Major burn resuscitation

Airway. Facial burns + hoarseness = inhalation injury risk (Otterness: upper-airway thermal burns, lower-airway irritants, plus CO and cyanide). Intubate early before oedema progresses. RSI with a large enough ETT for later bronchoscopy. 100% oxygen. Co-oximetry for COHb.^[4][8]

Breathing. 100% oxygen via non-rebreather (Chenoweth: primary treatment; HBO indications controversial). Assess circumferential chest burn (escharotomy if ventilatory compromise). Cyanide: soot plus neurological impairment — hydroxocobalamin 5 g IV (maximum 15 g) was used empirically by Borron; Jin 2025: mortality similar to supportive care, so use with caution.^[8][9][6]

Circulation. Two large-bore IVs. Starting crystalloid 2–4 mL/kg/%TBSA lactated Ringer / Hartmann's over 24 h (Parkland 4 mL; ABA 2024 adult start 2 mL). Mid-range 3 mL × 60 × 30 = 5400 mL in 24 h. Half (2700 mL) in the first 8 hours from the time of the burn (1 hour ago, so 7 hours remain ≈ 386 mL/h). Do not omit catch-up fluid from injury time (Hsiao: arrival-time calculations omit catch-up). Titrate to urine 0.5–1 mL/kg/h (30–60 mL/h).^[2][3][1]

Disability. GCS, pupils. CO causes headache through coma; pulse oximetry cannot distinguish COHb from oxyhaemoglobin.^[8]

Exposure. Cool with 20 minutes of running water within 3 hours, then re-warm (RCH; no ice). Estimate TBSA excluding erythema (rule of 9s / Lund-Browder). Circumferential burns → escharotomy if perfusion or ventilation fails.^[5]

Wound + analgesia. Clean and dress. Titrated IV opioid (Gregoretti: background vs procedural pain). Tetanus status stratified by immunisation history.^[10][11]

Disposition. 30% TBSA deep partial/full-thickness meets ABA eDelphi burn-centre consultation (deep partial ≥10% TBSA; full-thickness ≥5%). The eDelphi special-circumstance list is electrical, chemical, and radiation — not inhalation. Inhalation still warrants early specialist involvement as airway disease (Otterness; RCH local pathway).^[7][4][5]