What is the initial fluid management recommendation for a burns patient?

Initial Fluid Management in Burns Patients

Immediately administer 20 mL/kg of Ringer's Lactate or balanced crystalloid solution within the first hour to all burn patients, then calculate 24-hour requirements using the Parkland formula (2-4 mL/kg/%TBSA) with half given in the first 8 hours post-burn. 1, 2

Immediate First Hour Management

• Give 20 mL/kg of balanced crystalloid (preferably Ringer's Lactate) intravenously within the first 60 minutes, regardless of precise burn size assessment 3, 1, 2
• Do not delay this initial bolus while calculating exact total body surface area (TBSA) 2
• Ringer's Lactate is the preferred crystalloid because its electrolyte composition most closely matches plasma 2
• Avoid normal saline (0.9% NaCl) as it increases risk of hyperchloremic metabolic acidosis and acute kidney injury 1

Determining Who Needs Formal Resuscitation

• Adults with burns ≥10% TBSA require formal fluid resuscitation protocols 3, 1, 2
• Children with burns ≥5% TBSA require formal fluid resuscitation 3
• Use the Lund-Browder chart (not the Rule of Nines) to accurately assess TBSA, as the Rule of Nines overestimates in 70-94% of cases leading to dangerous fluid overload 1, 2

Calculating 24-Hour Fluid Requirements

Standard Parkland Formula (Adults)

• Calculate total 24-hour volume: 2-4 mL/kg/%TBSA of Ringer's Lactate 3, 1, 2
• Administer half of the calculated volume in the first 8 hours post-burn (not from arrival) 3, 1, 2
• Give the remaining half over the next 16 hours 3, 1, 2
• Use the higher end (4 mL/kg/%TBSA) for full-thickness burns, inhalation injury, or electrical burns 2

Modified Formula for Children

• Children require 3-4 mL/kg/%TBSA for 24 hours, with higher volumes (approximately 6 mL/kg/%TBSA over 48 hours) due to their greater surface area-to-weight ratio 3, 1, 2
• Use the same timing schedule: half in first 8 hours, half over next 16 hours 2

Special Considerations for Electrical Burns

• Use 3-4 mL/kg/%TBSA initially, as electrical burns cause deeper tissue damage than surface appearance suggests 3
• Target higher urine output (1-2 mL/kg/hour) to prevent myoglobin-induced renal injury from muscle damage 3

Monitoring and Titration

Primary Endpoint: Urine Output

• Target urine output: 0.5-1 mL/kg/hour in both adults and children 3, 1, 2
• This is the simplest and most reliable parameter for adjusting fluid rates 3, 2
• Adjust fluid infusion rates hourly based on urine output 1

Secondary Monitoring Parameters

• Monitor arterial lactate concentration for adequacy of resuscitation 1
• If hypotension persists despite adequate urine output, perform echocardiography to evaluate cardiac function before starting vasopressors 1
• Use advanced hemodynamic monitoring (cardiac output monitoring, central venous pressure) only in patients with persistent oliguria or hemodynamic instability 1

Colloid Supplementation

When to Add Albumin

• Start 5% albumin at 8-12 hours post-burn in patients with burns >30% TBSA or those requiring fluid rates above expected targets 1, 2
• Target serum albumin levels >30 g/L with doses of 1-2 g/kg/day 1
• Albumin reduces mortality (OR=0.34), abdominal compartment syndrome (from 15.4% to 2.8%), and overall crystalloid volumes 1

Contraindicated Colloids

• Never use hydroxyethyl starches (HES) - they are absolutely contraindicated in burn patients 1, 2
• Avoid gelatins and other synthetic starches due to negative effects on coagulation 1

Critical Pitfall: Avoiding "Fluid Creep"

Fluid creep (over-resuscitation) occurs in 76% of burn resuscitations and causes severe complications including compartment syndrome, pulmonary edema, and acute kidney injury. 2, 4

How to Prevent Fluid Creep

• Do not rigidly adhere to formulas - adjust rates continuously based on urine output 2
• Once adequate urine output (0.5-1 mL/kg/hour) is achieved, reduce fluid rates rather than continuing excessive administration 2
• Studies show average fluid administration of 6.3 mL/kg/%TBSA when guidelines recommend 2-4 mL/kg/%TBSA 2
• Monitor for compartment syndrome, especially with circumferential third-degree burns requiring escharotomy within 48 hours if circulatory impairment develops 3, 1
• Consider early albumin supplementation to reduce crystalloid volumes 1, 2

Special Clinical Scenarios

Inhalation Injury

• Significantly increases mortality and fluid requirements beyond standard formulas 2
• Assess for circumoral burns, oropharyngeal burns, and carbonaceous sputum 1

Electrical Burns

• Require monitoring for myoglobinuria and higher urine output targets (1-2 mL/kg/hour) 3
• Often need volumes at the higher end of the Parkland range due to deep muscle damage 3

Circumferential Burns

• Monitor closely for compartment syndrome 3, 1
• Perform escharotomy immediately if circulatory or respiratory compromise develops, ideally at a burn center 1

Practical Implementation Tips

• Obtain IV access in unburned areas whenever possible 3
• Contact a burn specialist immediately to determine need for transfer to a burn center 1
• Reassess TBSA during initial management to prevent both over- and under-resuscitation 1, 2
• Start enteral nutrition as soon as feasible while continuing IV resuscitation 2