Burns Resuscitation (ABA 2024)

Algorithm Steps

1. ▶

   Start

   Major Burn Injury

   Patient with significant thermal injury

   1. ⚠

      Warning

      Stop the Burning Process

      Remove from source, remove clothing/jewelry

      • Remove patient from heat source
      • Remove clothing and jewelry
      • Cool burns with room temp water (not ice)
      • Cover with clean dry sheets
      • Keep patient warm (prevent hypothermia)
      1. ●

         Action

         Primary Survey

         ABCDE with burn-specific considerations

         • A: Airway - assess for inhalation injury
         • Facial burns, singed nasal hairs, carbonaceous sputum
         • Early intubation if concern (edema progresses)
         • B: Breathing - circumferential chest burns may need escharotomy
         • C: Circulation - 2 large bore IVs (through burned skin if needed)
         • D: Disability - associated trauma?
         • E: Exposure - calculate TBSA
         1. ●

            Action

            Calculate TBSA

            Total Body Surface Area burned

            • Rule of 9s (adults):
            • Head/neck: 9%
            • Each arm: 9%
            • Anterior trunk: 18%
            • Posterior trunk: 18%
            • Each leg: 18%
            • Genitalia: 1%
            • Palm method: Patient's palm = 1% TBSA
            • Only count partial and full thickness burns
            1. ◆

               Decision

               IV Resuscitation Needed?

               Based on burn size and patient factors

               • Adults: ≥20% TBSA
               • Children/elderly: ≥10% TBSA
               • Inhalation injury present
               • High-voltage electrical injury
               • Associated trauma
               1. ●

                  Action

                  Minor Burn Care

                  <20% TBSA, no inhalation

                  • Oral hydration may suffice
                  • Wound care: clean, debride loose tissue
                  • Topical antimicrobials
                  • Pain control
                  • Tetanus prophylaxis
                  1. ●

                     Action

                     Burn Center Transfer Criteria

                     ABA referral guidelines

                     • Partial thickness >10% TBSA
                     • Burns to face, hands, feet, genitalia, major joints
                     • Full thickness (3rd degree) burns
                     • Electrical or chemical burns
                     • Inhalation injury
                     • Pre-existing conditions complicating care
                     • Associated trauma
                     • Children at non-pediatric hospitals
                     1. ✓

                        Outcome

                        Resuscitation Ongoing

                        Continue monitoring, transfer to burn center if indicated

               2. ●

                  Action

                  Calculate Initial Fluid Rate

                  ABA 2024 or Parkland formula

                  • ABA 2024 (preferred):
                  • 2 mL × kg × %TBSA in first 24h
                  • Half in first 8h, half in next 16h
                  • Traditional Parkland:
                  • 4 mL × kg × %TBSA in first 24h
                  • Use Lactated Ringer's
                  • Time starts from TIME OF BURN, not arrival
                  1. ●

                     Action

                     Example Calculation

                     70kg patient, 40% TBSA

                     • ABA 2024: 2 × 70 × 40 = 5,600 mL/24h
                     • First 8h: 2,800 mL = 350 mL/hr
                     • Next 16h: 2,800 mL = 175 mL/hr
                     • Parkland: 4 × 70 × 40 = 11,200 mL/24h
                     • First 8h: 5,600 mL = 700 mL/hr
                     1. ●

                        Action

                        Titrate to Urine Output

                        Formulas are guides - adjust to response

                        • TARGET UOP:
                        • Adults: 0.5-1 mL/kg/hr
                        • Children <30kg: 1 mL/kg/hr
                        • If UOP low: Increase rate by 10-20%
                        • If UOP high: Decrease rate by 10-20%
                        • Avoid over-resuscitation (fluid creep)
                        1. ●

                           Action

                           Resuscitation Adjuncts

                           Additional considerations

                           • Albumin: Consider for burns >30% or high fluid needs
                           • 5% albumin starting hour 8-12
                           • Monitor for abdominal compartment syndrome
                           • No routine high-dose Vitamin C (insufficient evidence)
                           • Pain management essential
                        2. ⚠

                           Warning

                           Escharotomy if Needed

                           For circumferential burns

                           • Chest escharotomy if impaired ventilation
                           • Extremity escharotomy if:
                           • Diminished pulses
                           • Poor cap refill
                           • Progressive paresthesias
                           • Incise lateral and medial midaxillary lines