## Immediate Management of Moderate-to-Severe Burns **Key Point:** In a 40% TBSA burn (moderate-to-severe), the priority is fluid resuscitation to prevent hypovolemic shock and acute kidney injury. The Parkland formula is the gold standard for calculating fluid requirements in the first 24 hours. ### Parkland Formula $$\text{Fluid (mL)} = 4 \times \text{TBSA (\%)} \times \text{Body weight (kg)}$$ - Half administered in first 8 hours from time of injury - Remaining half over next 16 hours - Titrate to maintain urine output: 0.5 mL/kg/hr (adults), 1 mL/kg/hr (children) **High-Yield:** This patient's current urine output (0.3 mL/kg/hr) is inadequate, indicating underfilling. His hypotension (95/60) and tachycardia (120/min) are signs of early hypovolemic shock. ### Why Parkland + Urinary Catheter Is Correct | Step | Rationale | | --- | --- | | IV fluid resuscitation | Prevents burn shock, organ failure, and death in first 24–48 hours | | Urinary catheter | Allows accurate real-time monitoring of urine output to titrate fluids | | Timing | Must begin immediately; delay increases mortality | **Clinical Pearl:** The "golden period" for fluid resuscitation is the first 24–48 hours post-burn. Inadequate resuscitation leads to acute kidney injury, sepsis, and multi-organ failure. ### Secondary Steps (Not Immediate) - Escharotomy: performed only if circumferential burns restrict chest wall movement or limb perfusion (not indicated yet in this patient) - Topical antibiotics: applied after initial resuscitation and wound assessment - Skin grafting: performed after wound stabilization (days 3–7), not acutely - Antibiotics: prophylactic antibiotics are NOT routine; reserved for specific indications **Mnemonic: BURN (Immediate priorities)** — **B**lood pressure support (fluids), **U**rine output monitoring (catheter), **R**esuscitation (Parkland), **N**o delay (start immediately)
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