Case of the Month #46 A Major Burn Injury: Taming the Flames

Published 13/02/2024

You admit the patient to the intensive care unit following their escharotomies. What considerations will you need to have for their ongoing care?

  • Ongoing fluid therapy 

  • Thermoregulation & the burns hyperinflammatory syndrome 

  • Nutrition 

  • Surgical intervention 

  • Infection 

  • Analgesia 

  • Psychology 


Fluid resuscitation 

  • Continue Parkland formula initially 

    • Then modify based on a number of clinical endpoints 
  • Usually target a urine output of 0.5-1ml/kg/hr ideal body weight  

    • Adjust fluid administration rate accordingly 
    • Also consider information such as lactate, acid-base balance, haematocrit, and peripheral perfusion 
  • Choice of fluid 

    • Warmed Hartmann’s is used in the first instance 
    • Albumin may have a role as ‘colloid rescue’ if fluid requirements predicted to be >6ml/kg/TBSA in the first 24h 
      • This may reduce overall volume requirements, and therefore reduce risks associated with ‘over-resuscitation’ 
        • These risks include cerebral & pulmonary oedema, abdominal compartment syndrome, tissue oedema and electrolyte disturbances.


Surgical intervention: 

  • Early debridement is advocated 
    • The aim is to improve wound healing, reduce inflammatory response, reduce infection risk 
  • Dressing changes will be required regularly 
    • This may pose challenges with regards to analgesia and sedation 


Infection risk: 

  • Loss of skin barrier makes patients high risk for infection 

  • Patients will become colonised, often with resistant organisms 

  • The burns hyperinflammatory state can make it difficult to diagnose infections clinically 

  • There are many possible pathogens: 

    • Gram-positive organisms early in the course 
    • Gram-negatives from environment or gut translocation e.g. Pseudomonas, Klebsiella, E. coli 
    • Fungal infections also a possibility 
  • Treatment with antibiotics in conjunction with microbiology teams is required 

    • Further surgical intervention may be required in certain cases 



  • Major burns cause a significant increase in the basal metabolic rate 

  • Patients are in a highly catabolic state 

  • Enteral nutrition should be started early 

  • Seek early specialist dietitian support 



  • Patients initially require warming to maintain temperature 

  • Then often hypothalamic temperature set point will become reset 

    • Patients may become hyperpyrexial  
      • In general, this should be treated if >39.5C 
      • Treatment may require the use of intravascular cooling devices 

Hyperinflammatory state 

  • This may persist for months, limiting recovery, and be difficult to manage 

  • Propranolol may be used 

    • May suppress catabolic effects of a burn  
    • Evidence is not clear cut for its benefit  
  • Oxandrolone can also be used in major burns 

    • It is an androgen receptor agonist 
      • This timulates muscle growth 
      • It is much less virilising than testosterone 
    • Oxandrolone should be considered after day 5 in ≥30% TBSA burns