A 28-year-old woman is brought to the emergency department 2 hours after sustaining a 40% total body surface area (TBSA) deep partial-thickness burn to her trunk and bilateral lower limbs from a kitchen fire. She is alert, breathing spontaneously at 24/min, and complaining of severe pain. Her blood pressure is 110/70 mmHg and heart rate is 118/min. What is the most appropriate immediate next step in management?

Explanation

## Immediate Management of Major Thermal Burns **Key Point:** In a patient with ≥20% TBSA burn (or ≥15% in children/elderly), fluid resuscitation must be initiated immediately using the Parkland formula to prevent burn shock and organ failure. ### Parkland Formula $$\text{Fluid requirement (mL)} = 4 \times \text{TBSA (\%)} \times \text{Body weight (kg)}$$ - **First half** administered over the first 8 hours from time of injury - **Second half** administered over the next 16 hours - Ringer's lactate is the fluid of choice (normal saline causes hyperchloremic acidosis) - Two large-bore IV cannulae are essential for rapid fluid delivery ### Why This Patient Needs Immediate Resuscitation | Finding | Significance | |---------|-------------| | 40% TBSA | Major burn; meets criteria for fluid resuscitation | | Deep partial-thickness | Third-degree involvement; massive fluid shift expected | | 2 hours post-injury | Still within the acute phase; resuscitation window critical | | HR 118, BP 110/70 | Early compensatory tachycardia; not yet in shock but at risk | **High-Yield:** The Parkland formula is the gold standard for initial fluid resuscitation in major burns. Delay in fluid resuscitation increases mortality from hypovolemic shock and acute kidney injury. **Clinical Pearl:** Fluid resuscitation should be titrated to maintain urine output of 0.5 mL/kg/hr in adults (goal: 200–300 mL/hr in this patient). However, the *first step* is to establish IV access and begin the calculated infusion immediately—monitoring and titration follow. ### Sequence of Immediate Actions ```mermaid flowchart TD A[Major burn ≥20% TBSA]:::outcome --> B[Establish 2 large-bore IV lines]:::action B --> C[Calculate Parkland formula]:::action C --> D[Infuse Ringer's lactate at calculated rate]:::action D --> E[Insert urinary catheter]:::action E --> F[Monitor urine output q1h]:::action F --> G{Urine output adequate?}:::decision G -->|Yes| H[Continue current rate]:::action G -->|No| I[Increase infusion rate]:::action A --> J[Analgesia, wound care, tetanus prophylaxis]:::action A --> K[Arrange burn centre transfer]:::action ``` **Mnemonic:** **FLUID** for burn resuscitation priorities: - **F**luids (Parkland formula, Ringer's lactate) - **L**arge-bore IV access (two cannulae) - **U**rine output monitoring (0.5 mL/kg/hr) - **I**nfusion titration (adjust based on response) - **D**ocumentation (time of injury, TBSA, fluid given) [cite:Park 26e Ch 9]