Question 18

College Answer

a)

• There is an extensive burn injury of the left lower leg consisting of areas of:
  • 1st degree burn - erythematous areas of skin without blistering
  • 2nd degree superficial partial thickness and likely deep partial thickness with blistering
  • 3rd Degree - Full thickness - white and mottled area although 4th degree cannot be excluded.

 

b)

• 4 possible complications:
  • Infection
  • Ischaemia
  • Scarring
  • Contracture
  • Pain
  • Amputation
  • DVT

 

c)

Important clinical features

• Other areas of burn – extent and type
• Basic resuscitation status, adequacy of resuscitation status to date and vital signs including urine output 
• Associated trauma
• Evidence of airway burn or inhalational injury
• Evidence of inhalation of toxic gases
• Evidence of facial, corneal or perineal burns
• Circumferential burns or evidence of compartment syndrome
• Temperature
• Analgesia requirements
• Vascular access issues 
• Co-existing conditions such as epilepsy or drug intoxication

 

Discussion

It is incredibly difficult to find an image of a burned left lower leg on Google which features the precise injuries which were described by the college answer. The best I could do is the above image of a couple of burned legs, retrieved without any permission whatsoever from an EMSWorld article on burns care. The picture itself is credited to Dr James H. Holmes IV, Burn Center Director Wake Forest University Baptist Health. The caption describes it as "Thermal burn injury involving anterior of both legs, uninjured areas include where shorts, socks and shoes provided partial protection. This is a 15% TBSA burn. Each leg, including the foot, is 18%. For this burn, the anterior surface of each leg, minus the area of the foot and the upper leg shielded by clothing, is approximately 15%. The patient is pictured following debridement upon admission at a burn center".

 

The possible complications of such a burn? One struggles to add anything to the already complete list provided by the college.

• Compartment syndrome and limb ischaemia
• Rhabdomyolysis
• Escharotomy
• Amputation
• Infection
• Scarring
• Peripheral nerve compression
• Contracture
• Pain
• DVT
• Loss of function

 

What are other important features on the initial clinical assessment of this patient?

This answer should follow some sort of system.

A) - Airway burns

B) - Carbon monoxide or cyanide poisoning

C) - Hypotension, hypovolemia, adequacy of fluid resuscitation;

- problems gaining vascular access

D) - Decreased level of consciousness, head injury; analgesia

E) - Electrolyte disturbance

- Exposure and assessment of total burned areas

F) - Urine output

The BMJ had published a series of 12 articles, titled "the ABC of burns". These are a valuable resource.

PRUITT Jr, BASIL A., DARYL R. ERICKSON, and ALAN MORRIS. "Progressive pulmonary insufficiency and other pulmonary complications of thermal injury."Journal of Trauma and Acute Care Surgery 15.5 (1975): 269-379.

Hettiaratchy, Shehan, and Remo Papini. "Initial management of a major burn: II—assessment and resuscitation." Bmj 329.7457 (2004): 101-103.

Hettiaratchy, Shehan, and Peter Dziewulski. "Pathophysiology and types of burns." Bmj 328.7453 (2004): 1427-1429.

Ansermino, Mark, and Carolyn Hemsley. "Intensive care management and control of infection." Bmj 329.7459 (2004): 220-223.