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Burn Casualty Resuscitation: When IV Fluids Run Out

Mike Shertz MD/18D

The US Joint Trauma System Clinical Practice Guideline on Burn Care, published June 10, 2025, now includes enteral resuscitation, meaning oral or nasogastric (NG) tube fluids, for burn casualties when IV fluid isn’t available in the quantities required.

Not Every Casualty Is a Candidate for Enteral Resuscitation

Oral fluids require a casualty who is awake, reasonably alert, and cooperative. NG tube resuscitation is an option as long as the casualty can protect their airway. Rectal fluid administration remains available for those who can’t safely swallow.

Contraindications That Rule Out the Gut

Anything that limits the gastrointestinal tract’s ability to absorb fluid is a contraindication. That includes abdominal injuries, vomiting, and burns exceeding roughly 40% total body surface area (BSA). Larger burns typically require intubation and aggressive airway control anyway, which takes oral resuscitation off the table. An NG tube is still an option; just weigh the aspiration risk.

Why an Isotonic Electrolyte Solution Is Non-Negotiable

Enteral resuscitation requires an electrolyte-based solution. World Health Organization Oral Rehydration Salts (ORS), or a commercial variant, is the most available option in austere or deployed settings. The fluid has to be isotonic: tap water or Gatorade will dilute the casualty’s electrolytes and create a new problem instead of solving the original one.

Useful in theory. But what does the evidence actually say?

The Evidence Trail Runs From a 1950 NIH Study to a 2024 Meta-Analysis

In 1950, an NIH Surgery Study Section specifically adopted oral saline solution “as standard practice in the treatment of shock due to burns and other serious injuries in the event of large-scale civil catastrophe.” Many in the field believe this technique was simply forgotten once IV fluids and plastic IV catheters became widely available.1

Early Animal Models Showed a Real Survival Benefit

The earliest supporting experiments used mice with trauma, traumatic shock, or burns. A standard “shock model” produced greater than 50% mortality within six hours. Oral resuscitation with isotonic fluid delivered a “great survival benefit” in that model. Pure water or glucose solutions did not improve survival.1

Between 1944 and 1991, 709 human patients with “moderate to severe” burns received enteral resuscitation across 12 studies. That data helped refine the solution itself: early formulas using only sodium chloride caused acidosis, which isn’t surprising, since aggressive 0.9% normal saline resuscitation causes hyperchloremic metabolic acidosis by the same mechanism.

Buffering the Solution Fixed the Acidosis, and the Taste

Adding bicarbonate, lactate, or citrate to the oral solution prevented the acidosis. It also made the solution more palatable and reduced nausea and vomiting.1

What the 2024 WHO-Linked Systematic Review Actually Found

A 2024 systematic review and meta-analysis of enteral burn resuscitation was conducted as part of the WHO Guidelines Development Group’s update to burn care in mass casualty incidents.2 The review covered major burns (>15% BSA) in adults, focused on resuscitation in the first 24 hours post-burn. It included 15 studies, but only 7 in humans, all hospital-based, spanning 5 burn units worldwide. Burn severity ranged from 10% to 95% BSA, and only thermal burns were represented. ORS was the most commonly used enteral fluid.

Human Data Is Thin: Just 100 Patients Across Three RCTs

Three randomized controlled trials, totaling 100 patients with 10-55% BSA burns, directly compared enteral to IV fluid resuscitation. There was no statistically significant difference in death rate between groups, but only 70 patients were in the single human study that measured that outcome. Acute kidney injury was assessed in just 24 burn patients. Urine output post-resuscitation, measured in 70 patients, showed no difference between groups. With outcome groups this small, the reliability of these results is, charitably, thin. A single descriptive cohort study of 3 patients (20-40% BSA) suggested up to 77.5% of burn resuscitation IV fluid could be replaced with enteral fluid in major burns. That’s proof of concept, not proof.2

Animal Data Is More Robust, But It's Still Animal Data

The remaining studies were conducted in dogs, pigs, and rats. Compared to no fluid at all, enteral fluids significantly improved mortality, kidney function, and urine output in these animal models.

The Field-Expedient Case: Why ORS Packets Beat IV Bags on Weight

Authors examining this question from a military field-expedient standpoint point out that ORS packets are dramatically lighter and lower-cube than IV fluid. They cite International Society of Burn Injuries guidelines recommending burn casualties drink 15% of body weight (kilos × 0.15 = liters) in fluid over the first two days post-burn; the WHO working group on burns uses a figure closer to 10% body weight daily. These authors also acknowledge, as is true everywhere in this literature, that there is very little hard evidence to support “strong guidelines.”3

Bottom Line: Enteral Resuscitation Is a Backup Plan, Not a Primary One

There is some evidence supporting enteral burn resuscitation, particularly for casualties under 40% BSA. In a deployed setting, blood may be plentiful while IV fluid is not, and burn casualties, especially in a mass casualty incident, can require volumes of IV fluid you simply may not have. Smaller burns can reasonably be resuscitated orally, preserving limited IV fluid for the larger burns that need it.

The evidence for enteral burn resuscitation is limited but real. Treat it as your alternate plan when resources run short, not your primary plan. IV fluid remains primary.

…And now you finally have a use for all those MRE accessory packets (containing salt and sugar so you can make your own ORS) you’ve been throwing in a box on deployment. 

The addendum to the Burn Care CPG outlining exactly how to administer enteral burn resuscitation: Burn Care CPG, 10 June 2025 (PDF)

References

1Kramer GC, Michell MW, Oliveira H, Brown TL, Herndon D, Baker RD, Muller M. Oral and enteral resuscitation of burn shock: the historical record and implications for mass casualty care. Eplasty. 2010 Sep 1;10:e56.

2Hsiao KH, Kalanzi J, Watson SB, Murthy S, Movsisyan A, Kothari K, Salio F, Relan P. Oral/enteral fluid resuscitation in the initial management of major burns: A systematic review and meta-analysis of human and animal studies. Burns Open. 2024 Nov;8(4).

3Jones IF, Nakarmi K, Wild HB, Nsaful K, Mehta K, Shrestha R, Roubik D, Stewart BT. Enteral Resuscitation: A Field-Expedient Treatment Strategy for Burn Shock during Wartime and in Other Austere Settings. Eur Burn J. 2024 Jan 18;5(1):23-37. doi: 10.3390/ebj5010003. PMID: 39600011; PMCID: PMC11571826.

Key Takeaways

  • The June 2025 JTS Burn Care CPG now formally endorses enteral (oral/NG) burn resuscitation as a fallback when IV fluid is insufficient.
  • Candidates need an intact, absorbing GI tract, an airway they can protect, and generally under 40% BSA burns; larger burns usually require intubation. 
  • Use an isotonic, buffered electrolyte solution (WHO ORS or equivalent); plain water or Gatorade risks dilutional electrolyte issues. 
  • The human evidence base is small (three RCTs, roughly 100 patients total) and outcome-specific groups are too thin to draw firm conclusions; animal data (dogs, pigs, rats) more consistently shows benefit over no fluid.
  • Enteral resuscitation is a resource-driven alternate plan, not a replacement for IV fluid as primary treatment, but it’s a real option in mass casualty and austere/deployed settings where IV fluid is the limiting resource.
Picture of Mike Shertz MD/18D

Mike Shertz MD/18D

Dr. Mike Shertz is the Owner and Lead Instructor at Crisis Medicine. Dr. Shertz is a dual-boarded Emergency Medicine and EMS physician, having spent over 30 years gaining the experience and insight to create and provide his comprehensive, science-informed, training to better prepare everyday citizens, law enforcement, EMS, and the military to manage casualties and wounded in high-risk environments. Drawing on his prior experience as an Army Special Forces medic (18D), two decades as an armed, embedded tactical medic on a regional SWAT team, and as a Fire Service and EMS medical director. Using a combination of current and historical events, Dr. Shertz’s lectures include relevant, illustrative photos, as well as hands-on demonstrations to demystify the how, why, when to use each emergency medical procedure you need to become a Force Multiplier for Good.