What is the initial treatment protocol for a burns patient in an intensive care unit (ICU)?

ICU Protocol for Severe Burns Management

Immediate Assessment and Resuscitation (First Hour)

Administer 20 mL/kg of Ringer's Lactate or balanced crystalloid solution intravenously within the first 60 minutes, regardless of burn size, to address early hypovolemic shock. 1, 2, 3

Initial Assessment Steps

• Measure total body surface area (TBSA) using the Lund-Browder chart, not the Rule of Nines, which overestimates TBSA in 70-94% of cases and leads to dangerous fluid overload 1
• Establish IV access immediately in unburned areas; use intraosseous route if IV access cannot be rapidly obtained 2
• Assess for inhalation injury by examining for circumoral burns, oropharyngeal burns, and carbonaceous sputum, as this significantly increases mortality 1
• Evaluate for circumferential burns that may cause compartment syndrome requiring escharotomy 1, 3
• Contact a burn specialist immediately to determine need for transfer to a burn center 1

Fluid Resuscitation Protocol (First 24 Hours)

Calculation and Administration

Calculate total 24-hour fluid requirements using the Parkland formula: 2-4 mL/kg/%TBSA of Ringer's Lactate. 1, 2

• Administer half of the calculated volume in the first 8 hours post-burn (not from admission time), with the remaining half over the next 16 hours 1, 3
• For adults with TBSA ≥15% and children with TBSA ≥10%, formal fluid resuscitation is mandatory 2
• Avoid normal saline (0.9% NaCl) as primary resuscitation fluid due to increased risk of hyperchloremic metabolic acidosis and acute kidney injury 1, 2
• Recent evidence suggests starting at the lower end (2 mL/kg/TBSA) is safe and results in lower 24-hour volumes (3.9 mL/kg/TBSA) without increased mortality 4

Pediatric Modifications

• Children require higher fluid volumes: approximately 3-4 mL/kg/%TBSA (some sources suggest up to 6 mL/kg/%TBSA) due to higher surface area-to-weight ratio 1, 2, 3
• Use pediatric Lund-Browder chart for accurate TBSA assessment 3

Hemodynamic Monitoring and Adjustment

Adjust fluid infusion rates continuously based on urine output, targeting 0.5-1 mL/kg/hour in adults. 5, 1, 2

Monitoring Parameters

• Hourly urine output is the primary parameter for fluid adjustment 5, 1, 2
• Monitor arterial lactate concentration for adequacy of resuscitation 5
• Use advanced hemodynamic monitoring (echocardiography, cardiac output monitoring, central venous pressure) in patients with persistent oliguria or hemodynamic instability 5
• If hypotension persists despite adequate fluid resuscitation, evaluate cardiac function with echocardiography before initiating vasopressors 5, 1, 2

Critical Pitfall: Fluid Creep

Avoid "fluid creep" (excessive fluid administration), which occurs in 76% of resuscitations and leads to compartment syndrome, pulmonary edema, and intestinal edema. 1, 3

• Studies show average administration of 6.3 mL/kg/%TBSA when Parkland recommends 2-4 mL/kg/%TBSA 3
• Excessive fluids are associated with increased pneumonia (AOR=2.0), extremity compartment syndrome (AOR=7.9), and prolonged mechanical ventilation 5, 6

Albumin Administration (After 6-12 Hours)

For patients with TBSA >30%, initiate 5% human albumin between 6-12 hours post-burn to reduce crystalloid volumes and prevent complications. 5, 1, 2

• Target serum albumin levels >30 g/L with doses of 1-2 g/kg/day 1, 2
• Meta-analysis shows albumin administration significantly reduces mortality (OR=0.34,95% CI 0.19-0.58, P<0.001) when studies with high bias are excluded 5
• Albumin reduces abdominal compartment syndrome from 15.4% to 2.8% (P<0.05) 5
• Early albumin administration decreases crystalloid requirements, organ failure incidence, and hospital length of stay 5, 1

Contraindicated Colloids

• Hydroxyethyl starches (HES) are absolutely contraindicated in severe burns per European Medicines Agency 1
• Do not use gelatins or other synthetic starches due to negative effects on coagulation 1

Compartment Syndrome Management

Monitor continuously for compartment syndrome, particularly in circumferential third-degree burns, and perform escharotomy within 48 hours if circulatory impairment develops. 1, 2

• Escharotomy should ideally be performed at a Burns Center; obtain specialist advice if transfer is not feasible 1, 2
• Monitor intra-abdominal pressure as abdominal compartment syndrome risk is significantly reduced with albumin use 5, 2
• Colloid use during first 24 hours reduces extremity compartment syndrome risk (AOR=0.06,95% CI 0.007-0.49) 6

Wound Management

Apply silver sulfadiazine cream 1% to burn wounds once to twice daily at approximately 1/16 inch thickness under sterile conditions. 7

• Cleanse and debride burn wounds before initial application 7
• Keep burn areas covered with cream at all times; reapply immediately after hydrotherapy 7
• Continue treatment until satisfactory healing occurs or burn site is ready for grafting 7
• Dressings are not required but may be used if patient requirements necessitate 7

Acute Kidney Injury Prevention

Use balanced crystalloid solutions exclusively and monitor for AKI development, which is common in severe burns. 2

• Balanced crystalloids (Ringer's Lactate) minimize hyperchloremic metabolic acidosis and AKI risk compared to normal saline 2
• If AKI develops, provide 20-30 kcal/kg/day total energy intake 2
• Protein requirements: 0.8-1.0 g/kg/day in noncatabolic AKI without dialysis; 1.0-1.5 g/kg/day on RRT; up to 1.7 g/kg/day on CRRT 2
• Provide nutrition preferentially via enteral route 2

Algorithm Summary for First 24 Hours

1. Hour 0-1: Give 20 mL/kg Ringer's Lactate bolus; assess TBSA with Lund-Browder chart; evaluate for inhalation injury and circumferential burns 1, 2, 3

2. Hour 1-8: Administer half of calculated Parkland formula (2-4 mL/kg/%TBSA); adjust hourly based on urine output 0.5-1 mL/kg/hour 5, 1, 2

3. Hour 6-12: Initiate 5% albumin if TBSA >30%, targeting serum levels >30 g/L 5, 1, 2

4. Hour 8-24: Administer remaining half of calculated fluids; continue urine output monitoring and fluid adjustment 1, 3

5. Continuous: Monitor for compartment syndrome, perform escharotomy if indicated; apply silver sulfadiazine to wounds; reassess TBSA to prevent over/undertriage 1, 7