Salt-containing fluids, such as World Health Organization Oral Rehydration Solution (WHO ORS), commercially available ORS (e.g., Drip Drop, Ceralyte), or homemade ORS solution (see below), can be given by mouth or nasogastric tube (NGT) when IV fluids are unavailable.

Protocol

1. Start enteral resuscitation as soon as tactically feasible using rule of 10s to determine initial fluid rate.

- Use a graduated container to measure intake (if one is not available, an adult sip is ~15 mL)
- A straw may make it easier for the casualty to drink.
- If the casualty becomes unconscious or is unable to drink on their own (e.g., hand burns) then place an NGT for administration of resuscitation fluids. Do not place the tube post pyloric, enteral resuscitation must be gastric.
- Obtain IV access and place Foley catheter if available.
- If patient arrives in shock,* administer 500-mL LR bolus prior to starting enteral resuscitation.

2. Monitor vital signs and urine output hourly (with Foley if available)

- Goal urine output is 30-50 mL/hr
- If urine output monitoring is not available resuscitate to vitals sign goals of:
  - HR <140 BPM
  - SBP >90 mmHg or present radial pulse
  - Normal mental status
  - Capillary refill time < 2 s
  - If patient is in shock* then administer 500 mL LR bolus and continue enteral resuscitation

3. Titrate fluids based on urine output similar to IV-based resuscitation covered above

4. Give at least 100 mL/hr of enteral resuscitation for the first 48 hours.

5. Ensure adequate pain control and anti-nausea therapy throughout resuscitation.

6. Handling GI discomfort and GI intolerance

- GI discomfort (nausea, fullness)—Continue enteral resuscitation, assess pain/nausea control, administer pro-kinetic agent (e.g., metoclopramide, erythromycin)
- GI intolerance (distention, vomiting)—Stop enteral resuscitation and start IV fluids at the same rate, administer prokinetic agent, restart enteral resuscitation in 2 hours once intolerance resolves.

7. When to augment enteral resuscitation with IV fluids or switch to IV fluid resuscitation

- Persistent shock* despite LR bolus
- Persistent oliguria for 4 hours
- Large burns >40%

Homemade ORS solution recipe:2

1. 1 L clean water (sterile water is not necessary)
2. Stir in ½ level teaspoon of salt (or 4 grams)
3. Stir in 6 level teaspoons of sugar (or 20 grams)

*Shock: SBP <90 or absent radial pulses.

References

1. Jones, IF; Nakarmi, K; Wild, HB, et al. Enteral resuscitation: a field-expedient treatment strategy for burn shock during wartime and in other austere settings. Eur. Burn J. 2024, 5, 23-37.
2. Anonymous. Oral rehydration solutions: Made at home. Mother and child health and education trust, Rehydration Project.