The Consensus, Parkland and Brooke formulas are commonly used as guidelines for initial fluid resuscitation.12,14,15 It is important to remember that fluid resuscitation formulas are a guide, not the law. Some patients need more fluids than the formulas recommend, and certainly some need less. These formulas calculate the amount of fluid to be given in the first 24 hours after the burn (not after presentation to EMS for treatment). The formulas are summarized by: "2-4cc x weight in kg x % of body burned." The "% burn" is commonly estimated by using the "Rule of 9s" or its pediatric variation.12
Imagine a previously healthy 220-lb. (100-kg), 20-year-old patient with a 60% total body surface area burn. Based on the formulas, he would receive 12,000-24,000cc in 24 hours, and 6,000-12,000cc or 6-12 liters of fluids in the first eight hours after the burn. That works out to a rate of 750cc-1500cc per hour for the first eight hours.13,28
It can be challenging for EMS providers to use the above formulas, because in the prehospital arena accurate weights are a rarity and IV infusion pumps are frequently not available. It may be easier just to give these patients a bolus of fluid in the prehospital environment. For children, a 20cc/kg fluid bolus should be administered, as with any pediatric trauma patient. In many cases, by the time the bolus is infused, the patient will be at the ED.2 The Prehospital Advanced Burn Life Support (ABLS) course simply recommends:
- 150cc/hr for patients under five years of age
- 250cc/hr for patients from five to 15 years of age
- 500cc per hour for those over 15 years of age.14
Some burn centers recommend EMS personnel simply administer fluids at a "wide-open" rate, as it is difficult to give the severely burned adult patient enough, let alone too much, fluid in the prehospital setting.4,9,13 In areas with prolonged prehospital transport times, these guidelines must certainly be adapted. Regardless of how the prehospital fluid delivery is calculated, an accurate estimate of the volume of fluid given during EMS transport is important. This amount of fluid will be figured into the total sum of fluids that the burn patient should receive according to the chosen fluid resuscitation formula.3,12,30
Burned clothing can initially be moistened to extinguish heat and then removed. This can be done within the privacy of an ambulance while en route to the hospital. If clothing adheres to the burned body parts, do not attempt to pull it off. Simply leave it in place; any remaining clothing will be removed with the burned tissue during debridement.13
While not specifically related to hypothermia issues, it is a good idea to remove jewelry with any significant burn injury. If the patient offers resistance to removing jewelry, explain that the earlier it is removed, the less chance it will have to be cut off later. There is the distinct possibility of the jewelry becoming a tourniquet of sorts as the surrounding tissues become edematous. Another important reason for early removal is that jewelry can retain heat and continue to burn. Even in non-burned areas, patients may later exhibit significant generalized swelling.15
Burn victims can easily and quickly become hypothermic. This is due not only to the physical loss of skin (and its thermoregulatory properties), but also from environmental factors such as wet clothing and the ambulance's or ED's cool ambient temperatures. In addition to maintaining a warm environment, remember that wet skin cools many times faster than dry skin.2,16 Hypothermia may result in prolonged blood clotting times, hemodynamic instability and even apnea in infants and children.
Infants and small children lose significant amounts of heat from their large heads, so a hat or towel can be applied to the head in an attempt to minimize heat loss. In the hospital setting, use intravenous fluids administered with a fluid warmer, since infusing large amounts of room-temperature fluids (68ºF/20ºC) can quickly result in disastrous hypothermia. Other interventions, such as turning up the heat in the ambulance or ED and later using a convection forced air warmer, such as the Bair Hugger from Arizant Healthcare in Eden Prairie, MN, or warming blankets, can also help to prevent heat loss in these patients.2,16
Dressings: Dry vs. Wet vs. ...