CHAPTER 6 Burn Shock and Fluid Resuscitation ecipitates a large amount of fluid sequestration into the area of injury and this process becomes generalised when the size of the burn is greater than 20% TBSA [17, 25, 75]. Generalised oedema formation (i.e. third spacing) results in significantly decreased plasma volume. This loss of circulatory volume is iso compounded by ongoing evaporative loss from the moist burn surface. The resultant intravascular hypovolaemia, if not corrected, precipitates organ system failure, especially renal failure [26, 75]. Burn injury pre Whilst extensive burns will cause hypovolaemic shock, a trauma patient with early signs of shock must have other haemorrhagic and non-haemorrhagic pathology excluded. A good example is the patient with 80% TBA burns who has jumped from a burning building, Their early shock would most likely be explained by a fractured pelvis, long bone injury or internal injuries. In this case the extensive burns are a confounder for hypovolaemic shock at the initial presentation. ‘Thermal injury causes marked changes in the microcirculation both locally at the site of injury and systemically [26]. As previously discussed a burn develops three zones of decreasing injury severity (see Figure 2.1 Jackson's Burn Wound Model p16): 1) Acentral zone of coagulative necrosis. 2) Anintermediate zone of injury characterised by stasis of blood flow. 3) ‘An outer, peripheral zone with vasodilatation, increased blood flow and hyperaemia. Mediators are produced and released at the burn wound site, altering vascular membrane integrity and increasing membrane permeability [2, 75]. These mediators include histamine, serotonin, prostaglandins, bradykinin and potent vasoconstrictor such as thromboxanes and angiotensin. Inlarge burns (>20% TBSA), the large quantity of these mediators produced at the burn site is so great that they induce widespread increased vascular permeability which leads to generalised oedema formation [23, 75]. Hypovolaemic shock soon follows. In addition to this, an anator | derangement of the endothelial lining of the microvasculature can be detected on electron microscopy. Evidence in favour of one resuscitation fluid in comparison with another is conflicting [42, 76]. From a practical point of view, however, the ready availability Of crystalloid solutions such as Hartmann’s Solution (Lactated Ringers) have made them the internationally accepted choice for initiation of resuscitation [2, 77]. Children have limited physiological reserve and greater surface area to mass ratio compared to adults. The threshold at which fluid resuscitation is required in AUSTRALIAN AND NEW ZEALAND BURN ASSOCIATION Ltd. www.anzba.org.au ‘© ANZBA 2016 48 Scanned with CamScannerchildren is lower than for adults (approximately 10%) and they tend to need 2 higher volume per kilogram [3, 23]. In fact, this increased need for fluids equates to the volume calculated with the Modified Parkland fluid resuscitation formula with the addition of the normal maintenance fluid requirements Inhalation injury further Increases fluid requirements. Oedema formation typically ceases between 18-30 hours post-burn [78]. Therefore, the duration of resuscitation is variable but can be said to conclude when the volume needed to maintain adequate urine output is equal to maintenance fluid requirements. Estimation of Resuscitation Fluid Needs ‘The extent of the burn is drawn onto a burn body chart and calculated using the “Rule of Nines”. If the estimated TBSA is >10% in children (<16yr) or >20% in adults, intravenous fluid resuscitation is required. Fluid should be administered via two large cannulae (at least 16G in adults), preferably inserted through unbumt skin, Consider intra-osseous (10) access if needed. If possible the patient is weighed or weight obtained during history taking. This, together with the TBSA% is now used in a fluid resuscitation formula [3, 23, 25, 38-41, 79, 80] to calculate an estimated amount of resuscitation fluid required in the first 24 hours [38] Modified Parkland Formula 3 ml crystalloids x kg body weight x percent (%) burn Bhiiw E———_—EEEE ing half Half the calculated volume is given in the first 8 hours [3] and the rem given over the subsequent 16 hours [38, 40, 42, 79). These time periods reflect the changing rate of burn oedema that is greatest soon after injury. Fluid resuscitation must be calculated from the time the burn injury ‘occurred, not from the time of presentation to the hospital (2). ‘The halving of the fluid resuscitation rate after 8 hours is related to the resolving of the widespread vascular permeability at around 8-10 hours post-burn. This, ‘gradual change is not matched by the abrupt change in the formula, highlighting that formulae are only guidelines that will need to be adjusted to match individual requirements [2, 40]. The aim in providing fluid resuscitation Is to give the least amount of fluid necessary to maintain tissue perfusion whilst maintaining vital physiological functions. In reality, fluid resuscitation is governed more by optimal urine output and haemodynamic status than strict adherence to the Modified Parkland Formula derived rates. © ANZBA2016 AUSTRALIAN AND NEW ZEALAND BURN ASSOCIATION Ltd. wwnw.anaba.org.au 49 Scanned with CamScannerChildren (<16 years) also recelve a separate maintenance fuid prescription, which is outlined separately below. Maintenance Fluids in Children (< 16 years) Fasting children are at risk of hypoglycaemia due to limited glycogen storage. To prevent hypoglycaemia, children (< 16 years) receiving fluid resuscitation should biso receive intravenous maintenance fluid containing glucose at the calculated hourly maintenance rate (3). Maintenance fluids for children are calculated as ml/kg/br using: 4;2:2" rule 4 mi/kg/hr up to 10 kg, + 2 mi/ke/hr from 11-20 kg ‘Lmifkg/hr for each kg over 20 ke Beppo a ee ‘The current recommended maintenance fluid choice is 0.9% (normal) saline with 59 dextrose. This choice aims to reduce risk of iatrogenic hyponatraemia due to administration of hypotonic solutions with excessive free water [81]. This represents a change from the previous recommendation, and Is In response to evolving evidence to support the use of 0.9% (normal) saline, or similar tonicity crystalloid for maintenance fluids in unwell children [82]. This calculation of maintenance fluids for children is discussed in greater detailed in Chapter 9. Monitoring Adequacy of Fluid Resuscitation The best, easiest and most reliable method of monitoring fluid resuscitation is by following urine output [3, 10, 21, 23-25, 37]: Adults. (0.5 mi/kg/hr = 30-50mi/hour Children (< 16 years)... 1.0 ml/ke/hr [77, 80, 83-85] ll cece ‘Adequate organ perfusion is being maintained if urine output is kept at or near these levels [24]. Low urine output indicates poor tissue perfusion and likely cellular injury; high urine output indicates excessive fluid resuscitation that will cause excess oedema formation. Clearly, a urinary catheter is vital for accurate monitoring and should be inserted for burns ‘© >10% TBSA in children (< 16 years) and «> 20% TBSA in adults TANZBA2016 AUSTRALIAN AND NEW ZEALAND BURN ASSOCIATION Ltd. www.anzba.org.au 50 Scanned with CamScannerIfurine output is not adequate, give extra fluid: * Boluses of 5-10 mi/kg or increase the next hour's fluids to 150% of planned volume, In the second 24 hours post burn, colloid fluids can be used to help restore circulating volume using the formula (77, 84]: + 0.5ml of 5% albumin x kg body weight x % burn. In addition, electrolyte solution should be provided to account for evaporative loss and normal maintenance requirements. If vomiting occurs such losses should also be replaced, Central invasive haemodynamic monitoring is only occasionally indicated. It may be useful for patients with pre-morbid cardiac disease or coexistent injuries causing blood loss such as multiple fractures. Significant acidaemia (pH <7.35) detected on arterial blood gas analysis commonly indicates inadequate tissue perfusion and is usually due to lactic acidosis. Increased fluid resuscitation is indicated. If unsuccessful in restoring pH or if haemochromogens are present in the urine, consider bicarbonate after discussion with the intensive care unit. Acidosis may also indicate the need for, or inadequacy of, escharotomy. Blood pressure readings with a sphygmomanometer are notoriously inaccurate due to oedema formation and accurate measurements can only be obtained via an arterial line. These are recommended in large burns. The heart rate is usually raised in burn patients due to pain and emotion and sois therefore a poor indicator of the adequacy of fluid resuscitation. Serum electrolytes should be measured initially and at regular intervals. Mild hyponatraemia is common due to dilution by the infusion depending on the sodium concentrate of the crystalloid solution used (Hartmann’s solution Na is, only 130 mEq/l). Hyperkalaemia commonly occurs with tissue injury in electrocution. Sodium bicarbonate and/or glucose plus insulin may be required to correct this problem, Restlessness, mental obtundation, and anxiety can indicate hypovolaemia, therefore assess the adequacy of fluid resuscitation. © ANZBA 2016 AUSTRALIAN AND NEW ZEALAND BURN ASSOCIATION Ltd. www.anzba.org.au 51 Scanned with CamScannerHaemochromogenuria Tissue injury, particularly muscle tissue, electrical injury, blunt trauma or tissue is haemoglobin, These haemochromoge: fallure will soon ensue as a result of de proximal tubules, and prompt treatm from extensive deep burn, high voltage ischaemia causes release of myoglobin and Ns colour the urine a dirty red. Acute renal Position of these haemochromogens in the rent is required [45]: + Increase urine output to 1-2 mi/kg/hr in adults, or >2 ml/ke/hr in children If this is ineffective discuss with burn unit and consider a single dose of Mannitol 12.5g/l resuscitation fluid over 1 hour and observe response Strongly consider performing a fasciotomy (as opposed to an escharotomy which doesn’t release deep muscle fascia). Problems with Resuscitation Formulae only estimate requirements and the individual patient must be closely monitored. Fluid overload Infants, elderly and those with cardiac disease should be monitored particularly closely as fluid overload may be precipitated. Fortunately, pulmonary oedema is uncommon due to disproportionately greater increase in pulmonary vascular resistance than systemic vascular resistance. It occurs in those with impaired myocardial function and often requires invasive monitoring, inotropic support, ventilation and close monitoring of fluid management. Extra fluid Conversely, low urine output indicates inadequate fluid resuscitation. The appropriate first response Is to Increase the rate of infusion. Diuretics are rarely necessary and should not be considered until after consultation with a burn unit. ‘The following patient groups routinely require extra fluid resuscitation [40] © Inhalation Injury [42] # Electrical Injury Delayed Resuscitation Dehydration - firefighters, intoxicated patients @ANZBA2016 AUSTRALIAN AND NEW ZEALAND BURN ASSOCIATION Ltd. www.anzba.org.au 52 Scanned with CamScanner| Children Children are prone to hypoglycaemia, dilutional hyponatraemia and over or under fluid resuscitation due to limited glycogen stores, higher surface area to Weight and intravascular volume ratios. They have less margin for error and careful titration to urine output is required. Blood glucose and electrolyte levels, should be measured regularly. Free water should be limited and a source of carbohydrate instituted early. This could be enteral feeding or addition of dextrose to the electrolyte solution. Abdominal Compartment Syndrome ‘This rare but serious secondary complication can occur in large burns in adults as well as children especially when the calculated fluid requirements: have been exceeded to achieve adequate urine output [26, 40, 86]. Itis suggested that if the presence or development of Abdominal Compartment Syndrome is being considered that bladder pressure monitoring can give valuable information. Summary Fluid resuscitation is necessary for survival '* Intravenous fluids for: children >10% TBSA adults >20% TBSA © Insert: Two large bore peripheral cannulae Urinary catheter * Resuscitation fluid calculation with Modified Parkland Formula = 3ml /kg/% burn half of the calculated total in first 8 hours, rest over next 16 hours - calculated from time of burn injury not presentation = use erystalloids (e.g. Hartmann’s solution) during the first 24 hours ‘Maintenance fluids apply only to children (<16 years) = calculate using “4:2:1" rule = use 0.9% (normal) saline with 5% dextrose to avoid hypoglycaemia © Haemochromogens: increase fluid resuscitation to double urine output. @ANZBA2016 AUSTRALIAN AND NEW ZEALAND BURN ASSOCIATION Ltd. ‘wwrw-anzba.org.au 53 Scanned with CamScanner