*Doc, how much fluids should be given to a burn patient and
can a person survive if fluids are given if the patient comes to the hospital
many hours after the burn incident? *

*Shawn**, **California*

As we discussed in an earlier
post, burn wounds loose body fluids from the wound surface as the skin
integrity is damaged. Greater the surface area of the burn, more the fluid
loss. In general the body is able to tackle the fluid loss that occurs from a
less than 15 percent TBSA (total burn surface area) in an adult, and less than 10 percent TBSA in a
child. Beyond this the body’s internal mechanisms are unable to handle this
loss and the patient will end up in shock if the lost body fluids are not
replaced. Once we understand this concept then we are faced with two questions:

a) At what rate should we
administer the intravenous fluids?

b) What is the type of
fluid that we should administer?

*Parkland** formula*

Charles Baxter from parkland hospital
(Texas, USA) made a large contribution to the management
of burns by his studies on the fluid loss in burns and their replacement. He observed
that the first 24 hours were critical to the survival of burn patients and the replacement
of fluids was to be done in the first 24 hours itself. In this the first 8
hours were crucial as the blood vessels and capillaries lost their integrity
totally and therefore the intravascular fluids leaked out on a large scale. In the
second 8 hours after the burn the capillaries regained their integrity and the
leaks were controlled to a great extent. Keeping this in mind Charles Baxter suggested
a fluid resuscitation formula in burn patients at 4 ml/kg/TBSA for the first 24
hours. The type of fluid suggested was Ringer Lactate. Of the total fluid calculated for 24 hours,
half of the volume was to be given in the first 8 hours and the rest in the
next sixteen hours.

*Why did Baxter suggest Ringer Lactate
as the resuscitation fluid?*

* ** *Obviously because he observed that it was more
physiological and had many advantages:

a) Ringer lactate has a lower sodium
concentration (130mEq/L) than normal saline.
b)The metabolized lactate had a buffering effect
on associated metabolic acidosis in burns.
c)Ringer lactate is an Isotonic
crystalloid solution
*Example for fluid calculation:*

Let’s take an example here – a patient
with a body weight of 65 kg comes to the
ER with flame burns of 45 percent TBSA.

TBSA 45%

Weight of the patient- 65 kg

Therefore the fluid calculation by
parkland formula-

4x% TBSA x body weight

i.e. 4 x 45 x 65

i.e. 11,700 ml for 24 hours

Half of this has to be given in the
first 8 hours

i.e. half of 11,700 – which is 5850
ml for 8 hours

Therefore for each hour in the first
8 hours the patient needs 5850/8 ie 731.25 ml or approximately 730ml per hour

For the next 16 hours the remaining
11700 ml needs to be spread out

So 5850/16 is 365 ml needs to be
given each hour for the next 16 hours

Thus the patient must receive 730 ml
per hour for the first 8 hours post burn and for the remaining 16 hours of the
first day the patient must receive 365 ml per hour.

Coming to the second part of the question- the fluid calculated has to be replaced in the time specified. However some patients appear later than the time of the burn and therefore the fluids which were not administered will have to be replaced at a higher rate but taking care to see that we do not overload the patient and put him into cardiac failure or pulmonary edema.

It must be noted that the calculation
of fluids by this formula is only a guide line and a number of factors must be
taken into consideration which administering fluids which we shall discuss in
another post …..

*(An original initiative in burn care and education from asktheburnsurgeon++)*

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