BURNSSurgical Emergencies 253(iii) Give additional maintenance fluid at 1.0–1.5 mL/kg per hour of
normal saline.
(iv) The Parkland formula and other fluid resuscitation formulae
such as the Muir and Barclay are a guide only. Aim for at least
1 mL/kg per hour urine output.6 The quantity of f luid is more important than the type.
(i) Consider albumin initially in extensive, deep (e.g. electrical)
burns, or when resuscitation is delayed.
(ii) Otherwise, use a crystalloid solution alone, such as Hartmann’s
(compound sodium lactate).
7 Insert a urinary catheter to assess the adequacy of resuscitation, aiming for a
urine output of 50 mL per hour in adults, or 1 mL/kg per hour in children
<30 kg.
8 Pass a nasogastric tube in patients with burns >20%, who may develop gastric
stasis.
9 Give morphine 0.1 mg/kg i.v. with an antiemetic such as metoclopramide
10 mg i.v. Remember that under-transfusion or hypoxia are more common
causes of restlessness than pain.
10 Give tetanus prophylaxis to all burn patients (see p. 321).
11 Consider the need for escharotomy in the following:
(i) Circumferential, leathery, full-thickness burns that may cause
distal ischaemia in limbs or digits by restricting blood flow, and
respiratory compromise by constricting chest wall movements.
(ii) Ask the surgical team to perform relieving incisions through the
burn area.
12 Leave any adherent clothing alone and do not break blisters in the burnt
area. Remove constricting articles such as rings, bracelets and watches.
(i) Cover the burn with a non-adherent, paraffin-impregnated gauze
dressing or plastic cling wrap. Beware of hypothermia in children
if wet soaks were left on.
(ii) Avoid silver sulfadiazine cream at this stage until the patient has
been assessed by the surgical or burns unit team.
13 All full-thickness burns of >1–2% BSA require hospital admission by the
surgical team. Refer patients on to a specialist burns unit with:
(i) Burns >10% in children and 15% in adults.
(ii) Burns of important functional areas, such as the face, hands, feet,
perineum and genitalia.
(iii) Respiratory burns.
(iv) Chemical burns and electrical burns, including lightning injury.
14 Assess all serious burns with care and resuscitate fully before departure,
similar to the precautions taken when transferring serious head injuries to a
neurosurgical unit.