烧伤：Parkland公式与中性粒细胞减少性发热

🧠 为什么重要

烧伤深度分为：浅表烧伤（发红、疼痛、无水疱）、部分厚度烧伤（有水疱、潮湿、非常疼痛）和全层烧伤（白色、皮革样或焦黑、中心无痛）。成人面积估算用九分法（RULE OF NINES）：头部9%，每条手臂9%，每条腿18%，躯干前面18%，躯干后面18%，会阴1%。PARKLAND公式：4 mL × kg × 烧伤总面积百分比的乳酸Ringer's液在24小时内输入，其中一半在受伤后的最初8小时内输入，其余在接下来的16小时内输入；滴定至尿量至少0.5 mL/kg/hr（约30 mL/hr），电烧伤伴深色尿时目标更高。许多烧伤中心现在对成人从2 mL × kg × %TBSA起步，并根据尿量调整，但考试仍按Parkland公式教学。急诊期（EMERGENT，最初24至48小时）会出现低血容量、细胞损伤引起的高钾血症（HYPERKALEMIA）和低钠血症；急性期（ACUTE）则会出现利尿、低钾血症和感染风险。出现面部烧伤、鼻毛烧焦、痰中带烟灰、声音嘶哑或喘鸣时，要怀疑吸入性（INHALATION）损伤，并准备尽早插管；一氧化碳中毒时给予100%氧气。环形烧伤需要进行焦痂切开评估以检查血液循环。止痛药经IV给药，绝不经IM给药，因为IM吸收不可靠。中性粒细胞减少预防措施（NEUTROPENIC PRECAUTIONS）适用于接受化疗且绝对中性粒细胞计数低于约1,000的患者（按机构规定）：单人病房、严格手卫生、不放鲜花或植物、按规定不吃生的或未煮熟的食物、不测肛温、不用栓剂、避免人群和生病的访客，并将38.0 °C（100.4 °F）或更高的体温视为急症（EMERGENCY），需要在一小时内做培养并使用抗生素。血小板减少（THROMBOCYTOPENIA）：当血小板降至约50,000以下时，采取出血预防措施：使用软毛牙刷、电动剃须刀，并尽可能避免注射。

BURN depth: superficial (red, painful, no blisters), partial thickness (blisters, moist, very painful) and full thickness (white, leathery or charred, painless at the center). Estimate area with the RULE OF NINES in adults: head 9%, each arm 9%, each leg 18%, anterior trunk 18%, posterior trunk 18%, perineum 1%. PARKLAND FORMULA: 4 mL × kg × % total body surface area of lactated Ringer's over 24 hours, half in the first 8 hours FROM THE TIME OF INJURY and the rest over the next 16; titrate to a urine output of at least 0.5 mL/kg/hr (about 30 mL/hr), higher with electrical burns and dark urine. Many burn centers now start adults at 2 mL × kg × %TBSA and adjust to urine output, but the exam still teaches Parkland. The EMERGENT phase (first 24 to 48 hours) brings hypovolemia, HYPERKALEMIA from cell damage and hyponatremia; the ACUTE phase brings diuresis, hypokalemia and infection risk. Suspect INHALATION injury with facial burns, singed nasal hair, soot in the sputum, hoarseness or stridor, and prepare for early intubation; give 100% oxygen for carbon monoxide. Circumferential burns need escharotomy checks for circulation. Pain medication is given IV, never IM, because absorption is unreliable. NEUTROPENIC PRECAUTIONS for chemotherapy clients with an absolute neutrophil count below about 1,000 (per facility policy): private room, meticulous hand hygiene, no fresh flowers or plants, no raw or undercooked foods per policy, no rectal temperatures or suppositories, avoid crowds and sick visitors, and treat any temperature of 38.0 °C (100.4 °F) or higher as an EMERGENCY requiring cultures and antibiotics within an hour. THROMBOCYTOPENIA: once platelets fall under about 50,000, use bleeding precautions: a soft toothbrush, an electric razor and no injections where possible.

🏥 真实场景

🧮 这名70 kg、烧伤面积40%的患者于1400烧伤，1600到达。Parkland公式：4 × 70 × 40 = 11,200 mL。一半即5,600 mL要在2200前输入，也就是烧伤后八小时，只剩下六小时来输完。护士把输液泵调到更快的速度，并密切观察尿量。考试的陷阱就是从到达时间开始计时。

🧮 The 70 kg client with 40% burns was burned at 1400 and arrives at 1600. Parkland: 4 × 70 × 40 = 11,200 mL. Half, 5,600 mL, is due by 2200, eight hours after the burn, which leaves only six hours to give it. The nurse sets the pump for the faster rate and watches the urine output. The exam's trap is starting the clock at arrival.

📌 要点总结

• 九分法：头部9，每条手臂9，每条腿18，躯干前面18、后面18Rule of nines: head 9, arms 9 each, legs 18 each, trunk 18 front and 18 back
• Parkland公式：4 mL × kg × %TBSA；前一半在受伤后8小时内输入；滴定至尿量至少0.5 mL/kg/hrParkland: 4 mL × kg × %TBSA; first half in 8 hours from injury; titrate to urine output of at least 0.5 mL/kg/hr
• 中性粒细胞减少：不放鲜花，不测肛温，体温达38 °C时需在一小时内使用抗生素Neutropenia: no flowers, no rectal temps, fever of 38 °C needs antibiotics within an hour

✅ 自我测试