Extremely interesting theory. Way to go.

first this is right to say that blood pressure is normal at early stage of burns.

second delayed fluid resuscitation is linked with AKI and death (see pediatric study of barrow et col resuscitation )

so both pain and hypovolemic shock must must be treated.

i agree with the bad effect of excessive fluid therapy; in our burn center we use a bundle of parameters (urine output, blood pressure, hematocrit, lactate and swan gang for large burn) to define amount of continuous fluid therapy. we use 20% serum albumin as early as possible.

Both burn shock and hemorrhagic shock belong to hypovolemic shock, but they are significantly different. Hemorrhagic shock can occur immediately and then blood pressure subsequently decreases. Burn shock occurs gradually along with plasma leakage from circulation. So primary blood pressure in the place of accident in can be normal.

[Experimental study on early escharectomy after major burns in minipigs].

[Article in Chinese]

Xu G, Duan CW, Chen SQ, Liu J, Li FS, Feng YZ, Liu DM, DU XH.

In the pre-hospital setting in Australia the emphasis has long been on cooling the burn, managing the airway and, then, pain and, lastly, infection. The need for active fluid replacement in the first 60-120 minutes has been regarded as a low priority as fluid loss from the circulatory system is a slow process. The practical problems include measuring blood pressure in the burns victim due to limbs being burnt leaving nowhere for the placement of the measuring cuff. A further problem is that the vein used to cannulate may be later restricted by swelling and the site of cannulation becomes an infection risk, particularly in uncontrolled situations. Further risk may also result from the pushing in of fluids if strict measurement of fluid output (urine etc) is not possible as the overload may increase the level of oedema in the tissues. The Alfred Hospital in Melbourne Australia has done some very good work in this area.

Thanks for all your answers. I referred to the very first initial situation after burn trauma. In Central Europe primary care mostly is organized by emergency doctors coming to the patients within emergency cars and start preclinical care with fluid appliance etc. very soon.

Burn shock is developing, no question according to time after burn and severity of injury.

Different reasons for developing capillary leak situation have been described targeting the glycocalyx as a tightening mean of the glycocalyx.

This can be Natriuretic peptide, TNF Alpha, or activated LPS.

After my knowledge of literature the very early cascade of development of capillary leak is initiated by NAP , the others following later.

Very early fluid in normotensive or hypertensive situations makes an increased output of natriuretic peptide, reproducable even in healthy volunteers with 1 l of fluid within one hour, which causes degradation as described by Chappell D, Jacob M, Becker BF, Hofmann-Kiefer K, Conzen P, Rehm M, et al. Expedition glycocalyx. A newly discovered “Great Barrier ReefReef”. Anaesthesist. 2008;57(10):959–69.

High and low responders of volume can be identified within 5 hours as described by Cancio LC, Chávez S, Alvarado-Ortega M, Barillo DJ, Walker SC, McManus AT, et al. , Predicting increased fluid requirements during the resuscitation of thermally injured patients. The Journal of trauma . 2004 ;56(2):404–13. So this indicates early capillary leak as reason for high fluid needs later.

Patients where resuscitation starts with higher amounts of fluids need more fluid later, what demonstrates an increased capillary leakage early after trauma.

(Kevin K. Chung, Steven E. Wolf, Leopoldo C. Cancio RA, John A. Jones, BS, Jeffery McCorcle, Booker T. King DJB, Evan M. Renz and LHB, Chung KK, Wolf SE, Cancio LC, et al. Resuscitation of severely burned military casualties: fluid begets more fluid. The Journal of trauma. 2009;67(2):231–7; discussion 237.)

Many authors describe, that patients receive more fluid preclinically than needed for 24 hours.

So I wonder, whether the primary situation, under wich resuscitation is started influences the development of capillary leak.

(Literture just as excerpt

Herbert

.

What you say makes sense,treat pain,start oral rehydration and monitor the situation,but when it comes to having a protocol where an experienced burn surgeon is not avialable the fluid resuscitation is key factor in major burns