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Practice Guidelines

Resuscitation of Patients With Burns: Guidelines From the American Burn Association

Michelle Nelson, MD

American Family Physician. 2025;112(2):219-220.

Author disclosure: Michelle Nelson, MD, disclosed stock ownership in Eli Lilly. This relevant financial relationship was mitigated when she sold her shares in May 2024, before her work on this content began.

This clinical content conforms to AAFP criteria for CME.

KEY POINTS FOR PRACTICE

  • Fluid resuscitation should be initiated at 2 mL/kg per %TBSA during the first 24 hours, rather than 4 mL/kg per %TBSA, to reduce fluid overload and edema-related complications.
  • Albumin infusion should be considered in the first 24 hours of fluid resuscitation as an adjunct treatment in patients with larger burns to improve urine output and minimize total volume of resuscitation fluids.
  • Resuscitation should be titrated by urine output instead of invasive or semi-invasive monitoring.
  • The use of computerized decision support software in burn resuscitation should be considered, although it is not a substitute for ongoing patient assessment and critical decision-making

From the AFP Editors

Providing intravenous fluids to prevent burn shock is challenging in the first 48 hours following an acute burn injury in adults with burns covering 20% or more of their total body surface area (TBSA). Intravascular fluid depletion from insufficient resuscitation can lead to organ failure and death; however, fluid resuscitation may increase local and pulmonary edema, which can increase morbidity and mortality. The American Burn Association (ABA) has published guidelines on the management of resuscitation to prevent burn shock in patients with significant burns.

RESUSCITATION VOLUME

Fluid resuscitation of 2 mL/kg per %TBSA, instead of 4 mL/kg per %TBSA (Parkland formula), over 24 hours to reduce the total volume of resuscitation fluid is recommended by the ABA because the lower volume is likely adequate to resuscitate patients without causing edema-related complications. The rate can be adjusted to produce a target urine output of 0.5 mL/kg per hour.

COLLOID FLUIDS

Albumin

The administration of albumin should be considered in the first 24 hours of resuscitation based on studies that showed improved urinary output and a reduction in the total volume of resuscitation fluids needed, especially for patients with larger burns. Administration of albumin is also recommended when resuscitation deteriorates despite increasing crystalloid administration. Although a Cochrane review suggested that adding colloid in the first 24 hours of crystalloid infusions had similar mortality to crystalloid only administration, the recommendation committee noted that the existing evidence is limited to small, heterogenous studies.

Fresh Frozen Plasma

Due to insufficient evidence of clinical benefit, the ABA recommends against the routine use of fresh frozen plasma. Studies suggest that adding fresh frozen plasma to crystalloid resuscitation reduces infusion volume but does not increase urine output. The use of fresh frozen plasma increases the risk of transfusion-related acute lung injury, which is one of the leading causes of transfusion-related death, and potential exposure to blood-borne pathogens.

High-Dose Vitamin C

It is uncertain whether high-dose (66 mg/kg per hour) vitamin C is beneficial for burn resuscitation. Studies suggest increased diuresis, but the uncertainty of dosing, risk of dehydration from osmotic diuresis, possible risk of oxalate nephropathy, and potential distortion of urine output measurements prevent a recommendation for the administration of high-dose vitamin C.

MEASURES TO GUIDE RESUSCITATION

Measurement of urine output to guide burn resuscitation is recommended. The ABA does not recommend invasive or semi-invasive monitoring, including transpulmonary thermodilution–derived variables, such as intrathoracic blood volume index, global end diastolic volume index, cardiac index, or extravascular lung water index. These methods resulted in equal or higher fluid resuscitation volumes, with similar edema-related complications. The benefit of measuring serum lactate in burn resuscitation is uncertain.

MICHELLE NELSON, MD, FAAFP, Michigan State University, East Lansing

Address correspondence to Michelle Nelson, MD, FAAFP, at michelle.nelson@mymichigan.org.

Author disclosure: Michelle Nelson, MD, disclosed stock ownership in Eli Lilly. This relevant financial relationship was mitigated when she sold her shares in May 2024, before her work on this content began.

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Michael J. Arnold, MD, MHPE, AFP Assistant Medical Editor.

A collection of Practice Guidelines published in AFP is available at https://www.aafp.org/afp/practguide.

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