What is the initial management protocol for a patient in the Burns Intensive Care Unit (ICU)?

Burns ICU Management Protocol

Initial Assessment and Resuscitation

For severe burn patients in the ICU, immediately initiate fluid resuscitation with Ringer's Lactate using 20 mL/kg bolus within the first hour, then calculate 24-hour requirements using the Parkland formula (2-4 mL/kg/%TBSA), administering half in the first 8 hours post-burn. 1

Burn Classification and Triage Criteria

• Classify burns by depth (superficial, partial-thickness, full-thickness) and measure total body surface area (TBSA) using the Lund-Browder chart, not the Rule of Nines, as the latter overestimates TBSA in 70-94% of cases leading to dangerous fluid overadministration 1

• Adults with burns ≥10% TBSA and children with burns ≥5% TBSA require formal fluid resuscitation 1, 2

• Burns involving face, hands, feet, genitals, or full-thickness burns require specialized burn center care regardless of size 1

• Assess for inhalation injury immediately by checking for circumoral burns, oropharyngeal burns, and carbonaceous sputum, as this significantly increases mortality 1

Fluid Resuscitation Protocol

Crystalloid Administration:

• Use Ringer's Lactate as first-line fluid—never use normal saline as primary resuscitation fluid due to higher risk of hyperchloremic metabolic acidosis and acute kidney injury 1, 2

• Administer initial bolus of 20 mL/kg within first hour 1, 2

• Calculate 24-hour requirements: 2-4 mL/kg/%TBSA (Parkland formula) 1, 2

• Give 50% of calculated volume in first 8 hours post-burn, remaining 50% over next 16 hours 1, 3

• Children require higher volumes (approximately 6 mL/kg/%TBSA) due to higher surface area-to-weight ratio 1, 2

Albumin Administration:

• For TBSA >30%, initiate 5% human albumin at 8-12 hours post-burn to reduce crystalloid volumes and prevent "fluid creep" 1

• Target serum albumin levels >30 g/L with doses of 1-2 g/kg/day 1, 2

• Albumin reduces mortality (OR=0.34,95% CI 0.19-0.58, P<0.001) and decreases abdominal compartment syndrome from 15.4% to 2.8% 1

• Never use hydroxyethyl starches (HES)—they are contraindicated in severe burns per European Medicines Agency 1

Hemodynamic Monitoring

Target urine output of 0.5-1 mL/kg/hour as primary resuscitation endpoint 1, 2, 3

• Monitor hourly urine output and adjust fluid rates continuously 1

• Track arterial lactate concentration for adequacy of resuscitation 1

• Use advanced hemodynamic monitoring (echocardiography, cardiac output monitoring) in patients with persistent oliguria or hemodynamic instability 1

• If hypotension persists despite adequate fluids, evaluate cardiac function with echocardiography before initiating vasopressors 1, 2

Complication Management

Compartment Syndrome

• Monitor for compartment syndrome in circumferential third-degree burns, which can cause acute limb ischemia or thoracic/abdominal compartment syndrome 1

• Perform escharotomy immediately (ideally within 48 hours) if deep circumferential burns cause circulatory or respiratory compromise 1, 2

• Monitor intra-abdominal pressure as albumin use reduces abdominal compartment syndrome risk 1

Acute Kidney Injury Prevention

• Monitor for AKI, a common complication in severe burns 1, 2

• In electrical burns with significant muscle damage, maintain higher urine output (1-2 mL/kg/hour) to prevent myoglobin-induced renal injury 3

• Balanced crystalloids minimize AKI risk compared to normal saline 2

Nutritional Support in AKI

• Provide 20-30 kcal/kg/day total energy intake 2

• Administer 0.8-1.0 g/kg/day protein in noncatabolic AKI patients without dialysis, 1.0-1.5 g/kg/day in patients on renal replacement therapy, up to 1.7 g/kg/day on continuous renal replacement therapy 2

• Provide nutrition preferentially via enteral route 2

Special Considerations

Electrical Burns

• Electrical burns cause deeper tissue damage than apparent on surface, requiring higher fluid volumes than thermal burns 3

• Use modified Parkland formula of 3-4 mL/kg/%TBSA for electrical burns 3

• Monitor for myoglobinuria and compartment syndrome 3

Pediatric Modifications

• Children require proportionally more fluid (6 mL/kg/%TBSA in first 48 hours) 1, 2

• Early albumin administration (8-12 hours) in pediatric severe burns reduces crystalloid requirements, fluid creep incidence, and hospital stay 1

Critical Pitfalls to Avoid

• Avoid "fluid creep" (excessive fluid administration) as it leads to compartment syndrome, ARDS, and congestive AKI 1, 2

• Never delay escharotomy when indicated—poorly timed escharotomy increases morbidity 1

• Do not underestimate fluid requirements in electrical burns 1, 3

• Avoid using Rule of Nines for TBSA assessment—use Lund-Browder chart 1

• Never use normal saline as primary resuscitation fluid 1, 2

• Do not use gelatins or synthetic starches due to negative effects on coagulation 1