Surgery

28 year old man is brought in from an apartment fire

Grace Huang on May 26, 2013

You are the surgery resident on call for acute care surgery and you are alerted that a 28 year old man is being transported to the ED by EMS who was involved in an apartment fire. He was removed from the scene about an hour ago.

What does the primary assessment of a burn case consist of?

Expand all answers
Airway, Breathing, Circulation, Neurologic Deficit, Exposure
Correct


Airway, Breathing, Circulation only
Primary assessment in trauma and burn cases includes evaluation of neurologic deficit and exposure


BP, HR, Temperature, RR, Oxygen Saturation
Though assessing vitals will give you an idea of his hemodynamic and functional status, in trauma or burn cases, it is important to assess ABCDE’s in a specific order to rule out emergent situations


Full Head to Toe Physical Exam

On presentation, patient is able to talk to you and you appreciate bilateral breath sounds. However, you do notice that he has carbonaceous sputum. Patient is tachycardic to 100 and has weak radial pulses bilaterally. His Glasgow coma score is 15. You notice burns that appear swollen and wet-appearing circumferentially around both his legs (TBSA ~ 36%). He has no evidence of trauma or other abnormalities anywhere else on his body.

  • Temp  37 C
  • HR  95
  • BP  100/80
  • RR  16
  • O2  95% on Room Air

En route to the hospital, patient received 500 mL LR. What rate of fluid should the patient receive? Assume the patient is 100 kg.

Expand all answers
600 mL/hr over the next 24 hours
950 mL/hr over the next 7 hours, 450 mL/hr for the following 16 hours
Correct. Using Parkland formula, patient should receive 4x100x36 = 14.4 L over the next 24 hours, 7.2 L (half) which he should receive in the first 8 hours. Because he already received 500 mL in the first hour, he should receive ~950 mL/hr over the next 7 hours.


900 mL/hr over the next 8 hours, 450 mL/hr for the following 16 hours
Incorrect. Patient received 500 mL LR during the first hour since burned, so the rate for the first 8 hours should be likewise adjusted.


150 mL/hr
Incorrect. Fluid needs for burn patients are substantial and should be calculated using the Parkland formula.


What is the best way to monitor patient’s volume status?

Expand all answers
Capillary Refill
Skin Turgor
Urine output
Correct. Patient should receive a Foley catheter upon presentation after checking that there is no urethral injury.


Vitals every 2 hours

Does the patient need to be intubated at this time?

Expand all answers
Yes. Due to his history of being in an enclosed space (apartment fire) and presence of carbonaceous sputum, the patient should be intubated immediately.
Correct. Patient may develop laryngeal edema later as a result of inhalation burns which would complicate intubation later. As a precaution, patient should be intubated on any sign of inhalation injury including perioral burns, singed nasal hairs, and carbonaceous sputum.


No. Patient's airway is clear and he is talking, so he can continue on room air.
No. However, patient should be put on 100% oxygen mask in case of CO poisoning.

You are the surgery resident on call for acute care surgery and you are alerted that a 28 year old man is being transported to the ED by EMS who was involved in an apartment fire. He was removed from the scene about an hour ago.

What does the primary assessment of a burn case consist of?

Expand all answers
Airway, Breathing, Circulation, Neurologic Deficit, Exposure
Correct


Airway, Breathing, Circulation only
Primary assessment in trauma and burn cases includes evaluation of neurologic deficit and exposure


BP, HR, Temperature, RR, Oxygen Saturation
Though assessing vitals will give you an idea of his hemodynamic and functional status, in trauma or burn cases, it is important to assess ABCDE’s in a specific order to rule out emergent situations


Full Head to Toe Physical Exam

On presentation, patient is able to talk to you and you appreciate bilateral breath sounds. However, you do notice that he has carbonaceous sputum. Patient is tachycardic to 100 and has weak radial pulses bilaterally. His Glasgow coma score is 15. You notice burns that appear swollen and wet-appearing circumferentially around both his legs (TBSA ~ 36%). He has no evidence of trauma or other abnormalities anywhere else on his body.

  • Temp  37 C
  • HR  95
  • BP  100/80
  • RR  16
  • O2  95% on Room Air

En route to the hospital, patient received 500 mL LR. What rate of fluid should the patient receive? Assume the patient is 100 kg.

Expand all answers
600 mL/hr over the next 24 hours
950 mL/hr over the next 7 hours, 450 mL/hr for the following 16 hours
Correct. Using Parkland formula, patient should receive 4x100x36 = 14.4 L over the next 24 hours, 7.2 L (half) which he should receive in the first 8 hours. Because he already received 500 mL in the first hour, he should receive ~950 mL/hr over the next 7 hours.


900 mL/hr over the next 8 hours, 450 mL/hr for the following 16 hours
Incorrect. Patient received 500 mL LR during the first hour since burned, so the rate for the first 8 hours should be likewise adjusted.


150 mL/hr
Incorrect. Fluid needs for burn patients are substantial and should be calculated using the Parkland formula.


What is the best way to monitor patient’s volume status?

Expand all answers
Capillary Refill
Skin Turgor
Urine output
Correct. Patient should receive a Foley catheter upon presentation after checking that there is no urethral injury.


Vitals every 2 hours

Does the patient need to be intubated at this time?

Expand all answers
Yes. Due to his history of being in an enclosed space (apartment fire) and presence of carbonaceous sputum, the patient should be intubated immediately.
Correct. Patient may develop laryngeal edema later as a result of inhalation burns which would complicate intubation later. As a precaution, patient should be intubated on any sign of inhalation injury including perioral burns, singed nasal hairs, and carbonaceous sputum.


No. Patient's airway is clear and he is talking, so he can continue on room air.
No. However, patient should be put on 100% oxygen mask in case of CO poisoning.

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