R. D. Shelby1, A. B. Nordin1, C. McCulloh1, J. Shi2,3, R. Fabia1,2, R. K. Thakkar1,2,3 1Nationwide Children’s Hospital,Pediatric Surgery,Columbus, OH, USA 2The Research Institute at Nationwide Children’s Hospital,Center For Pediatric Trauma Research,Columbus, OH, USA 3The Research Institute at Nationwide Children’s Hospital,Center For Injury Research And Policy,Columbus, OH, USA
Introduction: Fluid resuscitation remains the cornerstone of acute burn management. There is a delicate line between providing enough fluid volume and over resuscitation – one that can lead to significant complications. Total body surface area (TBSA) is the primary component in calculation of required fluid volume in burn injury resuscitation. We have previously shown that TBSA estimations for pediatric patients performed by prehospital emergency medical service providers were significantly higher than those reported by burn specialists at an American Burn Association (ABA)-verified pediatric burn center. Still, the relationship between TBSA overestimation and over resuscitation remains unclear. We sought to evaluate whether over estimation of TBSA prior to arrival at an ABA-verified pediatric burn center led to significantly higher fluid volume administration, resulting in over resuscitation.
Methods: A retrospective chart review was performed of our trauma registry of patients admitted to our burn center. Inclusion criteria were children presenting with large burns, defined as TBSA burns ≥15%, from 2007 to 2015. The TBSA estimate prior to arrival to the burn center, TBSA determined by the ED physician, TBSA determined by a burn specialist, total fluid volume given before arrival to the burn center, and demographics were reviewed. The experimental standard TBSA was set as the TBSA determined by pediatric burn specialists at our ABA-verified center. This was compared with prehospital emergency medical service providers, outside hospital physicians, and our burn center ED physicians to determine presence of overestimation of TBSA. TBSA’s ≥10% or ≤10% from the standard was designated as inaccurate. Expected fluid volume was then calculated using the standard TBSA and our burn resuscitation formula. Over resuscitation was defined as receipt of fluid volume ≥50% of the expected volume.Statistical significance was determined using a paired t-test with P < 0.05.
Results: A total of 72 patients ≤18 years old met inclusion criteria. Average TBSA was 19.5 ± 12.6%, and age of 2.5 ± 0.53 years. The most common mechanism was flame (50%) followed by scald burns (47.2%). 44.4% (n=32) of the patients received +50% of their expected resuscitative intravenous fluids based on the burn specialist determined TBSA, while 55.6% of patients were either appropriately resuscitated (n=10, 13.9%) or under resuscitated (n=30, 41.7%) (P=0.408).
Conclusion: Inaccuracies in TBSA calculation can lead to potentially life-threatening and disabling complications in pediatric patients with thermal injury. However, we were unable to demonstrate an association between over resuscitation and inaccurate TBSA in this cohort. Though less than majority of our cohort was over resuscitated, these patients received an average of 150-200% of excess fluid- a statistic that remains substantial, and requires further investigation.