• Emergency Medicine · Critical Care
Burns Management
Parkland Formula · Rule of Nines · Burn Depth · Fluid Resuscitation · Inhalation Injury · Escharotomy · Transfer Criteria
🔥 Burn Depth Classification
Superficial (1st°)
Epidermis only
Erythema, pain, dry
No blisters
Blanches with pressure
Heals 3–5 days
Not included in TBSA calculation
Partial Thickness (2nd°)
Epidermis + dermis
Superficial partial: Blisters, moist, painful, blanches → heals 14–21 days
Deep partial: White/red, fixed staining, decreased pain → may need grafting
Included in TBSA
Full Thickness (3rd/4th°)
All skin layers (±underlying)
Leathery, waxy, dry, painless
Does not blanch
Thrombosed vessels visible
4th°: muscle, bone involved
Requires skin grafting
💧 Parkland Formula — Fluid Resuscitation
4 × Weight (kg) × %TBSA
= mL Lactated Ringer's in 24 hours
First 8 hours: give ½ of total volume (from time of burn)
Next 16 hours: give remaining ½ of total volume
Only count 2nd° + 3rd° burns in TBSA; exclude 1st° burns
Use Lactated Ringer's — not normal saline, NOT dextrose
Titrate urine output: 0.5 mL/kg/h adults; 1 mL/kg/h children
Children: add maintenance glucose (D5LR) separately
Colloid (albumin 5%) may be added after 12–24h in large burns (>40% TBSA)
📐 Rule of Nines — %TBSA Estimation
Head & Neck9%
Chest (ant.)9%
Abdomen (ant.)9%
Upper back9%
Lower back9%
Each arm9%
Each thigh9%
Each lower leg9%
Perineum1%
Palmar method: Patient's palm + fingers ≈ 1% TBSA — useful for scattered burns
Children: use Lund-Browder chart (larger head %, smaller legs %)
💨 Inhalation Injury Assessment
Suspect if: facial burns, singed eyebrows/nasal hairs, hoarseness, stridor, carbonaceous sputum, burns in enclosed space
CO Poisoning: Send CO-oximetry (not pulse ox — falsely normal). COHb >25% → hyperbaric O₂ consider
High-flow O₂ 100% via NRB mask immediately; reduces CO half-life from 5h → 60–90 min
Early intubation: If stridor, hoarseness, progressive edema, or GCS ≤8 — airway edema can occlude within hours
Cyanide toxicity: co-expose in house fires (plastics); treat with hydroxocobalamin 5g IV
Bronchoscopy: confirms subglottic injury; guides prognosis
🏥 Wound Care & Escharotomy
Initial wound care: Cool with tepid water (15°C, 20 min); remove clothing/jewelry; cover with clean dressing
Do NOT use ice, butter, or toothpaste on burns
Topical agents: Silver sulfadiazine, mafenide acetate, silver-impregnated dressings
⚡ Escharotomy Indications
Circumferential full-thickness burn of limbs (compartment syndrome)
Circumferential chest burns (impaired ventilation)
Signs: absent pulses, paresthesias, pain with passive stretch, compartment pressure >30 mmHg
Fasciotomy if escharotomy insufficient
🚁 Transfer to Burns Centre Criteria (ABA)
Partial/full thickness >10% TBSA
Any full thickness burn
Burns of face, hands, feet, genitalia
Burns of major joints
Circumferential burns
Chemical / electrical burns
Inhalation injury
Burns + pre-existing illness
Burns + trauma (burn priority)
Pediatric / elderly patients
Stabilize airway + start Parkland fluids before transfer
⚠️ Critical Warnings
●No dextrose in first 24h — causes hyperglycemia and osmotic diuresis, masking true fluid status. Use Lactated Ringer's only.
●Pulse oximetry is unreliable in CO poisoning — SpO₂ reads falsely normal. Must use CO-oximetry (ABG co-ox panel) to detect COHb.
●Escharotomy must not be delayed — compartment syndrome from circumferential burn causes irreversible limb ischemia within 6 hours.
●Avoid over-resuscitation — "fluid creep" causes abdominal compartment syndrome, pulmonary edema, extremity edema. Target strict UO goals.
CCM Notes · FOAMed · Critical Care Clinical Reference
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Based on ABA Burn Centre Referral Criteria / ACS ATLS
Educational use only