns >20% BSA) sodium, or morality. No daa on deaths, rena falar, resuscitated with H5/colloid pulmonary edema, or compartment syndrome. LR/colloi,** All received cay ‘bypotonic enteral feedings and FEP to maintain albumin of 2.0 Ductal, 1991 Review of 3 consecutive groupe of 10 Voumes were 4.8 ml/kg/% LR, 32 kg/ml/6 HFT, and patients overage 16 with bums 2.7 mi/bg/% FFP. LR group guned 10.7% at 24 be vs. 30% BSA given LR, HSS, or FFP 7.9% for HSS and 2.4% for FED. At48 hr, LR = 13.8%, to maintain U/0 >05 al/kg/ie HSS = 12%, and FFP = 488, “Many” in HSS group, fr 48 et developed serum Na >160, but 20 data on renal or pulmonary flue. 7/30 deaths Bowser Wallace etl, Prospective train 38 patients under ‘TN requirement similar, but 50% greater Mi ond wth 1986" age 21 with >30% BSA altematey ‘LR colloid and sgniicandy greater weight pain 2848 ‘signed to resuscitation sith HLS tbr, Metabolic alkalosis and increase serum Na with HLS. or LR colloid. Inalation injury Colloid givens 48 br persisted only unl 96 he. ‘each. Analysis foe diferencesin {uid volume, Na load, and weight sin Bowser-Wallie et, Continued prospective tial of HLS oc Increased id and Na requirement inchilen younger 1986 ER /collold, now in SI hiléren ‘than 3 (s. older eldeen),disppeared if BSA rather than vith burns 30% BSA alternacly weight was used to calculate uid need. In children assigned to resusiation with HLS younger than 3, Nalosd wa che same with HLS or LR/ or LR/colloid.” Anahi for colloid, but Mid lod was greater with the later. Seruzt silferences in chldeen older of [Na levels were higher in children under 3 compare to younger than 3 olde cilien, and 4/8 HLS <3 y had serum Na > 160. Yoshioka ctal, Review of $3 patiens with burns TIL Total uid t 48 he were 4.8 ml/kg/% for LR, 3.3 ml/kg/ 1980" 304 BSA treated with LR, LR/ % for LR/colloid, and 2.2 mi/g/% for HLS, Toul Ne colloid, of HIS. LR and HIS eguirernent with LR was 30% higher than withthe other g20ups also sven colloid after 36 he, ‘weatmenss. AV O, difference widened with HIS and Al patients had §.G catheters arrowed with LR/coloid. ‘Monafo etal, 19847 Review of 74 patients with bums TIT —_Naloaés and urine ompacs comparable among all thee 40% BSA, rewospectively divided ‘groups, but LR group required 44% more fice water than Jn 3 groups based on the average HILS. Paints overage 60 required more Na and fee ‘osmolality ofthe resuscitation hid water than those under 60.7/74 died during the second in the rst 24 he, 24 hr, Overall, 31/74 died, but “no significant ‘conrltion” wis fond benveen uid concentration and Huang eta, 1995" Review of tree consecutive groups IL Total id ond in frst 24 hr was significant less forthe resuscitated inthe bara ICU with HSS group. All groups had U/O ofl ml/Ag/% forthe LR (x = 109), 8S (n = 65), then fase 48 hr In HSS group 26/65 developed real flare nother LR group (a = 39). Non (25 died, but only Le were predicted). In fist LR group, standard FSS resuscitation 11 of 109 developed renal ure (10 died, 8 predicted)Journal of Burn Care & Rebbiitsson Practice guidelines for burm care: Chapter 8 418 ‘Table 1.—Comsinued Reference Study Design Data Clas Conclusions (Gram ecal, 1988" Prowective BSA study of 4 patients TA Total lds were 6.7 mi/kg/ infest 24 h OF HIS. Na ‘with burns 20-60% BSA resuscitated Joa was 1 mBa/kg/% in ist 24 h and 1.2 foe fist 8 b ‘with HIS only. Blood sme for 6 14 had episode of erum Na > 160. 1 death— neurohumoral responses. 10 onpreventable paveats had Sg eathetert Bortolanictal, Prospective andemized wail oF 40 1 HIS patients reqited more Na but les flail volume than 19967 patents with hurme >40% BSA TLR patients. HIS patients had metabolic alkalosis, bat resuscitated with LR (Parkland) or lexser morbidity. Moraliy was higher with HES, who His had larger burns. Geiswold, 1991" Review oF 47 adlts with burns >20% —‘IT._——-Mean manimal weight gin was 7.3%, Only 2 patients BSA, resucited with HS ( requted 4 ml/ag/%¢ of HSS. HSS required 8 ml/eg/% 18) o HSS with cold (n = 29), and the HSS colloid required 2.3 ml/kg./% coral ids Colloid use determined by burn in the ise day. 4/18 died in che HSS group, nd 19/29 evo, premorbid sate oe poe led inthe HSS colloid, but all patients survived a least response to HSS, 5 days. Jelenko etl, 1979" Prospective randomized tian 19 Patients given mixed HSS/albumin equired les id, were pens with buens ver 20-98% resuscitated more quickly, met uid needs poinshorcer ISA, resuscitated with LR (a = 7), ‘ime and required ls otal Suid in fist 72 howe than HSS (n = 8), or HSS /albumin (a = the other wo groups. No escharoromies with 7)! All patients had SG catheter |HS8/albomin but 10/12 in the other groups. Veat suppor 1/7 with HSS albumin, but 6/7 with LR and 3/5 with HSS. No ena luce in any group, 4/19 late dest, Demling, 19833 Review of 16 patents er 1980 with ‘IN_—_-Patient treated with HS/olloidin frst 24 hours had 30% puns >50% BSA resusisred with decrease in uid requtements compared to historical 1HScolloid compared with 13 coats similar burns before 1980 resuscitated with LR. Other treatment changes included eater ‘excision and rapid insiution of enteral feedings Shimazaki etal, Prospective non-randomized wal of U—_Nalloads were the same but water was greater for LR. 50% 19917 46 putienss with baens >30% BSA ‘OF LR patients required endotracheal intubation, Changes resuscitated with HS (a = 17) oF Jn funcional extracellular fuid volume correlted with L&(n = 29), Pulmonary function respiratory index (A-aD0,/P202) parameters analyzed on day 3-5. Shimazaki etl, Review oF 12 paints resuscitated with TT]__Na loads were equal in the two groupe, i id volume 19778 "ILS compared r0 26 resuscitated ‘was educed by moce chan 40% with HIS at 48 he, vith LR. Serum Na of 165 associated with marked decree in renal function, 145%, areioenousonygen cone difeenc; FFP, fe frozen plasm HS, peti lactated saline; HSS, yperoak aie soluon; LR, aad lage? 5.6 San- Gans; 1/0, ize arpet * Day 12 mi/eg/6 15 in fr 26 b(n fh) wih 0 fe water, bt en onl iy eons to hry Day 2-H, 06nd ora idan’ sols (Ne 78, K60 mE Cl 60 mig, aed bicarbonate 18 mB per te). "Inhlason injury exces, 2/5/24 rn st 8 he) wd 0 ee water. “Adon Mid by response to therapy" Day2—L 1 ml/g WLR and ane ie water, HLS, 0.6 ml/ag/ ad ol Haldane soon. 1 tahiti injec. 2o/Ag/in is 24 be (+ ns 8 he wh oe wate. “Adana uid by tsponse wo then.” Day2—LR, 1 a/R and wae fie water, HLS, 0.6 l/eg/ and orl Haldane soon. 5 1 ined wo maintain U/0 ofl /Sg/ and peony BP valves, Cold we deremin’ by bun seve, premotid ste, and response to HSS "LR gen omni U/O of 0-50 l/l, MAP af 60-110, ac pute leehan 110 SS oe HSS albumin gen tomaitin U/0 of 30-60 /b, MAR of 0-110, ac es than ; consined ul Hud nes met po. “TLR ico cr HL gen to malas U/0 greater han “60% of opium.” Cold beg a 36 be or LR of HLS, beta m0 12 he or Leo Lor HPT (NaCL 164 mig and sx acetate 10D mag pric) vn # ml /Ag/ia i 28h, BEP group cated at 75 e/g over 36 pon 2 Ll LR per day, Noo intake fo ny group fr 48. ++ HS(Na250 mis, Cl 187 még, cae 70 Ea, KA a9 and C3 mB er 14 Os) LA gen to tsa 11/0 of 05-1 liga inion tase deft on ABG. Conined about 24h nti patent mabe on Sido 1 5 ml/tg/. Alf gven PHP afin ep albmin>2 for? dae428 Practice gideline for burn care: Chapter 8 Smaller series supporting the addition of colloid in the first 24 hours await confirmation. KEY ISSUES FOR FUTURE INVESTIGATION ‘The optimal resuscitation regimen using hypertonic saline has not been defined. Use of hypertonic sola- sions beyond the first 24 hours may increase the risk ‘of renal failure, despite an apparently adequate urine output.”® Further studies are needed to delineate these risks, and any incremental benefit of colloid solutions EVIDENTIARY TABLE Table 1 presents a summary of research on hypertonic resuscitation. REFERENCES 1. Lund T, Onasheim H, Reed RK. Pathogenesis of edema formation in bur ijusies. World J Surg 199231629. 2, Youn¥-K, Lalonde C, Demling R. The ole of mediacorsin the response to thermal injury. World J Surg 1992;16:30~ 36 8. Arturson G. Pathoptysiological aspects of the burn syn- frome. Acta Chir Seand 1961;278( Spl). 4, Warden G, Barn shock resuscistion, World J Sung 1992316: 16-23. 5. Reaves LE, Antonacei AC, Shires GT. Fld and electrolyte resuscitation ofthe thenmaly injured patent. World J Sarg 1983;16:566-72 (6. Monafo WW. The treatment of burn shock by the intrave- ‘ous ad oral administration of hypertoni lactated saline olution, J Trauma 197010:575-86. 7. Shimazal 8, Yukioks T, Matuda H. Fhid diseibution and pulmonary dysfunction’ following bur shock. J Trams 1991;31:623-6. 8. Moylan JA, Jr, Ricler JM, Mason AD J. Resuscitation with ypertonic lactate saline in tema njary, Am J Surg 1973, 1IS880, 9. Bowser-Wallace BE, Cone JB, Caldwell FT Jr. Hypertonic 10, n. 12, 13. 14 16. 16. 18. . 20 21 23, 24 Journal of Burn Care & Rehabiittion ‘Apri 2001 lactate sine resuscitation of severely burned patents over 60 yeas of age. J Trauma 1985 253:22-6. Caldwell FF; Bowser BEL. Crtcal evaluation of hypertonic tnd hypotonic solutions to resuscitate severely burned Children: a promective study. Ann Surg 1979:189546-52. Bowser Wallace BH, Caldwell FT J, prospective analysis of iypertonic lactated saline vs. Ringers latate-collo for the resuscitation of severely burned children. Bums Incl ‘Therm Inj 1986 12402-9, Bowser Wallace BH, Caldwell FT J. Fluid requirements of severely bummed children up 0 3 yeas old: hypertonic lac ‘ated saline s. Ringers acate-coloid. Burns inl Ther In 1986 ,12:549-55, Bortolani A, Govern M, Barsoni D. Fuid replacement in burned patents. Acta Chir Pas 1996;38:132~6 Guiswold JA, Anglin BL, Love RT Js, Scott-Conner C. By- pertonicslineresusseation”efeacy in a community based burn unit. South Med | 1991;84:692-6. Jelenko C 34, Willams JB, Wheeler MIL, er al. Seales ia shock and resuscation, I: Use of a hypertonic, albumin onzaining, uid demand regimen (HALFD) in resusita tion. Gris Care Med 1979:7:157-67. Monafo WW, Chuntraskul C, Ayvarian VH. Hypertonic sodium solutions in the treatment of burn shock. An] Surg 1975;126778-83. ‘Yoshioka 1, Maemora K, Ohhashi¥, Sugimoto H, Takahashi 1M, Sugimoto T, Efecofintavenovaly adminiered fd on, heimodynamic change and respiratory function ia extensive ‘eval injury. Surg Gynecol Obstet 1980;151:503-7. ShimazakS, Yoshioka T, Tanaka N, Sugimoto T, On. Body idl ebanges during hypertonic lactated sline solution therapy for bur shock. J Tauma 1977;17:38—33, (Crum &, Bobrow B, ShackfordS, Harsbrough J, Brown MR ‘The neurohumoral response to bura injury in paints rex slated with hypertonic saline, | Trauma 1988;28:1181~7. Hung PP, Sticky #5, Dimick AR, Treat RC, Bessey PQ, Rue LW. Hypertonic sodium resuscitation is associated with renal Blue and death. Ann Surg 1995221:543-54, Demling RI, Improved survival after massive burns, J Traums 1983:23:179-84 Du GR, Site, Goldfrb1W. Influences of diferent ress citation regimens on acute eary weight gain in extensively bhumed patients. Burs 1991:17-147-50. Gunn ML, Hansbrough JE, Davi TW, Furst SR, Feld TO. Prospective randomized tl of hypertonic sodium lactate ‘versus lactated Ringers solution for urn shock essctation, J Tratma 1989,20"1261-7. Monafo WW, Halverson JD, Schechtman K. The role of ‘concentrated sium solutonsin he resuscitation ofpatients ith severe burns. Surgery 1984:95:129~5.Chapter 9 Fluid Resuscitation: Colloid Resuscitation RECOMMENDATIONS Standards ‘There are insufficient data to support a treatment standard at this time Guidelines: ‘There are insufficient data to support a treatment standard at this time. Options ‘The use of colloid-containing fluid may aid in restor ing oncotic pressure and maintaining intravascular volume following dilution of plasma proteins by crys- talloid resuscitation. It is most effective when used. during the second 12 to 24 hours following bum. injury or in patients who cannot be resuscitated with, crystalloid alone, Colloid-containing fluids have no demonstrated advantage over crystalloid when used, in the first 8 to 12 hours postburn ‘The use of colloid-containing fluids may facilitate ‘bur shock resuscitation with smaller total volumes than are needed for resuscitation with isotonic, crystalloid. Initiation of resuscitation with colloid-containing fluid is associated with an increase in extravascular lung water. The clinical significance of this finding is unknown, OVERVIEW Purpose The purpose of this guideline is to review the devel- ‘opment and use of colloid-based resuscitation formu- las, and to present a rational and reasonable approach. for the use of such formulas in the cate of bum patients. Users This guideline is designed to aid those physicians who are responsible for the triage and initial management of bum patients. Clinical Problem ‘The goal of fluid resuscitation in the burn patient is maintenance of vital organ function without fluid overload. To optimize Buid resuscitation in severely bburned patients, the amount of fluid should be just enough to maintain vital organ function without pro: ducing iatrogenic pathological changes. Plasma pro: teins are important in the circulation, because they generate the inward oncatic force that counteracts the outward capillary hydrostatic force. During the first 8 to 12 hoursafter thermal injury, there i a rapid accumulation of edema fluid locally; in large bums, these capillary leaks occur throughout the body. Re suscitation with crystalloid uid may result in a marked decrease in plasma proteins and loss of plasma concotic pressure. Considerable controversy exists concerning the role of colloids in burn resuscitation. Experimental evidence supports the concept that during the fist 8 to 12 hours postbur, colloid-con raining fluid has no demonstrated advantage over crystalloid and is associated with an increase in ex- sravascular lung water. Jn large burns, however, the loss of oncotic pres- sure during the final 8 to’ 12 hours of burn shock resuscitation may require the administration of col- Joid to achieve resuscitation. This is a common find ing in pediatric burn patients. Regardless of the com position of the fluid in the first 24 hours postburn, it should be individualized to the particular patient. The use of hypertonic, crystalloid, and colloid solu- tions at various times postburn often will minimize the amount of edema formation and facilitate burn shock resuscitation. PROCESS A Medline search was conducted for the years 196610 1998 for all English-language publications on re search done in humans involving the key words “re: suscitation,” “burns,” “thermal injury,” “colloid,” “dextran,” “albumin,” “plasmanate,” and “fresh fro- zen plasma.” Inaddition, selected articles dating back. to 1972 were collected from Irving Feller’s Interna~ tional Bibliography of Burns. Of particular interest, there was only one Category 43844S Prasice guideline for bum care: Chager 9 article in which a prospective, randomized study was done comparing colloid ys. crystalloid resuscitation, ‘The remaining articles were clinical publications of retrospective reviews of individual authors? use of a particular resuscitation fluid. Animal models were not ‘used except in the pathophysiology of burn injury. ‘SCIENTIFIC FOUNDATION Modern fluid resuscitation formulas originate from experimental studies in the pathophysiology of bura shock. Burn shock is both hypovolemic and cellular shock, and is characterized by specific hemodynamic changes, including, decreased cardiac output, de creased plasma volume, and oliguria, As in the reat- iment of other forms of shock, the primary goal is to restore and preserve tissue perfusion in order to avoid ischemia. However, in burn shock, resuscitation is complicated by obligatory burn edema, and the vo- Juminous transvascular fluid shifis that result from a ‘major burn are unique to thermal trauma, Although the exact pathophysiology of the postburn vascular changes and fluid shifts is unknown, one major com- ponent of burn shock is the inerease in total body capillary permeability. Direct thermal injury eesults in marked changes in the microcirculation. Most of the changes occur locally t the burn ste, when maximal edema formation occurs: at about 8 hours to 12 hours postinjury in smaller burns, and 12 hours to 24 hours postinjury in major thermal injuries. The rate of pro- gression of tissue eclema depends on the adequacy of resusitation.! ‘Although the etiology of burn shock is not totally understood, many authors have studied the fluid vol- tume shifts and hemodynamic changes that accom- pany burn shock. Easly work by Moyer, Baxter, and Shires established the definitive role of erystalloid so- lutions in burn resuscitation and delineated the fluid volume changes in the early postbur period.” Baxter went on to demonstrate that during the frst 4 hours postbur, plasma volume changes were independent Of the type of infused fluid, whether exystalloid or colloid, but at approximately 24 hours postiajury, an infused amount of colloid would increase the plasma volume by the sume amount.’ His findings suggested that colloid-concaining solutions are an unnecessary component of fluid resuscitation in the first 24 hours. He recommended their use only after capillary intex~ rity was restored, to correct the persistent plasma vol- ume deficit of about 20% as measured externally. In 1973, Moylan and associates,* using @ canine model, defined the relationships among fluid volumes, so dium concentration, and colloid in restoring cardiac output during the frst 12 hours postinjury. No sig: Journal of Bura Care Se Rehabilitation ‘Apil 2001 nificant colloid effect on cardiac output was noted in those first 12 hours. In addition, 1 mEq of sodium ‘was found to exert an effect on cardiac output equal to 13 times that of 1 ml of salt-free volume. This experiment established the fact that any combination of sodium and volume within the broad limits of the study would effectively resuscitatea thermally injured patient. ‘Arturson’s® landmark studies in 1979 on vascular permeability characterized the nature of the “leaky capillary” in the postburn period. He demonstrated ina canine model that increased capillary permeability is found both locally and in nonburned tissue at dis tant sites when the total body surface area burn ex- ceeds 25%, He proposed that the burn woundis char- acterized by rapid edema formation due to dilatation of the resistance vessels (precapillary arterioles); in- creased extravascular osmotic activity, duc to the products of thermal injury; and increased microvas- ‘cular permeability to macromolecules. The increased permeability permits molecules of up to 350,000 mo- lecular weight to escape from the microvasculature, a size that allows essentially all elements of the vascular space except red blood cells to escape from it. Further studies by Demling and coworkers®” have demon- strated that in 50% TBSA burns, one half ofthe inital fluid resuscitation requirement may end up in non- thermally injured tissues. Plasma proteins are extremely importantin the cir culation, because they generate the inward oncotie force that counteracts the outward capillary hydro- static force. Without protein, plasma volume could not be maintained and massive edema would result. Protein replacement was an important component of early formulas for burn management. The Evans for- mula, advocated in 1952, used 1 ml/kg of body weight/% burn each for colloid and lactated Ringer’s over the first 24 hours.® The Brooke formula clearly ‘was based on estimate rather than determined scien~ tically, but the formula used 0.5 ml/kg/% bum as colloid and 1.5 ml/kg/% bum as lactated Ringer's? The buen budget of Moore similarly used a substan- tial amount of colloids.” Considerable confusion exists concerning the role of protein in a resuscitation formula. There are three schools of though: 1. Protein solutions should not be given in the first 24 hours because during this period they are no more effective than salt water in maintaining intravascular volume, and they promote accu- ‘mulation of lung water when edema fluid is be- ing absorbed from the burn wound." 2. Proteins, specifically albumin, should be given from the beginning of resuscitation along withJournal of Burn Care & Rehabilitation exystalloid; they usualy should be added to salt 3. Protein should be given between 8 and 12 hours postburn using striey crystalloid in the first 8 hours to 12 hours because of the massive ffuid shifts during this period. Demling’? demonstrated experimentally that res- toration and maintenance of plasma protein contents were not effective until 8 hours postburn, after which adequate levels can be maintained with infusion. Be cause nonburned tissues appear to regain normal per- ‘meability very shortly after injury and because hy- poproteinemia may accentuate the edema, the action advocated by the first school appears t0 be least appropriate. Warden and associates! have utilized a modified hypertonic and colloid resuscitation in major thermal injuries >40% TBSA burn. The resuscitation uid contains 180 mEq NA" (lactated Ringer's + 50 mEq NaHCOj). The solution is used until the reversal of metabolic acidosis is achieved, usually by 8 hours postburn. The volume administered is begun at arate calculated by the Parkland formula (4 ml/kg/% burn), with volume titrated to maintain urine output at 30 to 50 ml/h. After 8 hours the resuscitation is completed using lactated Ringer's to maintain urine output at 30 to $0 mi/hr. This hypertonic formula ‘can be used in infants and in elderly patients without the accompanying risk of hypernatremia. In large bburns colloid is added to the resuscitation fluid dur- ing hours 17 to 24 to maintain plasma oncotic pressure. The choice of the type of protein solution can be confusing. Heat-fixed protein solutions, eg., Plas- ‘manate™ (Bayer, Elkhart, IN), are known to contain some denatured and aggregated protein, which de- creases the oncotic elect. Albumin solutions clearly ‘would be the most oncoticaly active solutions. Fresh frozen plasma, however, contains all the protein frac- tions that exert both the oncotic and the nononcotic actions. The optimal amount of protein to infuse re- ‘mains undefined. Demling!™ uses between 0.5 and 1 ml/kg/% bum of fresh frozen plasma during the fist 24 hours, beginning at 8 hours to 10 hours postbur. He emphasizes that all major burns require large amounts of fluid, but notes that older patients with ‘bums, patients with bums and concomitant inhala- tion injury, and patients with burns in excess of 50% ‘TBSA not only develop less edema but also maintain hemodynamic stability better with the addition of protein. Slater and coworkers,'* based on, publications of Griffiths ct al! and Aharoni ct al,* recently have used fresh frozen plasma during bum shock. They use Practice guidelines for burn cave: Chagrer 9. 45S, lactated Ringer's, 2 liters for 24 hours, and fresh fro- zen plasma, 75 ml/kg/24 hrs. Although the volume of fresh frozen plasma is calculated, the volume in- fused is titrated to maintain an adequate urine output. Although the authors are using colloid early in the tburn shock period, they emphasize that most bum patients have received lactated Ringer's in significant volumes during ficld management. Dextran is a colloid consisting of glucose molecules that have been polymerized into chains to form high- ‘molecular-weight polysaccharides.!© This compound is commercially available in a number of molecular sizes. Dextran, which has an average molecular weight of 40,000 daltons, is referred to as low-molecolar-weight dextran, British dextran has amean molecular weight of 150,000, whereas the dextran used predominantly in Sweden has a molecular weight of 70,000. Dextran is ‘excreted at the kidneys, with 40% removed within 24 hours. The remainder is slowly metabolized. Demling and associates have utilized dextran 70 in a 6% solution to prevent edema in nonbumed tissues.” Dextran 70 cartes some risk of allergic reaction and can interfere with blood typing. Dextran 40 actualy improves the ‘microcirculatory flow by decreasing red cell aggreya- tion." Demling and colleagues"® demonstrated that thenet requirements to maintain vascular presureat the baseline levels with dextran 40 were about half those seen with lactated Ringer's alone during the fist 24 hours postbum. These authors have used an infusion rate of dextran 40 and saline of 2 ml/kg//hr along with sufficient lactated Ringer’s to maintain aclequate perf- sion. At hours, an infusion of fresh frozen plasma at 0.5 to 1.0 mi/kg/% TBSA burn over 18 ho i tuted, along with necessary additional crystallo In the young pediatric burn patient with major burn injury, colloid replacement often is required be- cause serum protein concentration decreases rapi luring burn shock. The Shriners’ Hospitals for Chil- dren in Cincinnati and Galveston both routinely use colloid during resuscitation of children with major thermal injuries.” SUMMARY The finid volume necessary to resuscitate burn pa tients depends on severity ofinjury, age, physiological status, and associated injury. Consequently, the vol- ume predicted by a resuscitation formula commonly must be modified according ¢o the individual's re- sponse to therapy. In optimizing fluid resuscitation in severely burned patients, the amount of fluid should be just enough to maintain vital organ function with- out producing iatrogenic pathological changes. The ‘composition of the resuscitation fluid, within fimita-46S Practice guideline for burs care: Chapter 9 Journal of Burn Care & Rehabilitation ‘pail 2002 Table 1. Evidentiary Table: Colloid Resuscitation Reference: Description of Study Data Class ‘Conclusion /Comments ‘Goodwin eal, Report of 79 patients randomly T Theadditon of colloid to crystalloid resuscitation Maids 983 assigned to receive lactated Ringers sulted in deceased Mod equirement but produced 20 solutions of albumin lace, long-lasting benefs on roa body blood flow and -Resuscistion with albumin was promoted the simulation oflung water with edema seared immediately afer bar. Aid being reabsorbed fiom the burn wound. Patents cated with ental Comment: The clinical Sigiicance of increased hung water required more fui for successful ‘unknown resuscitation than those receiving, colloid (P< 01). Lang water remained unchanged inthe crystalloid tested group but increased progressively inthe 30% TBSA bums.' Moreover, only 60% of the respon: dents who addressed treatment goals following PAC insertion indicated that they used predetermined physiologic parameters to direct fluid therapy. PROCESS ‘A Medline search of human studies using the key- words “resuscitation,” “fluid therapy,” “burns,” “monitoring:physiologic,” and “catheterization- ‘Swan-Ganz” identified 50 English-language publica tions from 1965-1998, Additional literature was selected relating to pulmonary artery catheter moni- toring and endpoints of resuscitation in other criti cally il and trauma patients. Thirty-two citations were found to be clinically relevant and were used as the basis for this analysis.Journal of Buen Care & Retaiitation SCIENTIFIC FOUNDATION (Clinical monitoring of bum shock resuscitation tra- ditionally has relied on clinical assessment of cardio- vascular, renal, and biochemical parameters as indica- tors of vital organ perfusion. Heart rate, blood pressure, and clectrocardiographic recordings are the primary modalities for monitoring cardiovascular sta- tus in any patient, Fluid balance during burn shock resuscitation typically is monitored by measuring. hourly urine output via an indwelling urethral eathe- ter. Te has been recommended that urine output be maintained between 30 and 50 mi/hr in adults? and between 0.5 and 1.0 mi/kg/br in patients weighing, less than 30 kg?; however, there have been no clinical studies identifVing the optimal hourly urine output needed to maintain vital organ perfusion during burn, shock resuscitation. Because large volumes of fluid and electrolytes are administered both initially and throughout the course of resuscitation, itis important to obtain base- Jine laboratory measurements: complete blood ‘count, electrolytes, glucose, albumin, and acid-base balance.t Laboratory values should be repeated as clinically indicated throughout the resuscitation pe- riod. These parameters usually are sufficient to assess the physiologic response of most burn patients during, burn shock resuscitation. Although clinical interpre- tation of the data should rely on the evaluation of trends rather than on isolated measurements, there have been no studies demonstrating which tests should be performed, how often they should be re- peated, or the effect of frequent laboratory testing on the success of resuscitation. Invasive hemodynamic monitoring permits the di- rect, and sometimes continuous, measurement of central venous pressure (CVP), pulmonary capillary ‘wedge pressure (PCWP), and pulmonary vascular he- ‘modynamics as well as the calculation of cardiac out- put (CO), systemic vascular resistance (SVR), oxygen delivery (DO), and oxygen consumption (VOp). ‘The decision to perform such monitoring requires consideration of risks, cost-effectiveness, and impact, ‘on clinical outcome. The Swan-Ganz catheter is most, commonly used in patients in whom routine moni- toring is felt to be ineffective, when there isa history of preexisting cardiac disease, or when there are other complicating, factors. Pulmonary artery catheter (PAC)-guided therapy has been studied most extensively in trauma and crit- ically ill surgical patients. Kirton and Civetta® per- formed a critica literature review to determine if use ofthe PAG in trauma patients altered outcome. They conchided that hemodynamic data derived from the Practice guidelines for burn care: Chapter 10498 PAC appeared to be beneficial to ascertain cardiovas- cular performance, to direct therapy when noninva- sive monitoring was felt to be inadequate, or when the endpoints of resuscitation were difficult to define. ‘These findings were echoed at the 1997 Pulmonary Artery Catheter Consensus Conférence; however, ‘here was no unanimity that PAC guided therapy al tered mortality in trauma patients Studies of PAC use for monitoring burn shock re- suscitation are limited. Retrospective analyses ofadult patients with extensive bum injuries have concluded that PCWP is a more reliable indicator of circulatory volume than central venous pressure,” and that CO is -more accurate in assessing the efficacy of resuscitation than hourly urine output.’ These findings were sup- ported by Dries and Waxman,’ who noted that urine ‘output and vital signs monitoring did not correlate with PCWP, cardiac index (CI), SVR, DO,, or VO,, ‘They concluded that PAC monitoring may be bene- ficial in patients at high risk for adverse outcomes due to suboptimal resuscitation, Most recently, Schiller and Bay have reported their retrospective experience in 95 patients treated over a 4-year period during Which an attempt was made to maximize circulatory cendpoints.!? They concluded that early invasive mon- itoring facilitated more aggressive resuscitation and resulted in increased survival, and that the inability to achieve hyperdynamic endpoints predicted resuscita- tion failure. PAC-guided monitoring also has been used to aid in achieving predetermined therapeutic endpoints during the resuscitation and management of trauma and critically ill patents, In a series of prospective, randomized class IT trials, Shoemaker et al"! dem- ‘onstrated that patients resuscitated to hyperdynamic ‘endpoints (i.e, increased CI, DOI, VO3l) had de- creased mortality, decreased ICU stay, and fewer ven- tilator days compared to patients who were resusci- tated to normal hemodynamic values. Recent studies, by Fleming" and Bishop'® not only have supported these conclusions, but also have demonstrated a de- creased incidence of organ failure. Although the data supporting hyperdynamic resus-

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