ER PRESENTATION

Bushra Zia

MR 197-27-15 Date: 26.10.14

Time: 12 noon
42Y, F, 75kg -- Co-morbids none reported
- Presented with painful burns on the back and upp
er limbs.
- Completely fine the night before. Woke up in the
morning to the fire due to AC short-circuiting 3h a
go. Got caught in house fire while trying to save h
ousehold items.
- 15 -20mins stayed in the room -smoke inhalation

- Escaped herself. No loss of consciousness.

- No complaint of headache, dizziness, difficulty
in breathing
- Did not report any trauma/injury elsewhere
- No Hx of prev transfusion, surgery
- Immunization complete. Immunization > 10y a
go.
- No addictions reported.
- No significant drug Hx
- Family Hx positive for HTN and DM-2

On examination
Middle aged lady with extensive soot staining all
over her body. Singed hair, eyebrows and nose h
air. Orientation x3
VITALS:
HR: 83bpm BP: 110/80 RR: 13/min, Sat 97-98%
on R.A but mask ventilation given regardless
BURNS:
1. Back: 2nd degree - painful weeping blisters
2. Forearm and Hands: small sporadic 2nd deg

SYSTEMIC EXAMINATION: Unremarkable.

Nasal and oral mucosa - no apparent signs of infl
ammation, edema. Slight hoarseness of voice ? E
dema ? Soot

ER management
- (ABC)
- Airway assessment
- Extensive rehydration
- Pain management
- Investigations
- Antibiotics cover (oral +topical)
- Cleaned soot / burns
- in patient admission under care of Dr. Fazl-urRahman

INVESTIGATIONS
ABGs .
pH
7.43
pCO2 31.60
pO2 110.90
BIC 21.10
B.E
-1.8
O2 Sat 98.00

CBC
Hb 12.7
Hct 41.1
TLC 24.0 (80.8/13.9)
Plts 423
LYTES
BUN 10
Na. 129
Cl 94

Cr. 1.1
K 3.4
BIC 16.9

BURNS
CLASSIFICATION
1. Accidental vs Non-accidental
2. Source - Thermal, chemical, electrical, radiati
on
3. Depth

EXTENT
Rule of 9's for adults gives a rough estimate of b
ody surface area. Do not include 1st degree burn
s.

Pathophysiology
- Denaturing proteins - cell/tissue damage - coag
ulative necrosis
- inflammation -capillary leakage - edema - fluid
losses -- diminished end organ perfusion
- disrupted cell membrane - electrolyte imbalanc
e. Sodium in, potassium out

Management
First ABC then burn care!
1. Airway:
Assess patency, intubate early if suspect obstruct
ion.
Look for: facial/perioral/mucosal burns, hoarsen
ess of voice, accessory respiratory muscles use.
ETT regardless if large 3rd degree burn > 40%

2. Breathing:
- Hypoxia - oxygen supplementation
- CO poisoning - monitor carboxyhemoglobin le
vels. Treat with hyperbaric O2 or 100% O2
- Smoke inhalation injury (mucosal cell death in
distal bronchioles, atelectasis) Dx on bronchosco
py. Supportive management

3. Circulation
Assess for shock. If present follow shock protoco
l.
Otherwise: Parkland Formula
4 mL/kg/% TBSA burned
80kg male, 20% TBSA??
50% in first 8h from time of injury, rest in remain
ing 16h, maintain urine output 30-50ml/hr
Fluid of choice: Lactated Ringer Solution. NS ma
y cause hyperchloremic acidosis.
(however may switch to NS for maintenance)

4. Wound care:
Wash with soap and water
Bacitracin (polyfax) for 1st degree
Silver sulfadiazine (quench) for 2nd degree
Surgical escharotomy/skin grafting for 3rd and 4t
h degree
Change dressing daily
Try to keep it elevated

5. Analgesia -IV opoids

6. Correction of electrolyte imbalance
7. Tetanus prophylaxis
8. Initiate enteral nutrition as early as possible
9. Physiotherapy - to regain/optimize functionality
10. No prophylactic antibiotics recommended

Referral to burn unit?

Thank you
Questions?