Fluid Resuscitation in Burns
Disclaimer: This is my opinion and does not reflect the view of any entity that I trade time for cash with. Everything is meant for educational food for thought and you should always “follow your protocols.”
Every time you think about burns the Parkland formula comes up. Right?
Calculating the TBSA, trying to remember the right chart to use, then doing the math to get to the right amount of fluid for the time you will have the patient. If you think this is way too much trouble then you are not alone.
Recent research states that EMS in general has been overestimating TBSA and weight when trying to calculate the right amount of fluid to give. This leads to over-resuscitation of patients and that fluid overload has caused adverse events leading to pulmonary/cerebral edema or compartment syndrome of the extremities or abdomen. When actually delving down to the 15 or so minutes we actually have the patient, it turns out that the formula doesn't require as much fluid as you think. The goal of burn resuscitation is that you protect the kidneys and perfuse the tissue. Hospital providers measure this by monitoring urine output depending on the age and type of burn. For us, we don't really measure that stuff. Well, not on purpose at least. So to take this into account, the American Burn Association came out with a guideline for paramedics and initial hospital management before TBSA can be calculated.
American Burn Association Guidelines on Fluid Resuscitation for Initial Management
This is great in the sense that we don't have to bother with all that silly math and it's one less thing on your plate. If you need to give more, due to polytrauma or other medical conditions, then by all means do so. This is a starting point for burn management if all you have to worry about is just the burn.
With fluid management, I would also like to mention something about IV/IO access. If you can always try to access unburned tissue, but if you must, burned tissue is also available. If you have someone with that much TBSA of burns, might want to consider IO access because (in my opinion) I would just be going to be putting them down the k-hole or DSI so they don't have to remember the event and I don't have to worry about airway. At the very least, give them as much Fentanyl as they can tolerate.
If you're using tachycardia as a marker of the need for increased fluid resuscitation, this is a poor indicator as the increased HR is more a sign of inadequate pain management in the burn patient without other bleeding involved. A HR of 110-120 is normal in initial burns, and HR of 140+ is considered a need for more pain management.
So, there you go. Something to think about when trying to do calculus on your next burn patient. References are from the 2018 ABA Provider Manual and the study attached.
