Burn Resuscitation Guidelines

Initial Fluid Resuscitation

The American Society of Anesthesiologists recommends calculating the initial fluid resuscitation for a patient with burns using the Parkland formula (4 mL/kg/%TBSA) plus maintenance fluids, with half given in the first 8 hours, and adjusting based on clinical response rather than rigidly adhering to formula calculations 1
The initial fluid resuscitation should be approximately 2-4 mL/kg/%TBSA for the first 24 hours, with children requiring higher fluid volumes (approximately 6 mL/kg/%TBSA) due to higher body surface area/weight ratio 1

The American College of Surgeons recommends avoiding excessive fluid administration, which can lead to complications including pulmonary edema, abdominal compartment syndrome, and increased morbidity, and considering albumin administration after the first 6 hours for burns >30% TBSA 1
Balanced crystalloids, such as Lactated Ringer's solution, are recommended as first-line fluid due to its electrolyte composition being closer to plasma, with an initial dose of 15-20 mL/kg in the first hour 1, 2
Normal saline should be avoided as primary resuscitation fluid due to risk of hyperchloremic metabolic acidosis and acute kidney injury, except in patients with traumatic brain injury (TBI) where it is preferred over Ringer's solution due to its higher sodium content and absence of calcium (Grade 1B) 1, 3, 4
Hartmann solution should be avoided in patients with crush syndrome or rhabdomyolysis due to its potassium content, and potassium-free solutions are preferred to avoid exacerbating hyperkalemia 5
Fluid rates should be adjusted based on clinical response, aiming for a urine output of 0.5-1 mL/kg/hour in adults, and 1-2 mL/kg/hour in cases with myoglobinuria, with additional monitoring including arterial lactate concentration, echocardiography, and hemodynamic parameters 1

Hourly urine output is a key parameter for assessing adequacy of resuscitation, and additional monitoring may include arterial lactate concentration, echocardiography, and hemodynamic parameters, to avoid both under-resuscitation and "fluid creep" 1
Monitor for intra-abdominal hypertension, which may require escharotomy within 48 hours if circulatory impairment occurs 1
Suspect smoke inhalation in patients with a history of fire in an enclosed space, soot on the face, dysphonia, dyspnea, wheezing, or blackish sputum, and avoid bronchial fibroscopy outside of burn centers to avoid transfer delays, as suggested by the American Thoracic Society 1

Adults with ≥15% total body surface area (TBSA) burns and children with ≥10% TBSA require an immediate fluid bolus, and patients with 40% TBSA burns require immediate intubation, aggressive fluid resuscitation with balanced crystalloids, and specialized burn center care to reduce morbidity and mortality, as recommended by the American Burn Association and the American College of Surgeons 1
All patients with 40% TBSA burns should be transferred to a specialized burn center as soon as possible after initial stabilization, without delaying transfer for non-essential procedures, as recommended by the American Burn Association 1
Implement multimodal analgesia immediately, titrating all analgesics based on validated pain assessment scales, and consider combining intravenous ketamine with other analgesics for severe burn pain, incorporating non-pharmacological techniques during dressing changes for stable patients 1
Escharotomy is rarely indicated immediately except for compromised airway/ventilation, but consider for intra-abdominal hypertension or circulatory impairment within 48 hours, and should be performed at a Burns Center or after specialist consultation 1