Electrical injuries, incineration burns, and associated crush injuries may produce rhabdomyolysis and myoglobinuria, leading to renal failure. See Chap.,,2,71 for further discussion.
Thermal injury in the presence of concomitant multisystem trauma generally requires fluids in excess of calculated needs. Inhalation injuries have been shown to increase total fluid needs. Burn patients with preexisting cardiac or pulmonary disease require much greater attention to fluid management. Fluid resuscitation should be monitored closely by frequent assessment of the patient's vital signs, signs of cerebral and skin perfusion, and urinary output as well as hemodynamic monitoring. The urinary output should be 0.5 to 1.0 mL/kg per hour.
There are several methods of calculating fluid resuscitation for infants and children. One method is to use the Parkland formula and modify it to maintain urinary output of 1 mL/kg per hour. Alternatively, a pediatric maintenance rate for 24 h can be calculated plus an additional amount of 2 to 4 mL/kg multiplied by percent of BSA burned, with the entire amount infused over the first 24 h. In children weighing less than 25 kg, a urine output of 1.0 ml/kg per hour is necessary.
It is possible for patients with major burns to receive excessive intravenous fluids during the prehospital and ED phases, particularly if two large-bore peripheral catheters are in place with fluid infusing wide open. Total fluids infused should be documented and titrated to the patient's response.
Two additions or modifications to isotonic crystalloid resuscitation have been studied—adjuvant colloid and hypertonic saline. However, neither improves patient outcome. Adjuvant colloid given along with isotonic crystalloid resuscitation has not proven beneficial and is associated with increased accumulation of water in the lungs and decreased glomerular filtration rate.12 Hypertonic saline has produced an increased rate of renal failure and death. 13
Routine tetanus toxoid prophylaxis should be administered based on the patient's immunization history. Tetanus immune globulin should be administered in patients without a history of primary immunization. The use of systemic prophylactic antibiotics is inappropriate.
Treatment of inhalation injury includes humidified oxygen, intubation and ventilation, bronchodilators, pulmonary toilet, and hyperbaric oxygen for severe carbon monoxide poisoning.
Burns to a pregnant patient are associated with significant morbidity to mother and child. The outcome of the pregnancy is determined by the extent of mother's injury; spontaneous termination of pregnancy is the common outcome in large-BSA burns. Fluid requirements may exceed the estimated formula. Fetal monitoring and early consultation with the obstetrician is mandatory.
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