BCCCP: Burns Pharmacotherapy

Question 1 of 10

1. Question

A 45-year-old man with extensive third-degree burns covering 40% of his total body surface area is admitted to the ICU burn unit. He has a history of chronic malnutrition, evidenced by a low pre-admission serum albumin level. Despite adequate fluid resuscitation and early wound care, he remains in a catabolic state with delayed wound healing. Which of the following clinical interventions is most critical to prioritize to optimize his wound healing and long-term outcomes?

Early surgical debridement and skin grafting.
Tight glycemic control with insulin infusion.
Aggressive nutritional support with early enteral nutrition (30–35 kcal/kg/day and 1.5–2.0 g protein/kg/day).
Prophylactic broad-spectrum antibiotic therapy.

Question 2 of 10

2. Question

A 45-year-old, 70 kg man is admitted to the intensive care unit 2 hours after sustaining full-thickness flame burns involving 30% of his total body surface area. On arrival, he is hypotensive (BP 85/50 mm Hg), tachycardic (HR 125 bpm), and has a urine output of 0.3 mL/kg/hr. Which of the following is the most critical initial consideration for this patient’s fluid management?

Begin isotonic crystalloid resuscitation using the Parkland formula (4 mL/kg/%TBSA burned) over the first 24 hours, administering half of the calculated volume in the first 8 hours post-injury and titrating to a urine output of 0.5–1 mL/kg/hr.
Estimate fluid needs at 2 mL/kg per %TBSA over 72 hours (similar to Stevens–Johnson syndrome protocols) and administer evenly over that period.
Prioritize initiation of early enteral nutrition to meet hypermetabolic demands, with fluid resuscitation deferred until nutritional goals are met.
Delay crystalloid resuscitation until invasive hemodynamic monitoring (e.g., pulmonary artery catheter) is fully established to reduce the risk of pulmonary edema.

Question 3 of 10

3. Question

A 62-year-old man with 40% total body surface area full-thickness burns is admitted to the ICU. He is intubated, on norepinephrine for hemodynamic support, and has a history of type 2 diabetes mellitus and chronic heart failure with preserved ejection fraction (HFpEF). Given his burn severity and cardiac comorbidity, which adjustment to his fluid resuscitation should be MOST critically prioritized by the critical care pharmacist?

Individualize crystalloid infusion rates using invasive hemodynamic monitoring (e.g., arterial waveform analysis) plus urine output and lactate targets to avoid volume overload.
Administer early boluses of 3% hypertonic saline to reduce total crystalloid volume requirements.
Add 5% albumin after the first 24 hours to maintain oncotic pressure and limit edema formation.
Guide all fluid resuscitation by urine output alone (0.5–1 mL/kg/hr) without hemodynamic monitoring.

Question 4 of 10

4. Question

A 35-year-old man is admitted to the ICU with 40% total body surface area full-thickness burns after a house fire. During the acute resuscitation phase, despite aggressive fluid replacement guided by urine output and hemodynamics, he remains hypotensive with tachycardia and oliguria. Laboratory studies show hypoalbuminemia. Which pathophysiological process is most critically contributing to his persistent hypovolemia and requires the most immediate understanding for management?

Profound capillary leak syndrome leading to massive plasma protein and fluid extravasation
Systemic hypermetabolic response causing rapid glycogenolysis and severe hyperglycemia
Increased insensible fluid losses through damaged skin and respiratory tract
Direct myocardial depression from circulating inflammatory cytokines

Question 5 of 10

5. Question

A 45-year-old, 70 kg male with 40% total body surface area full-thickness burns initially received fluid resuscitation via two 18-gauge peripheral IV catheters placed in unburned upper extremities according to the Parkland formula. After 4 hours, his urine output has decreased to 0.2 mL/kg/hr, and generalized edema has developed. One peripheral IV line has infiltrated. His blood pressure is 85/50 mmHg, requiring norepinephrine infusion through a newly placed central venous catheter. The burn team anticipates continued high-volume fluid requirements for the next 24–48 hours. Considering the patient’s escalating fluid needs, hemodynamic instability, and compromised peripheral access, which of the following is the most appropriate next step to ensure reliable high-volume crystalloid administration?

Attempt placement of additional large-bore peripheral IV catheters in the lower extremities.
Insert an intraosseous (IO) line for primary fluid administration.
Utilize the existing central venous catheter for primary fluid administration.
Place a peripherally inserted central catheter (PICC) for fluid administration.

Question 6 of 10

6. Question

A 35-year-old man (70 kg) is admitted to the burn unit 1 hour after sustaining 40% total body surface area (TBSA) full-thickness burns and confirmed inhalation injury. He is hemodynamically unstable with a blood pressure of 85/60 mmHg, heart rate of 120 beats/min, and urine output of 0.3 mL/kg/hr since admission. The critical care team must initiate fluid resuscitation to restore perfusion while minimizing the risk of fluid overload and pulmonary edema. Which initial fluid resuscitation formula should be prioritized to provide a cautious but effective starting volume that allows for careful titration to avoid over-resuscitation?

Parkland formula: 4 mL/kg/%TBSA of lactated Ringer’s solution (half given in the first 8 hours post-injury)
Modified Brooke formula: 1.5 mL/kg/%TBSA of lactated Ringer’s solution over the first 24 hours
Evans formula: 1 mL/kg/%TBSA of lactated Ringer’s plus 1 mL/kg/%TBSA of 5% albumin over the first 24 hours
Brooke formula: 2 mL/kg/%TBSA of lactated Ringer’s solution over the first 24 hours

Question 7 of 10

7. Question

A 45-year-old man (70 kg) is 10 hours post-burn after sustaining full- and partial-thickness burns covering 35% of his total body surface area in a house fire. He was intubated and has a central venous catheter. Fluid resuscitation was started 2 hours after injury using the Parkland formula (4 mL/kg/%TBSA lactated Ringer’s): half the total volume in the first 8 hours from the time of burn and the remainder over the next 16 hours. He is now 2 hours into that second phase and is receiving LR at 400 mL/hr. Over the past 2 hours his urine outputs were 20 and 25 mL/hr. Heart rate is 115 bpm, blood pressure 90/55 mmHg, and serum lactate is 3.2 mmol/L. Considering his ongoing burn shock despite current crystalloid therapy, which adjustment to his fluid regimen is most appropriate?

Adjust lactated Ringer’s infusion to 306 mL/hr per Parkland formula for the 8–24 hour period
Administer a 500 mL bolus of lactated Ringer’s over 30 minutes
Initiate 5% albumin infusion at 100 mL/hr
Decrease lactated Ringer’s infusion rate to 200 mL/hr

Question 8 of 10

8. Question

A 35-year-old male is admitted to the intensive care unit with severe burns covering 40% of his total body surface area. The critical care team must initiate fluid resuscitation promptly to restore intravascular volume and maintain organ perfusion. Considering the pharmacoeconomic implications and current evidence in the context of severe burn injury, which statement best prioritizes the initial fluid resuscitation strategy?

Prioritize crystalloids due to their lower acquisition cost, wide availability, and comparable efficacy and safety profile in initial burn resuscitation.
Initiate albumin immediately to rapidly restore intravascular volume and reduce total fluid requirements, despite its higher acquisition cost.
Utilize hydroxyethyl starches as they are more cost-effective than albumin and provide efficient plasma volume expansion.
Administer crystalloids for the first 24 hours, then transition to albumin to minimize edema, justifying the increased cost for improved outcomes.

Question 9 of 10

9. Question

A 45-year-old man is admitted to the ICU 2 hours after a house fire. He is intubated on assist-control ventilation and receiving norepinephrine 0.1 µg/kg/min via a central line. Vital signs: BP 90/60 mm Hg on norepinephrine, HR 120 bpm. He produces 20 mL urine over the last hour. Physical exam reveals full-thickness burns over his entire left arm (9% TBSA) and anterior trunk (18% TBSA) for a total of 27% TBSA burned. Weight is 70 kg. Which of the following represents the MOST appropriate immediate management strategy?

Use lactated Ringer’s at 2 mL/kg/%TBSA (total 3,780 mL), with half given in the first 8 hours post-injury, and arrange transfer to a specialized burn center.
Use lactated Ringer’s at 4 mL/kg/%TBSA (total 7,560 mL), with half given in the first 8 hours post-injury, and arrange transfer to a specialized burn center.
Use lactated Ringer’s at 4 mL/kg/%TBSA (total 7,560 mL), with half given in the first 8 hours post-injury, and continue management in the current ICU.
Defer crystalloid resuscitation since hemodynamics are supported with norepinephrine, and focus on wound care and pain control.

Question 10 of 10

10. Question

A 58-year-old male (weight 75 kg) with chronic heart failure (EF 30%) and end-stage renal disease (ESRD) on thrice-weekly hemodialysis (anuric) presents to the ICU with 30% TBSA second-degree burns after a house fire. Initial vital signs: BP 85/55 mm Hg, HR 115 bpm. Given his comorbidities and anuria, which fluid resuscitation strategy is most appropriate to balance adequate perfusion and minimize fluid overload?

Initiate isotonic crystalloid resuscitation at approximately half the Parkland volume (≈2 mL/kg/%TBSA over the first 24 h), titrated to hemodynamic parameters (MAP, lactate, capillary refill) with early coordination for renal replacement therapy.
Administer standard Parkland formula fluids (4 mL/kg/%TBSA) in 24 h, with close monitoring for pulmonary edema and adjustment if needed.
Use aggressive loop diuretics to prevent fluid overload, then guide additional fluid boluses by central venous pressure (CVP) measurements.
Provide minimal maintenance fluids (e.g., D5W + 0.45% NaCl at 1 mL/kg/h) and rely solely on thrice-weekly hemodialysis for fluid removal.

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