The ABCDE Approach
Acute burn — resuscitation priorities
A — AirwayAssess for inhalation injury; intubate early before oedema closes the airway (see Airway tab)
B — Breathing100% O₂; look for chest-wall restriction from circumferential burns → escharotomy; treat hypoxaemia
C — CirculationLarge-bore IV (through unburnt skin if possible); warmed crystalloid; treat hypovolaemia
D — DisabilityGCS; consider CO/cyanide & associated trauma/head injury as causes of altered sensorium
E — Exposure & EstimateRemove clothing/jewellery, estimate %TBSA, keep warm (huge evaporative loss), look for other injuries
Fluid Resuscitation — the Parkland Formula
Parkland (Baxter) formula
4 mL × body weight (kg) × %TBSA of Ringer's lactate in the first 24 hours — half in the first 8 hours from the time of the burn, the remaining half over the next 16 hours. Titrate, don't fix
🎯 The number that actually matters — urine output
- The formula is only an estimate of the starting rate. Titrate to a urine output of 0.5–1 mL/kg/h in adults and 1–1.5 mL/kg/h in children.
- Timing runs from the moment of injury, not from arrival — subtract fluid already given.
- Colloid is generally withheld for the first ~24 h (capillary leak); crystalloid is the mainstay early.
- Beware "fluid creep" / over-resuscitation → worsening oedema, abdominal & extremity compartment syndrome, pulmonary oedema.
- Add maintenance dextrose-containing fluid in children (limited glycogen reserve → hypoglycaemia).
Inhalation Injury, CO & Cyanide
Suspect inhalation injury if…
- Fire in an enclosed space, ↓ consciousness at scene
- Facial/neck burns, singed nasal hair, soot around mouth/nose
- Carbonaceous sputum, hoarse voice, stridor, wheeze
- Three components: upper-airway (thermal) oedema, lower-airway (chemical) injury, and systemic (CO/cyanide) toxicity
Carbon monoxide & cyanide
- CO: binds Hb with ~250× the affinity of O₂ → left-shifts the ODC → tissue hypoxia. SpO₂ is falsely normal (pulse oximeter reads COHb as O₂Hb) — measure COHb by co-oximetry / ABG.
- Treat CO with 100% O₂ — cuts the CO half-life from ~4–5 h (room air) to ~1 h; consider hyperbaric O₂ in severe cases.
- Cyanide (burning plastics) → histotoxic hypoxia, lactic acidosis, normal PaO₂ → antidote hydroxocobalamin (± sodium thiosulfate).
Common trap
A "normal SpO₂ of 99%" in a patient pulled from a house fire is reassuring but meaningless — the SpO₂ cannot see carboxyhaemoglobin. Trust the co-oximeter and the story, and give 100% O₂ regardless.
Circumferential Burns & Escharotomy
Deep circumferential full-thickness burns form a rigid, non-compliant eschar. Around a limb this acts as a tourniquet → distal ischaemia (loss of pulses, pain, pallor). Around the chest/abdomen it restricts ventilation → rising airway pressures and hypoxia. The treatment is an escharotomy — an incision through the full thickness of the eschar to release the constriction. Escharotomies are usually painless (insensate full-thickness skin) but need anaesthetic vigilance for bleeding and analgesia at the incision margins.