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Burns — Parkland, Airway, Sux Cutoff
TEXTCrisis II · 9 min read
Parkland 4 mL/kg/%TBSA. Early intubation for inhalation injury. Sux contraindicated 24h-2yr post-burn. NMB resistance in chronic burn.
After this lesson you can
4 min read8 sections- Estimate TBSA + activate burn protocol.
- Calculate Parkland fluid requirements.
- Identify inhalation injury + early airway.
- Avoid sux 24 hr - 2 yr post-burn.
TBSA estimation + initial assessment
- head 9%
- each arm 9%
- each leg 18%
- anterior trunk 18%
- posterior trunk 18%
- perineum 1%
Pediatric Rule of Nines modified for proportionally larger head (18% age <1, scaling down with age).
Patient's palm = 1% TBSA for irregular burn estimation.
Count only 2nd-degree (partial thickness) + 3rd-degree (full thickness) burns — 1st degree (superficial, like sunburn) does NOT count toward Parkland.
Major burn = >20% TBSA adult or >10% TBSA pediatric/elderly resuscitation protocol activation.
Parkland fluid resuscitation
4 mL/kg/%TBSA of LACTATED RINGER'S over 24 hours — half (50%) in the first 8 hours from TIME OF INJURY (not arrival), half in the next 16 hours.Calculate from the time the burn occurred.
Titrate to urine output: adult 0.5-1.0 mL/kg/hr, pediatric (<30 kg) 1-2 mL/kg/hr.
- Brooke (3 mL/kg/%TBSA)
- restrictive Brooke (2 mL/kg/%TBSA)
- Galveston pediatric formula — modern trend is toward LESS fluid to reduce burn edema + compartment syndrome + ARDS
Albumin 12-24 hours post-injury in selected patients with persistent shock or massive burn.
Avoid over-resuscitation ('fluid creep') — leads to abdominal compartment syndrome.
Inhalation injury — early intubation
Suspect inhalation injury when patient has: enclosed-space fire, soot in oropharynx or sputum, singed nasal hair or facial hair, carbonaceous sputum, hoarseness or voice change, stridor, dyspnea, neurologic depression.
Upper airway edema progresses over HOURS — what looks like a mild airway at hour 1 can be totally obstructed at hour 6. EARLY DECISIVE AIRWAY MANAGEMENT before swelling makes intubation impossible.
Awake fiberoptic intubation if cooperative + time permits; otherwise GA induction with full readiness for surgical airway.
Bronchoscopy at intubation to assess + document injury depth.
Lower airway injury (thermal injury rare due to upper airway heat absorption; chemical injury from inhaled toxins, smoke particulates) ARDS over 24-48 hr.
CO + cyanide poisoning
CO binds Hb with 250× affinity over O₂ reduces O₂ carrying + shifts dissociation curve left (impairs tissue delivery).
Pulse oximeter reads NORMAL (it can't distinguish HbO₂ from HbCO) — measure CO-Hb directly with co-oximetry or pulse-CO-ox (Masimo Rad-57).
Treatment: 100% O₂ via non-rebreather (reduces CO half-life from 4-5 hr room air to ~75 min on 100%).
HYPERBARIC O₂ for severe poisoning (LOC, neurologic deficit, MI, pregnancy, COHb >25%) — reduces persistent neurocognitive sequelae.
CYANIDE poisoning (smoke inhalation, especially burning plastics, wool, polyurethane): cellular asphyxiant — blocks cytochrome oxidase.
Treatment: HYDROXOCOBALAMIN (Cyanokit) 5 g IV over 15 min — binds CN to form cyanocobalamin, renally excreted.
Don't wait for cyanide level; treat empirically when suspected.
Succinylcholine contraindicated 24 hr - 2 yr post-burn
AVOID sux from day 5-10 post-burn through wound healing — generally cited as 24 hours to 2 years post-burn (and longer in some patients with chronic wound).
SAFE within the first 24 hours (before receptor upregulation completes).
Use non-depolarizing NMBs (rocuronium most common).
- severe muscle trauma
- prolonged immobility/ICU
- denervation injury
- MS/stroke with motor weakness
- severe sepsis
- Duchenne MD
NMB resistance in chronic burn — opposite
Mechanism: upregulated extrajunctional receptor population (more receptors to block) + altered protein binding + increased clearance + altered Vd.
This is OPPOSITE to acute critical illness sensitivity.
TITRATE to TOF response, never to mg/kg.
Sugammadex still reverses rocuronium + vecuronium effectively regardless (binds to the drug, not the receptor).
Resistance persists 1-2 years post-healing in some patients.
Document the actual dose used to inform subsequent anesthetics.
Airway management for burn surgery
Facial burn patients: pre-emptively intubate if upper airway edema progressing; use uncut ETT (facial edema can prevent tape adhesion → secure to teeth with wire).
DLT for any thoracic surgery + escharotomy.
Cuff considerations: facial/neck burn may need over-the-top tube fixation; some burn ICUs use Anchor Fast or umbilical-tape ties.
Eye protection if face involved.
Difficult airway equipment ready (VL, bougie, surgical airway) — burn airway is the prototype for 'cannot delay' airway management.
Pain + nutrition + temperature management
Multimodal: high-dose opioids (often 2-5× normal doses), KETAMINE (workhorse — pre-dressing change bolus 1-2 mg/kg IM or 0.5-1 mg/kg IV; infusion in ICU), DEXMEDETOMIDINE, gabapentin scheduled, regional where anatomy permits (brachial plexus, lumbar plexus catheters).
Procedural sedation for dressing changes: ketamine + midazolam + opioid combination commonly used.
HYPERMETABOLIC state: glucose + protein + caloric requirements 1.5-2× baseline; aggressive enteral nutrition started early.
HYPOTHERMIA exacerbates everything — keep OR temperature 28-32°C, fluid warmers, under-body warmer (forced-air over open burn surfaces is harmful).
Glucose control: hyperglycemia common; insulin infusion targets.
⚠ Common pitfalls
- Delaying intubation for facial/airway burn — edema progresses over hours.
- Standard sux dose 24 hr - 2 yr post-burn — fatal hyperkalemia.
- Trusting normal SpO₂ in CO poisoning — falsely normal; cooximetry needed.
- Skipping cyanide treatment in smoke inhalation — hydroxocobalamin if suspected.
💎 Clinical pearls
- Parkland: 4 mL/kg/%TBSA LR over 24 hr, half in first 8 hr from INJURY time.
- Sux contraindicated 24 hr - 2 yr post-burn (receptor upregulation); rocuronium safe.
- CO half-life: room air 4-5 hr; 100% O₂ ~75 min; HBO ~25 min — treat aggressively.
- Cyanide: hydroxocobalamin 5 g IV over 15 min if smoke inhalation suspected (don't wait for level).
Recap
- Parkland: 4 mL/kg/%TBSA LR over 24 hr, half in first 8 hr from INJURY time.
- Sux contraindicated 24 hr - 2 yr post-burn (receptor upregulation); rocuronium safe.
- CO half-life: room air 4-5 hr; 100% O₂ ~75 min; HBO ~25 min — treat aggressively.
- Cyanide: hydroxocobalamin 5 g IV over 15 min if smoke inhalation suspected (don't wait for level).
Mark each section done to complete the module.