7-22
solution of 125 meq/L). If you give normal saline alone, you should also start D5W at the rate given
below (1cc/kg/TBSA burned/24 h), because of the high sodium concentration in normal saline. You can
also use 5% albumin (or fresh frozen plasma) during the first 24 hours post-burn in combination with
crystalloid, according to a formula such as albumin (0.5 cc/kg/TBSA burned/24 h) plus LR or saline
(1.5cc/kg/TBSA burned/24 h).
- If unable to provide IV fluids, start oral resuscitation using the following oral formula: 1 liter of water, 1⁄4
tsp of salt, 1⁄4 tsp of sodium bicarbonate (if no bicarbonate, use total of 1⁄2 tsp salt), 2 tbsp of sugar or
honey and a little orange or lemon juice.
Patient Education
Wound care: Change the dressings bid. Soak the dressings off to decrease pain and prevent disruption
of the healing process, wash with soap and water, apply topical burn cream and new dressings. Keep the
dressings dry and clean. After the burns are healed, apply a moisturizing cream to the burned area bid. Use
sunscreen and sun precautions, since burned skin is more susceptible to sunburn.
Activity: Ambulate, and do range of motion exercises 5-10 minutes every hour to prevent edema and
contractures.
Diet: Eat a diet high in calories and proteins during the healing process.
Prevention: Avoid burn agents to prevent further accidents.
No Improvement/Deterioration: Return to the clinic for any difficulty breathing, hoarseness, or worsening
cough, and for any increased pain in the burn area, increased redness and blanching to the burn area, red
streaks from the burn area, or fever.
Follow-up Actions
Return evaluation: If the patient is reliable, the burn encompasses < 10% TBSA partial thickness burn, and
there are no associated injuries such as inhalation burns, then the patient may be able to perform wound care
at home. See the patient at least twice weekly until healed. If the patient is unreliable or if burns are > 10%
TBSA, then daily follow-up or hospitalization is recommended.
Evacuation/Consultation Criteria: Evacuate those with > 20% TBSA burned or those with serious associ-
ated injuries, such as inhalation injury or fractures. Consult a trauma surgeon or emergency medicine
specialist for all burn cases other than sunburns.
NOTES: After initiating IV fluid therapy, calculate the total body surface area (TBSA) burned using the “Rule
of Nines” (Figure 7-1). First-degree burns are not significant and need not be included. The hand, including
the 5 fingers, represents approximately 1% of the total body surface. Find out or estimate the patient’s
pre-burn weight in kilograms (kg).
The total fluid (Lactated Ringers) required during the first 24 h after injury is estimated using the modified
Brooke formula for adults: 2 cc/ kg/%TBSA. Plan to give 1⁄2 of the estimated fluid in the first 8 hrs. In
children weighing less than 30 kg the infusion rate is estimated at 3 cc/kg/%TBSA. Plan to give 1⁄2 of the
estimated fluid over the first 8 h. Children will also need maintenance fluids of 5% dextrose in 1⁄2 normal
saline. This should be given using a rule such as the 4-2-1 rule: 4cc/kg/h for the first 10 kg, 2cc/kg/h for
the next 10 kg, and 1cc/kg/h for the next 10 kg. If a patient’s resuscitation is delayed by a few hours,
then give fluid more rapidly.
Adjust the initial fluid infusion rate to the urine output. Failure to monitor and record the urine output (catheter
or bedpan) and adjust the fluid rate hourly may result in death or in severe complications. Adequate urine
output is 30-50cc/h in an adult and 1cc/kg/h in a child who weighs less than 30 kg. If the output is greater,
or less, than the target for 2 consecutive hours, decrease, or increase, the IV rate by 20% respectively until
the rate is satisfactory.
After the first 24 hours, switch resuscitation fluids to albumin (diluted to 5% in normal saline or similar
crystalloid) at 0.5 cc/kg/%TBSA burned over 24 h at a constant rate. If albumin is unavailable, use fresh frozen
plasma, or continue the LR while adjusting the rate as before. At the 24 hour point after injury also start D5W at
1cc/kg/%TBSA burned each 24 h at a constant rate (subtract po amount from the total needed per day).
After 48 hours, patients with large burns continue to need fluid (i.e., water or D5W) at 1cc/kg/%TBSA/day, but
may be very thirsty, so watch their intake carefully to avoid over-drinking.