Burn Classification
Superficial (1st degree): erythema only, no blisters, painful (sunburn). Superficial partial-thickness (2nd degree): erythema, blisters, very painful, blanches. Deep partial-thickness: pale, less painful, does not blanch. Full-thickness (3rd degree): white/black/charred, painless (nerve damage), leathery. 4th degree: involves muscle, bone. Rule: burn is dynamic — may deepen over 24–48h.
TBSA Calculation
Rule of Nines: Head 9%, each arm 9%, each leg 18%, anterior trunk 18%, posterior trunk 18%, perineum 1%. Pediatric (Lund-Browder): head is larger (18% infants → 9% adults), legs smaller. Palmar method: patient's palm including fingers = 1% TBSA. Count only 2nd and 3rd degree burns. Exclude 1st degree.
Parkland Fluid Resuscitation
Formula: 4 mL × kg × %TBSA = total lactated Ringer's for first 24h. Half in first 8 hours from time of burn, half in next 16 hours. Goal urine output: adults 0.5 mL/kg/hr, children 1 mL/kg/hr. Example: 70 kg patient with 40% TBSA. 4 × 70 × 40 = 11,200 mL. 5,600 mL in first 8h, 5,600 mL in next 16h. Titrate to UO.
Emergent Management
Stop the burning: remove clothing, cool with water (not ice). Airway: assess for inhalation injury (singed nasal hairs, soot in mouth, carbonaceous sputum, voice changes). Early intubation if airway edema suspected. IV access: two large-bore, may need through burned skin. Pain control: IV opioids (IM absorption unreliable). Tetanus prophylaxis. NG tube: decompress (gastric ileus common). Foley catheter: monitor UO.
Complications
Inhalation injury: carbon monoxide poisoning (SpO2 falsely high — use co-oximetry), airway edema (intubate early), chemical tracheobronchitis. Sepsis: leading cause of death in burn patients — strict asepsis. Stress ulcers (Curling's): PPI prophylaxis. Compartment syndrome: escharotomy for circumferential full-thickness burns. Hypothermia: warm room, fluids. Renal failure: from myoglobinuria and hypovolemia.
Important Notes
- Inhalation injury: early intubation is safer than waiting — airway edema progresses rapidly and can become impossible to intubate.
- Carbon monoxide poisoning: SpO2 falsely elevated — use co-oximetry ABG. Treat with 100% O2; hyperbaric for severe cases.
Clinical Tips
- Parkland formula is a STARTING point — titrate fluids to urine output (0.5 mL/kg/hr adults). Over-resuscitation causes compartment syndrome and pulmonary edema.
Summary
Burn management requires accurate TBSA calculation, Parkland fluid resuscitation titrated to urine output, early airway management for inhalation injury, and prevention of complications like sepsis and compartment syndrome.
