Question

Case 2-125 yr-old male arrives with second and third degree burns to his posterior head and face, entire trunk and anterior arms. He has a black, charred looking substance around his mouth and nose. He is conscious and responding appropriately. Paramedics were able to get a large-bore IV enroute. Vitals: BP (unable to obtain due to the burns); respiratory rate=40/min; heart rate=155; pulse oximetry=93% on room air; Weight=195 lbs

1.Using the “Rule of nines” calculate the body surface area of this patient that is burned.

2.Using the answer you calculated from above and the “Parkland Formula” for burn fluid resuscitation, calculate the total fluid he should be given over the next 24 hours (in ml). [Include total fluid, breakdown of fluid and the rates at which they would be given.]

3.Consider the fact that this patient has burns to his face. What are you most worried about regarding this?

4.What might indicate that the (answer to #3) needs to be addressed? (What might you see, hear, feel etc?)

5.What is the appropriate management for this (refer to the answer for #3 and #4). Be very specific. What would you do for this particular patient (think both in terms of fluid resuscitation and other things)?

6.What would be an indication that you have adequately replaced the fluid lost?

Answer 1

1.Rule of nine which is also known as Wallace rule of nine discovered by Dr.Alexander Wallace.This is a method for identifying the total body surface area who have burns.Mainly it is uesd in second degree/partial thickness burns and in third degree/full thickness burns.Identifying total body surface area is very necessary for the further management of patients with burns .

In rule of nine,each body parts were calculated as particular percentage of burns.i.e

BODY PARTS. PERCENTAGE

Head 9%

Arms    9%

Anterior Trunk 18%

Posterior trunk 18%

Legs      18%

So in this patient,

Posterior head and face=9%

Entire trunk=18+18=36%

Anterior arms=9%

So when we add all these amount we get the total body surface area burned

i.e.9%+36%+9%=54%

Total surface area burned=56%

2.parkland formula which is also known as baxter formula is used to calculate the fluid replacement to be done in patients with burns.As they are in high risk for fliud deficit it is necessary to replace the fluid in body to prevent hypovolemuc shock.

According to parkland formula:

Amount of fluid=4ml*%of body surface area*weight of the patient

First step is to found the weight of patient in kg.For that divide the weight in pounds by 2.2

Here weight is 195pounds.so to convert it to kilogram,

195/2.2=88.6kgi.e calculate as 89kg

So total volume to infuse=4*56*89=19,936ml

Mostly Ringer lactate is the solution used for fluid replacement.

The first half of the fluid is givem over 8hrs and next half of fluid is given in the next 18hrs.

Here,for first 8hours amount of fluid infused is 19,936/2=9,968ml

And the rate per hour=9968/8=1246ml per hour (for first 8hours)

Rate of fluid per hour for next 18hrs=9968/18=553.7=554ml per hour

3.The most and probable fact to be consider is to clear the airway.As the patient having burns in face and head there is high risk for obstruction of airway .As per Maslows hierarchy need ,airway is the first priority which is to be given in these kind of patients.

4.It is necessary to assess the airway , presence of any obstruction,respiratory rate,saturation,level of consciousness e.t.c.Here in this case patient has black charred looking substance around his mouth and nose.so the chances of blockage of airway is high.So we need to monitor respiratory status of the patient.Also we need to minitor the blood pressure and fluid volume of patient.Urine output also need to monitor.

5.The appropriate management for these patient is to clear the airway,do suctioning,monitoring of vital signs,replacement of fluid,clean the wound with sterile solution,continous monitoring of patient,prepare all the emergency equipment near the patient bedside .

6.The blood pressure maintains a normal level if adequate amount of fluid replaced.Also the amount of urine per hour should be greater than 30ml per hour.