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. 456 BC MEDICAL JOURNAL VOL. 54 NO. 9, NOVEMBER 2012 www.bcmj.org Provincial clinical practice guidelines for the management of major burn trauma 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 re suscitation 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 re assessment 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 www.bcmj.org VOL. 54 NO. 9, NOVEMBER 2012 BC MEDICAL JOURNAL 457 Provincial clinical practice guidelines for the management of major burn trauma 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%.