Major burns early fluid resuscitation — FFICM MCQ

Correct answer: C — Use a burns resuscitation formula and titrate to urine output and perfusion

The correct answer is C, use a burns resuscitation formula and titrate to urine output and perfusion. This patient has 45% TBSA burns with evidence of inadequate end organ perfusion (hypotension, lactate 4.2 mmol/L, oliguria at 10 ml/hour), so formula guided fluid resuscitation must begin immediately and be adjusted dynamically rather than given as a fixed volume. UK ICU burns practice uses a modified Parkland style formula (commonly 1.5 to 4 ml/kg per percent TBSA burned over 24 hours, with half in the first 8 hours from time of injury) purely as a starting estimate, with hourly urine output (target around 0.5 ml/kg/hour in adults), heart rate, blood pressure and lactate clearance used to titrate the rate up or down. Peripheral oedema is an expected consequence of capillary leak in major burns and is not a reason to withhold resuscitation fluid when the patient is shocked and oliguric; the priority is restoring perfusion while avoiding fluid creep. Why the other options are wrong: B. Give fixed 30 ml/kg crystalloid then stop: burn resuscitation is a continuous, weight and burn size proportional process guided by ongoing losses, not a single bolus followed by cessation, which risks both under and over resuscitation. A. Avoid fluids because oedema is present: oedema reflects capillary permeability from the burn injury itself, not fluid overload, and withholding fluid in a patient with lactate 4.2 mmol/L and 10 ml/hour urine output will worsen shock and precipitate acute kidney injury. D. Use dextrose 5% as the main resuscitation fluid: dextrose 5% distributes into total body water and provides negligible effective intravascular volume expansion, so it cannot correct hypovolaemic shock in major burns. E. Delay fluids until burn depth is confirmed: TBSA and physiological status, not depth, drive resuscitation volume, and delaying treatment in an already hypotensive, oliguric patient with a raised lactate is dangerous. Key point: In major burns, start a weight and TBSA based resuscitation formula immediately and titrate hourly to urine output, heart rate and lactate rather than fixed volumes or arbitrary delays.

Reference: North Bristol NHS Trust, Southmead ICU Burns Fluid Resuscitation Guideline: modified Parkland formula (1.5 ml/kg/%TBSA), titrated to urine output target 0.5 ml/kg/hour, https://www.nbt.nhs.uk/sites/default/files/Southmead%20ICU%20Burns%20Fluid%20Resuscitation%20Guideline.pdf