Case of the Month #46 A Major Burn Injury: Taming the Flames

• Ongoing fluid therapy 

• Thermoregulation & the burns hyperinflammatory syndrome 

• Nutrition 

• Surgical intervention 

• Infection 

• Analgesia 

• Psychology 

Fluid resuscitation 

• Continue Parkland formula initially 

  • Then modify based on a number of clinical endpoints 

• Usually target a urine output of 0.5-1ml/kg/hr ideal body weight  

  • Adjust fluid administration rate accordingly 
  • Also consider information such as lactate, acid-base balance, haematocrit, and peripheral perfusion 

• Choice of fluid 

  • Warmed Hartmann’s is used in the first instance 
  • Albumin may have a role as ‘colloid rescue’ if fluid requirements predicted to be >6ml/kg/TBSA in the first 24h 
    • This may reduce overall volume requirements, and therefore reduce risks associated with ‘over-resuscitation’ 
      • These risks include cerebral & pulmonary oedema, abdominal compartment syndrome, tissue oedema and electrolyte disturbances.

Surgical intervention: 

• Early debridement is advocated 
  • The aim is to improve wound healing, reduce inflammatory response, reduce infection risk 
• Dressing changes will be required regularly 
  • This may pose challenges with regards to analgesia and sedation 

Infection risk: 

• Loss of skin barrier makes patients high risk for infection 

• Patients will become colonised, often with resistant organisms 

• The burns hyperinflammatory state can make it difficult to diagnose infections clinically 

• There are many possible pathogens: 

  • Gram-positive organisms early in the course 
  • Gram-negatives from environment or gut translocation e.g. Pseudomonas, Klebsiella, E. coli 
  • Fungal infections also a possibility 

• Treatment with antibiotics in conjunction with microbiology teams is required 

  • Further surgical intervention may be required in certain cases 

Nutrition 

• Major burns cause a significant increase in the basal metabolic rate 

• Patients are in a highly catabolic state 

• Enteral nutrition should be started early 

• Seek early specialist dietitian support 

Thermoregulation 

• Patients initially require warming to maintain temperature 

• Then often hypothalamic temperature set point will become reset 

  • Patients may become hyperpyrexial  
    • In general, this should be treated if >39.5C 
    • Treatment may require the use of intravascular cooling devices 

Hyperinflammatory state 

• This may persist for months, limiting recovery, and be difficult to manage 

• Propranolol may be used 

  • May suppress catabolic effects of a burn  
  • Evidence is not clear cut for its benefit  

• Oxandrolone can also be used in major burns 

  • It is an androgen receptor agonist 
    • This timulates muscle growth 
    • It is much less virilising than testosterone 
  • Oxandrolone should be considered after day 5 in ≥30% TBSA burns