Initial management of a major burn: II—assessment and resuscitation
BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7457.101 (Published 08 July 2004) Cite this as: BMJ 2004;329:101
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
"The greatest amount of fluid loss in burn patients is in the first
24 hours after injury. For the first eight to 12 hours, there is a general
shift of fluid from the intravascular to interstitial fluid
compartments"(1).
According to Shires, surgical trauma per se (without administration
of fluids) leads to a decrease in functional ECV which is proportional to
the degree of surgical trauma. The decrease in functional ECV was
attributed to sequestration of fluids within the traumatized area or
expansion of the intracellular volume. His findings and recommendations
are much debated largely because of conflicting data. Might the
controversy be due to the uncontrolled effects of tissue pH that often
occurs in these circumstances?
If net fluid transport across membranes follows net sodium transport,
as in gut mucosa, and a cellular acidosis initiates an efflux of H+ which
induces an influx of sodium and its osmotic equivalent of water ICF volume
should rise and ECF volume fall. Intravenous infusions in these
circumstances might, therefore, be expected to cause the ICF volume to
rise more causing what Shires called "third spacing". If, on the other
hand tissue pH is kept normal by "keeping up with the fluid losses" an
excess of fluids might be expected to be excreted in urine. Certainly the
capacity of a rugger player's kidneys to accommodate his excessive intake
of beer without systemic consequences after a game is considerable.
If instead the intracellular pH were allowed to rise, as might occur
unintentionally from the loss of CO2 from the surface of a burn or open
abdomen placed in contact with the hypocarbic environment in atmospheric
air, ICF volume might be expected to contract and ECF volume to rise. Any
excess of iv fluids administered in these circumstanes might, therefore be
expected to cause an increase in ECF volume and the risk of its
cardiopulmonary consequences.
The mechanism of action in the case of an increase in pH might well
be the down regulation of oxidative phosphorylaton and upregulation of
anaerobic glycolysis in renal tubules caused by the accompanying reduction
in the protonmotive force driving ATP resynthesis by oxidative
phosphorylation and stimulation of anaerobic glycolysis by the alklosis
(3).
Given this scenario the "general shift of fluid from the
intravascular to interstitial fluid compartments" in the resuscitation of
burned patients might be averted by increasing the pCO2 in the air with
which the surface of the burn was in contact to 40 mmHg and thereby
decreasing the likelihood of developing an alkalosis. The same might be
accomplished in a open wound most easily in laparoscopic surgery. An added
advantage should be the hypothetical myocardial benefits of averting over
dependence upon substrate delivery for ATP resynthesis by anaerobic
glycolysis(4).
The notion that not only fluid distribution and balance but also
renal tubular finction and myocardial workload might be a managable
function of tissue pH is, I believe, novel. If true it should reconcile
the findings of the Shires "wet" and Moore "dry" schools (2,5).
Furthermore the opportunity of using real-time metabolic monitoring (6)to
manage these variables already exists in burned patients. Unfortunately
measurments of critical metabolic measurement, tissue pH, has yet to be
used to guide routine management as repeatedly advocated(7).
1. Shehan Hettiaratchy and Remo Papini
Initial management of a major burn: II—assessment and resuscitation
BMJ 2004; 329: 101-103
2. K. Holte, N. E. Sharrock and H. Kehlet. Pathophysiology and
clinical implications of perioperative fluid excess British Journal of
Anaesthesia, 2002, Vol. 89, No. 4 622-632
3. Cain SM. pH effects on lactate and excess lactate in relation to
O2 deficit in hypoxic dogs.
J Appl Physiol. 1977 Jan;42(1):44-9.
4. Successful evolutionary adaptation to environmental stress?
Richard G Fiddian-Green
Heart Online, 14 Jul 2004 eLetter r: D A Lawlor, G Davey Smith, R
Mitchell, and S Ebrahim
Temperature at birth, coronary heart disease, and insulin resistance:
cross sectional analyses of the British women’s heart and health study
Heart 2004; 90: 381-388
5. Fiddian-Green RG. eLetters re: Satoshi Ohki, Fumio Kunimoto,
Yukitaka Isa, Hiroshi Tsukagoshi, Susumu Ishikawa, Akio Ohtaki, Toru
Takahashi, Tetsuya Koyano, Noboru Oriuchi, and Yasuo Morishita
Changes in gastric intramucosal pH and circulating blood volume following
coronary artery bypass grafting
Can J Anesth 2000; 47: 516-521
6. Light TD, Jeng JC, Jain AK, Jablonski KA, Kim DE, Phillips TM,
Rizzo AG, Jordan MH. The 2003 Carl A Moyer Award: real-time metabolic
monitors, ischemia-reperfusion, titration endpoints, and ultraprecise burn
resuscitation.
J Burn Care Rehabil. 2004 Jan-Feb;25(1):33-44.
7. Worshipping false gods
Richard G Fiddian-Green
Chest Online, 13 Sep 2003 eLetters re: David Roy Dantzker
Monitoring Tissue Oxygenation : The Quest Continues
Chest 2001; 120: 701-702
Competing interests:
Tonometric patents issued in my name
Competing interests: No competing interests
Sir,
In 2001 the Faculty of Pre-Hospital Care of the Royal College of
Surgeons of Edinburgh proposed the use of Serial Halving as the technique
of choice for assessing burns in the pre-hospital setting.
Work has been done in our department to compare Serial Halving with
the Rule of Nines technique. Serial Halving was found to be a very simple
method for quickly assessing burn area. The technique can be taught
quickly and assessments using it can easily be guided over the telephone.
Serial halving was found to be no worse than the rule of nines technique
as a basis on which to make clinical decisions.
The review of major burn assessment failed to mention this important
technique which may well be playing an important role on the future of
assessing and resuscitating burn injury.
Competing interests:
None declared
Competing interests: No competing interests
Dear colleagues:
My question is simple. How many of the cases were suicide acts?. Burning
is a common method of suicide in my territory
mainly in young female with love troubles, with a hight mortality rate.For
many years burning have been a second method more frequent used to commit
suicide(the first is hanging).
Could you show me another country who use that method of suicidal
behaviour, please?
Sincerely yours
Prof. Dr. Sergio A. Perez Barrero
Founder WPA Suicidology Section
IASP National Representative
PAHO- WHO Temporal Advisor for the Suicide Prevention in The Americas.
Member of IASR, IATS, BI.
Competing interests:
None declared
Competing interests: No competing interests
Re: Initial management of a major burn: II—assessment and resuscitation
Dear Editor
The diagram in this paper showing the Lund and Browder percentage total body surface area is not an accurate reflection of the original paper - that of the percentage surface area for each aspect of the hands. In the diagram in this article each aspect of the hand has a percentage surface area of 1.5%, whereas in the Lund and Browder paper each aspect of the hand has a percentage surface area of 1.25%, Whilst this is a small difference the error has been copied into citing articles, including Wikipedia, and will almost certainly be reflected in 'Lund and Browder' charts being used in clinical practice.
Yours faithfully,
Iain Mackenzie
Competing interests: No competing interests