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.

  • List the initial priorities in this patient’s management.
  • What features on history and examination would suggest a significant airway injury?
  • List the differential diagnoses for his altered mental state.

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College Answer

  • a)
    • Resuscitation including primary and secondary survey
    • Assessment and management of potential airway burn (including early intubation, not cutting ETT, avoiding nasal tube)
    • Obtain large bore IV access and administration of fluid bolus (20 ml/kg) for probable hypovolaemic shock (mention groins are usually spared in burns and are a good site for clean skin vascath access
    • Look for signs of traumatic injury and assess extent of body surface area and depth of burn
    • Risk of hypothermia
    • Seek collateral history for past medical history, medication history and history of acute events
  • b)
    • Burns occurring in a closed space
    • Cough, stridor, hoarseness of voice
    • Burns to face, lips, mouth, pharynx or nasal mucosa
    • Soot in sputum, nose or mouth
    • Hypoxaemia or dyspnea
    • Carboxyhaemoglobin levels >2%
    • Acute confusional state or depressed conscious level
  • (c)
    • Traumatic brain injury
    • CO / Cyanide poisoning
    • Alcohol intoxication / drug overdose
    • Other pathology eg CVA, intracranial haemorrhage, seizure-related, hypoglycaemia

Discussion

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.

  • Some mention of the estimation of burns area should probably be made; the Wallace rule of nines is a good method for adults.
  • Fluid resuscitation should be vigorous, given that the greatest amount of fluid loss in burns patients in over the first 24 hours.
  • The Parkland formula may be used to estimate fluid resuscitation requirements, even though it frequently underestimates the fluid requirements

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:

A BMJ article from the "ABC of burns" series contains Table 1, "Warning signs of airway burns", which I reproduce below:

  • Burns occurred in an enclosed space
  • Stridor, hoarseness, or cough
  • Burns to face, lips, mouth, pharynx, or nasal mucosa
  • Soot in sputum, nose, or mouth
  • Dyspnoea, decreased level of consciousness, or confusion
  • Hypoxaemia (low pulse oximetry saturation or arterial oxygen tension) or increased carbon monoxide levels (>2%)

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:

  • Traumatic brain injury
  • Carbon monoxide poisoning and thus hypoxia
  • Cyanide poisoning and thus hypoxia
  • Intoxication

Generic differentials:

  • Stroke
  • Intracranial infection
  • Hypoglycaemia
  • Post-ictal state
  • Cerebral vasculitis
  • Hypothyroidism/hypoadrenalism

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.

References

References

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.