What are the initial management steps for circulation in a burn patient?

Initial Management of Circulation in Burn Patients

For burn patients, immediate fluid resuscitation with balanced crystalloid solutions (preferably Ringer's Lactate) at 20 mL/kg within the first hour is essential, followed by calculated fluid requirements using the modified Parkland formula (2-4 mL/kg/%TBSA) for the next 24 hours. 1, 2

Initial Assessment and Fluid Requirements

• Adult patients with burns ≥10% TBSA and pediatric patients with burns ≥5% TBSA require formal fluid resuscitation 2, 3
• For immediate management, administer 20 mL/kg of crystalloid within the first hour to address early hypovolemic shock, regardless of burn size assessment 1, 2
• After initial bolus, calculate 24-hour fluid requirements using the Parkland formula (2-4 mL/kg/%TBSA) 2, 4
• The American Burn Association recently recommended initiating resuscitation based on providing 2 mL/kg/% TBSA burn to reduce overall resuscitation fluid volumes 4

Fluid Type and Administration Schedule

• Balanced crystalloid solutions (such as Ringer's Lactate) are the preferred choice for initial resuscitation 1, 2
• Half of the calculated 24-hour fluid requirement should be given in the first 8 hours post-burn, with the remaining half over the next 16 hours 2, 5
• Intravenous access should be obtained as soon as possible, preferably in unburned areas; if IV access cannot be rapidly obtained, intraosseous access is recommended 1, 2

Monitoring Parameters and Adjustments

• Urine output is the simplest parameter to monitor, targeting 0.5-1 mL/kg/hour in adults and children 2, 6
• For electrical burns with significant muscle damage, maintain higher urine output (1-2 mL/kg/hour) to prevent myoglobin-induced renal injury 2
• Adjust fluid rates based on clinical response, with inadequate resuscitation leading to burn shock and excessive administration causing complications 6, 7

Special Considerations

• Children require proportionally more fluid than adults due to higher surface area-to-weight ratio, with retrospective studies showing approximately 6 mL/kg/%TBSA over the first 48 hours 1, 6
• For children with burns >10% TBSA, many centers calculate daily basal fluid requirements using Holliday and Segar's 4-2-1 rule and add this to the modified Parkland formula requirements 1
• Electrical burns often cause deeper tissue damage than apparent on the surface, potentially requiring higher fluid volumes than thermal burns 2

Avoiding Complications

• "Fluid creep" (excessive fluid administration) must be avoided as it can lead to complications including compartment syndrome 2, 7
• Monitor for compartment syndrome in patients with circumferential burns or electrical injuries 2
• If hypotension persists despite adequate fluid resuscitation, evaluate cardiac function and consider vasopressors 2, 8
• For vasopressor support, norepinephrine can be administered when intraaortic pressures must be maintained to prevent cerebral or coronary artery ischemia, but only concurrently with blood volume replacement 8

Recent Advances in Burn Resuscitation

• The American Burn Association recommends considering human albumin solution, especially in patients with larger burns, to lower resuscitation volumes and improve urine output 4
• Selective monitoring of intra-abdominal and intraocular pressure during burn shock resuscitation is recommended for patients at risk of compartment syndromes 4
• Computer decision support software may help guide fluid titration and lower resuscitation fluid volumes 4