According to this excellent LITFL resource, important determinants in this hot case are:

• Phase of the burn:
  • Resuscitation (Day 1) – resuscitation, CO, CN, coagulopathy, compartment syndrome, management of traumatic injuries, co-morbidities
  • Post-resuscitation (Day 2-6) – debridement and grafting, nutrition, fluid therapy, bleeding.
  • Inflammatory/infective (Day 7) – differentiating sepsis from SIRS, extubation/tracheostomy.

Important issues to establish in this hot case are:

• Is this patient well resuscitated?
• Are there any burns-related complications:
  • Airway burns
  • Inhalational injury
  • Carbon monoxide or cyanide poisoning
  • Compartment syndrome from circumferential burns
• Is there sepsis, or merely SIRS?
• Is this patient eveg going to get extubated, or should we be thinking about tracheostomy?

Previous hot cases with this sort of theme to them can be found below.

~Examination of the Burns Patient in ICU~

The standard introduction Listen to the introductory statement. Wash hands; don gloves and gown. Ask examiners about turning up the lights   The environment Monitoring Ventilator Urine catheter Drains (surgical, intercostal, etc) Dialysis IABP / ECMO Infusions EVD   The physical examination The details of this section can be seen in the opposite column.   The obs and investigations Temperature, urinalysis, drain output, urine output ABG, ECG, bloods, culture results CXR, CT images and CSF analysis. The Presentation "This burns patient has the following complications:"

The Physical Examination in Brief Detail Ask the examiners to sit the patient up Expose to the waist and observe. Ask the examiners about any language barriers GCS Hands, the nail signs, pulse and arterial line Arm tone and upper limb lymph nodes Neck lymph nodes, trachea, thyroid Pupils and the higher cranial nerves Airway and the lower cranial nerves - ask about the sputum Chest palpation, percussion, auscultation, and ask to roll over Praecordium palpation, auscultation, and ask for Valsalva Ask examiners to lay the patient flat. Abdominal palpation, percussion, auscultation Pelvis: groins, lines, and ask about performing a PR Legs: oedema and calf compressors. Leg muscle tone. Feet and Babinsky; clonus. Power in the limbs

The standard introduction

• The examiner will give you a history.

The prelude to the dance

• Wash hands.
• Gown and glove.
• Ask, if relevant:
  • "Can I turn on all the lights?"
  • "Are there any movement restrictions? Can I sit them up, or roll them on their side?"
  • "Is there a language barrier?"
• Introduce yourself: “Hi Mr or Mrs Bloggs, I’m Dr So-and-so. I’m going to examine you.”

The Monitors

• Rhythm
• Rate
• Morphology: QRS width,
• MAP and abnormal morphology of the arterial waveform
• CVP and abnormal morphology of the CVP waveform
• Ancillary waveforms eg. the PA catheter waveform
• End-tidal CO₂ waveform and level
• Oxygen saturation measurement, and the quality of the waveform

A co-oximeter may be in the room. One should ask fro co-oximetry to determine whether there is much carboxyhaemoglobin floating around. The saturation measurement is useless without this information.

A pacing box?

• Pacing mode
• Set rate

Sensitivity and pacing threshold may not be relevant.

The Ventilator

One can ask the examiners the following questions:

• How are we oxygenating this patient?
• How are we ventilating this patient?

One should ask about the following parameters:

• FIO₂
• PEEP
• Peak pressure
• Plateau pressure
• Tidal volume and minute volume

One should ask to look at the pressure-volume loops.

The oedematous post-hot-gas-inhalation lung will be ventilated in an ARDS-like fashion.

Urine catheter

• Unusual colour
• Anuria

Drains (surgical, intercostal, etc)

There may be surgical drains (what is in them? How much of it?). Asking how much has been coming out may be relevant in a hot case which focuses on the diagnosis of a shock state.

The pleural catheters are also interesting. One should make a mental note of whether the ICCs are on free drainage or on suction. The content of these drains could be informative, especially if one notices blood or chyle.

Dialysis

A CVVHDF or SLEDD process may be in progress. The savvy candidate may wish to ask the following questions:

• Which modality is being used?
• What is the dose of dialysis?
• What is the rate of fluid removal?
• How is the circuit anticoagulated?
• How long has this filter lasted?

These questions may go unanswered.

IABP / ECMO

The patient you are examining may have some sort of extra gadget hooked up. If ECMO is in progress, one may wish to ask about the following parameters:

• VA or VV?
• Flow rate
• Fresh gas flow
• Any recent problems with the circuit

If IABP counterpulsation is in progress, it raises additional questions. One may wish to ask the examiners whether one may be able to switch it to 1:2, to assess the efficacy of augmentation.

Infusions

This stage is critically important. The drug and fluid infusions which are currently in progress give a clue as to what problem is currently being addressed. One should not neglect the labelled bags; the choice of antibiotics gives one some idea of where the source of sepsis is thought to be.

Fluid management in the first stages of resuscitation is guided by the Parkland formula:

Volume = 4 × mass (kg) × percentage body surface area affected.

EVD

One should observe the following features of an EVD:

• Set height
• Whether it is open or closed
• The CSF colour - eg. is it full of blood?

Weird machinery

A metabolic cart may be present, suggesting that in this patient nutritional goals are being inferred from the direct measurement of metabolic rate.

---

The physical examination

Expose and observe

Ideally, one should get the patient sitting up to 30-45°. This may not be possible. However, one should still ask for it.

Ideally, the patient should be exposed from the waist up. The candidate can then stand back and look for anything externally obvious:

• Skin colour, eg. jaundice or the discolouration of chronic renal failure
• Muscle wasting, obesity
• The evidence of other trauma
• The pattern of breathing (eg. whether there is a characteristic chest flail)
• The extent of the burns
• Any escharotomy wounds

it would be worthwhile to mention to the examiners that you would like to look at all the burned surfaces during dressing changes.

GCS

Performing the GCS should be the first step, unless you notice that a neuromuscular junction blocker is among the infusions. The level of consciousness then determines how you go about examining the rest of the patient.

A traditionalist, who is examining Mr Bloggs, would approach the GCS in the following manner:

• Grab hold of both of the patient's hands.
• "Mr Bloggs!" One pauses to observe for eye opening.
• "Can you squeeze my hands?"
• If hand squeezing and eye opening is not observed, one administers a painful nail bed stimulus to both hands, to observe the response to pain.

The burns patient is likely to be heavily narcotised.

Hands, nail signs, pulse and the arterial line.

One has just performed a GCS assessment; one is still holding the hands.

Now, time to look at them more closely.

First, one should spent a second assessing whether they are warm or cold.

Then, one can focus on the nails. Nail signs are numerous and deserve their own page.

In brief, the nail signs one could look for are as follows:

Done with the nails, one may want to briefly consider (and maybe even comment upon) the presence of any sort of characteristic deformities, eg. assymetrical wasting of the small muscles, or the joint changes of rheumatoid arthritis.

Next comes the pulse. While one still has both of the patient's hands, one ought to try to compare the radial pulses. It would be worthwhile to look up at the arterial line trace at this stage; abnormalities such as the widened pulse pressure of aortic regurgitation may not have been noticed until this stage.

Arms

Tone of the upper limbs

Move up from the hands. While you are still holding the hands, you can perform a sort of gross examination of tone by pronating and supinating the wrists, and by flexing and extending the elbows.

Asterixis

In the conscious patient, it may be possible to assess asterixis by asking the patient to hold both their arms up with the wrists dorsiflexed.

Cubital fossa

Examine the cubital fossa for

• Peripheral lines
• Evidence of multiple venepunctures
• Lymph nodes
• Brachial pulse
• The presence of an obvious AV fistula

One should then palpate the axillary lymph nodes.

The Neck

• Inspect any central lines
• Look again at the CVP

Palpate the neck:

• Trachea: is it midline? Is there space for a tracheostomy?
• Thyroid gland
• Cervical lymph nodes
• Carotid pulse - one side at a time!
• Submandibular lymph nodes
• Pre- and post-auricular lymph nodes

Pupils and the higher cranial nerves

The examination of the face and head is desirable, but may be impossible. If one can see any exposed facial skin, one should look for signs of facial burns - singed eyebrows and eyelashes, for example.

One may wish to limit their examination to the lower cranial nerves, when one can also look for carbonaceous material in the oral cavity.

• Gag reflex

• Cough reflex

Gag reflex

The Yankeur sucker is used to probe the posterior pharynx, on both sides. A gag reaction should result from this.

This collectively tests CN X and IX.

Cough reflex

While on the subject of CN X, one may test the cough reflex by suctioning the trachea.

This tests CN X.

This is also a convenient time to ask about the volume and character of the secretions.

When testing the cough reflex, pay attention to the sputum, and ask whether blackened sooty sputum has been observed.

Chest palpation, percussion and auscultation

Palpation:

One puts both their hands on the chest to assess the symmetry of chest expansion.

Percussion:

One might wish to percuss the chest. If this is done in a slick fashion, it can be forgiven.

Changes in percussion resonance may be worth commenting on.

Auscultation:

One may begin by auscultating the apices anteriorly. Then, one should auscultate as posteriorly as possible. In a supine ICU patient, one might gain access to the contralateral chest by grabbing the opposite arm and pulling the shoulder forward, thus pulling the patient's opposite side slightly off the bed. The money is in the bases.

Palpation and auscultation of the praecordium

Palpation:

The clever candidate will make a big show of palpating both the apex and the right sternal edge.

Auscultation:

One should auscultate in the following sequence:

• Apex
• Left sternal edge, lower
• Left sternal edge, upper
• Right sternal edge, lower
• Left sternal edge, upper
• Both carotids

The various clicks and murmurs one encounters are discussed elsewhere.

Abdominal palpation, percussion and auscultation

For this, one should ask to lay the patient flat.

Abdominal observation

• Take a moment to behold the abdomen. One may ask the examiners to look under any surgical dressings; one is likely to be denied this part of the examination (they will tell you the wound looks clean and dry).

Abdominal palpation

• All quadrants should be palpated.
• Then, feel for the liver edge; observe respiratory excursion
• Then, feel for the spleen.
• Then, try to ballot the kidneys. Enquire about renal tenderness.

Abdominal percussion

• This can double as a test for peritonism.
• If there is some suspicion of ascites, one may ask to roll the patient, so shifting dullness can be better appreciated. The examiners may not permit this test.

Abdominal auscultation

• One should spend a good length of time on this, if one suspects bowel obstruction or ileus.

Examination of the pelvis and groins

The pelvic content would have been palpated during the abdominal examination.

The more important part of this examination is the groin.

At this stage, the patient should be re-draped - cover them from the waist up, and uncover their legs.

Observation and palpation of the pelvis:

• There may be a rash of thrush, or a groin haematoma, or an external fixation device.
• The posterior pelvis and sacrum should ideally be palpated for pitting oedema.

Examination of the lines

• One should take notice of anything going into or coming out of the femoral vessels.
• There may be a vascath, a PiCCO catheter or some sort of angiography sheath. These are important clues. Why did this patient get an angiogram? What is the PiCCO for?

Examination of the genitals and rectum

• A complete examination would call for the palpation of the testes, and a comment on their size. However, this may not be practical.
• One should take note of any sort of waste management devices, eg. rectal tube, SPC or IDC.
• One should definitely ask about performing a PR.
• If one is forbidden from performing the PR, one should ask about the following features:
  • Anal sphincter tone
  • Size and quality of the prostate
  • Presence of melaena or hard stool

Once one is finished with the pelvis, one should cover it again, so that only the legs are sticking out.

Examination of the lower limbs

One should ask to remove TEDs and compression stockings.

• One should observe whether the lower limbs are mottled, and whether they are of the same size (assymetrical swelling leads one to suspect lymphoedema or DVT)
• One should palpate the larger muscles. Muscle wasting - especially of the quads- is an important feature of malnutrition. Additionally, one gets to appreciate the temperature difference between the limbs, which could be important in the assessment of peripheral vascular disease.
• Pitting oedema should be palpated.

Leg muscle tone

The best way to test muscle tone is by holding the knee. Roll the knee gently to distract the patient; then try to lift it off the bed. In the presence of increased tone, the leg will remain straight and the whole thing will lift up; with normal or decreased tone, only the knee will bend

Calf tenderness

In the conscious patient, one might be able to assess whether a gentle calf squeeze produces the characteristic pain which suggests a DVT may be present.

This brings one to the feet, and to the beginning of the neurological examination.

Feet and the Babinsky reflex

The feet would have already been palpated to assess their temperature, and to look for pitting oedema.

Observation of the feet

One should look specifically for changes suggestive of chronic diabetic foot disease, or chronically poor vascular supply.

Palpation of the feet

This should consist of palpating the dorsalis pedis and posterior tibial pulse.

Babinsky reflex

One should test the Babinsky bilaterally.

Clonus

One should attempt to assess clonus in both feet.

Power in the limbs

Neurological examination of the burns patient will be limited by what the sedation and wounds permit.

Power of the muscle groups may be tested in the following sequence:

• Ankle dorsi and plantarflexion
• Knee flexion and extension
• Hip flexion, extension, adduction and abduction.

• Hand grip
• Wrist dorsiflexion/palmarflexion
• Elbow flexion/extension
• Shoulder adduction / abduction

The measured observations

Ask to see the obs chart. If it is not allowed, ask for the following:

• Trends of blood pressure and heart rate
• Temperature
• Drain output
• Urine output

One may also wish do demonstrate an interest in the trends of any sort of advanced haemodynamic monitoring, eg. cardiac index as measured by PAC or PiCCO

The laboratory investigations

One needs to show an interest in the following labs:

• ABG - looking for carboxyhaemoglobin and lactic acidosis
• Routine bloods
• Urinalysis - specifically, whether there is myoglobinuria
• Culture results
• Case-specific bloods, eg. CK, troponin, LFTs, pancreatic enzymes, inflammatory markers...

Imaging and other investigations

One should always ask for the following:

• ECG
• CXR

You sometimes want to see the following:

• CSF analysis
• CT or MRI results

 

Case presentation and discussion: when you have a good idea of what is going on

"Mr Bloggs is suffering from severe burns. The more severe of these burns cover [percentage of the body surface area]."

"This burns injury has resulted in a series of complications: [infection, compartment syndrome, SIRS shock, pulmonary injury, airway injury]"

"I have come to this conclusion on the basis of the following findings: [insert clinical findings here]"

"I would like to confirm my diagnosis with the following investigations: [insert appropriate investigations]"

"The current management issues are as follows: [a brief list of management priorities]"

"I would approach the management of these issues in the following manner: [list of management strategies; it helps to organise this into an A,B,C,D,E approach if one has a complex multisystem problem to manage]"