Over-resuscitated burn with rising pressures and missed referral — down-titration, sepsis trigger, and transfer rescue

Expected management

• Down-titrate now, never inherit the rate: 6.3 +/- 2.9 with 76% above the 4.3 Baxter ceiling happened through failure to titrate down and tolerance of high urine output — his 90 ml/hr with rising pressures and tense abdomen is creep, not success.^[7]
• Re-target to least fluid for perfusion with urine output recognised as a poor target — creep buys respiratory failure and compartment syndromes including intra-abdominal hypertension.^[8]
• Re-run endpoints as five together with lactate superior and no single endpoint sufficient — his lactate and base deficit, not his urine output, decide the next hour.^[9]
• Trigger the sepsis workup at >3 ABA criteria (temperature, tachycardia, tachypnea/ventilation, platelets from day 3, hyperglycemia, feed intolerance) — but remember the trigger's area is 0.638 with only heart rate and temperature correlating, so culture and examine rather than declare.^[25]
• Plan excision inside the controversy: counsel the 0–3-day cohort benefit (deaths 3.84 vs 6.09%, infection 37.84 vs 42.48%) against the systematic-review late-mortality signal — book early excision for infection and stay while resuscitation and airway come first.^[22]
• Feed early enterally with protein 1.5–2 g/kg, glucose capped at 55% and 5 mg/kg/h with ≤8 mmol/l control, fat ≤30%, and early trace/vitamin replacement — energy by Toronto equation without calorimetry accepting overfeeding risk.^[34]
• Rescue the referral today: hand and face burns meeting criteria are the classic kept-back pattern, 48% of eligible nonburn cases go untransferred, and every nonburn death had qualified — transfer to the burn centre now.^[17]

Examiner traps

• Chasing the 90 ml/hr urine output upward while lactate and pressures rise — the documented reason creep never reversed.^[7]
• Calling the ABA trigger a diagnosis at 0.638 — it prompts cultures, never certainty.^[25]
• Booking definitive excision before resuscitation and airway are controlled — early surgery helps infection and stay only after perfusion and ventilation.^[22]
• Defending the nonburn plan for hand/face burns — the gap data condemns exactly this patient.^[17]