1. Chapter 12 FLUID BALANCE IN ADULTS Anne Francis

2. Introduction This presentation investigates severe burn injuries, and their impact on fluid balance in adults. In conjunction with the book chapter, these slides should enable you to: Identify the population at risk of burn injury Recognise the types and causes of burn injury Explore the available evidence-base to inform the management of the burn-injured individual Examine the role of the nurse within the multidisciplinary team in the assessment, planning, implementation, evaluation and co-ordination of the care of a burn-injured individual Identify the factors contributing to maintaining fluid balance in the burn-injured individual

3. Epidemiology An understanding of epidemiology is vital when considering the population at risk of a burn injury and accident prevention initiatives. In your learning groups, consider the implications of this statement “Every 90 seconds someone in the UK is burned or scalded in an accident at home and around 112,000 patients are treated in hospital for burns every year. 60% of these are children under 12 years of age. The number of burn victims can only be guessed at, particularly in developing nations” (http://www.raft.ac.uk/research_burns.htm)

4. Types of Burn Contact Scald Electrical Flame Radiation Flash Explosion Chemical

5. Assessment Airway & cervical spine management Breathing Circulation Disability Exposure Fluids Tools such as the Lund & Browder chart can assist with assessment

6. Lund and Browder burn assessment chart Lund & Browder Chart

7. Estimation of Burn Depth Erythema Partial thickness - Superficial - Deep Full thickness

8. Treatment MUIR & BARCLAY Colloid resuscitation with plasma The first 36 hours are divided into time periods of 4,4,4,6,6,12 hour intervals Each interval = 0.5 x %BSA x Wt (Kg)

9. PARKLAND FORMULA Day 1 4ml Hartmann Solution/Kg/%TBSA in the first 24 hours after the burn. Half is given in the first 8 hours after injury and the second half in the next 16 hours Day 2 700-2000ml colloid, to maintain urine output No crystalloid and 5% dextrose maintenance fluids

10. Rehabilitation Rehabilitation should begin at time of injury and may involve splinting and positioning and physiotherapy Social and emotional support is vital. The clinical psychologist and social worker can play a vital role in supporting the patient and family At a later stage self help groups and organisations can provide extra support and skills training to facilitate the patient and his or her family to make a successful recovery

11. Ongoing Considerations Nutrition Body image Psychological implications Social considerations Contractures Scarring If in doubt refer to a Specialist Burn Centre or Unit, they will always be willing to help you.

12. Activities On the remaining slides you will find a series of questions, which you can use as discussion points within your learning groups, and a stimulus for further investigation.

13. SCENARIO Peter is a 38-year-old accountant, weighing 70 kg, whose hobby is sailing. He sustained flame burns to 40% of his body, including his face, chest, arms and legs. His burns were mainly partial thickness with deeper areas on his anterior thighs. Q. Calculate the fluid Peter will require using both the Parkland and Muir and Barclay formula Q. How will we know if the fluid replacement has been successful? Q. What observations will the health care practitioner need to take?

14. EARLY WARNING SCORING AND MODIFIED EARLY WARNING SCORES Q. What is the purpose of the early warning scoring? Q, Develop a working knowledge of the score in use in your own clinical area. Q. Does this differ from those used in other Trusts?

15. SEPTIC SHOCK Q. What are the main signs and symptoms associated with septic shock? Q. Why is an individual with a major burn at risk from developing septic shock?

16. DONOR SITE MANAGEMENT Q. Consider the principles of managing a donor site wound, including the rate of healing, frequency and types of dressings.

17. NUTRITION Q. Following a significant burn injury an individual undergoes a catabolic state. What do we mean by anabolism and catabolism? Q. How can we compensate for a catabolic state? Q. Consider the role of healthcare practitioners in managing nutrition.

18. THE NEED FOR SURGICAL INTERVENTION Q. The two main modes of treatment for the burn wound are: conservative management and surgical management. What are the implications of both conservative and surgical management for the burn wound? Q. Consider the principles of managing a burn wound - include the rate of healing, frequency and types of dressings

19. HEALTH PROMOTION AND ACCIDENT PREVENTION Q. Reflecting on the scenario of Peter, what issues might be relevant for health promotion and accident prevention, and why? Q. What strategies may be utilised and when?