You have received a call from a junior doctor at a rural hospital awaiting retrieval for a 40-year-old male who has just presented with severe burns after a gas canister explosion.

How will you guide the junior doctor through the assessment of the patient? (Details about the management are not required).
 

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College answer

Initial assessment of patient:

  • Brief review of history to establish likelihood of other trauma (e.g. blast injury/ trauma from explosion or fall) and time of event
  • Primary survey:
    • Airway and potential for airway involvement
      • Burns to face/soot in mouth/nose/singed facial hair/hoarse voice
      • Whether trapped in enclosed space with fire- increase risk of inhalational injury
      • Signs of potential airway compromise or likely to develop airway compromise- may need to organise for early intubation if skilled airway practitioner available; otherwise await retrieval team
    • Breathing:
      • Particularly with assessment of possible complications if blast injury occurred or additional trauma e.g.: pneumothoraces – check airway is midline, bilateral air entry present or not- whether chest X-ray has been done and checked for pneumothorax.
      • Possible pulmonary contusions
      • Blood gas to assess ventilation, oxygen saturation, carbon dioxide, carboxyhaemoglobin levels
    • Circulation:
      • Confirm haemodynamic parameters- heart rate, blood pressure, peripheral perfusion
      • Whether adequate iv access available; ideally 2 large bore cannulae through non- burnt skin; through burnt skin if necessary, IO if unsuccessful at obtaining this access need to be organised.
    • Disability:
      • Assessment of GCS of the patient for any head injury or evidence of CO poisoning.
      • Pupillary responses
    • Exposure:
      • To assess extent of burns + environmental/temp control
  • Assessment of extent of burns – with reference to estimated percentage and depth – refer junior doctor if required to Lund Browder burns chart, Wallace rule of 9s (quicker in emergency) or Hand surface area to estimate percentage; with superficial burns (erythema only) not being included in assessment – and establish if circumferential involvement
  • use of photos or tele-health if available may facilitate assessment
  • establish if any compromise neurovascularly in case early escharotomies required
  • assessment of whether local surgical expertise is available to do this.
  • Secondary Survey:
    • Establish past medical history/co-morbidities/medications/allergies
    • Head to toe exam particularly looking for complications of burns or blast:
      • E.g.: head injury
      • Eye injury + protection/chlorsig if eye involvement
      • Fractures/lacerations
      • Neurovascular complications from circumferential burns to limbs
      • Circumferential burns to chest which may impair ventilation
    • Other assessments:
      • Pain assessment and need for analgesia
      • Urine output monitoring by inserting IDC
      • Temperature assessment

Examiners Comments:

A number of candidates gave long lists of investigations and personnel only available in a large centre- candidates were marked down for this though not failed if the rest of the answer was of an acceptable standard

Discussion

Assessment of the burns patent in this SAQ scenario was made more flavourful by the additional complexity of telemedicine. What would you ask this junior doctor to look for, and how would you describe the findings over the phone? This is a pleasant variation on the same theme as  Question 16 from the second paper of 2019, Question 26 from the second paper of 2016, Question 18 from the second paper of 2012, and so forth. 

  1.  Look for signs of  airway burns:
    1. Singed nose hairs
    2. Oral or nasal burns
    3. Soot in the sputum
    4. Mucosal oedema
    5. About twenty other features...
  2.  Features of carbon monoxide or cyanide poisoning
    1. Get an ABG:  look at the carboxyhaemoglobin concentration and lactate
    2. There may be no ABG machine in this bucolic wonderland. Look at your blood sample: if the venous sample looks suspiciously scarlet, there may be carbon monoxide toxicity
  3.  Hypotension, hypovolemia, access for fluid resuscitation:
    Determine where you are going to put your IV access
    Determine whether there are any concerning burn patterns:
    1. Presence of circumferential burns
    2. Presence of corneal, perineal or genital burns 
  4. Decreased level of consciousness, head injury; don't forget to think about analgesia
  5. Electrolyte disturbance: hyponatremia and hyperkalemia
    Send some bloods for biochemistry (EUCs and CMPs)
    Exposure and assessment of total burned areas:
    1. Wallace rule of nines
    2. Palmart surface method
  6. Urine output (the most important parameter to guide fluid resuscitation)
  7. Haematocrit: haemoconcentration is a sign of volume depletion
  8. Temperature: the patient may either still be hot from the fire (in which case, put them out) or - more likely - they will be hypothermic from their loss of thermoregulation (in which case, expose them to radiant heat to maintain normothermia).

References