When to intubate in GCS?

GCS ≤ 8 requires intubation for airway protection. The patient cannot protect their own airway at this level of consciousness. Motor score is the most prognostically important component.

What is the best initial fluid for sepsis resuscitation?

Lactated Ringer's (LR) is the preferred resuscitation fluid. The SMART trial (2018) showed balanced crystalloids reduced death, new renal failure, and persistent renal dysfunction compared to normal saline.

When to start vasopressors in septic shock?

Start norepinephrine (first-line vasopressor) if MAP remains < 65 mmHg after initial 30 mL/kg crystalloid resuscitation, or earlier if patient is profoundly hypotensive. Do not delay pressors to complete full fluid resuscitation.

Why can serum uric acid be normal during acute gout?

During acute inflammation, IL-6 increases renal urate excretion and redistributes urate from plasma to tissues. Up to 40% of acute gout flares have normal serum uric acid. Joint aspiration with polarized microscopy is needed for definitive diagnosis.

How do you distinguish lupus flare from infection in SLE?

Key clues: CRP is low/normal in flare but elevated in infection. Complement (C3/C4) drops in flare but is normal/elevated in infection. Procalcitonin is elevated in bacterial infection but normal in flare. Anti-dsDNA rises in flare, stable in infection.

What is the difference between DKA and HHS?

DKA features acidosis (pH 600), hyperosmolality (> 320), and minimal ketosis -typically in Type 2 DM. DKA requires insulin drip; HHS requires aggressive fluid resuscitation first.

When to give tPA in acute ischemic stroke?

IV alteplase (tPA) can be given within 4.5 hours of last known well time in eligible patients. CT head must rule out hemorrhage first. For large vessel occlusion, mechanical thrombectomy can be performed up to 24 hours with favorable imaging.

What antibiotics for community-acquired pneumonia?

Inpatient non-ICU: ceftriaxone + azithromycin. ICU: ceftriaxone + azithromycin (add vancomycin if MRSA risk). Outpatient healthy: amoxicillin. Outpatient with comorbidities: augmentin + azithromycin or respiratory fluoroquinolone. Duration: 5 days if clinically stable for 48 hours.

How to interpret iron studies?

Iron deficiency: low ferritin (< 30), high TIBC, low iron, low transferrin saturation (< 20%). Anemia of chronic disease: normal/high ferritin (acute phase reactant), low TIBC, low iron. A ferritin of 50-100 in an inflamed patient may still represent iron deficiency.

What is the correction rate for hyponatremia?

Correct sodium no more than 8 mEq/L in 24 hours to avoid osmotic demyelination syndrome (ODS). For symptomatic severe hyponatremia with seizures, give 3% hypertonic saline 100-150 mL bolus over 10-20 minutes. If overcorrected, use D5W + DDAVP rescue protocol.

When to start antibiotics in meningitis?

Within 30-60 minutes. Do NOT delay antibiotics for LP or CT. Draw blood cultures, start empiric antibiotics (vancomycin + ceftriaxone ± ampicillin if > 50 or immunocompromised), then perform LP when possible. Dexamethasone should be given before or with the first antibiotic dose.

DOACs vs warfarin in antiphospholipid syndrome?

DOACs are contraindicated in APS. The TRAPS trial (2018) showed rivaroxaban was inferior to warfarin with more thrombotic events in triple-positive APS patients. Warfarin with INR target 2-3 is the standard for APS, indefinitely.

How to manage scleroderma renal crisis?

ACE inhibitors (captopril) are life-saving -start immediately and titrate aggressively. Do NOT hold for rising creatinine. Steroids > 15 mg prednisone per day precipitate scleroderma renal crisis. ARBs are NOT a substitute -evidence is only for ACEi.

What are the 4 pillars of heart failure treatment?

Guideline-directed medical therapy (GDMT) for HFrEF: (1) ARNI or ACEi/ARB, (2) beta-blocker (carvedilol, metoprolol succinate, or bisoprolol), (3) MRA (spironolactone or eplerenone), (4) SGLT2 inhibitor (dapagliflozin or empagliflozin). All four should be initiated and titrated to target doses.

RoundsRx

Dashboard

Overview

Recent

Rotations

Quick Reference

Antibiotic Guide Analgesia Guide Sedation Guide Bowel Regimen Electrolyte Replacement Pain Management & Conversions Drug Interactions Anticoag Reversal IV Fluid Guide Inotropes Guide Vasopressors Insulin Guide Code Blue & Rapid Response Procedures Guide ECG Interpretation Lab Interpretation Radiology Quick Ref GCS Pocket Card Admission Orders & I-PASS Landmark Trials

Tools

💎 Clinical Pearls 🧠 Pimp Me Quiz 🧮 Clinical Calculators 📰 What's New 🎓 Intern Survival Guide ✅ Rounding Checklists 🩺 Procedure Guides ⚡ Electrolyte Replacement 💧 IV Fluids Guide 🩸 Transfusion Guide 💓 ECG Pattern Guide 🧪 Lab Interpretation Guide 📱 QR Poster 🔗 Resources 🎙️ Channels & Podcasts 🎮 Medical Games 🏛️ Famous Cases 🎬 Media Library

ℹ️ About

Available offline

EmergentEM

Burns Management

Rule of 9s for BSA estimation. Parkland formula for fluid resuscitation (4 mL × kg × %BSA burned). Major burns: ≥ 20% BSA, inhalation injury, circumferential, face/hands/genitals. Early intubation if airway concern.

🔍 Overview

Burn Classification

Depth	Appearance	Sensation	Healing
Superficial (1st)	Red, dry, no blisters (sunburn)	Painful	3–5 days, no scarring
Partial thickness (2nd)	Blisters, moist, pink/red	Very painful	Superficial: 2–3 wks. Deep: 3–8 wks, may need grafting
Full thickness (3rd)	White/brown/black, leathery, dry	Painless (nerves destroyed)	Requires excision and grafting
4th degree	Extends to muscle, bone, tendon	Painless	Amputation may be required

Rule of 9s (Adult BSA)

Head: 9%
Each arm: 9%
Anterior trunk: 18%
Posterior trunk: 18%
Each leg: 18%
Perineum: 1%
Patient's palm ≈ 1% BSA

Inhalation injury clues: singed nasal/facial hair, carbonaceous sputum, stridor, hoarseness, facial burns. Intubate early -airway edema worsens over hours. Once obstructed, intubation becomes impossible.

Electrical Burns

Type	Mechanism	Key Concerns
Low voltage (<1000V)	Household current	Can cause cardiac arrhythmias (VFib). Get ECG. Monitor 24h if abnormal.
High voltage (>1000V)	Severe deep tissue injury along current path	Damage often far worse than skin appearance. Rhabdomyolysis common → check CK, urine myoglobin, aggressive IVF for renal protection. Compartment syndrome risk → fasciotomy may be needed. Entry and exit wounds.
Lightning	Cardiac arrest (asystole), neurologic injury	Tympanic membrane rupture, cataracts. "Reverse triage" -treat those who appear dead first (cardiac arrest is often reversible with lightning).

Chemical Burns

Alkali burns (lye, cement, drain cleaner): MORE dangerous than acid. Cause liquefactive necrosis → deeper penetration. Irrigate with water for 30+ minutes.
Acid burns: Coagulative necrosis → self-limiting depth. Irrigate with water.
Hydrofluoric acid (HF): Uniquely dangerous. Fluoride binds calcium → hypocalcemia, fatal arrhythmias. Treat with topical calcium gluconate gel. IV calcium if systemic toxicity. Can be fatal even with small burns.
Key point: IRRIGATE first, remove contaminated clothing. Do NOT try to neutralize (exothermic reaction → more damage).

Burn Center Transfer Criteria: ≥20% BSA partial/full thickness, full thickness >5% BSA, face/hands/feet/genitals/perineum/major joints, electrical burns (including lightning), chemical burns with threat of cosmetic/functional impairment, inhalation injury, circumferential burns, pre-existing conditions complicating management, children (if facility lacks pediatric capability).

🚨 Management

Parkland Formula (First 24h)

4 mL × body weight (kg) × %BSA burned = total LR in 24h. Give half in first 8 hours (from time of burn, not arrival), second half over next 16 hours. Only count 2nd/3rd degree burns. Titrate to urine output 0.5–1 mL/kg/hr (adults).

Key Interventions

Airway -early intubation if inhalation injury suspected. Do NOT wait for desaturation.
Escharotomy -circumferential full-thickness burns → compartment syndrome. Limb: loss of pulse. Chest: restricted ventilation. Emergent bedside incision through eschar.
Tetanus prophylaxis
Pain control -IV opioids (burns are extremely painful)
Wound care -gentle debridement, topical antimicrobials
Transfer to burn center -≥ 20% BSA, full thickness > 5%, face/hands/feet/genitals, inhalation, electrical/chemical, children

📋 Case 1, Major Thermal Burn with Inhalation Injury

Patient: 25M pulled from house fire. Singed nasal hair, carbonaceous sputum, stridor. 35% BSA partial thickness burns.

Action:

Intubate NOW -do not wait for desaturation. Stridor + singed hair + carbonaceous sputum = inhalation injury. Airway edema will worsen rapidly.
Parkland formula: 4 × 80kg × 35% = 11,200 mL LR in 24h. Give 5,600 mL in first 8h (from time of burn).
Target UOP: 0.5–1 mL/kg/hr.
Check COHb, obtain CXR, tetanus prophylaxis, IV morphine for pain.

📋 Case 2, Electrical Burn with Rhabdomyolysis

Patient: Electrician, 220V shock to right hand, exit wound left foot. Skin burns appear small. CK 15,000. Dark urine.

Action:

Electrical burns are WORSE than they look. Deep tissue injury along current path -muscle, nerve, vessel damage far exceeds skin appearance.
Aggressive IVF -target UOP 1–2 mL/kg/hr (higher than standard burn resuscitation for myoglobinuria).
ECG monitoring × 24h -risk of cardiac arrhythmias.
Watch for compartment syndrome -check pulses, compartment pressures if concern. Fasciotomy may be needed.
Consider IV sodium bicarbonate to alkalinize urine and prevent myoglobin precipitation in renal tubules.

📋 Case 3, Hydrofluoric Acid Burn with Systemic Toxicity

Patient: Lab worker spills hydrofluoric acid on hand, small burn area. Develops tingling in hand, then cardiac monitor shows prolonged QT.

Action:

HF acid burns are life-threatening even when small. Fluoride chelates calcium → hypocalcemia → arrhythmias.
Apply topical calcium gluconate gel to affected area immediately.
Check ionized calcium (iCa) -if low, give IV calcium gluconate.
Continuous cardiac monitoring -prolonged QT, arrhythmias from hypocalcemia can be fatal.
Irrigate thoroughly with water. Do NOT attempt to neutralize the acid.

🧪 Workup

BSA estimation (Rule of 9s or Lund-Browder chart)
CBC, BMP, lactate, coags
Carboxyhemoglobin (COHb) -if enclosed-space fire (CO poisoning)
ABG -metabolic acidosis, CO levels
CXR -inhalation injury
Type and screen
Urine myoglobin -if electrical burn or rhabdomyolysis suspected

💊 Medications

Drug	Dose	Purpose
Lactated Ringer's	Parkland formula	Resuscitation fluid of choice (NOT NS -hyperchloremic acidosis risk)
Morphine (MS Contin)	0.1 mg/kg IV q2–4h	Pain -burns are extremely painful. IV only (poor absorption otherwise).
Silver Sulfadiazine (Silvadene)	Topical to wounds	Topical antimicrobial. Avoid on face (staining). Sulfa allergy caution.
Mafenide (Sulfamylon)	Topical	Penetrates eschar -used for ear burns (prevents chondritis). Painful on application. Can cause metabolic acidosis.
Tetanus prophylaxis	Tdap (or Td) 0.5 mL IM ± TIG 250 units IM	Give Tdap/Td if last booster > 5 years (dirty wound) or > 10 years (clean wound) or unknown status. Add tetanus immunoglobulin (TIG) 250 units IM for high-risk wounds (deep, contaminated, necrotic, burns) in patients with < 3 prior vaccinations or unknown status. Burns are considered tetanus-prone.

📋 On Rounds

Pimp Questions

Why do you use Lactated Ringer's instead of Normal Saline for burn resuscitation?

Burns require massive fluid volumes (Parkland formula). Large-volume NS causes hyperchloremic metabolic acidosis (dilutional, from supraphysiologic Cl⁻ concentration). LR has a more physiologic electrolyte composition. Additionally, LR contains lactate which is converted to bicarbonate by the liver, providing a mild buffer effect.

When is escharotomy indicated?

Circumferential full-thickness burns that compromise circulation or ventilation. The burned eschar is inelastic -as underlying tissue swells, pressure rises. Limb: loss of distal pulses, paresthesias, pain with passive stretch (compartment syndrome). Chest: inability to ventilate (restricted chest wall expansion). Escharotomy is a bedside procedure -longitudinal incision through eschar to release pressure.

What is the significance of carboxyhemoglobin (COHb) levels?

CO binds hemoglobin with 250× greater affinity than O₂ → left-shifts the oxyhemoglobin curve → tissue hypoxia despite "normal" PaO₂. SpO₂ is UNRELIABLE -pulse ox cannot distinguish COHb from OxyHb. COHb > 15% is significant, > 25% is severe. Treatment: 100% O₂ via NRB (half-life of COHb drops from 5h to 1h). Hyperbaric O₂ for severe cases (COHb > 25%, neurologic symptoms, pregnancy).

Why is succinylcholine contraindicated in burn patients after 48 hours?

Burns cause upregulation of extrajunctional (immature) nicotinic acetylcholine receptors across the entire muscle membrane. Succinylcholine depolarizes ALL these receptors simultaneously → massive potassium release → fatal hyperkalemia. This risk begins ~48h post-burn and lasts 1–2 years. Use rocuronium instead.

A burn patient develops dark/tea-colored urine. What do you suspect and how do you treat?

Myoglobinuria from rhabdomyolysis (especially electrical burns or deep thermal burns). Myoglobin is nephrotoxic → can cause ATN and AKI. Treat: aggressive IV LR (target UOP 1–2 mL/kg/hr for myoglobinuria -higher than standard burn resuscitation), consider IV sodium bicarbonate to alkalinize urine (prevents myoglobin precipitation in tubules), monitor CK and renal function. Avoid mannitol (controversial).

⚡ Summary

Rule of 9s

Head 9%, each arm 9%, anterior trunk 18%, posterior 18%, each leg 18%, perineum 1%.

Parkland Formula

4 mL × kg × %BSA. Half in first 8h (from burn time), half over next 16h. LR, not NS.

Urine Output

Primary resuscitation target: 0.5-1 mL/kg/hr adults, 1 mL/kg/hr children.

Airway

Intubate EARLY if inhalation injury suspected. Singed hair, stridor, carbonaceous sputum.

Escharotomy

Circumferential full-thickness burns → compartment syndrome. Bedside incision through eschar.

CO Poisoning

COHb levels (SpO₂ unreliable). 100% O₂ NRB. Hyperbaric if severe.