Burns

Example: Parkland Formula Calculation

Patient: Age 50 years; weight 75 kg

10% TBSA superficial (first degree)

50% TBSA partial and full thickness (2nd/3rd degree)

4 mL × 50% TBSA × 75 kg = 15 liters

Half is administered over the first 8 hours:Total volume: 15 L/2 = 7.5 L

Hourly rate: 7.5 L/8 hours = 940 mL/hour

Half is administered over the remaining 16 hours:Total volume: 7.5 L/16 hours

Hourly rate: 469 mL/hour

Adjustments to initial volume resuscitation should be based on the patient’s physiological response. Fluid adjustments should be made cautiously with the goal of gentle normalization of global perfusion and resuscitation parameters.

Over-resuscitation should be avoided as it has been shown to increase morbidity and mortality. Patients are at risk for compartment syndromes and over resuscitation even with close and appropriate following of the Parkland formula.

Normalization of lactate levels, base deficit, pH.
Urine output (0.5 mL/kg/hour).

Failure of initial resuscitation: Evaluate the patient for proper preload (intravascular volume).

Consider central venous access or advanced hemodynamic monitoring.
Evaluate the patient for proper myocardial contractility/cardiac output:
- Cardiac insufficiency has been observed following major thermal injuries and may persist for several months.
- Cardiac insufficiency should be addressed with the appropriate inotrope to support the abnormal physiological condition.

Evaluate the patient for proper peripheral vascular tone. Thermal injuries are associated with a significant systemic inflammatory response, which may result in decreased peripheral vascular tone. After ensuring appropriate intravascular volume (preload), peripheral vascular tone should be supported with an appropriate vasopressor (e.g., levophed). Decreased peripheral vascular tone should not be treated with volume since this may lead to over-resuscitation and increased morbidity and mortality.

Prevention of hypothermia: Depending on the size of injury, hypothermia can develop quickly. During initial evaluation all efforts should be made to prevent hypothermia.

Provide a warm surround environment in the emergency room.
Cover exposed surfaces with sterile clean dressings to prevent heat loss.
Prevent vascular compromise/compartment syndrome.

Prophylactic antibiotics are not indicated in the initial management of thermal injury.

Secondary assessment

The secondary assessment of a thermal injured patient should follow a systematic approach similar to that of a trauma patient. The thermal injuries should be evaluated and classified based on degree and extent of injury. A Lund and Browder chart can assist in the establishment of the extent and depth of thermal injury based on the body part affected.

First degree – superficial thermal injury
a. Extent of injury: one or more layers of the epidermis
b. Sensitivity: hyperalgesic
c. Appearance: erythema
d. Treatment: moisturizers and analgesics

Second degree – partial thickness thermal injury
a. Extent of injury: typically epidermis destroyed, dermis involved
b. Sensitivity: hyperalgesic
c. Appearance: blisters, pink, moist
d. Treatment: topical antibiotics and analgesics
e. A deep dermal injury may require excision and grafting

Third degree – full thickness thermal injury
a. Extent of injury: epidermis and dermis destroyed
b. Sensitivity: insensate
c. Appearance: opaque, white, black, leathery
d. Treatment: early excision and autografting

Fourth degree
a. Extent of injury: extends to the subcutaneous tissue, muscle/bone
b. Sensitivity: insensate
c. Appearance: disfiguring, black, leathery
d. Treatment: debridement, reconstruction, amputation

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