Burns Emergency Care
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Direct answer
Burns emergency care stops the burning, secures an airway that may swell shut over hours, replaces the fluid weeping from burnt skin on a calculated schedule, and keeps the patient warm — hypothermia deepens coagulopathy. Depth decides healing and surface area drives volume: the rule of nines (or the patient's palm as roughly one per cent) sizes the burn, and the Parkland formula — 4 mL per kilogram per per cent of body surface area in 24 hours, half in the first 8 — sets Ringer lactate against the clock from the moment of injury, not from the moment of arrival. Any hint of an inhalation component, a face or circumferential burn, or an electrical or chemical mechanism changes the plan and usually the destination.
What you must remember
- Rule of nines, adult: head and neck 9, each upper limb 9, each lower limb 18, anterior trunk 18, posterior trunk 18, perineum 1; the patient's palm (fingers included) approximates 1 per cent for patchy burns.
- Parkland formula: 4 mL × weight (kg) × per cent TBSA of Ringer lactate over 24 hours from the burn time, half in the first 8 hours — recalculate against urine output, which is the true endpoint.
- Resuscitation targets: urine 0.5 mL/kg/hour in adults, 1-2 mL/kg/hour in children — falling output means the rate is behind; a child's head is relatively larger (about 18 per cent) and limbs smaller, and only partial and full-thickness areas count.
- Inhalation injury markers: singed facial hairs, carbonaceous sputum, hoarseness, stridor, soot, entrapment history — early intubation before the swelling, not after the stridor matures.
- Depth in one line: superficial blanches; superficial dermal blisters and is painful; deep dermal is mottled with sluggish refill; full-thickness is leathery and painless.
- Escharotomy triggers: circumferential full-thickness burns compromising limb perfusion or chest excursion — deep release incisions under analgesia.
- First aid and chemical specifics: 20 minutes of cool running water (not ice); chemical burns get copious irrigation; electrical burns carry visible and hidden contact wounds and a dysrhythmia risk on ECG.
- Referral is broad: burns over 10 per cent TBSA in adults, 5 in children; any burn of face, hands, feet, perineum or joints; inhalation, chemical, electrical and non-accidental patterns — all move to a burns-capable centre.
Sizing and running a 60-kg kitchen-fire patient
A 30-year-old sari catches fire at a stove; she arrives 45 minutes after the burn with blistered anterior trunk and both arms. Counting the surface: 18 per cent anterior trunk plus 9 and 9 for the arms gives 36 per cent partial thickness. The Parkland arithmetic: 4 × 60 × 36 = 8640 mL in 24 hours, and because the clock started at the stove, the remaining half of the first 8-hour volume — about 4300 mL over 7 hours 15 minutes — sets the rate now. A urinary catheter goes in: if she makes 20 mL in an hour at the calculated rate, the rate rises — the formula is a starting estimate that urine output continuously corrects. Her face has singed nasal hairs and her voice is hoarse — the airway decision is made early while the glottis is still visible, and she is intubated electively, not crash-intubated later. She is covered with dry sheets and warmed, rings cut off swollen fingers, both arms elevated and checked for circulation — a circumferential burn strangles a limb like a tourniquet.
How the exam frames it
The numerical trap leads: candidates who start the clock at ED arrival calculate a gently wrong rate — the formula runs from injury time. The second is depth-versus-area confusion: superficial erythema (sunburn-like) is excluded from TBSA counting, and a stem that includes it inflates the answer. Indian exam questions carry social gravity — stove and kerosene burns, firecracker injuries around Diwali, and the safeguarding question whenever a child's burn pattern does not fit the story. The viva asks why ice is forbidden (vasoconstriction, further injury) and why the first 8 hours matter most — capillary leak is fastest then.
Frequently asked questions
What is the Parkland formula and its clock?
4 mL × body weight in kg × per cent total body surface area of Ringer lactate over the first 24 hours, half within 8 hours — counted from the time of the burn, not hospital arrival.
How is burnt surface area estimated quickly?
The rule of nines for regions plus the patient's palm including fingers as about 1 per cent for scattered areas, counting only partial- and full-thickness burns.
What marks inhalation injury and what does it trigger?
Singed nasal hairs, carbonaceous sputum, hoarseness, soot and an entrapment history — prompting early elective intubation before airway oedema closes the window.
When is escharotomy indicated?
Circumferential full-thickness burns that compromise limb circulation or chest-wall expansion, releasing the leathery eschar along defined incision lines.
What urine output confirms adequate burn resuscitation?
About 0.5 mL/kg/hour in adults and 1-2 mL/kg/hour in children — the bedside endpoint that continuously corrects the calculated Parkland rate.