Sol Gregory, MD, Mark Vu, MD, FRCPC, David Sweet, MD, MPH, FRCPC, Erik Vu, MD, FRCPC, Gordon Finlayson, MD, FRCPC, Ross Brown, OMM, CD, MA, MD, FRCPC, FACS, Alec Ritchie, MD, FCCFP, Donald Griesdale, MD, MPH, FRCPC, Vinay Dhingra, MD, FRCPC, Anthony Papp, MD, FRCPC

Provincial clinical practice guidelines for the management of major burn trauma

A multidisciplinary working group has developed guidelines based on a literature review and an audit of major burn resuscitation at the BC Professional Fire Fighters’ Burn, Plastic and Trauma Unit.

ABSTRACT: The impact of major burn ajor burn trauma (MBT) tury, made clear that patients with trauma on patients and health care represents a relatively small major burn trauma commonly died systems is enormous. This is due in Msubset of major trauma, yet from severe hypovolemia and acute part to the complex physiology of the impact on patients and health care renal failure in the early days post- burns and the need for multidiscipli- systems is enormous, in part due to trauma. Seminal research by Under- nary medical and surgical manage- the complex physiology of burns and hill, Cope, Moore, and others was fol- ment. Some aspects of this manage- the need for multidisciplinary medical lowed by the work of Drs Baxter and ment are the subject of ongoing and surgical management. Shires at Parkland Memorial Hospital clinical controversy. To address the in Dallas, Texas, that further recog- challenges faced by medical person- History of major burn nized and promoted the importance of nel caring for burn patients in differ- trauma resuscitation early, aggressive fluid resuscitation to ent settings, a multidisciplinary group Historical experience, especially from re-establish intravascular volume to of physicians collaborated in 2010 world conflicts in the early 20th cen- improve early survival.1,2 In a retro- to systematically review the litera- ture on burn resuscitation and con- duct an internal audit of burn care at Dr Gregory is senior resident in the Division Anesthesiology and Perioperative Care. Dr the BC Professional Fire Fighters’ of Plastic Surgery at the University of Brown is medical director of trauma serv- Burn, Plastic and Trauma Unit in Van- British Columbia. Dr Mark Vu is section ices for the British Columbia Provincial couver. The results of the literature head, Trauma Anesthesia in the Depart- Health Services Authority. He is also a staff review and audit were then used to ment of Anesthesiology and Perioperative surgeon in the Division of General Surgery develop the Adult Major Burns Clini- Care at Vancouver General Hospital (VGH). at VGH. Dr Ritchie is former head of the cal Practice Guidelines now avail- Dr Sweet is a staff physician in the Division Department of Emergency Medicine at able to practitioners throughout of Critical Care Medicine at VGH and in the Lions Gate Hospital. Dr Griesdale is a staff BC. These guidelines include best- hospital’s Department of Emergency Med- physician in the Division of Critical Care practice protocols and serve as a icine. Dr Erik Vu is a staff physician in the Medicine at VGH and in the hospital’s resource for the resuscitation of Department of Emergency Medicine at Department of Anesthesiology and Periop- adult major burn patients in prehos- VGH and the Department of Critical Care at erative Care. Dr Dhingra is a staff physician pital, rural, and tertiary care set- Surrey Memorial Hospital, and a medical in the Division of Critical Care Medicine at tings. The guidelines recognize that consultant for the British Columbia Ambu- VGH. Dr Papp is director of the BC Profes- comprehensive major burn care lance Service. Dr Finlayson is a staff physi- sional Fire Fighters’ Burn, Plastic and Trau- requires the skills of many health cian in the Division of Critical Care Medicine ma Unit at VGH. He is also a staff surgeon professionals, including rural emer- at VGH and in the hospital’s Department of in the hospital’s Division of Plastic Surgery. gency physicians and critical care transport paramedics. This article has been peer reviewed.

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spective analysis of major burn trau- first 24 hours, with the lower figure in gery, though comprehensive care is ma, Baxter noted that patients who this range being half of what the Park- multidisciplinary and includes para- were resuscitated in the first 24 hours land formula endorses.4 Many other medics, emergency physicians, inten- posttrauma with a crystalloid solution major trauma systems have adopted re- sive care physicians, trauma surgeons, of between 3 and 5 millilitres per kilo- suscitation formulas of less than 4 mL/ and anesthesiologists, as well as spe- gram per percentage of total body sur- kg/%TBSA in the first 24 hours,4-9 cialized nurses and other allied health face area (mL/kg/%TBSA) burned including formulas based on the Lund- care professionals. had lower mortality rates than patients who received less fluid. The resusci- tation benchmark of 4 mL/kg/%TBSA in the first 24 hours posttrauma be - came known as the Parkland formula. This remains the burn resuscitation formula most widely used today. Bax- Recently, burn specialists began ter also experimented with different to notice an important subset of kinds of resuscitation fluids, includ- ing crystalloids, colloids, and blood patients suffering significant products. Over 40 years later, the morbidity and mortality related to choice of resuscitation fluid remains a topic of ongoing controversy.1 over-resuscitation with fluids. The intersection of modern military conflicts and advanced trauma care has significantly increased our experi- ence with major burn trauma.3,4 Rela- tively recently, burn specialists began to notice an important subset of patients Browder chart.10 In addition to new With burn care changing, an ad suffering significant morbidity and concepts in fluid resuscitation for hoc working group on major burn mortality related to over-resuscitation burns, novel therapies such as high- trauma was assembled in 2010 to with fluids.5-7 Complications such as dose vitamin C,9,11,12 early colloid review the literature and update re - acute respiratory distress syndrome, administration, and selective use of gional practice standards for major congestive heart failure, cerebral ede- vasoactive agents to improve perfu- burn resuscitation. The MBT group ma, sepsis, and extremity or abdomi- sion pressures are also gaining trac- sought to engage tertiary and rural nal compartment syndrome were spe - tion in complex burn care.9 care providers to improve province- cifically associated with resuscitation wide burn management using an volumes in excess of 6 mL/kg/%TBSA Management of major inclusive, multidisciplinary model. burned in the first 24 hours and were burn trauma in BC Specialist physicians from plastic sur- also associated with a steep increase In British Columbia major burn care gery, trauma surgery, anesthesiology, in mortality.4 “Fluid creep,” as it be - is delivered in two centres. The Royal critical care medicine, emergency came known, emerged as a new threat Jubilee Hospital Burn Unit in Victoria medicine, and prehospital care were to major burn trauma patients, and provides burn care for the Vancouver represented. This group met regularly experts called for a reassessment of Island Health Authority (VIHA) and over a 1-year period and performed resuscitation protocols to address handles select provincial referrals. a systematic review of the medical these potentially avoidable complica- The BC Professional Fire Fighters’ literature to scrutinize international tions.5,6,8 Burn, Plastic and Trauma Unit (BPTU) practice patterns and standards for In light of changing perspectives at Vancouver General Hospital (VGH) major burn resuscitation. An internal on burn pathophysiology, the Cana- serves as the quaternary referral cen- audit of major burn resuscitation was dian and American military and the tre for major burn trauma for the also performed at the BPTU to identi- American Burn Association now province. Primary burn medical and fy areas of clinical strength and areas specify a resuscitation formula of 2 surgical care is led by clinical special- for improvement. Over the course of to 4 mL/kg/%TBSA burned for the ists from the Division of Plastic Sur- this process, the MBT group focused on

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Table. Issues identified by the MBT group and actions recommended to improve major burn trauma resuscitation in British Columbia.

Issue Consequence Action 1. 50% of major burn trauma patients referred Rural emergency physicians, family physicians, Major Burns Clinical Practice Guidelines to the BC Professional Fire Fighters’ Burn, and paramedics spend an important portion of (CPGs) were developed to improve assessment Plastic and Trauma Unit (BPTU) over the last the first 24 hours posttrauma with major burn and early management. Recommendations 10 years were from outside the Lower patients. include resuscitation algorithms that Mainland. Transfer times ranged from 2–26 prehospital and rural medical care providers hours (mean, 18 hours). can use. 2. Estimates of total body surface area (TBSA) Fluid resuscitation based on inaccurate TBSA A TBSA estimation chart based on the Lund- burned made by different care providers estimates can lead to complications. Higher Browder chart was included in the Major varied enormously. rates of abdominal compartment syndrome Burns CPGs to improve inter-user reliability and were noted in patients when TBSA calculations reduce the variability of resuscitation fluid were overestimated (unpublished data volumes administered. collected by Drs Gregory and Papp at the BPTU in 2011).

3. 85% of major burn patients referred to the Inadvertent over-resuscitation with crystalloid The resuscitation formula in the Major Burns BPTU were over-resuscitated by an average (beyond 4 mL/kg/%TBSA in the first 24 hours) CPGs (3 mL/kg/%TBSA in the first 24 hours) of 10%. can be responsible for significant, preventable was included to reflect current consensus contributions to subsequent morbidity and recommendations. mortality.

4. Hemodynamically unstable patients were Inadvertent over-resuscitation with crystalloid Hemodynamic instability was addressed in the commonly treated with successive fluid (beyond 4 mL/kg/%TBSA in the first 24 hours) Major Burns CPGs with recommendations on boluses, while the use of vasoactive agents can be responsible for significant, preventable selective use of colloids and vasoactive was avoided. contributions to subsequent morbidity and agents. mortality.

resuscitation in the first 24 hours. This • Hemodynamically unstable patients CPGs will be available through the approach was taken for two reasons: were commonly treated with suc- Provincial Health Services Authority • Resuscitation in the first 24 hours cessive fluid boluses, while the use at www.bcguidelines.ca. has a significant impact on morbid- of vasoactive agents was avoided. ity and mortality later in a patient’s MBT group members agreed that Moving forward with care. a set of clinical practice guidelines burn care in BC • Medical and surgical management (CPGs) should be developed to sum- The Adult Major Burns CPGs were after the first 24 hours rapidly be- marize the results of their literature introduced into clinical practice at comes extremely complex and be - review and address the issues identi- Vancouver General Hospital in the yond the scope of the MBT group’s fied. Initially, the goal of this initiative summer of 2011 and shortly after mandate. was to improve local hospital (VGH) were adopted by BC Ambulance crit- After reviewing, debating, and dis- practice; however, input from region- ical care transport paramedics. Physi- cussing the scientific literature and the al and provincial trauma leaders soon cian leaders in Vancouver, Victoria, results of the internal BPTU audit, the prompted the MBT group to collabo- and other provincial health authorities MBT group identified four clinically rate with burn physicians at VIHA and are now using CME lectures, newslet- significant issues (see the Table ): to expand their mandate provincially. ters, scientific publications, and elec- • Many patients were transferred to The Adult Major Burns CPGs that tronic media to disseminate the CPGs the BPTU from outside the Lower resulted (seeFigures 1–5 ) were design - to all emergency health care providers Mainland after time had elapsed (2 ed using human factors engineering in the province. To date, the CPGs to 26 hours). principles. They are practical, easy to have been field tested during two • Health personnel estimates of the use, and reflect best practice in major major industrial burn trauma scenar- percentage of TBSA burned varied burn management. Currently, copies ios in northern BC, and in major burn widely. of the CPGs can be downloaded from trauma cases elsewhere in the pro - • The majority of patients referred to http://apt.ubc.ca/hospital-sites/vancou vince. Informal feedback regarding the BPTU were found to be over- ver-general-hospital/clinical-practice- the structure and usability of the CPGs resuscitated. guidelines/. In the near future, the Continued on page 464

458 BC MEDICAL JOURNAL VOL. 54 NO. 9, NOVEMBER 2012 www.bcmj.org Provincial clinical practice guidelines for the management of major burn trauma

Figure 1. First 12 Hours Post Burn.

This guideline outlines an initial approach to fluid resuscitation for major burn trauma. Note that the resuscitation formula recommended in step 3 (Ringers Lactate 3 mL/kg/%TBSA) is to be titrated according to clinical end points (i.e., urine output).

www.bcmj.org VOL. 54 NO. 9, NOVEMBER 2012 BC MEDICAL JOURNAL 459 Provincial clinical practice guidelines for the management of major burn trauma

Figure 2. 12 Hour Assessment.

This worksheet is designed to assist with early identification of over-resuscitation with fluids.

460 BC MEDICAL JOURNAL VOL. 54 NO. 9, NOVEMBER 2012 www.bcmj.org Provincial clinical practice guidelines for the management of major burn trauma

Figure 3. TBSA Burn Estimation Chart.

This chart is based on the Lund-Browder TBSA assessment chart,10 which has high inter-user reliability. When used as the standard TBSA assessment tool, the chart can reduce the variability of resuscitation fluid volumes administered.

www.bcmj.org VOL. 54 NO. 9, NOVEMBER 2012 BC MEDICAL JOURNAL 461 Provincial clinical practice guidelines for the management of major burn trauma

Figure 4. Resuscitation Flow Sheet.

This worksheet records resuscitation details for the first 24 hours posttrauma. Note that the two “stop checks” to assess total resuscitation fluids administered at 12 and 24 hours are designed to assist with early identification of over-resuscitation.

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Figure 5. ICU.

This clinical tool for fluid resuscitation and monitoring in the intensive care unit provides step-by-step instructions for management in standard and more complex major burn trauma. Note that some patients may require large fluid resuscitation volumes, or may be hemodynamically unstable and require colloid administration and/or vasoactive medications. Note also that early contact with an on-call burn physician is encouraged.

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Continued from page 458 first 24 hours after burn trauma, and vere burns. Ann N Y Acad Sci 1968; has been positive, and more rigorous guidance on obtaining more accurate 150:874-894. analysis of the clinical impact of these assessment of the TBSA burned using 2. Alvarado R, Chung KK, Cancio LC, et al. CPGs will occur during scheduled the Lund-Browder chart. This infor- Burn resuscitation. Burns 2009;35:4-14. quality reviews at 2 and 5 years. mation is intended for all levels of care 3. Chung KK, Blackbourne LH, Wolf SE, et Updates in burn medicine will be inte- providers and should help reduce vari- al. Evolution of burn resuscitation in oper- grated into the CPGs every 5 years, or ability in fluid resuscitation calcula- ation Iraqi freedom. J Burn Care Res more frequently as required. There are tions. Information is also provided to 2006;27:606-611. some concerns that the changes in improve care in some major burns 4. Ennis JL, Chung KK, Renz EM, et al. Joint fluid management strategies recom- cases that require the selective use of Theater Trauma System implementation mended by the CPGs may result in colloid and vasoactive agents. of burn resuscitation guidelines im- proves outcomes in severely burned mil- itary casualties. J Trauma 2008;64:S146- 151; discussion S51-52. 5. Pruitt BA Jr. Protection from excessive resuscitation: “Pushing the pendulum back.” J Trauma 2000;49:567-568. This information is intended for 6. Cartotto R, Zhou A. Fluid creep: The pen- dulum hasn’t swung back yet! J Burn all levels of care providers and Care Res 2010;31:551-558. should help reduce variability in 7. Oda J, Yamashita K, Inoue T, et al. Resus- citation fluid volume and abdominal com- fluid resuscitation calculations. partment syndrome in patients with major burns. Burns 2006;32:151-154. 8. Saffle JIL. The phenomenon of “fluid creep” in acute burn resuscitation. J Burn Care Res 2007;28:382-395. 9. Latenser BA. Critical care of the burn patient: The first 48 hours. Crit Care Med unintended under-resuscitation of ma - The guidelines will be reviewed 2009;37:2819-2826. jor burn trauma patients, and that this and updated regularly, and all feed- 10. Miminas DA. Critical evaluation of the will compromise end-organ function. back is welcomed by the MBT group. Lund and Browder Chart. Wounds UK Feedback regarding this and other 2007;3:58-68. Summary concerns can be directed to Dr Antho- 11. Tanaka H, Matsuda T, Miyagantani Y, et The management of major burns is ny Papp ([email protected] ) and al. Reduction of resuscitation fluid vol- challenging and requires multidisci- Dr Mark Vu ([email protected]). umes in severely burned patients using plinary care. Prehospital personnel ascorbic acid administration: A random- and rural emergency physicians spend Acknowledgments ized, prospective study. Arch Surg 2000; an important portion of time with The MBT group gratefully acknowledges 135:326-331. major burn trauma patients, and the the ongoing assistance of the Department 12. Kahn SA, Beers RJ, Lentz CW. Resusci- care these practitioners provide early of Plastic Surgery at Royal Jubilee Hospital tation after severe burn injury using high- in the resuscitation process has a and the Critical Care Transport Program of dose ascorbic acid: A retrospective major impact on patient morbidity and the BC Ambulance Service. review. J Burn Care Res 2011;32:110- mortality later on. 117. The Adult Major Burns CPGs Competing interests were developed to improve the burn None declared. care delivered by all health care per- sonnel in British Columbia. The guide- References lines provide up-to-date information 1. Baxter CR, Shires T. Physiological res - regarding fluid resuscitation in the ponse to crystalloid resuscitation of se -

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