Trauma, burns and environmental emergencies

Burns: resuscitation and inhalation injury

Reviewed Nov 2026·2 references
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TBSA estimation, Parkland/ABA fluid resuscitation, airway and inhalation injury, CO and cyanide, escharotomy and early ICU care.

Definition
Major burn (adult): partial or full thickness ≥ 20% TBSA (≥ 15% in many protocols), or any burn with inhalation injury, high-voltage electrical injury, or burns of face, hands, perineum or circumferential limbs. Formal fluid resuscitation is needed above ~20% TBSA in adults.

At the bedside

Timed steps
  1. 1

    Stop the burning, cool, cover

    0 min

    Remove clothing and jewellery; cool burn with running tap water for 20 min (within 3 h); cover with cling film; keep the patient warm (avoid hypothermia).

  2. 2

    Airway: look for inhalation injury

    0-10 min

    Enclosed-space fire, facial/neck burns, singed nasal hair, carbonaceous sputum, hoarseness, stridor, soot in mouth. Intubate early if stridor, deep facial burns, GCS ≤ 8, or large burns needing transfer; use uncut ETT ≥ 7.5-8.0.

  3. 3

    CO and cyanide

    100% oxygen via non-rebreather or ventilator for CO (SpO2 is falsely normal: check COHb on co-oximetry). Suspect cyanide if coma, shock and lactate > 8 mmol/L: hydroxocobalamin 5 g IV.

  4. 4

    Estimate TBSA and depth

    Rule of nines (adults) or Lund-Browder chart; patient's palm with fingers ~1%. Exclude simple erythema (superficial burns).

  5. 5

    Calculate fluids from time of burn

    Ringer lactate 2-4 mL/kg/%TBSA over 24 h (Parkland 4 mL; ATLS/ABA start 2 mL/kg/%TBSA in adults); half in first 8 h from injury, rest over next 16 h. Electrical injury: 4 mL/kg/%TBSA.

  6. 6

    Titrate hourly to urine output

    Hourly

    Urinary catheter. Target 0.5 mL/kg/h (30-50 mL/h) in adults; 1-1.5 mL/kg/h if myoglobinuria. Increase rate by 20-30% if below target; decrease if above. Avoid fluid creep (> 6 mL/kg/%TBSA).

  7. 7

    Escharotomy and compartments

    Circumferential full-thickness burns of limbs or chest restricting ventilation: escharotomy. Monitor intra-abdominal pressure in large burns with high fluid volumes.

  8. 8

    Early ICU care

    Early enteral feeding (< 24 h), high protein (1.5-2 g/kg/day), DVT prophylaxis, tetanus, no prophylactic systemic antibiotics, glucose control, early excision and grafting, pain management.

Burns resuscitation

Ringer lactate

IV
Dose
2-4 mL/kg/%TBSA over 24 h; half in first 8 h from time of burn
Target
Urine 0.5 mL/kg/h
Worked example
70 kg, 40% TBSA, Parkland 4 mL: 11,200 mL/24 h; 5,600 mL in first 8 h = 700 mL/h (if started at injury). With 2 mL/kg/%TBSA: 5,600 mL/24 h, 350 mL/h for 8 h.

Subtract fluid already given; time starts from burn, not from arrival.

Open Burns fluid in first 24 h

CO poisoning

Oxygen

Non-rebreather / ETT FiO2 1.0
Dose
100% oxygen until COHb < 3% and symptoms resolve

Cyanide toxicity

Hydroxocobalamin

IV
Dose
5 g over 15 min; repeat once if needed

Rule of nines (adult)

Region% TBSA
Head and neck9
Each upper limb9
Anterior trunk18
Posterior trunk18
Each lower limb18
Perineum1
Red flag · call your senior now
Hoarseness, stridor or soot in the mouth: airway oedema progresses for 24-48 h; intubate early before swelling makes it impossible.
Red flag
Urine output persistently < 0.5 mL/kg/h despite increased fluids, or dark urine (myoglobin): senior review, check compartments.
Pitfall
Counting erythema (superficial burns) in TBSA leads to over-resuscitation.
Pitfall
Starting the 8-hour clock at hospital arrival instead of time of burn.
Pitfall
Trusting SpO2 in CO poisoning; pulse oximeters read carboxyhaemoglobin as oxyhaemoglobin.
Pearl
Formulas are only a starting point; urine output and perfusion guide the rate. Consider albumin rescue if fluid needs exceed 1.5x predicted.
Pearl
Do not cut the ETT in facial burns: swelling can pull a cut tube out.

Calculators for this topic

Burns fluid in first 24 h

mL/kg/%TBSA × weight × %TBSA (partial + full thickness). Half in the first 8 h from the time of burn.

References

  1. 1

    ISBI Practice Guidelines Committee. ISBI Practice Guidelines for Burn Care. Burns 2016;42:953-1021.

  2. 2

    American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual, 10th ed. Chicago: ACS; 2018.

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