Burn Resuscitation With a Tight Chest Eschar
A 34-year-old man, 80 kg, is brought in 25 minutes after a house fire. He has deep partial- and full-thickness burns over the anterior trunk, both arms, and the right leg. Using the rule of nines, the burn team estimates 45% total body surface area. He has singed nasal hairs, hoarseness, soot in the oropharynx, and a carboxyhemoglobin level of 28%. HR 130, BP 90/60, RR 28, SpO2 96% on 15 L nonrebreather. He is awake but agitated. A chest eschar is tight and leathery. The receiving burn center is 2 hours away by ground and has one ICU bed.
1. Calculate and describe the initial fluid resuscitation plan, including how you will titrate it and what pitfalls you will watch for.
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Parkland formula: 4 mL x 80 kg x 45% = 14,400 mL in 24 hours. Give half, 7,200 mL, in the first 8 hours from the time of injury, not from emergency department arrival. Since 25 minutes have already passed, give the first 8-hour portion over about 7.5 hours. Give the remaining 7,200 mL over 16 hours. Start Lactated Ringer's and titrate to urine output of 0.5 to 1 mL/kg/h in adults, not to the formula alone.
Inhalation injury and delayed resuscitation can increase fluid needs, but over-resuscitation worsens edema and compartment pressure. Reassess every hour: urine output, BP, HR, mental status, breathing, and signs of abdominal or extremity compartment syndrome. If urine output falls, increase the rate; if pulmonary edema or worsening oxygenation develops, reduce the rate and reassess. Do not give colloid for initial resuscitation, and document the time of injury because it drives the schedule.
2. How would you manage the airway, carbon monoxide exposure, and the tight chest eschar before transfer?
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Give 100% oxygen by nonrebreather. Do not rely on SpO2 alone because carboxyhemoglobin can falsely normalize the reading. Hoarseness, soot, agitation, and singed nasal hairs suggest inhalation injury and impending airway edema; prepare for early intubation with a large-bore tube and anticipate a difficult airway. High-flow oxygen shortens carbon monoxide half-life. Consider hyperbaric consultation for carboxyhemoglobin 28% with neurologic symptoms, but do not delay transfer if transport is already arranged.
If cyanide exposure from an enclosed-space fire is suspected, give hydroxocobalamin. The tight chest eschar can impair ventilation; perform escharotomy if chest wall compliance is reduced or oxygenation deteriorates. Secure the airway and start fluids before ground transfer. Request critical care transport and communicate the airway risk, burn size, and escharotomy status to the burn center.