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Burns: Resuscitation in the First 24 Hours

Contact Hours: 5

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Contact Hours: 5

This educational activity is credited for 5 contact hours at completion of the activity.

Course Purpose

The purpose of this course is to provide healthcare professionals with a brief overview of burn types, causes, burn degrees, fluid resuscitation options, considerations for burn shock, and nursing considerations.


Burns are traumatic injuries typically to the skin, the body’s largest organ that on average, covers a surface area of about 2 m2. A burn can result in the loss of the physical barrier function of the skin, opening the door to fluid loss, renal and circulatory failure, and invasion of harmful microorganisms, which can lead to infection, and ultimately, the development of sepsis. This course examines burn injuries, detailing their types, pathophysiology, and initial interventions. It also discusses the various formulae used in fluid management for both adult and pediatric patients, along with consideration of fluid management of electrical burns, long-term care, and nursing in an emergency setting.

Course Objectives

Upon completion of this course, the learner will be able to:

  • Define the several types of burns based on the causative agent and the extent of tissue damage (1st, 2nd, and 3rd degree).
  • Review the Rule of Nines and the Lund-Browder Chart for estimating total body surface area burn percentages.
  • Review the pathophysiology of burn shock
  • Understand the initial management of burn injuries and burn shock based on the American Burn Association practice guidelines and various evidenced based formulae available.
  • Analyze the advantages and disadvantages of crystalloid and colloid fluid administration in burns.

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AcidA chemical substance that neutralizes alkalis, dissolves some metals, and turns litmus red; typically, a corrosive or sour-tasting liquid of this kind. 
Activated Partial Thromboplastin Time (aPTT)A screening test that helps evaluate a person’s ability to appropriately form blood clots.
Acute Radiation Syndrome (ARS)Illness caused by exposure to large dose of ionizing radiation in a short duration of time.
Acute Respiratory Distress Syndrome A type of respiratory failure characterized by rapid onset of widespread inflammation in the lungs.
AlkalinizeTo make alkaline.
Alkali A basic, ionic salt of an alkali metal or an alkaline earth.
AllograftThe transfer of tissue between genetically nonidentical members of the same species.
Alpha RaysConsist of two protons and two neutrons bound together into a particle identical to a helium-4 nucleus.
AnasarcaA general accumulation of serous fluid in various tissues and body cavities characterized by swelling of the whole body.
Antidiuretic Hormone (ADH)Helps the body regulate the water content of your blood, which impacts blood pressure and volume. 
AnxietyNatural response to stress that can become a disorder if it affects one’s life.
AutograftGrafts that have been harvested from the patient at the time of surgery and are the “gold standard” by which the success of other grafting techniques is assessed.
Beta ParticleAlso called beta ray or beta radiation (symbol β), is a high-energy, high-speed electron or positron emitted by the radioactive decay of an atomic nucleus during the process of beta decay. 
Burn ShockA unique combination of hypovolemic and distributive shock, accompanied by cardiogenic shock. 
BurnTissue damage that results from heat, overexposure to the sun or other radiation, or chemical or electrical contact
Capillary Leak PhaseA rare disease that involves the leaking of massive amounts of plasma and protein through capillaries, leading to hypovolemic shock, which deprives major organs of oxygen.
Central Venous PressureThe blood pressure in the venae cava, near the right atrium of the heart. 
Chemical BurnInjuries to the eyes, mouth, skin, or internal organs caused by contact with a corrosive substance.
Coagulation NecrosisA type of cell death that occurs when blood flow to cells stops or slows (ischemia).                               
ContracturesA permanent shortening and tightening of muscle fibers that reduces flexibility and makes movement difficult.
DepressionA mood disorder that causes a persistent feeling of sadness and loss of interest. 
DermisThe middle layer of your skin that supports your epidermis, protects your body from harm, produces sweat and hair, and feels different sensations
DialysisA blood purifying treatment given when kidney function is not optimum.
Disseminated Intravascular Coagulation (DIC)A rare blood clotting disorder that can cause organ damage and uncontrollable bleeding.
Distributive ShockA medical emergency where the body cannot get enough blood to the heart, brain, and kidneys.
DiuresisA condition that causes increased urination because of increased fluid filtration from the kidneys.
Electrical BurnA burn that results from electricity passing through the body causing rapid injury.
EpidermisThe top layer of the skin that protects internal organs from harm, maintains hydration, produces new skin cells, and contains melanin. 
First-Degree BurnA superficial burn that affects only the epidermis of the skin.
Full Thickness BurnA third-degree burn that affects the epidermis and dermis of the skin.
Gamma RayA penetrating form of electromagnetic radiation arising from the radioactive decay of atomic nuclei.
HyperkalemiaA condition in which potassium levels are too high in blood, which can cause muscle weakness, heart problems and other complications.
Hypertrophic ScarThick, raised scars that form when skin is injured and heals with too much collagen.
HyperuricemiaWhen there’s too much uric acid in blood, which can cause gout, kidney stones, and other health problems.
HypocalcemiaA condition when the level of calcium in your blood is too low. 
HypothermiaA condition of having a lower body temperature than normal body temperature.
ImmunosuppressionThe partial or complete suppression of the immune response of an individual, either naturally because of disease or another condition or artificially induced to help the survival of an organ after a transplant operation.
InfectionThe invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins that they produce.
Inflammatory MediatorsSubstances produced by cells in response to injury or infection.
Keratin LayerFibrous structural protein of hair, nails, horn, hoofs, wool, feathers, and of the epithelial cells in the outermost layers of the skin.
Liquefaction NecrosisOccurs when affected cells are completely digested by hydrolytic enzymes, resulting in a soft, circumscribed lesion consisting of pus and the fluid remains of necrotic tissue. 
Lund-Browder ChartA tool useful in the management of burns for estimating the total body surface area affected. 
Mean Arterial PressureThe average arterial pressure throughout one cardiac cycle, systole, and diastole. MAP = DP + 1/3(SP – DP).
MicrothrombiA microscopic clump of fibrin, platelets, and red blood cells.
Modified BrookeRecommended as a starting point for fluid resuscitation for burns >15% BSA in children and >20% BSA in adults. 2mls x body surface areas burned (BSAB) x weight. 
Modified Parkland FormulaA reasonable starting point for determining fluid requirements in adult patients. -> Adults – 4ml/kg/%
-> Children – 3-4ml/kg/%.
MyoglobinuriaA condition where urine turns dark red or brown due to excess myoglobin, a protein that carries oxygen in muscles.
OliguriaLow urine output of less than 400ml a day.
Parkland FormulaAn essential tool for calculating fluid resuscitation in patients with critical burns. Total crystalloid fluid over the first 24 hours = 4 milliliters x % TBSA (total body surface area burned) x body weight (kg). In children, the formula is edited to 3 ml x % TBSA x weight (kg)
Partial-Thickness BurnAlso known as a second degree burn) is a burn that affects the top two layers of skin, called the epidermis and hypodermis.
Post-Traumatic Stress Disorder (PTSD)A mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations.
Prothrombin Time (PT)A test to evaluate blood clotting.
Radiation BurnA damage to the skin or other biological tissue and organs as an effect of radiation.
Renin-Angiotensin-Aldosterone System (RAAS)A system of hormones, proteins, enzymes, and reactions that regulate r blood pressure and blood volume on a long-term basis.
RhabdomyolysisA serious condition where damaged muscle fibers leak into the blood, causing kidney and heart problems, or even death.
Rule of NinesA tool to estimate the burn percentage of total skin. It divides  the body into sections by multiples of 9% each.
Second-Degree BurnA mild to moderate burn that damages the top layer of skin (epidermis) and the second layer of skin (dermis).
SepsisAn infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever.
SolventsLiquids that can dissolve, suspend, or extract other substances without changing them chemically.
Stratum SpinosumA layer of the epidermis found between the stratum granulosum and stratum basale.
Thermal BurnSkin injuries caused by excessive heat, typically from contact with hot surfaces, hot liquids, steam, or flame.
Third-Degree BurnA severe burn that destroys all the tissue of the epidermis and dermis and extends into the fatty tissue below the dermis.
ThromboprophylaxisA medical treatment to prevent the development of blood clots inside blood vessels in those considered at risk for developing thrombosis.
Total Body Surface Area (TBSA)An effortless way to get a rough burn size estimate that can be used when calculating a patient’s fluid resuscitation needs. 
Venous Thromboembolism (VTE)A condition that occurs when a blood clot forms in a vein. 

Burns are traumatic injuries typically to the skin, the body’s largest organ that, on average, covers a surface area of about 2 m2. This vital barrier consists of the epidermis and the dermis, which protects inner structures and promotes wound healing. A burn can result in the loss of the physical barrier function of the skin, opening the door to fluid loss, renal and circulatory failure, and invasion of harmful microorganisms, which can lead to infection and ultimately, the development of sepsis.1

Burn injuries are one of the most common injuries worldwide, with more than one million cases in the United States every year.2 Any burn, even ones considered minor, can have long-term functional and aesthetic implications lasting a patient’s lifetime. Given the substantial risk of complications, burn injuries require appropriate treatment strategies implemented in the shortest possible time from the occurrence to save the patient’s life and shorten recovery time, making the first 24 hours crucial. This course examines burn injuries, detailing their types, pathophysiology, and initial interventions. It also discusses the various formulae used in fluid management for both adult and pediatric patients, along with consideration of fluid management of electrical burns, long-term care, and nursing in an emergency setting.

Defining Burns

A burn is a traumatic injury to the skin or other tissues triggered by exposure to thermal, chemical, electrical, or radiation sources. Burns are classified based on the causative agent and the extent of tissue damage. Thermal Burns are produced by exposure to heat sources, such as flames, hot objects, steam, or hot liquids. They can be superficial, involving just the outer layer of the skin (epidermis), or more severe, affecting underlying layers. 90% of all burns are thermal burns, which can be further divided into scalds, dry heat burns, and contact burns. Scalds are caused by hot liquids and are the most common type of burn, accounting for approximately 70% of burn injuries in children. Scalds are usually called partial-thickness burns. Dry heat burns are usually caused by direct contact with radiant heat or a flame. Most common in adults, these types of burns often present with smoke inhalation complications. They are typically partial or full thickness and generally require surgical intervention. Contact burns are produced by direct contact with a hot object. Prolonged contact with a moderately hot object can also cause a thermal burn, commonly associated with loss of consciousness. Contact burns are usually deep and require surgery. 1-4

Chemical Burns are the result of contact with corrosive substances like acids, alkalis, solvents, or other harmful chemicals, accounting for 3% of all burn cases. This type of burn causes the denaturation of proteins and results in immediate tissue damage upon contact. The severity of the burn depends on the nature and concentration of the chemical as well as the duration of exposure. Alkali burns tend to be more serious, causing deeper penetration into the skin by liquefying it (liquefaction necrosis). Acid burns are short-lived and penetrate less because they cause a coagulation injury (coagulation necrosis). Electrical Burns are produced by contact with an electric current, leading to injury along the path of the current. These burns account for less than 5% of all burn injury cases and typically lead to internal injuries, such as damage to muscles, nerves, and internal organs. The severity depends on the voltage, amperage, current type, contact duration, and current pathway through the body. An electrical burn from less than 1000 V can cause small, deep burns at the entrance and exit points. Alternating currents can interfere with heart function and lead to arrhythmias. High voltage burns of more than 1000 V can lead to extensive tissue damage, often with loss of limbs, muscle breakdown (rhabdomyolysis), cardiac arrhythmia, asystole, and renal failure. It is important to note that electrical burns are known to be deceptive as entry and exit wounds may be small, misleading on the extent of internal damage. Given the high potential of hidden injuries, this type of burn is associated with a higher mortality rate compared to other burns.1-5 Radiation Burns result from exposure to harmful radiation, such as alpha, beta, and gamma rays. Alpha rays are positively charged helium ions. They are heavy, traveling only a few centimeters in the air, and cannot penetrate the keratin layer of the skin. However, they are high-energy particles with high sievert values, which can cause extensive tissue damage upon ingestion or inhalation. Beta particles are negatively charged electron beams that travel several feet in the air, causing superficial sunburn-like injuries because of their limited ability to penetrate deep into tissue. Gamma rays from X-rays and the natural decay of radioisotopes can travel several feet in the air and penetrate deep into tissues, causing considerable damage to organs and bone marrow, and impacting cells’ DNA. Deep gamma-ray burns also cause systemic symptoms known as Acute Radiation Syndrome (ARS).1-4,6

Burn Degrees

Burns are divided into three types based on the depth of tissue damage, each with distinct characteristics and underlying damage. These degrees are first-degree, second-degree, and third-degree. First-degree burns, also known as superficial burns, involves damage to the thin outer layer of the skin, called the epidermis, without damage to underlying structures. First-degree burns result in redness, pain, and swelling. Common examples include mild sunburn. Healing usually occurs within ten days with minimal scarring.1-4

Second-degree burns, or partial-thickness burns, extend into the underlying dermal layer of the skin, which contains blood vessels, nerves, and hair follicles. These burns, whether resulting from scalds, flames, or chemicals, can lead to more significant pain and have a higher potential for scarring and complications compared to first-degree burns. They also cause redness, swelling, and blistering, which can cause the formation of a fluid-filled sac in the intact stratum spinosum layer of the epidermis on the burn site. This fluid is an ultrafiltrate of plasma. Healing typically takes 10 – 14 days but can take longer depending on the extent and cause of burn.1-7   Third-degree burns, also called full-thickness burns, extend through all skin layers, including the epidermis and dermis, potentially reaching subcutaneous tissues, muscles, and even bones. The burned area may appear white, brown, or charred, with nerve damage that can result in numbness, hence less pain than a second-degree burn. Self-healing can take over six weeks, and there is a high chance of extensive fluid loss and further complications with extended exposure to external elements. Emergency medical attention is crucial for third-degree burns, which often involve surgical interventions like skin grafts due to the complete destruction of the skin layers and the potential involvement of underlying tissues.1-5

Initial Interventions

In the initial management of burn injuries, several crucial interventions are performed immediately to assess and address potential complications. A thorough airway assessment is done in thermal burns, specifically in cases involving fires where inhalation injury is suspected. Signs of inhalation injury include facial burns, singed nasal hair, hoarseness, and respiratory distress. Immediate interventions may include providing supplemental oxygen, and if necessary, securing the airway through intubation to ensure adequate oxygenation. Clothing should also be removed to assess the extent of the burn injury on the body. This step helps healthcare providers determine the total body surface area (TBSA) affected, vital information that is needed for guiding subsequent management and fluid resuscitation.1,2,4,8

The placement of wet sterile dressings over the burned area is a critical measure to cool the affected tissue and alleviate pain. Research has shown that the immediate cooling of the injured area improves physiological response and provides palliative relief, benefiting the burn victim. The cooling agent should be applied promptly but must be at the right temperature. Extreme cold with ice can cause further damage by reducing the flow of blood to the injured area (cold-induced vasoconstriction). Also, cooling a large skin area over an extended period is likely to induce hypothermia. There is also a risk of frostbite on cooled surfaces. The optimal temperature for cooling a burn injury is 10–20 °C. Early management of moderate to severe burns also includes initiating fluid resuscitation, as burn injuries can lead to severe fluid and electrolyte loss, potentially resulting in shock. Intravenous administration of fluids is initiated to restore and maintain adequate blood volume.1,2,4,8

Total Body Surface Area Burn Percentages (TBSA%)

Estimating Total Body Surface Area Burn percentages (TBSA%) is crucial in determining the severity of burn injuries and guiding the management of burn patients, particularly for fluid resuscitation. Two commonly used methods for assessing TBSA% are the Rule of Nines and the Lund-Browder Chart. The Rule of Nines is a quick and widely used method to estimate the TBSA% in second and third-degree burns. It divides the body into regions, representing approximately 9% of its surface areaThese regions and their percentages are the head and neck (4.5% for anterior, 4.5% for posterior, 9% for total), arms (9% each, 18% for both), the anterior torso (18%), posterior torso (18%), the perineum (1%), and legs (18% each, 36% for both). The Rule of Nines is particularly useful for providing a rapid estimation in adult patients but may not be as accurate for obese patients, infants, or children due to differences in body proportions.9,10

The Lund-Browder Chart is a more precise and individualized method for estimating TBSA%. It is especially suitable for children as it considers age-related variations in body proportions. Instead of using fixed percentages for each body part, the Lund-Browder Chart divides the body into smaller, age-specific areas. The percentage of burns for each region is determined based on the patient’s age. As the Lund-Browder Chart provides a detailed representation of the body, it provides a more accurate assessment of the TBSA%.9-11

Pathophysiology of Burn Shock

Burn shock is a distributive shock characterized by inadequate tissue perfusion and oxygen delivery despite a normal or increased cardiac output. Initially, there is a brief period of vasoconstriction as a response to the sympathetic nervous system activation. This is accompanied by an increased heart rate (tachycardia) to maintain cardiac output. Severe burns also trigger a systemic inflammatory response. Inflammatory mediators are released, increasing capillary permeability, and allowing plasma and proteins to leak into the interstitial spaces. This results in the loss of intravascular volume and is known as the capillary leak phase.12

During this stage, hypovolemia ensues, causing fluid shifts and a reduction in cardiac output despite compensatory tachycardia. Endothelial dysfunction occurs, impairing microcirculatory blood flow. Microthrombi and sludging of red blood cells contribute to tissue hypoperfusion. Inadequate blood flow to tissues leads to cellular hypoxia, further compromising organ function. This inflammatory response also activates the coagulation cascade, leading to disseminated intravascular coagulation (DIC) in severe cases.

In addition, a burn injury induces a state of immunosuppression, making patients more susceptible to infections. Compensatory mechanisms, including the renin-angiotensin-aldosterone system (RAAS) to retain sodium and water, are activated to compensate for the volume loss. Antidiuretic hormone (ADH) is also released to promote water reabsorption in the kidneys, conserving fluid. Clinically, burn shock manifests as hypotension, persistent tachycardia, cool and clammy skin due to peripheral vasoconstriction, and oliguria resulting from impaired renal perfusion.13

Formulae Used for Fluid Management In Major Burns

In large deep partial-thickness or full-thickness burns covering more than 20% of TBSA in adults and greater than 10% in children, fluid management is vital. It refers to the administration of intravenous crystalloid solutions to address the profound hypovolemia that occurs in the initial stages of severe burns, primarily during the capillary leak phase. The most used formulas for fluid management are Parkland, modified Parkland, Brooke, modified Brooke, Evans, and Monafo. These formulae consider the body weight and the burn surface area, guiding healthcare providers in the appropriate fluid replacement for burn patients during the initial 24 hours post-injury. The choice of the formula depends on the patient’s specific characteristics, institutional practices, and the clinical judgment of the medical team. Regular reassessment and adjustments are often necessary based on the patient’s response and ongoing fluid needs.1,2

The Parkland Formula

The Parkland Formula is a well-established formula developed in the 1960s by Charles Baxter at Parkland Hospital at Southwestern University Medical Center. It is the most used formula in US burn centers today. For adults, the formula advises administering 4 ml/kg/% burn (ml per kilogram of body weight per percentage burned) of Lactated Ringers (LR) solution during the initial 24 hours. For children, the recommended rate is slightly reduced to 3 mL/kg/% burn. Lactated Ringers solution is preferred for maintenance in children with specific rates assigned based on their weight: 4 ml/kg/hour for children weighing 0–10 kg, 40 ml/hour + 2 ml/hour for those weighing 10–20 kg, and 60 ml/hour + 1 ml/kg/hour for children weighing 20 kg or higher. Notably, this formula advocates for excluding colloids in the initial 24 hours. In the subsequent 24 hours, the approach shifts to include colloids, constituting 20 – 60% of the calculated plasma volume, while crystalloids are excluded during this period. This phase also introduces glucose in water, so urinary output is maintained at 0.5 – 1 ml/hour in adults and 1 ml/hour in children.14,15

Modified Parkland Formula

The Modified Parkland Formula is a variation that adjusts the fluid rate during the initial 24 hours. It involves administering 2 – 4 ml/kg/% burn of LR solution that is then divided, with half given within the first 8 hours post-burn and the remaining half infused over the subsequent 16 hours. This approach allows for a more gradual and controlled administration of fluids, taking into consideration the specific needs of each patient. For adults during the initial 24 hours, the formula specifies using LR solution at a rate of 4 ml/kg/% burn. In the subsequent 24 hours, it also includes the infusion of colloid in the form of 5% albumin. The recommended rate for colloid infusion is 0.3 – 1 ml/kg/% burn, administered over 16 hours.15

Brooke Formula

Developed at the Surgical Research Unit at Brooke Army Hospital in the 1950s, the Brooke Formula recommends a lower fluid rate than the Parkland Formula. In the initial 24 hours post-burn, it advises 1.5 ml/kg/% burn of LR solution + 0.5 ml/kg/% burn colloids + 2000 ml glucose in water. In the next 24 hours, the RL solution is decreased to 0.5 ml/kg/% burn and colloids to 0.25 ml/kg/% burn. Glucose in water remains the same.15,16

Modified Brooke Formula

Like the Brooke Formula, the Modified Brooke Formula removes colloids from fluid management in the first 24 hours but increases LR solution to 2 ml/kg/% burn in adult patients and 3 ml/kg/% burn in pediatric patients. In the following 24 hours, crystalloids are stopped, and colloids are introduced at 0.3–0.5 ml/kg/% burn. Glucose in water is added as necessary to maintain good urinary output.15

Evans Formula

The Evans Formula is another approach to fluid resuscitation in burn patients. It was developed by Dr. Everett Evans and co-workers at the Medical College of Virginia in the 1950s following unsatisfactory results from previous guidelines. This formula recommends administrating 1 ml/kg/% burn of crystalloids + 1 ml/kg/% burn of colloids + 2000 ml glucose in water in the first 24 hours post-burn. In the next 24 hours, Crystalloids and colloids are decreased to 0.5 ml/kg/% burn each but are administrated with the same amount of glucose in water, 2000 ml.15,16

Monafo Formula

Monafo’s formula was developed in the early 1980s and advocates fluid resuscitation with hypertonic saline solutions that contain 250 mEq of sodium, 150 mEq lactate, and 100 mEq of chloride in the first 24 hours, but amounts can be adjusted according to the urine output. In the following 24 hours, the solution should be titrated with one-third normal saline or according to urinary output.15,16

Formulas Developed for Children

The resuscitation formulae mentioned above were developed for adult burn patients and were previously used on pediatric burn patients by proportionally reducing quantities. However, this led to complications as children have unique fluid needs following a burn injury, given they have proportionally larger BSA to mass ratios than adults. In general, standard fluid management formulae underestimate the fluids needed. Thus, pediatric-specific formulas have been developed to address this issue. These formulae are the Shriner’s Cincinnati Formula and the Galveston Formula.17

The Shriner’s Cincinnati formula was developed by Shriners Hospitals for Children in Cincinnati, and it is like the Parkland formula but adds in a maintenance fluid calculation based on BSA. It is also adjusted for older and younger children. In the initial 24 hours, older pediatric burn patients are given 4 ml/kg/% burn RL Solution + 1500 ml/m2 total BSA (half the total volume given over 8 hours and the rest during the following 16 hours). In younger children, the formula is more complex. In the first 24 hours, these patients are given the same composition (4 ml/kg/% burn + 1500 ml/m2 total), but then the compositions change every 8 hours. In the first 8 hours, the fluid is RL solution + 50 mEq of sodium bicarbonate. In the second 8 hours, only LR solution is administered. In the third 8 hours, LR solution + 12.5 g of 25% albumin per liter should be administered. The team at Shriners Hospitals for Children in Galveston developed the Galveston formula and only used BSA to calculate the fluids needed. In the initial 24 hours post-burn, the Galveston formula recommends 5000 ml/m2 burn LR solution as resuscitation fluid and 2000 ml/m2 total BSA as a maintenance fluid. Half is given over the first 8 hours, and the remainder is given over the next 16 hours.17

Fluid Types

For fluid resuscitation in burn injuries, the ideal fluid restores plasma volume without adverse reactions. Typically, isotonic crystalloid, hypertonic, and colloid solutions are used. Crystalloids are typically used in the early hours of post-burn. They include Lactated Ringers (LR) solution, a balanced electrolyte solution containing sodium, potassium, calcium, and lactate, Hartmann solution (similar composition to LR solution), and normal saline. While crystalloids are the most used type of fluid, they have a few adverse effects, such as high volumes of normal saline, which can result in hyperchloremic acidosis. High volumes of LR solution have been associated with increased activation of neutrophils, which is part of the inflammatory response and may contribute to tissue damage. Lactated ringers solution may also increase the production of reactive oxygen species (ROS). Reactive oxygen species can cause oxidative stress, potentially leading to cellular damage. Regardless of the type, crystalloids have been shown to influence coagulation, contributing to an increased risk of thromboembolic events.15

Hypertonic solutions are fluids with a higher osmolarity than normal body fluids and have been shown to address the shift in sodium ions during burn shock. The rapid infusion of 250 mEq/l saline solutions can lead to an osmotic fluid shift from the intracellular to the extracellular space, which helps reduce cellular edema and expand intravascular volume more effectively than isotonic solutions. However, research has also shown that after 48 hours, cumulative fluid loads were like patients treated with LR solution. Also, hypertonic sodium solution was associated with an increased incidence of renal failure and death.15

Colloids are hyperosmotic solutions that increase intravascular osmolality to support intravascular volume and stop the extravasation of the crystalloids. They include albumin, a solution, and glucose in water for maintaining a specific urinary output and preventing dehydration. While the necessity of colloids is well established, debate continues when to introduce them. Some studies suggest that colloids given in the first 24 hours post-burn have insignificant effect and may adversely affect pulmonary function. However, compared with pure crystalloid resuscitation, it has also been demonstrated to decrease mortality, volume requirements, and weight gain if given in the early post-burn period.15,18

Considerations: Fluid Management in Electrical Burns

Fluid management in patients with high-voltage electrical burns ( > 1,000 V) is a far more complex challenge than standard burn management. These burns can cause both superficial and deep injury. Superficial burns are caused by electrical contact, which creates flames capable of igniting the patient’s clothing. This flash can cause large, third-degree burns. As these surface burns are visible, they are accounted for in fluid resuscitation formulae. However, deep tissue burns may not be because of the resistive heating of internal tissues such as the skeleton, which can cause necrosis of deep structures, particularly muscles, ankles, and wrists. At the same time, deep tissue burns can also cause derivative injuries such as compartment syndromes and rhabdomyolysis, which, in turn, can compromise renal function and urine output, further increasing the magnitude of the injury. High-voltage electrical burn patients often develop acute kidney injury, which increases their risks of chronic kidney disease and mortality.19

Fluid resuscitation needs to consider these internal injuries. While the Parkland formula can be used as a standard starting point, it is critical to remember that electrical burn patients require additional fluid as the %TBSA can lead to under-management. Also, children will require proportionally greater fluids than adult burn patients due to their increased surface area-to-volume ratios. However, over-resuscitation must be avoided as it can induce compartment syndromes, as well as pulmonary or cerebral edema, increased risks of infectious complications, acute respiratory distress syndrome, and anasarca. Improper resuscitation and fluid management can also cause the burn injury to increase in depth and size. Therefore, fluid loading should be avoided when attempting to resuscitate a patient sufficiently. The current consensus primary endpoint is urine output, which is 75–100 ml/hour or 1 ml/kg/hour. When urine output is compromised, other indicators must be repeatedly measured to guide fluid management, such as laboratory values such as lactic acid, base deficit, and hemoglobin, supplemented by continuous hemodynamic monitors such as mean arterial pressure and central venous pressure.19

Considerations: Acute Renal Failure and Dialytic Support In Severe Burns

Major burns can significantly impact renal function, resulting in acute kidney injury and renal failure, necessitating dialytic support. The severity of burn injuries, especially in cases of extensive or deep burns, can lead to complications such as rhabdomyolysis and myoglobinuria, causing the release of myoglobin into the bloodstream from damaged muscles. Myoglobinuria is characterized by serum myoglobin levels over 1.5–3 µg/ml or 0.02 µg/ml in the urine, resulting in dark or “tea-colored” urine. This condition can overwhelm the kidneys, potentially leading to tissue damage. If signs of acute renal failure emerge, prompt intervention may be necessary, and dialytic support may be considered. Dialysis can help manage fluid and electrolyte imbalances, remove waste products, and support the kidneys during recovery. However, burn patients requiring dialysis have an associated mortality risk of up to 80%, and a minority will require long-term dialysis.1,13,19

In cases of rhabdomyolysis, should the urine fail to clear in adult patients within the initial hours of the burn resuscitation, 25 g of mannitol can be administered every 6 hours with a continuous infusion of 5% sodium bicarbonate to alkalinize the urine. Alkalinizing the urine can make the myoglobin present more soluble and easier to clear. However, this treatment can artificially elevate base deficit values. In such settings, lactate levels should be closely monitored to reflect a patient’s metabolic progress accurately. While bicarbonate and mannitol are administered, serum calcium, potassium levels, and urine pH should be monitored to guard against hypocalcemia, hyperkalemia, and hyperuricemia. Hyperkalemia should be managed with diuresis or dialysis. If urine pH fails to increase within 6 hours or other electrolyte complications develop, bicarbonate should be stopped. 1,13,19

American Burn Association Practice Guidelines for Burn Shock Resuscitation

The American Burn Association provides practice guidelines for burn shock resuscitation, emphasizing tailored approaches based on body size, surface area burned, and the severity of the burn injury. For adults and children with burns exceeding 20% TBSA, formal fluid resuscitation is recommended. Commonly used formulas suggest initiating resuscitation with a crystalloid solution ranging from 2–4 ml/kg/% burn during the first 24 hours. Regardless of the solution type or estimated need, fluid resuscitation should be titrated to maintain a urine output of approximately 0.5–1.0 ml/kg/hour in adults and 1.0–1.5 ml/kg/hour in children. Maintenance fluids for children should be administered in addition to calculated fluid requirements caused by the burn injury. Patients with full-thickness injuries, inhalation injuries, or delayed resuscitation may experience increased volume requirements. Several additional support options are considered in burn shock resuscitation.20

Adding colloid-containing fluid after the first 12 – 24 hours post-burn may decrease overall fluid requirements. Oral resuscitation is a consideration for patients with moderately sized burns who are alert and awake. The use of hypertonic saline should be reserved for healthcare providers experienced in this approach, closely monitoring plasma sodium concentrations to avoid excessive hypernatremia. The administration of high-dose ascorbic acid is advised as a potential strategy to decrease overall fluid requirements. However, further study is needed to establish its efficacy in burn shock resuscitation. It is important to note that the American Burn Association recommends burn center referrals for patients with partial thickness burns of more than 10% of total body surface area, full thickness burns, burns of the face, hands, feet, genitalia, or major joints, chemical burns, electrical, or lighting strike injuries, significant inhalation injuries, burns in patients with multiple medical disorders, and burns in patients with associated traumatic injuries.20

Additional Considerations

In burn patients, several additional therapy considerations include antimicrobial therapy, attenuating hypermetabolism, nutrition support, pain control, risk for coagulopathy, and thromboprophylaxis. Antimicrobial therapy is crucial to manage infections and prevent sepsis, a significant complication in burn injuries. Burn wounds are susceptible to bacterial colonization and infection due to compromised skin integrity. Preventative strategies such as topical antimicrobial dressings, early excision, and grafting are often recommended. Early initiation of broad-spectrum antibiotics without sufficient evidence is not currently advised. In patients who are immunocompromised or have contaminated wounds, performing a bacteria culture is recommended, along with introducing antibiotic prophylaxis and antifungal agents, if necessary.1,2,4,20

Burn injuries trigger a hypermetabolic state characterized by increased energy expenditure, catabolism, and elevated stress hormone levels. In patients with a TBSA of less than 10%, resting energy expenditure remains at physiological levels, but for those with a TBSA over 40%, this rate is twice as high. Attenuating this hypermetabolism is essential in preventing complications such as delayed wound healing, muscle wasting, and organ dysfunction. Nutritional support plays a key role in providing an adequate nutrient supply to meet the increased energy expenditure in hypermetabolism. In burn patients with more than 40% TBSA, increasing room temperature has been shown to help reduce resting energy expenditure. Pharmacological interventions, such as anabolic or anti-catabolic agents, may also be necessary to modulate the hypermetabolic response and improve overall outcomes.1,2,4,20

Nutrition support is a cornerstone in caring for burn patients, as they experience increased energy and protein requirements to support wound healing and attenuate the hypermetabolic response. Early enteral nutrition is preferred within the first 24 hours over oral nutrition alone, as it helps maintain gut integrity and motility while lowering the risk of sepsis. Initially, enteral feeding should be administered continuously at a low volume, gradually working towards the target volume to ensure the patient can tolerate the regimen. As for the dietary profile, given the high rates of amino acid oxidation in burn patients, it is advisable to stimulate protein synthesis with a high protein, high carbohydrate diet, which will maintain lean body mass and increase endogenous insulin production. Early intravenous supplements that include essential micronutrients such as zinc, iron, copper, and vitamins A, C, and D are also necessary to counter the fast-progressing deficiencies noted during initial fluid loss. However, precise nutrition support must be individualized based on the patient’s nutritional status, burn severity, and metabolic demands. Effective pain control enhances comfort, facilitates wound care, and improves overall outcomes. A multimodal approach involving analgesics, both opioid and non-opioid, may also be employed. Regional anesthesia techniques, such as epidural analgesia, may be utilized to provide targeted pain relief. Close monitoring of pain levels and side effects is essential, and adjustments to the pain management plan should be made based on individual patient responses and changing clinical circumstances. 1,2,4,20

Burn injuries can predispose patients to coagulopathy due to factors such as tissue damage, inflammation, and fluid resuscitation. Regular monitoring of coagulation parameters, including prothrombin time (PT), activated partial thromboplastin time (aPTT), and platelet counts, is crucial to detect and manage coagulopathy promptly. Individualized interventions may be necessary to maintain hemostasis, such as administering clotting factors or blood products. Burn patients are at an elevated risk of venous thromboembolism (VTE) due to factors like immobility, hypercoagulability, and endothelial dysfunction. Thromboprophylaxis is vital to prevent VTE complications. Mechanical measures, such as intermittent pneumatic compression devices may be necessary. Pharmacological prophylaxis with anticoagulants may also be indicated, but the choice and timing of agents should be individualized based on the patient’s overall risk profile and potential contraindications, such as the risk of bleeding from burn wounds. 1,2,4,20 

Long-Term Care Considerations

Long-term care for burn patients encompasses a comprehensive strategy to address the physical, emotional, and psychological aspects of the injury. While individualized interventions, ongoing monitoring, and a multidisciplinary team are essential, several considerations should be considered for most cases. Changes in physical appearance are among the most significant, as they impact self-esteem and quality of life. Extensive burns often result in scarring and alterations in skin color and texture. A patient may also need autografts (using the patient’s skin) or allografts (using donated skin). Not only do these grafts need long-term care to ensure viability and function, but they may also cause hypertrophic scarring. While scar management techniques, such as pressure garments, silicone sheets, and topical treatments may be employed to minimize scarring, there is no guarantee that they will enhance the appearance of the healed burn areas. Surgical interventions, including scar revisions, may be a better option to improve aesthetics. Grafts may also be needed. Thus, counseling and psychosocial support become integral components during healing to address any emotional distress that may arise from the altered physical appearance and promote self-acceptance. 21

Physical and occupational therapy play crucial roles in managing and preventing contractures, which are the tightening of the skin and underlying tissues that can cause mobility issues, particularly if joints are involved. Range-of-motion exercises, splinting, and other therapeutic modalities should be employed to maintain joint mobility and prevent the development of contractures. In severe cases, surgery may be necessary to release contractures and restore functional mobility. Long-term monitoring and regular physical therapy are typically necessary to prevent disability. Long-term emotional and psychological support is fundamental for burn survivors as they navigate the impact of their injuries. Burns can result in profound emotional distress, including anxiety, depression, and post-traumatic stress disorder (PTSD). Over time, it can negatively influence daily functioning, relationships, and overall well-being. Regular mental health assessments, counseling, and therapy provide ongoing support for managing any developing concerns and building coping mechanisms to help adapt to life after the initial recovery phase.21

Nursing Considerations

Nurses play a significant role in managing a burn patient. They must be well versed with the various protocols not only in medical care but also in the psychological assessment of the victim and the family. To ensure the patient receives optimal care, they must also communicate and document every intervention. This will enable trauma surgery, burn surgery, and emergency department teams to access all the necessary information when the patient arrives at a burn center, which should be contacted before beginning extensive local burn care treatments. Patients transferred to burn centers often do not need extensive debridement or topical antibiotics. A team of nurses must be present to assist with Foley and intravenous catheters, while trained personnel will manage central and arterial catheter placement as required. As with any trauma or critical patient, two large-bore peripheral intravenous catheters should be placed immediately, preferably through unburned skin. Intravenous catheters can be placed through burned skin if needed. Peripheral intravenous access is the most efficient and least invasive way to administer high fluid volumes when patients arrive at emergency department rooms. If peripheral access is unattainable, central venous catheterization or an interosseous line must be considered. 22,23

A critical, yet sometimes forgotten concept is that all burn patients are trauma patients, and they may have additional injuries contributing to their presentation. Initial assessments of airways, hypothermia, and pain must be completed, as hypotension is often a late finding in burn shock. If a patient arrives hypotensive, healthcare professionals should consider other traumatic causes of low blood pressure, such as hemothorax, cardiac tamponade, neurogenic shock, and internal abdominal and pelvic bleeding.

Burn nurses coordinate all patient care activities and must possess a broad knowledge of multisystem organ failure, critical care techniques, diagnostic studies, and rehabilitative and psychosocial skills. In addition, these nurses must also be specialists in wound care. As a burn wound heals, either spontaneously or through excision and grafting, the nurse is responsible for noting subtle changes requiring immediate attention, preventing infection, and managing pain. 22,23


The comprehensive management of burns, particularly in the first 24 hours, involves a meticulous understanding of the diverse types and degrees of burns, as well as the pathophysiological underpinnings of burn shock. While guided by well-established formulae, fluid management demands individualized care tailored to the patient’s weight, burn percentage, and age. The utilization of various fluid types underscores the importance of fluid balance and electrolyte management in burn patients. Along with immediate interventions and the American Burn Association’s practice guidelines, additional considerations encompassing antimicrobial therapy, strategies to attenuate hypermetabolism, nutrition support, effective pain control, and vigilance against coagulopathy and thrombosis must also be accounted for, highlighting the comprehensive approach required for optimal burn care. Long-term care considerations delve into the multifaceted aspects of a burn survivor’s journey to accepting the changes in physical appearance and managing contractures. Recognizing the enduring impact of burns, nursing considerations ensure the delivery of compassionate, evidence-based care throughout the entire spectrum of burn management.

In essence, a comprehensive and multidisciplinary approach is imperative to address the complexities of burns, from the critical initial hours to long-term care. The union of medical, surgical, and nursing considerations ensures not only the survival of burn patients but also their successful reintegration into society, emphasizing the significance of patient-centered burn care.

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