Propranolol (Burns — Hypermetabolic Response)

How it works

It competitively antagonises beta-1 and beta-2 adrenoceptors, reducing the sympathetic and catecholamine surge that drives the post-burn hypermetabolic state, thereby lowering heart rate, cardiac work and peripheral lipolysis.

Prescribing in practice

• Avoid in asthma or significant reversible airways disease and use caution in haemodynamic instability or hypovolaemia, as non-selective beta-blockade can provoke bronchospasm and unmask shock by limiting compensatory tachycardia.
• Use is an adjunct within a specialist burns critical-care setting once the patient is adequately resuscitated, not during the acute fluid-shift phase.
• Beta-blockade can mask the adrenergic warning signs of hypoglycaemia, which is relevant given the disordered glucose metabolism of major burns.

Monitoring

Monitor heart rate, blood pressure and tissue perfusion closely, titrating to a target reduction in resting heart rate while watching for bradycardia or hypotension.

Counselling the patient

• Explain to the team that the aim is to dampen the burn-induced stress response and support recovery, not to treat blood pressure.
• Report new wheeze, marked slowing of the pulse, dizziness or signs of poor perfusion promptly.
• Do not stop the drug abruptly without specialist advice.

Evidence & guidelines

Use in burns hypermetabolism is supported by clinical studies in major thermal injury, though it remains an unlicensed specialist application.