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Resuscitation of Severely Burned Military Casualties: Fluid Begets More Fluid

Chung, Kevin K. MD; Wolf, Steven E. MD; Cancio, Leopoldo C. MD; Alvarado, Ricardo MD; Jones, John A. BS, BBA; McCorcle, Jeffery PA; King, Booker T. MD; Barillo, David J. MD; Renz, Evan M. MD; Blackbourne, Lorne H. MD

The Journal of Trauma: Injury, Infection, and Critical Care: August 2009 - Volume 67 - Issue 2 - p 231-237
doi: 10.1097/TA.0b013e3181ac68cf
Original Article

Background: In November 2005, institution of a military-wide burn resuscitation guideline requested the documentation of the initial 24-hour resuscitation of severely burned military casualties on a burn flow sheet to provide continuity of care. The guidelines instruct the providers to calculate predicted 24-hour fluid requirements and initial fluid rate based on the American Burn Association Consensus recommendation of 2 (modified Brooke) mL · kg−1 · % total body surface area (TBSA)−1 to 4 (Parkland) mL · kg−1 · %TBSA−1 burn. The objective of this study was to evaluate the relationship between the estimated fluid volumes calculated, either by the Modified Brooke or the Parkland formulas, and actual volumes received.

Methods: From November 2005 to December 2008, 105 patients were globally evacuated with >20% TBSA burns, of whom 73 had burn flow sheets initiated. Of these, 58 had completed burn flow sheets. Total fluids administered in the first 24-hour period for each patient were recorded. Chart reviews were performed to extract demographic and clinical outcomes data.

Results: Of the 58, the modified Brooke formula was used in 31 patients (modified Brooke group) to estimate 24-hour fluid requirements and the Parkland formula was used in 21 (Parkland group). In six, 3 mL · kg−1 · %TBSA−1 was used and were excluded from analysis. No significant difference was detected between the two groups for age, %TBSA burned, inhalation injury, or Injury Severity Score. Actual 24-hour resuscitation in the modified Brooke group was significantly lower than in the Parkland group (16.9 L ± 6.0 L vs. 25.0 L ± 11.2 L, p = 0.003). A greater percentage of patients exceeded the Ivy index (250 mL/kg) in the Parkland group compared with the modified Brooke group (57% vs. 29%, p = 0.026). On average, those who had 24-hour fluid needs estimated by the modified Brooke formula received a 3.8 mL · kg−1 · %TBSA−1 ± 1.2 mL · kg−1 · %TBSA−1 resuscitation, whereas the Parkland group received a 5.9 mL · kg−1 · %TBSA−1 ± 1.1 mL · kg−1 · %TBSA−1 resuscitation (p < 0.0001). No differences in measured outcomes were detected between the two groups. On multivariate logistic regression, exceeding the Ivy index was an independent predictor of death (area under the curve [AUC], 0.807; CI, 0.66–0.95).

Conclusion: In severely burned military casualties undergoing initial burn resuscitation, the modified Brooke formula resulted in significantly less 24-hour volumes without resulting in higher morbidity or mortality.

From the United States Army Institute of Surgical Research (K.K.C., S.E.W., L.C.C., J.A.J., J.M., B.T.K., D.J.B., E.M.R., L.H.B.), Fort Sam Houston, Texas; and University of Texas Health Science Center at San Antonio (S.E.W., R.A.), San Antonio, Texas.

Submitted for publication January 13, 2009.

Accepted for publication April 30, 2009.

The views herein are those of the authors and do not necessarily reflect those of the Army Medical Department or the Department of Defense.

Address for reprints: Kevin K. Chung, MD, 3400 Rawley E. Chambers Avenue, San Antonio, TX 78234; email:

© 2009 Lippincott Williams & Wilkins, Inc.