The stem
A 30-year-old man weighing 70 kg was burned in a house fire two hours ago. He has partial-thickness burns over the whole front of his trunk and the whole of his right arm, front and back.
Burns chart
| Region | Whole region | Front only |
|---|---|---|
| Head and neck | 9% | 4.5% |
| Each arm | 9% | 4.5% |
| Front of trunk | 18% | 18% |
| Back of trunk | 18% | – |
| Each leg | 18% | 9% |
| Perineum | 1% | 1% |
Rule of nines for adults. In children the head is proportionally larger.
The examiner’s questions
Question 1What percentage of his body surface is burned?Show the model answer
27%: the front of the trunk is 18% and the whole right arm is 9%. Only partial- and full-thickness burns are counted; simple redness (erythema) is not.
Question 2Calculate his fluid requirement with the Parkland formula.Show the model answer
4 mL × 70 kg × 27% = 7,560 mL of Hartmann’s solution in the first 24 hours from the time of the burn. Half, 3,780 mL, is given in the first 8 hours. Two hours have passed, so 3,780 mL is given over the next 6 hours (630 mL per hour), and the remaining 3,780 mL over the following 16 hours (about 236 mL per hour).
Question 3How do you know if the fluid is enough?Show the model answer
By urine output, aiming for about 0.5 mL per kg per hour in an adult, 35 mL per hour for him. The rate is adjusted to the output. Some protocols, including the current ATLS edition, start adults at 2 mL per kg per % burn and titrate in the same way.
Question 4What else concerns you after a house fire?Show the model answer
Inhalation injury: burns to the face, singed nasal hair, soot in the mouth, hoarse voice or stridor need early senior airway assessment. Carbon monoxide poisoning: check carboxyhaemoglobin. Circumferential burns may need escharotomy. A burn of this size needs referral to a burns unit.
After you answerThe teaching pointShow
The formula starts from the time of the burn, not the time of arrival. Fluid missed before arrival is made up within the first 8 hours.
The patients are written for teaching and are not real.