Burns Management: Wallace Rule of Nines, Parkland Formula & Care

**1. Depth of Burn Injury** * **First-Degree (Superficial)**: Involves epidermis only (e.g., sunburn). Erythematous, painful, dry, no blisters; heals within 3–6 days without scarring. * **Second-Degree (Partial-Thickness)**: - *Superficial Partial-Thickness*: Involves papillary dermis; red, weeping, exquisitely painful with thin-walled intact blisters; heals within 2 weeks with minimal scarring. - *Deep Partial-Thickness*: Extends into reticular dermis; mottled pale ivory, diminished sensation; requires excision and skin grafting. * **Third-Degree (Full-Thickness)**: Complete destruction of epidermis, entire dermis, and adnexa; leathery, white, charred, dry, completely anesthetic (painless to pinprick); requires surgical debridement and grafting. * **Fourth-Degree**: Extends through deep fascia into underlying muscle, tendon, and bone. **2. Estimation of Total Body Surface Area (TBSA)** * **Wallace Rule of Nines (Adults)**: - Head and Neck: 9% - Each Upper Limb: 9% (anterior 4.5%, posterior 4.5%) - Anterior Trunk: 18% (chest 9%, abdomen 9%) - Posterior Trunk: 18% (upper back 9%, lower back 9%) - Each Lower Limb: 18% (anterior 9%, posterior 9%) - Perineum & Genitalia: 1% * **Lund and Browder Chart**: Preferred in pediatric patients to adjust for larger relative head proportion and smaller lower extremities. * **Palmar Surface Rule**: Patient's palm including fingers corresponds to approximately 1% TBSA. **3. 🔬 Fluid Resuscitation: The Parkland (Baxter) Formula** Major burn injury (>20% TBSA in adults, >10% in children) triggers systemic capillary leak, massive plasma extravasation, and hypovolemic burn shock. * **Parkland Formula**: $$\text{Total 24-Hour Fluid (Ringer's Lactate)} = 4 \text{ mL} \times \text{Weight (kg)} \times \% \text{TBSA Burn}$$ * **Fluid Infusion Schedule**: - **First 8 Hours**: Administer **50% (half)** of the calculated volume, calculated from the *time of injury* (NOT time of hospital admission). - **Next 16 Hours**: Administer the remaining **50% (half)** of the calculated volume. * **Fluid of Choice**: **Ringer's Lactate (Hartmann's solution)**. Avoid normal saline due to risk of hyperchloremic metabolic acidosis. * **Monitoring Resuscitation Adequacy**: **Urine Output** is the single best clinical guide: - *Adult Target*: 0.5 to 1.0 mL/kg/hour (approx 30–50 mL/h). - *Child Target*: 1.0 to 1.5 mL/kg/hour. - *Electrical Burn / Hemochromogenuria Target*: 1.5 to 2.0 mL/kg/hour (aim to prevent myoglobin-induced renal tubular obstruction). **4. 📖 Standard Textbook Reference** * *Bailey & Love's Short Practice of Surgery*, 28th Ed., Ch. 5: Burns and Trauma, pp. 62–78. * *Sabiston Textbook of Surgery*, 21st Ed., Ch. 19: Burns, pp. 495–518.