Rule of Nines Calculation for TBSA
The correct answer is C. 54% TBSA.
Calculation Breakdown
Using the standard Rule of Nines for adults, the burned areas calculate as follows:
- Entire right leg: 18% TBSA (9% anterior + 9% posterior) 1, 2
- Anterior thorax including abdomen: 18% TBSA (anterior trunk = 18%) 1, 2
- Both arms (entire surface): 18% TBSA (9% per arm × 2 arms, including both anterior and posterior surfaces) 1, 2
Total TBSA burned = 18% + 18% + 18% = 54%
Clinical Significance of This Burn Size
This patient requires immediate aggressive resuscitation and specialized burn center care. Burns exceeding 40% TBSA in adults are associated with significantly increased mortality and morbidity, even in highly specialized centers 3.
Critical Management Priorities
Fluid resuscitation must be initiated immediately using the Parkland formula: 2-4 mL/kg/%TBSA of balanced crystalloid solution (Ringer's Lactate preferred), with half given in the first 8 hours post-burn 2
For this 60-kg patient with 54% TBSA burns: Calculate 2-4 mL × 60 kg × 54% = 6,480-12,960 mL over 24 hours, with 3,240-6,480 mL in the first 8 hours 2
Target urine output of 0.5-1 mL/kg/hour (30-60 mL/hour for this patient) to guide ongoing fluid administration 2
Consider albumin administration after the first 6 hours to maintain serum albumin >30 g/L, as this patient's TBSA exceeds 30% 4
Airway Management Considerations
This patient does not require routine intubation based on burn distribution alone, as the burns do not involve the face or neck 4. However, intubation should be considered if any of the following develop:
- Symptoms of airway obstruction (voice changes, stridor, laryngeal dyspnea) 4
- Severe respiratory distress, hypoxia, or hypercapnia 4
- Evidence of smoke inhalation 4
Common Pitfalls to Avoid
- Do not delay fluid resuscitation, as every minute counts in preventing hypovolemic shock and organ failure 2
- Avoid "fluid creep" (excessive fluid administration beyond calculated needs), which leads to compartment syndrome and respiratory complications 2
- Monitor for compartment syndrome in the circumferentially burned right leg, which may require escharotomy 2
- Ensure immediate transfer to a burn center, as burns >10% TBSA in adults require specialized care 1, 2