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Background: Resource limitations in settings such as burn mass casualty incidents (MCIs) present challenges to the judicious fluid resuscitation required for major burns. Previous recommendations for burns care in MCIs have suggested certain adaptations from routine care, such as delaying intravenous (IV) fluid resuscitation until arrival at facility; using a fluid calculation formula that is independent of percentage of total body surface area (%TBSA) burned; or using fluid calculation formula based on time of arrival to first receiving facility rather than from time of injury, thus omitting ‘catch-up’ fluid. Objectives: To synthesize and assess certainty of evidence from resource-limited settings on the three adaptations to fluid resuscitation for patients with major burns in MCIs. Methods: PubMed, EMBASE, CINAHL, and Cochrane Library were searched on 8 September 2023 with an update search on 8 July 2024. Primary quantitative studies in resource-limited settings meeting eligibility criteria as assessed by two reviewers were included. Where available, outcome effects for these adaptations compared to routine burns care were calculated. Evidence certainty was determined by GRADE. Results: Two eligible studies were identified from 544 search results. One study with 48 participants provided very uncertain evidence that delayed IV fluid resuscitation may increase acute kidney injury compared to prehospital resuscitation (OR 2.48, 95% CI 0.58–10.62). The other study with a cohort of 10 children provided very uncertain evidence that calculating fluid requirements based on time of arrival to first receiving facility, i.e. omitting ‘catch-up’ fluids, may maintain adequate urine output and be associated with no complications of fluid over- or under-resuscitation. There were no studies on use of a simplified %TBSA-independent fluid calculation formula. Conclusions: There is very limited and uncertain evidence to inform on delayed IV fluid resuscitation, simplified %TBSA-independent formula, and omission of ‘catch up’ fluids for burns care in MCIs. Contextual factors, local values, preferences and feasibility also need to be considered.

Background: Timely and safe intravenous (IV) fluid resuscitation for major burns may be difficult or impossible during mass casualty burn incidents. Oral/enteral fluid resuscitation may be an alternative. Objectives: To synthesize and assess certainty of evidence on oral/enteral fluid resuscitation as compared to IV or no fluid resuscitation for major burns. Methods: PubMed, EMBASE, CINAHL, and Cochrane Library were searched on 8 September 2023. Primary quantitative studies meeting criteria as assessed by two reviewers were included. Meta-analyses for outcome effects of oral/enteral versus IV and of oral/enteral versus no fluid resuscitation were conducted. Evidence certainty was assessed using GRADE. Results: Seven human and eight animal studies were included. Three human RCTs totalling 100 participants contributed to estimates. Compared to IV fluid resuscitation, oral/enteral fluid resuscitation is associated with a statistically insignificant increased risk of mortality (OR 1.33, 95% CI 0.33–5.36) but the evidence is very uncertain, and no difference in urine output (SMD −0.17, 95% CI −0.65–0.31) with moderate certainty of evidence. Eight controlled animal studies totalling 212 participants contributed to estimates. From these animal studies, enteral fluid resuscitation may increase mortality (OR 36.00, 95% CI 2.72–476.28), worsen creatinine levels (MD 22 mmol/L, 95% CI 15.8–28.2), and increase urine output (MD 1 ml/kg/h, 95% CI 0.55–1.45) compared to IV, but all with very low certainty of evidence. Again, from animal studies, all the evidence is very uncertain, but compared to no fluid resuscitation, enteral resuscitation is associated with a statistically insignificant reduction in mortality (OR 0.29, 95% CI 0.08–1.09), improved creatinine levels (SMD −3.48, 95% CI −4.69 to −2.28), and increased urine output (MD 0.55 ml/kg/h, 95% CI 0.38–0.72). Conclusions: Current evidence comparing oral/enteral and IV fluid resuscitation for major burns is limited and uncertain. However, where IV fluid resuscitation is unavailable or delayed, oral fluid resuscitation could be considered.