Major burn — cooling, TBSA, Parkland and escharotomy

(a) Cooling. Cool running water for 20 minutes, ideally within 3 hours of injury; continue in ED if incomplete prehospital. Stop or shorten if the patient becomes hypothermic — warm the rest of the body. Avoid ice; remove clothing and jewellery, leaving adherent material.^[1]

(b) TBSA. Rule of nines (adult): anterior trunk 18%, one upper limb 9%, face/head contribution if partial/full-thickness (up to 4.5% anterior face/head portion of the 9% head-neck unit — examine carefully). Only partial- and full-thickness burns count; pure erythema is excluded. A reasonable exam answer: anterior trunk 18% + RUL 9% + face (partial/full) ~4–5% → approximately 31–32% TBSA, refined by Lund-Browder if available.^[1]

(c) Fluid. Hartmann's (compound sodium lactate) from time of burn. Classic Parkland starts 4 mL/kg/%TBSA/24 h (ANZBA 3–4 range), half in the first 8 hours from burn time — but current ABA guidance recommends starting at 2 mL/kg/%TBSA and titrating to urine output, to curb fluid creep. Example at 4 mL and 32% TBSA: 80 × 4 × 32 = 10 240 mL/24 h → 5120 mL in first 8 h from burn (≈2560 mL at a 2 mL start). Subtract any prehospital fluid already given. Adult urine output target 0.5 mL/kg/h; titrate.^[3]

(d) Escharotomy. Circumferential full-thickness burn of the right upper limb risks progressive vascular compromise; circumferential chest/trunk can impair ventilation. Perform escharotomy through full-thickness eschar to viable tissue (mid-axial lines on limbs; bilateral anterior axillary lines + costal margin release on chest if needed) — the reliable, fast approach in critically burned patients — with analgesia, asepsis and haemorrhage control, before compartment syndrome is established.^[2]