You are asked to review a 64-year-old male who has been brought to the Emergency Department having been burned in a house fire. He is drowsy and confused with a persistent cough and unable to give a coherent history. His heart rate is 120 beats/minute, blood pressure is 88/52 mmHg, respiratory rate is 28 breaths/min and oxygen saturation is 94% on high flow oxygen via a reservoir mask.
A structured answer to (a) would resemble the following:
A) Assessment of the airway and of the need for immediate intubation
B) Ventilation with high FiO2; investigation of possible carbon monoxide poisoning with ABG, and investigation for pulmonary thermal injury with CXR.
C) Establishment of secure vascular access, and the administration of crystalloid to replace intravascular volume.
The college wanted a specific mention of the groins as regions which are frequently spared in house fires. I presume this excludes those fires which started in the groin.
D) Adequate analgesia and sedation
Features suggestive of airway burns:
This table, with minimal modification, seems to form the basis of the college answer.
Other differentials for a decreased level of consciousness in a burned trauma patient include the following:
Burn and trauma-associated:
Many others could be generated. Maybe this guy was assaulted, and then left for dead in a shed which was set ablaze as a forensic countermeasure.
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.
Cartotto, Robert C., et al. "How well does the Parkland formula estimate actual fluid resuscitation volumes?." Journal of Burn Care & Research 23.4 (2002): 258-265.
Ansermino, Mark, and Carolyn Hemsley. "Intensive care management and control of infection." Bmj 329.7459 (2004): 220-223.
Michielsen, Dirk PJ, and Cynthia Lafaire. "Management of genital burns: a review." International journal of urology 17.9 (2010): 755-758.