Burns
Depth, size, fluid resuscitation and the phases of burn care
Burn depth
| Superficial | Epidermis only; red, painful, no blisters (sunburn); heals in ~1 week |
| Superficial partial-thickness | Into the upper dermis; blisters, moist, pink, very painful; heals in 2–3 weeks |
| Deep partial-thickness | Deeper dermis; mottled red and white, less pain, may need grafting |
| Full-thickness | Whole dermis; white, brown or leathery, painless (nerves destroyed); needs grafting |
Burn size: rule of nines (adult)
| Head and neck | 9% | Each arm | 9% |
| Front of trunk | 18% | Back of trunk | 18% |
| Each leg | 18% | Perineum | 1% |
Children have bigger heads and smaller legs: use the Lund-Browder chart. The patient's own palm (with fingers) ≈ 1% of body surface. Don't count superficial burns in the total.
Emergent phase (first ~24–48 h)
- Airway first: inhalation injury signs: burns to face or neck, singed nasal hair, soot in mouth or sputum, hoarseness, stridor → early intubation.
- Carbon monoxide: pulse oximetry reads falsely normal: check carboxyhemoglobin; give 100% oxygen.
- Capillary leak → fluid shifts out of vessels → hypovolemia, high K⁺ (cell damage), high hematocrit.
- IV opioids for pain (not IM); tetanus; stress-ulcer prophylaxis; NG tube for large burns (ileus).
Fluid resuscitation
Parkland formula: 4 mL × kg × %TBSA (partial + full thickness) of lactated Ringer's over 24 h. Half in the first 8 h from the time of the burn, half over the next 16 h.
Adjust to urine output 0.5 mL/kg/h in adults (~30–50 mL/h), 1 mL/kg/h in children <30 kg.
Burn centers now often start lower (2 mL × kg × %TBSA in adults) to avoid over-resuscitation. Know Parkland for exams.
Adjust to urine output 0.5 mL/kg/h in adults (~30–50 mL/h), 1 mL/kg/h in children <30 kg.
Burn centers now often start lower (2 mL × kg × %TBSA in adults) to avoid over-resuscitation. Know Parkland for exams.
Example: 80 kg, 40% TBSA → 4 × 80 × 40 = 12,800 mL. First 8 h: 6,400 mL (800 mL/h).
Acute and rehab phases
- Fluid moves back (~48–72 h): diuresis, low K⁺.
- Infection is the main threat: strict asepsis; no plants or flowers.
- Wound care, debridement, grafts (keep graft immobile).
- High-calorie, high-protein diet; premedicate before dressing changes.
- Prevent contractures: positioning, splints, range of motion; pressure garments (~23 h/day) for scars; psychosocial support.
Special burns
- Electrical: damage is deeper than it looks: cardiac monitoring (dysrhythmias), muscle breakdown (dark urine: keep urine output higher), compartment syndrome.
- Chemical: brush off dry chemicals, then flush with large amounts of water.
- Circumferential burns: watch circulation and breathing (escharotomy).
- First aid: cool running water (not ice) ~20 min; remove jewelry and clothing; cover with clean dry cloth.