21 y/o male involved in industrial fire. Patient was welding a steel structure when a spark from the torch ignited a barrel of flammable material that was inadvertently placed in his work area. Patient sustained full-thickness burns over the upper half of his chest and circumferential burns to bilateral arms. Patient also sustained superficial partial-thickness burns to face, neck and bilateral hands. His entire abdomen, upper half of his back and front of his upper legs sustained deep partial-thickness burns.
Patient was transported to small community hospital where two IV lines were started; a Foley catheter and NG tube were inserted, and humidified O2 at 3L/min via NC. He was given mannitol 12.5g IV before being transported to a major burn center. VS pre-transport were as follows: BP- 136/84 mm Hg
Temp 37.2 º C (oral)
Pre-burn weight was 72 kg (160lb). He was received in the burn unit approximately 4 hours after sustaining burn injury. At admission to the unit, patient was alert and oriented and VS were: BP- 140/90 mm Hg
HR- 110 bpm
Temp- 36.1 º C (oral)
Lungs sounds clear in all fields on auscultation with an occasional productive cough of a small amount of carbon-tinged sputum. Voice was becoming hoarse. Absent bowel sounds with NG tube draining dark yellow-green liquid. Peripheral pulses were obtained with Doppler as they could not be palpated manually. Foley catheter draining burgundy-colored urine. Urine output total since insertion 4 hours ago =280ml. Fluid resuscitation efforts since the burn injury included 4L of lactated Ringer’s solution through the IV lines. Labs as follows:
ABGs on 3L O2-----
Specific gravity 1.040
Burn unit MD performed fiberoptic bronchoscopy, which revealed minimal redness of the glottis and no edema. Esharotomies were performed on bilateral arms immediately after the admission to the burn unit. Patient was bathed and scalp shaved. Burns were dressed in occlusive silver sulfadiazine (Slivadene) dressings. Burns were then dressed twice a day with this medication. The following regimen was prescribed: Zantac 150 mg IV push q12h; antacid 30mlevery hour instilled via NG tube and clamped for 15minutes for the first 48 hours after the burn; morphine sulfate 3 mg IV push every hour as needed for pain.
Bowel sounds returned on day 3, NG tube was removed and high-calorie, high-protein diet was begun. On day 5 of hospital stay, patient was taken to surgery for the first of a series of surgical procedures to excise and graft the areas of full-thickness injury with split-thickness autografts. Donor sites included his buttocks and backs of his legs. Patient was dc’ed from hospital after a 65 day hospital stay with follow-up and rehab scheduled.
Discuss the patho of burns, including the classification of burn depth and severity of burn injury Burn injury is the result of heat transfer from one site to another. Tissue destruction results from coagulation, protein and denaturation or ionization of cellular contents. The skin and mucosa of the upper airways are sites of tissue destructions. The depth of the injury depends on the temperature of the burning agent and the duration of contact with the agent. Burns are classified according to the depth of tissue destruction as superficial partial-thickness injuries, deep partial-thickness injuries or full-thickness injuries. These categories are similar to first, second, third degree burns. Burn depth determines whether epitheliazation will occur. Determining burn depth can be difficult. The following factors are considered in determining the depth of...