Page 131 - Journal of Special Operations Medicine - Spring 2016

decrease in the fluid rate. Trends of UOP over time are The %TBSA of second- or third-degree burns will drive
important to properly manage your patient and will the fluid resuscitation approach. In general:
help accurately communicate the overall status of your
patient to higher medical authority. • <15% TBSA: nonaggressive fluid resuscitation rec-
ommended, PO hydration may be sufficient
• 15%–40% TBSA: this is the patient population in
Maintenance Fluids
PFC that requires our diligent management; morbid-
Maintenance fluid should be provided orally in any ity is likely to be reduced in this group if proper resus-
patient who is capable of drinking. If the patient can- citation and attention are given
not drink because of diminished mental status, phar- • >40% TBSA: this will require major resuscitation,
macologic sedation, or abdominal wounds, fluid can likely airway management with cricothyrotomy or en-
be provided by IV or PR. For IV maintenance fluid, we dotracheal intubation, and has an ominous prognosis
recommend LR solution or another balanced solution,
such as Plasma-Lyte A. Burns require large amounts of resuscitation fluids. For
this reason, LR or Plasma-Lyte A are recommended
For adults, we recommend starting at a total daily re- over NS. A recommended formula to estimate fluid re-
placement volume of 1.2L (50mL/hr). If the patient has quirements is the Rule of Tens (for burns): 10mL/hr ×
inadequate UOP for more than two consecutive hours, %TBSA of second- and third-degree burns.
bolus 250–500mL of crystalloid, increase the hourly
rate by 25%, and continue to reassess. • If the patient weighs 40–80kg, multiply the %TBSA
by 10 to get the hourly infusion rate
For children, we recommend the “4-2-1” formula to de- • If the patient weighs >80kg, add 100mL/hr for each
rive the initial hourly maintenance fluid rate, based on 10kg over 80kg
the patient’s body weight, as follows:
For example: For a 100kg patient with a 40% TBSA
(4mL/kg for the first 10kg) + (2mL/kg for the next burn, the formula calculations would be as follows:
10kg) + (1mL/kg for the remainder of the patient’s
weight) = hourly maintenance fluid rate (40% TBSA × 10 = 400mL/hr [for the first 80kg])
+ (100mL × 2 = 200mL/hr [for the remaining 20kg]).
For a child weighing 40kg, for example, the formula cal- 400mL + 200mL = 600mL/hr infusion rate
culations would be as follows: of LR or Plasma-Lyte A

(4mL/kg × 10kg = 40mL) + (2mL/kg × 10kg = 20mL) If UOP is <30mL/hr, increase the hourly fluid rate by
+ (1mL/kg × 20kg = 20mL). 20% for the next hour and reassess. If UOP is >50mL/
40mL + 20mL + 20mL = 80mL/hr is this patient’s hr, decrease the hourly fluid rate by 20% for the next
initial hourly maintenance requirement. hour and reassess.

Both over- and under-resuscitation with fluids can cause
Resuscitation Strategy and Goals for significant complications in burn patients (most impor-
Nonhemorrhage Scenarios
tantly, hypovolemic shock in the former and compart-
The following cases, in particular, require early call for ment syndromes in the latter).
telemedicine.
The key part of burn management is the need to monitor
Burns UOP and be as ready to decrease fluid rate for suprath-
If a patient has large burns (>20% second degree or erapeutic UOP as to increase it for suboptimal output.
>10% third degree [%TBSA]), burns involving the air- One cause of “fluid creep” that can lead to compart-
way, circumferential burns, or burns of critical areas ment syndrome may be that providers are less likely to
(head, hands, feet, genitalia), early telemedicine con- decrease infusion rates when UOP is above goal than
sultation is critical. The greatest risk to the patient is they are to increase rates when UOP is below goal. 16
hypotension due to intravascular fluid leak into the in-
terstitial space. The goal of initial burn resuscitation is Colloid infusion, either plasma (including freeze-dried
to maintain adequate blood pressure (MAP >55mmHg), plasma) or albumin, has been shown to reduce fluid
heart rate <130, and appropriate level of consciousness. requirements in burns, as well as decrease the incidence
UOP between 30mL/hr and 50mL/hr is a good indicator of abdominal compartment syndrome. One approach is
of adequate perfusion, but hemodynamic stability is the to change to a colloid infusion for patients whose 24-
most important goal. 13 hour crystalloid requirements exceed 250mL/kg, the

Fluid Therapy Recommendations 115