Provincial clinical practice guidelines for the management of major burn trauma

Major burn trauma (MBT) represents a relatively small subset of major trauma, yet the impact on patients and health care systems is enormous, in part due to the complex physiology of burns and the need for multidisciplinary medical and surgical management. 

History of major burn trauma resuscitation
Historical experience, especially from world conflicts in the early 20th century, made clear that patients with major burn trauma commonly died from severe hypovolemia and acute renal failure in the early days posttrauma. Seminal research by Underhill, Cope, Moore, and others was followed by the work of Drs Baxter and Shires at Parkland Memorial Hospital in Dallas, Texas, that further recognized and promoted the importance of early, aggressive fluid resuscitation to re-establish intravascular volume to improve early survival.[1,2] In a retrospective analysis of major burn trauma, Baxter noted that patients who were resuscitated in the first 24 hours posttrauma with a crystalloid solution of between 3 and 5 millilitres per kilogram per percentage of total body surface area (mL/kg/%TBSA) burned had lower mortality rates than patients who received less fluid. The resuscitation benchmark of 4 mL/kg/%TBSA in the first 24 hours posttrauma be­came known as the Parkland formula. This remains the burn resuscitation formula most widely used today. Baxter also experimented with different kinds of resuscitation fluids, including crystalloids, colloids, and blood products. Over 40 years later, the choice of resuscitation fluid remains a topic of ongoing controversy.[1] 

The intersection of modern military conflicts and advanced trauma care has significantly increased our experience with major burn trauma.[3,4] Relatively recently, burn specialists began to notice an important subset of patients suffering significant morbidity and mortality related to over-resuscitation with fluids.[5-7] Complications such as acute respiratory distress syndrome, congestive heart failure, cerebral ede­ma, sepsis, and extremity or abdominal compartment syndrome were spe­cifically associated with re­suscitation volumes in excess of 6 mL/kg/%TBSA burned in the first 24 hours and were also associated with a steep increase in mortality.[4] “Fluid creep,” as it be­came known, emerged as a new threat to major burn trauma patients, and experts called for a re­assessment of resuscitation protocols to address these potentially avoidable complications.[5,6,8] 

In light of changing perspectives on burn pathophysiology, the Cana­dian and American military and the American Burn Association now specify a resuscitation formula of 2 to 4 mL/kg/%TBSA burned for the first 24 hours, with the lower figure in this range being half of what the Parkland formula endorses.[4] Many other major trauma systems have adopted re­suscitation formulas of less than 4 mL/kg/%TBSA in the first 24 hours,[4-9] including formulas based on the Lund-Browder chart.10 In addition to new concepts in fluid resuscitation for burns, novel therapies such as high-dose vitamin C,[9,11,12] early colloid administration, and selective use of vasoactive agents to improve perfusion pressures are also gaining traction in complex burn care.[9]

Management of major burn trauma in BC
In British Columbia major burn care is delivered in two centres. The Royal Jubilee Hospital Burn Unit in Victoria provides burn care for the Vancouver Island Health Authority (VIHA) and handles select provincial referrals. The BC Professional Fire Fighters’ Burn, Plastic and Trauma Unit (BPTU) at Vancouver General Hospital (VGH) serves as the quaternary referral centre for major burn trauma for the province. Primary burn medical and surgical care is led by clinical specialists from the Division of Plastic Surgery, though comprehensive care is multidisciplinary and includes paramedics, emergency physicians, intensive care physicians, trauma surgeons, and anesthesiologists, as well as specialized nurses and other allied health care professionals. 

With burn care changing, an ad hoc working group on major burn trauma was assembled in 2010 to review the literature and update re­gional practice standards for major burn resuscitation. The MBT group sought to engage tertiary and rural care providers to improve province-wide burn management using an inclusive, multidisciplinary model. Specialist physicians from plastic surgery, trauma surgery, anesthesiology, critical care medicine, emergency medicine, and prehospital care were represented. This group met regularly over a 1-year period and performed a systematic review of the medical literature to scrutinize international practice patterns and standards for major burn resuscitation. An internal audit of major burn resuscitation was also performed at the BPTU to identify areas of clinical strength and areas for improvement. Over the course of this process, the MBT group focused on resuscitation in the first 24 hours. This approach was taken for two reasons:

•    Resuscitation in the first 24 hours has a significant impact on morbidity and mortality later in a patient’s care.
•    Medical and surgical management after the first 24 hours rapidly be­comes extremely complex and be­yond the scope of the MBT group’s mandate. 
After reviewing, debating, and dis­cussing the scientific literature and the results of the internal BPTU audit, the MBT group identified four clinically significant issues (see the Table):
•    Many patients were transferred to the BPTU from outside the Lower Mainland after time had elapsed (2 to 26 hours). 
•    Health personnel estimates of the percentage of TBSA burned varied widely. 
•    The majority of patients referred to the BPTU were found to be over-resuscitated.
•    Hemodynamically unstable patients were commonly treated with successive fluid boluses, while the use of vasoactive agents was avoided.  

MBT group members agreed that a set of clinical practice guidelines (CPGs) should be developed to summarize the results of their literature review and address the issues identified. Initially, the goal of this initiative was to improve local hospital (VGH) practice; however, input from regional and provincial trauma leaders soon prompted the MBT group to collaborate with burn physicians at VIHA and to expand their mandate provincially. 

The Adult Major Burns CPGs that resulted (see Figures 1-5) were design­­ed using human factors engineering principles. They are practical, easy to use, and reflect best practice in major burn management. Currently, copies of the CPGs can be downloaded from http://apt.ubc.ca/hospital-sites/vancouver-general-hospital/clinical-pra.... In the near future, the CPGs will be available through the Provincial Health Services Authority at www.bcguidelines.ca.

Moving forward with burn care in BC
The Adult Major Burns CPGs were introduced into clinical practice at Vancouver General Hospital in the summer of 2011 and shortly after were adopted by BC Ambulance critical care transport paramedics. Physician leaders in Vancouver, Victoria, and other provincial health authorities are now using CME lectures, newsletters, scientific publications, and electronic media to disseminate the CPGs to all emergency health care providers in the province. To date, the CPGs have been field tested during two major industrial burn trauma scenarios in northern BC, and in major burn trauma cases elsewhere in the pro­vince. Informal feedback regarding the structure and usability of the CPGs has been positive, and more rigorous analysis of the clinical impact of these CPGs will occur during scheduled quality reviews at 2 and 5 years. Updates in burn medicine will be integrated into the CPGs every 5 years, or more frequently as required. There are some concerns that the changes in fluid management strategies recommended by the CPGs may result in unintended under-resuscitation of ma­jor burn trauma patients, and that this will compromise end-organ function.

Summary
The management of major burns is challenging and requires multidisciplinary care. Prehospital personnel and rural emergency physicians spend an important portion of time with major burn trauma patients, and the care these practitioners provide early in the resuscitation process has a major impact on patient morbidity and mortality later on. 

The Adult Major Burns CPGs were developed to improve the burn care delivered by all health care personnel in British Columbia. The guidelines provide up-to-date information regarding fluid resuscitation in the first 24 hours after burn trauma, and guidance on obtaining more accurate assessment of the TBSA burned using the Lund-Browder chart. This information is intended for all levels of care providers and should help reduce variability in fluid resuscitation calculations. Information is also provided to improve care in some major burns cases that require the selective use of colloid and vasoactive agents. 

The guidelines will be reviewed and updated regularly, and all feedback is welcomed by the MBT group. Feedback regarding this and other concerns can be directed to Dr Anthony Papp (anthony.papp@vch.ca ) and Dr Mark Vu (mark.vu@vch.ca). 

Acknowledgments 
The MBT group gratefully acknowledges the ongoing assistance of the Department of Plastic Surgery at Royal Jubilee Hospital and the Critical Care Transport Program of the BC Ambulance Service.

Competing interests
None declared.

This article has been peer reviewed.

Dr Gregory is senior resident in the Division of Plastic Surgery at the University of British Columbia. Dr Mark Vu is section head, Trauma Anesthesia in the Department of Anesthesiology and Perioperative Care at Vancouver General Hospital (VGH). Dr Sweet is a staff physician in the Division of Critical Care Medicine at VGH and in the hospital’s Department of Emergency Medicine. Dr Erik Vu is a staff physician in the Department of Emergency Medicine at VGH and the Department of Critical Care at Surrey Memorial Hospital, and a medical consultant for the British Columbia Ambulance Service. Dr Finlayson is a staff physician in the Division of Critical Care Medicine at VGH and in the hospital’s Department of Anesthesiology and Perioperative Care. Dr Brown is medical director of trauma services for the British Columbia Provincial Health Services Authority. He is also a staff surgeon in the Division of General Surgery at VGH. Dr Ritchie is former head of the Department of Emergency Medicine at Lions Gate Hospital. Dr Griesdale is a staff physician in the Division of Critical Care Medicine at VGH and in the hospital’s Department of Anesthesiology and Perioperative Care. Dr Dhingra is a staff physician in the Division of Critical Care Medicine at VGH. Dr Papp is director of the BC Professional Fire Fighters’ Burn, Plastic and Trauma Unit at VGH. He is also a staff surgeon in the hospital’s Division of Plastic Surgery.