A 50-year-old, 75-kg, male is brought into the emergency department by EMS. He was found ambulating at the scene of a house fire approximately 2 hours prior. He is noted to have circumferential third-degree burns to his entire right and left upper extremities as well as his entire head and neck. In the emergency department he is alert and oriented, and complains of a dry mouth.
1. What is the first step in assessing this patient?
2. How large is this patient’s burn?
As with every trauma, begin with ATLS protocol and assessment of ABCs. In this case the patient will require intubation for airway protection. Given the size (>20%) and location of the burn, the patient will require large-volume resuscitation and will likely develop significant facial and airway edema. Elective intubation prior to the development of airway edema is common practice for larger burns.
The rule of 9’s allows for a simplified approach to calculate total body surface area (TBSA) for a burn (Figure 16-1). The Lund and Browder method (which utilizes a chart) is commonly used for estimation of burn size in children.
In the case above, each upper extremity is 9, head is 9, neck is 1 = 28% TBSA.
The Parkland formula is a formula used for the initial fluid resuscitation of a burn patient with >20% TBSA. It estimates the overall fluid total as 4 mL × % TBSA × weight (kg). Half of this volume is to be administered in the first 8 hours post burn, while the second half of this volume is to be administered over the next 16 hours.
The Parkland formula should only serve as a guide to resuscitation. Global (ie, lactate, base deficit, pH) and regional (ie, urine output, mental status) parameters of perfusion should be followed and trended in order to fine-tune the resuscitation volumes. Typically crystalloid is used for the first 8 hours and varying quantities of colloid (ie, albumin) are added in according to patient needs and surgeon preference. As resuscitation volumes approach and exceed 6 cm3/% TBSA/kg, the incidence of compartment syndromes and intra-abdominal hypertension increases. In such cases, the addition of colloid may allow for slightly less overall fluid administration.
In this case 4 mL × 28% third-degree burn × 75 kg = 8400 cm3. This is the total fluid to be given over 24 hours (4200 cm3/first 8 hours, 4200 cm3/next 16 hours). Since the patient presented 2 hours post injury, the first 4200 cm2 should be given over 6 hours. IVF rates would be 700 cm3/h (first 6 hours), and 262.5 cm3/h (second 16 hours).
Yes; because this second-degree burn involves the face, this patient should be transferred to a burn center. According to the American ...
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