Major burn: initial resuscitation
Adult burn >20% TBSA or child >10% TBSA, or a high-risk burn. Call the burn service early.
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Trauma SurgeryEmergency
Major Burns Resuscitation (ANZ modified Parkland / ABA 2024)
Major Burns Resuscitation (ANZ modified Parkland / ABA 2024): Major burn: initial resuscitation → First aid: stop the burning, cool the burn, keep the p...
Pathway Overview
17 steps
Algorithm Steps
17 total
01Start 02Action First aid: stop the burning, cool the burn, keep the patient warm
Cool running water for 20 min is useful up to 3 h after the burn. Never use ice.
- Remove from the heat source; remove clothing, nappy and jewellery
- Cool the burn, but keep the patient warm: pause cooling if cold, cool small areas in turn in children
- Cover with cling film laid lengthways (not on the face or a chemical burn)
- Chemical burn: brush off powder, then irrigate with plenty of water. Hydrofluoric acid: then apply calcium gluconate 2.5% gel, check calcium and ECG, and call Poisons 13 11 26
03Action Primary survey (ABCDE): treat life threats before the burn
Enclosed-space fire: give 100% oxygen even if SpO2 is normal (SpO2 is falsely normal in carbon monoxide poisoning).
- A: stridor, hoarse voice, soot in mouth or sputum, facial or neck burns: airway at risk; get senior airway help early and consider intubation
- B: humidified 100% oxygen, 15 L/min by mask or ETT
- C: 2 large-bore IV cannulae (IO or central if needed); shock in the first hours: look for another cause such as bleeding
- C: pregnant over 20 weeks: tilt 20° to the left or push the uterus to the left by hand; call obstetrics early
- D: confusion or reduced consciousness: think of carbon monoxide or cyanide, and hypoxia
- A: spinal precautions if trauma, explosion or electrical injury
- B: circumferential chest or abdominal burn with poor ventilation: consider escharotomy (burn service)
- E: expose, then cover and warm (warm blankets and warm IV fluid)
04Warning Enclosed-space fire: carbon monoxide or cyanide poisoning
Give 100% oxygen regardless of SpO2.
- Blood gas with COHb and lactate
- Suspected cyanide (reduced consciousness, high lactate): call Poisons Information Centre 13 11 26 about hydroxocobalamin
- Do not delay airway care or fluid resuscitation
05Action Estimate burn size (%TBSA) and weight
Count only partial-thickness (dermal) and full-thickness burns. Do not count epidermal burns (red skin, no blisters).
- Child: use a paediatric Lund-Browder chart (larger head, smaller legs)
- Adult: Rule of 9s: head and neck 9%, each arm 9%, each leg 18%, front of trunk 18%, back of trunk 18%, perineum 1%
- Small or patchy burns: the patient’s palm with fingers is about 1%
- Weigh the patient, or ask, or estimate the weight
06Decision IV fluids needed: adult >20% TBSA or child (under 16 y) >10% TBSA?
- If Yes
07Action Yes (adult >20%, child >10% TBSA): start Hartmann’s by modified Parkland formula
24 h volume = 3 mL x kg x %TBSA from the time of burn, not arrival. Half in the first 8 h, half over the next 16 h. Child: also give maintenance fluid with glucose (next step).
- First-8-h rate = (half the 24 h volume minus IV fluid already given) ÷ (8 minus hours since burn; use 7 if more than 7 h)
- Result below 0 (late arrival or large fluid already given): get burn clinician advice before more fluid
- Use 4 mL x kg x %TBSA for inhalation injury, electrical injury or major trauma
- Hartmann’s (compound sodium lactate); sodium chloride 0.9% if Hartmann’s is not available
- US (ABA 2024, adults): start at 2 mL x kg x %TBSA to reduce total fluid volume
- The formula sets the starting rate only: titrate to urine output
08Action Worked example: adult 70 kg, 40% TBSA, 2 h after burn, no fluid given
3 x 70 x 40 = 8,400 mL in 24 h.
- First half: 4,200 mL over the 6 h left of the first 8 h = 700 mL/h
- Second half: 4,200 mL over the next 16 h = about 263 mL/h
- Then change the rate by urine output, not by the formula
09Action Child: add maintenance fluid with glucose on a separate line
Sodium chloride 0.9% with glucose 5%, in addition to the Hartmann’s resuscitation fluid. Check blood glucose.
- 3-10 kg: 4 mL/kg/h
- 10-20 kg: 40 mL/h + 2 mL/kg/h for each kg above 10 kg
- 20-60 kg: 60 mL/h + 1 mL/kg/h for each kg above 20 kg
- Maximum 100 mL/h
10Warning Electrical injury or dark (pigmented) urine: more fluid needed
The skin burn underestimates muscle injury. Call the burn service now.
- Start at 4 mL x kg x %TBSA
- Adult with pigmented urine: increase fluid to a urine output of 75-100 mL/h until the pigment clears; child: burn service advice
- ECG monitoring; check CK
11Action Titrate the rate every 1-2 h to urine output (urinary catheter)
Target: adult 0.5-1 mL/kg/h (30-50 mL/h); child <30 kg 1 mL/kg/h.
- Below target: increase the rate by 10-20%, then reassess
- Above target: decrease the rate by 10-20%, then reassess
- Also check heart rate, blood pressure, capillary refill and lactate; keep a fluid balance chart
- Kidney failure (little or no urine) or heart failure: urine output is not a reliable guide; get ICU and burn service advice early
- Nil by mouth and a nasogastric tube in major burns
12Warning Too much fluid: watch for over-resuscitation
Rising fluid needs are a warning sign. Call the burn service and ICU.
- Large burns or high fluid volumes: measure bladder (intra-abdominal) pressure
- Tense abdomen, rising airway pressure or falling urine output despite more fluid: think of abdominal compartment syndrome
- Albumin can lower fluid needs in larger burns (ABA 2024): the burn service decides the dose and timing
13Warning Circumferential deep burn: check for escharotomy
Escharotomy is a high-risk procedure. Discuss with the burn service before doing it.
- Limb: elevate; check pulses, capillary refill, warmth and sensation every hour
- Chest or abdomen: difficult ventilation or high ventilator pressures
- Cool limb, weak or absent distal pulse, or poor ventilation: call the burn service now
14Action Other early care: analgesia, wounds, tetanus
Give IV analgesia early and reassess the pain score often.
- IV morphine, adult: 2-5 mg, repeat every 5 min to effect; smaller doses if hypotensive or elderly
- IV morphine, child over 12 months: 0.1 mg/kg (max 5 mg per dose), repeat every 5 min to effect, maximum 0.3 mg/kg. Infant 1-12 months: 0.05 mg/kg; under 1 month: 0.025 mg/kg
- Cover wounds with cling film laid lengthways if transfer is soon; elevate burnt limbs
- Tetanus prophylaxis if needed
- High-dose vitamin C and fresh frozen plasma: not routine (ABA 2024 makes no recommendation)
15Action Refer to the burn service if any referral criterion applies (ANZBA)
Discuss early; the burn service and retrieval service advise on transfer.
- Burn >10% TBSA in adults, >5% TBSA in children, or full thickness >5% TBSA
- Face, hands, feet, genitalia, perineum, major joints; circumferential limb or chest burn
- Inhalation, electrical or chemical burn; major trauma; pre-existing illness; pregnancy
- Young children and the elderly; suspected non-accidental burn (follow child protection steps)
16Outcome Ongoing care and burn service referral
IV fluids running: reassess every 1-2 h. All patients: keep warm; transfer to the burn service when referral criteria are met.
If No17Action No (adult ≤20%, child ≤10% TBSA): oral fluids and burn care
High-voltage electrical injury or dark urine: IV fluids and burn service advice, whatever the burn size.
- Oral fluids if able to drink; IV fluids if not
- Analgesia; clean the wound and cover it
- Circumferential deep burn: elevate; check distal perfusion every hour; call the burn service
- Tetanus prophylaxis if needed
- Check the burn service referral criteria (next step)
- Path rejoins step 15Shared downstream outcome
Guideline Source
American Burn Association Clinical Practice Guidelines on Burn Shock Resuscitation (Cartotto et al., J Burn Care Res 2024;45(3):565-589)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- The formula gives a starting rate only: titrate every 1-2 h to urine output and perfusion; get burn service advice early.
- Children, electrical or inhalation injury, late arrival, pregnancy, and heart or kidney failure need specialist advice; urine output may mislead in kidney or heart failure.
- TBSA estimates are often wrong: recheck, and use a Lund-Browder chart in children.
- The ABA 2024 CPG covers adults with burns ≥20% TBSA only; child and Australian content comes from RCH, VicBurns and ANZBA sources.
Applicable Regions
AUNZUSUKEU
AU: Australian burn services: Hartmann’s 3 mL x kg x %TBSA from time of burn (4 mL for inhalation, electrical or major trauma), plus maintenance fluid with glucose in children; ANZBA referral criteria (RCH Burns CPG 2026; VicBurns).
EU: Starting volume of 2-4 mL/kg/%TBSA varies by burn centre; follow the local burn centre protocol.
NZ: ANZBA referral criteria and modified Parkland formula; contact the regional burn service.
UK: Follow the regional burn network (operational delivery network) guidance for starting volume and referral.
US: ABA 2024 CPG (adults ≥20% TBSA): start at 2 mL/kg/%TBSA; ABA 2022 referral guidelines.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Major Burns Resuscitation (ANZ modified Parkland / ABA 2024)?
The Major Burns Resuscitation (ANZ modified Parkland / ABA 2024) is a emergency clinical algorithm for Trauma Surgery. It provides a structured decision tree to guide clinical decision-making, based on American Burn Association Clinical Practice Guidelines on Burn Shock Resuscitation (Cartotto et al., J Burn Care Res 2024;45(3):565-589).
What guideline is the Major Burns Resuscitation (ANZ modified Parkland / ABA 2024) based on?
This algorithm is based on American Burn Association Clinical Practice Guidelines on Burn Shock Resuscitation (Cartotto et al., J Burn Care Res 2024;45(3):565-589) (DOI: 10.1093/jbcr/irad125).
What are the limitations of the Major Burns Resuscitation (ANZ modified Parkland / ABA 2024)?
Known limitations include: The formula gives a starting rate only: titrate every 1-2 h to urine output and perfusion; get burn service advice early.; Children, electrical or inhalation injury, late arrival, pregnancy, and heart or kidney failure need specialist advice; urine output may mislead in kidney or heart failure.; TBSA estimates are often wrong: recheck, and use a Lund-Browder chart in children.; The ABA 2024 CPG covers adults with burns ≥20% TBSA only; child and Australian content comes from RCH, VicBurns and ANZBA sources.. Individual patient factors may require deviation from these recommendations.
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