Goal: Over the first 24–48 hours post burn, plasma is lost into the burned and unburned tissues, causing hypovolemic shock (when burn size is >20%). The goal of burn-shock resuscitation is to replace these ongoing losses while avoiding over-resuscitation.

Best: Isotonic crystalloids (e.g., lactated Ringer’s, Plasma-Lyte IV [Baxter, http://www.baxter.com/]);

- Start intravenous (IV) or intraosseous (IO) administration IMMEDIATELY.
- IV/IO can be placed through burned skin if necessary.
- NO bolus (unless hypotensive, in which case, bolus only until palpable pulses are restored).
- Initial IV rate 500mL/h; start while completing initial assessment.
- Adults: Measure burn size (TBSA) and multiply by 10. This is now your IV fluid rate. For example, if the burn size is 30%: 30 Å~ 10 = 300. Starting rate is 300mL/h.
  - For patients with weight >80kg, add an extra 100mL/h for each 10kg. For example, for a 100kg patient with 30% burns, the starting rate is 300mL/h + 200mL/h = 500mL/h.
  - If resuscitation is delayed, DO NOT try to “catch up” by giving extra fluids.
  - For children, 3 x TBSA x body weight in kg gives the volume for the first 24 hours. One half is given during the first 8 hours.

Better: Enteral (oral or gastric) intake of electrolyte solution

- Sufficient volume replacement will require “coached” drinking on a schedule using approximately the same amount of fluids that would be given IV/IO (see above).
- Oral resuscitation of patients with burns up to about 30% TBSA is possible (see Hydration sidebar below).
- If a nasogastric tube (NGT) is available, it is preferable to resuscitate with infusion of electrolyte solution via NGT (e.g., 300–500mL/h). But watch for nausea/vomiting.

Minimum: Rectal infusion of electrolyte solution. Rectal infusion of up to 500mL/h can be supplemented with oral hydration (see Hydration side bar.)