We received an excellent talk by the best plastic surgeon in Chicago also working for the burns unit of Concord Hospital. Here are some key points. She stressed the importance of the Parkland formula as a guide. Both due to individual differences between patients, but also due to the inter-observer difference in evaluating a patient’s burns percentage. Keep an eye on the urine output.
The most important indicator is urine output. If the kidney’s stop, they’re dead. Of course, urine output is a delayed indicator, so the Parkland formula is still important to give you an idea of the huge amount of fluids needed, so you can keep ahead of the game. But if urine output is more than adequate, you can think about stepping down a little, especially if the patient has contraindications to severe fluid loading.
What fluids to use? Crystalloids. Even though you know most of it will go extra-cellular. And yes, the patient will get massive edema. The patients albumin is low. Why not albumin or colloids? Well, the capillary leaking is the cause of the low albumin. Albumin or synthetic colloids, will only follow the patients albumin into the interstitial space, drag fluid with it, and increase the fluid load there.
Escharotomies. If you think they might be neccessary, they are. Do them. You don’t need to worry about healing, infections or scarring. The skin is dead and will need grafting anyway. Save the limb, avoid abdominal compartment, make ventilation easier. You don’t really need analgesia for the actual escharotomy, the nerves are dead. Cut deep enough to get some bleeding. Cut long enough to get into healthy skin – and at these two ends you can and should apply some local anaesthetic.
The skin needs to heal within two weeks. After that time window the continuing and massive immune response will get you collagen deposits, and give those nasty looking contractures of the skin. The patient doesn’t want that.
Take home message: The most important indicator for treatment is urine output.