13.2 Burn Resuscitation and Flight Considerations
Key Takeaways
- American Burn Association-style adult starts now lean toward 2 mL/kg/%TBSA lactated Ringer's over 24 hours; Parkland 4 mL and modified Brooke 2 mL are starting points, with about half in the first 8 hours from the time of burn.
- Titrate adult urine output to about 0.5 mL/kg/hour and avoid fluid creep; the formula starts the drip, the bladder runs it.
- Closed-space fire means 100 percent oxygen for carbon monoxide, cyanide treatment when the story fits, and a hyperbaric-capable destination if indicated.
- Cover with dry clean sheets, stop wet dressings, prevent hypothermia, and elevate burned limbs; a cold cabin will finish an ice or wet-wrap injury.
- Intubate the swelling face before loading, watch Boyle's law on the endotracheal-tube cuff, and loosen circumferential dressings before climb.
Once the flame is out, the flight problem is volume, toxin, temperature, and a destination that can graft. Domain 3.G of the August 2026 Certified Flight Registered Nurse (CFRN) outline still sits under burn, but this section is the hop: American Burn Association (ABA)-style fluid starts, urine-output titration, carbon monoxide (CO) and cyanide (CN), dry sheets, and a cabin that steals heat. Depth, chemicals, electrical paths, and escharotomy recognition are section 13.1. Pediatric hourly targets stay in Chapter 18.
ABA-style starting points, not a religion
Parkland (historically 4 mL/kg/%TBSA of lactated Ringer's (LR) over 24 hours) and modified Brooke (2 mL/kg/%TBSA LR over 24 hours) are labeled starting points. Give about half in the first 8 hours, and start that clock at the time of burn, not at arrival. Current ABA-style adult teaching has moved toward 2 mL/kg/%TBSA as the adult start (many services still use 3 mL for children and 4 mL for high-voltage electrical injury—clinical teaching, not a Board of Certification for Emergency Nursing (BCEN) table). Prefer LR over 0.9% sodium chloride; large chloride loads add acidosis.
The formula starts the drip. Urine output (UOP) runs it. Titrate to about 0.5 mL/kg/hour in adults. Pigmented urine after electrical injury usually needs a higher protocol target, commonly near 1 mL/kg/hour, until the urine clears. Do not use the adult 0.5 mL number on an infant (Chapter 18).
Fluid creep
Fluid creep is over-resuscitation: the kind drip at the landing zone becomes abdominal compartment syndrome and pulmonary edema. Do not add extra volume for every blood-pressure dip when the bladder is already making urine. Recalculate TBSA if the sending number included first-degree skin. Subtract what has already been given. True hemorrhagic shock from associated trauma is blood (Chapter 8), not triple Parkland.
| Starting construct | Typical adult teaching | What you actually do |
|---|---|---|
| Parkland | 4 mL/kg/%TBSA LR over 24 hours | Start, then titrate |
| Modified Brooke / current ABA-style adult | 2 mL/kg/%TBSA LR over 24 hours | Preferred adult start in many 2020s protocols |
| First 8 hours | About half the 24-hour volume | Clock starts at the burn, not at lift |
| Titration | Adult UOP about 0.5 mL/kg/hour | Avoid fluid creep |
Carbon monoxide and cyanide
A closed-space fire is a toxin scene. Pulse oximetry (SpO2) cannot tell oxyhemoglobin from carboxyhemoglobin. Place a nonrebreather or a secured tube on 100 percent oxygen. High fraction of inspired oxygen (FiO2) shortens the half-life of CO. Choose a destination that can run a CO-oximeter and that has hyperbaric oxygen (HBO) capability if indicated—typical clinical triggers include loss of consciousness, persistent neurologic findings, pregnancy, and severe metabolic acidosis (thresholds vary; BCEN does not publish a cutoff).
Cyanide from burning plastics presents as unexplained lactic acidosis, collapse, and a sooty closed-space story. If your kit carries hydroxocobalamin, that is the usual prehospital antidote when the story fits. Do not withhold oxygen to "save the CO level."
Dalton's law drops inspired oxygen tension as you climb. A CO-poisoned brain that looked merely confused at sea level can seize when cabin altitude rises. Raise FiO2 and ask for a lower cabin when the aircraft can give you one.
Dry sheets, heat, limbs, and what not to wrap
Burned skin leaks heat. A night helicopter is a refrigerator. Hypothermia is a flight killer. Cover with dry, clean sheets. No wet dressings for transport. Wet gauze evaporates, then freezes. Elevate burned limbs. Do not wrap a circumferential burn like a tourniquet.
Packaging checklist before lift:
- Dry sheet and blankets; no ice, no wet wraps
- Two working accesses and a bladder catheter you can actually read
- Burned limbs elevated and wraps loose enough to reassess pulses
- Face and neck rechecked after every transfer
Airway, Boyle, and loading
Facial and neck edema progresses. If the face is burned, the mouth is sooty, or the voice is changing, intubate early—before loading—and secure the endotracheal tube (ETT) as if vibration will steal it.
Boyle's law expands gas as cabin altitude rises. Check ETT cuff pressure on climb and descent (or follow a program saline-cuff protocol). Tight circumferential dressings plus altitude-related swelling act like an unplanned eschar. Loosen them. Escharotomy remains a receiving or physician skill (section 13.1).
Destination: ABA burn-center thinking
Fly capability. Conceptual ABA burn-center referral thinking includes partial-thickness injury over about 10 percent TBSA; any full-thickness burn; burns of the face, hands, feet, genitalia, perineum, or major joints; chemical or electrical injury; inhalation injury; and burned patients with serious comorbidities or concomitant trauma. If trauma is the immediate killer, the first capable trauma center stabilizes hemorrhage, then the system moves the patient to a verified burn center. Do not spend the night at a hospital that cannot graft just because the pad was closer.
An 80-kg adult has 40 percent TBSA partial- and full-thickness flame burns from 2 hours ago. Which starting fluid plan matches current American Burn Association-style adult teaching?
You are packaging a 50 percent TBSA burn for a winter night rotor flight. What covering and temperature plan is correct?
A circumferential forearm burn is wrapped tightly, the face is sooty, and you are about to climb with a cuffed endotracheal tube. What is the correct Boyle and packaging concern?