Burns and Burn Edema, Implications for Primary Care in Burns

In burns resuscitation controversial findings could be demonstrated and led to the general acceptance of facts: Delay in shock treatment for more than two hours is linked to increased mortality [1–3] Some patients need higher amounts of fluid than 4ml/kg/TBSA. [4–6] . Fluid Creep developed over the years under the same resuscitation targets.[7] Albumin can reduce the amounts of fluids needed[6,8,9] Patients receiving higher amounts of fluid in the beginning need higher amounts of fluid even later on [10] People who get more fluid do not have higher urine outputs! [7,11] People who receive higher amounts of opioids need higher amounts of fluid[12]. People with extensive 3rd degree burns needed more resuscitation fluid than predicted. [13] Edema develops faster in partial thickness burns than in 3rd degree.[13] People with inhalation injury needed more resuscitation fluid than predicted. [13] Higher fluid loads can cause “deepening of burns” [14,15] Higher amounts of fluid needed are linked to severe complications like compartment syndrome, escharotomies, impaired gas exchange, prolonged mechanical ventilation and hospital stay. [16–18] Some people, receiving higher amounts of fluids develop abdominal compartment syndrome. [4,5,19] There are better results in burn treatment regarding mortality when using smaller amounts of fluid [20–22] All these findings still need an underlying theory. Most of them can be explained by recent findings in the vascular system and influencing components of permeability. The regulatory system of vascular permeability is mainly based on the ESL (Endothelial Superficial Layer). Once destroyed, vascular system in various body regions acts like a sieve. Different mediators like vagal nerve stimulation can additionally influence permeability[23]. As in contrary to the concept of reabsorption based on the Starling principle there is no relevant reabsorption of fluids to the vessels in vascular leak situation, the most important actuator for burn edema is systolic blood pressure. This leads to a reinvention of the old empirical concept of permissive hypotension[24] and oliguria[25] in resuscitation. Concepts and findings on these facts will be demonstrated. 1. Barrow RE, Jeschke MG, Herndon DN. Early fluid resuscitation improves outcomes in severely burned children.