Burns and Wound Management
4 mL/kg/%
Parkland Formula
Half in first 8 hours from burn time
9
Rule of Nines
BSA estimation method
#1
Inhalation Injury
Cause of death in burn patients
Parkland Formula and Fluid Resuscitation
The Parkland formula calculates 24-hour fluid needs as 4 mL times body weight (kg) times percent BSA burned. Half of the total volume is given in the first 8 hours from the time of burn. The remaining half is given over the next 16 hours. Urine output (0.5-1 mL/kg/hr in adults) guides titration.
Parkland timing starts from TIME OF BURN, not hospital arrival. If the patient arrives late, compress the remaining first-half volume into the time remaining.
Inhalation Injury and Burn Classification
Inhalation injury is the leading cause of death in burn patients. Indicators include singed nasal or facial hair, carbonaceous sputum, hoarseness, stridor, and facial or oropharyngeal burns. Early elective intubation is critical because progressive edema can make later intubation impossible.
Superficial
Red, painful, no blisters, blanches
Partial Thickness
Blistered, weeping, painful, blanches
Full Thickness
White or charred, painless, does not blanch
Key Values to Memorize
Parkland = 4 mL/kg/%BSA
Half in first 8 hrs
UOP 0.5-1 mL/kg/hr
Rule of Nines for BSA
Circumferential = escharotomy
Fluid shift reverses at 48-72h
burn resuscitation math is a CCRN staple
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Practice CCRN QuestionsExam Traps
Parkland timing starts from TIME OF BURN, not hospital arrival
Half the calculated volume must be infused in the first 8 hours from the time of injury. If the patient arrives 3 hours after the burn, you only have 5 hours to deliver that first half. The exam will give you an arrival time that differs from injury time to test this concept.
Inhalation injury means intubate early, before edema makes it impossible
Signs of inhalation injury include singed nasal hairs, facial burns, soot in sputum, hoarseness, and stridor. Airway edema can progress rapidly to complete obstruction. By the time stridor appears, the window for safe intubation is closing. Early intubation is prophylactic, not reactive.
Circumferential burns may require escharotomy
A full-thickness circumferential burn on an extremity or the chest creates a rigid, inelastic eschar. As tissues swell underneath, compartment syndrome develops in extremities and ventilatory restriction develops with chest burns. Escharotomy (incision through the eschar) releases the pressure.
Fluid shift phases change management drastically
The first 24-48 hours is the resuscitation phase with massive capillary leak and third-spacing. After 48-72 hours, fluid remobilizes back into the vascular space. The patient who was hypovolemic is now at risk for fluid overload and pulmonary edema. Management must shift accordingly.
Parkland Clock
The Parkland clock starts at BURN TIME, not hospital time. Half the volume in the first 8 hours from injury. Adjust for late arrivals.
Airway First Always
Singed nasal hairs, soot, hoarseness, facial burns = intubate NOW. Waiting for stridor means waiting too long.
The burn damage makes all the blood vessels leaky. Fluid pours out of the vascular space into the tissues (third-spacing). The patient is swelling visibly. The vascular pipes are running dry. You must pour fluid in (Parkland formula) to keep the pipes from collapsing.
The leaky pipes start to seal. All that fluid that leaked into the tissues now starts returning to the vascular space. Suddenly the pipes are overfull. The patient who desperately needed fluid 24 hours ago is now at risk for pulmonary edema and heart failure.
Inhalation injury is like a fire inside the pipes of the lungs. The tissue swells, the airway narrows, and within hours it can swell shut completely. Once shut, you cannot force a tube through. That is why early intubation saves lives.
A circumferential full-thickness burn is like a concrete cast around a limb. As the tissues swell inside, the cast does not stretch. Pressure builds until blood flow stops. Escharotomy cuts through the cast to release the pressure.
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