A 62year-old man is brought to the emergency department by helicopter 75 minutes after sustaining burns over 35-45% of his total body surface area in a warehouse fire. The paramedics report that the patient was trying to protect his coworkers from an isopropyl alcohol fire that took place at an auto parts warehouse. His pulse is 108/min, respirations are 26/min, and blood pressure is 148/78 mm Hg. The areas of burned skin are covered in a black/brown eschar, with the dermal layer visible in some areas.
Over the next 24 hours, which of the following is the first priority in management?
E) Intravenous fluid resuscitation
Immediate intravenous fluid resuscitation is the most crucial intervention for managing an adult patient with severe, full-thickness burns involving more than 20% of the total body surface area (TBSA). Significant burns can cause various complications, including compartment syndrome due to circumferential eschar formation, acute kidney injury, coagulopathies, and infections. However, the immediate priority within the first 24 hours is to replace the substantial fluid losses that occur immediately after a severe burn. The Parkland formula is commonly used to estimate fluid needs, which is based on the patient's weight in kilograms and the percentage of TBSA burned. According to this formula, 50% of the total fluid requirement is administered within the first 8 hours post-burn, with the remaining 50% given over the next 16 hours. Ongoing fluid resuscitation beyond the first 24 hours should be adjusted based on urine output, with a target of 0.5 to 1 mL/kg/hr. Subsequent management should include temporary wound coverage, nutritional support, pain management, and prevention and management of complications like compartment syndrome and infections.
Answer Choice A: Administration of tetanus toxoid vaccine, is incorrect. Tetanus toxoid administration is important for burn patients with non-superficial burns who need their tetanus vaccine status updated, but it is less critical than immediate fluid resuscitation in severely burned patients.
Answer Choice B: Broad-spectrum antibiotic therapy, is incorrect. Prophylactic broad-spectrum antibiotics are not recommended for severe burn patients. Although many of these patients may develop infections during their treatment and recovery, using broad-spectrum antibiotics without confirmed or suspected infection does not improve outcomes.
Answer Choice C: Excision and grafting, is incorrect. Excision and grafting may be performed within the first 24 to 72 hours using various techniques but are not the initial priority in patients with severe burns.
Answer Choice D: Hyperbaric oxygen therapy, is incorrect. Hyperbaric oxygen therapy has not been shown to improve outcomes in acute burn management, although it may be used later for compromised skin grafts. Its primary use is in treating carbon monoxide poisoning and decompression sickness.
Key Learning Point
Severe burns result in significant fluid loss, potentially leading to multi-organ dysfunction or death if not aggressively managed within the first 24 hours. The Parkland formula, calculated using the total body surface area (TBSA) burned and the patient's weight, is frequently employed to estimate fluid requirements in the first 24 hours.
