You get a phone call from a frantic mother. Her 7 year old girl spilled Drano all over her arms
and legs. You can hear the girl screaming in pain in the background.
Management: The point of this question is that chemical injuries – particularly alkalis-need
copious, immediate, profuse irrigation. Instruct the mother to do so right at home with tap water,
for at least 30 minutes before rushing the girl to the E.R.
43. – While trying to hook up illegally to cable TV, an unfortunate man comes in contact with a high
tension electrical power line. He has an entrance burn wound in the upper outer thigh and an exit
burn lower down on the same side.
Management: The issue here is that electrical burns are always much bigger than they appear to
be. There is deep tissue destruction. The patient will require extensive surgical debridement, but
there is also another item (more likely to be the point of the question): Myoglobinemia, leading to
myoglobinuria and to renal failure. Patient needs lots of IV fluids, diuretics (osmotic if given that
choice i.e. Mannitol), perhaps alkalinization of the urine.
44. – A man is rescued by firemen from a burning building. On admission it is noted that he has burns
around the mouth and nose, and the inside of his mouth and throat look like the inside of a
chimney.
What is it? – The issue here is respiratory burns, i.e.: smoke inhalation producing a chemical burn
of the tracheobronchial tree. It happens with flame burns in an enclosed space. The burns in the
face are an additional clue that most patients will not have.
Diagnosis is made with bronchoscopy.
Management revolves around respiratory support.
45. – A patient has suffered third degree burns to both of his arms when his shirt caught on fire while
lighting the back yard barbecue. The burned areas are dry, white, leatherly anesthetic, and
circumferential all around arms and forearms.
What is it? – You are meant to recognize the problem posed by circumferential burns: The
leatherly eschar will not expand, while the are under the burn will develop massive edema, thus
circulation will be cut off. (Or in the case of circumferential burns of the chest, breathing will be
compromised). Note that if the fire was in the open space of the backyard, respiratory burn is not
an issue.
Management: Compulsive monitoring of peripheral pulses and capillary filling.
Escharotomies at the bedside at the first sign of compromised circulation.
46. – A toddler is brought to the E.R. with burns on both of his buttocks. The areas are moist, have
blisters and are exquisitely painful to touch. The story is that the kid accidentally pulled a pot of
boiling water over himself.
What is it ? – Burns, of course…but there are several issues: first, how deep. The description is
classical for second degree. (Note hat in kids third degree is deep bright red, rather than white
leatherly as in the adult). How did it really happen? Burns in kids always bring up the possibility
of child abuse, particularly if they have the distribution that you would expect if you grabbed the
kid by arms and legs and dunked him in a pot of boiling water.
Management for the burn is silvadene (silver sulphadiazine) cream. Management for the kid may
require reporting to authorities for child abuse.
47. – An adult male who weight “X” Kgs. Sustains second and third degree burns over —whatever—
The burns will be depicted in a drawing, indicating what is second degree (moist, blisters, painful)
and what is third degree (white, leatherly, anesthetic). The question will be about fluid
resuscitation.
Management: - Time to dust off the old formula: 4cc per Kg. of body weight per percentage of
burned are (up to 50). Percentage to be calculated by the rule of nines: one nine each for head and
arms, two nines for each leg, four nines for the trunk. (In kids the head is twice as big, the legs
take up the slack). Give ringers lactate, pour it in so that half of the calculated dose goes in during
first 8 hours.
Lots of additional questions could ensue from the basic burn vignette:
If the colloids are to be used, give them in the second day (not the first).
Monitoring to see if your calculation are correct: CVP and hourly urinary output. Keep the former
below 15 or 20, aim for 1 cc per Kg body weight per hour for the latter.
Circumstances where additional fluid is needed (aiming for urinary output of two cc per Kg per
hour, instead of one): electrical burns, patients who get escharotomy.
A classical one, bound to be in the test somewhere: Patient was well resuscitated, had good
hemodynamic parameters but required a lot of fluid. On the third day he starts to pee out a storm.
What does that mean? : nothing. You expect it. The fluid from the burn edema is coming back to
the circulation.
What to do for the burn areas? After the obvious cleansing, silvadene cream for most areas,
sulphamyelon where deep penetration is needed (cartilage, thick eschar), triple antibiotic ointment
in the face near the eyes (silvadene hurts the eyes).
Skin grafting will ensue, but they will not ask about it ( too technical). However the emphasis on
prevention may lead to questions about the timing of rehabilitation: the answer is that
rehabilitation starts on day one.
48. – A 42 year old lady drops her hot iron on her lap while doing the laundry. She comes in with the
shape of the iron clearly delineated on her upper thigh. The area is white, dry, leatherly,
anesthetic.
What is the issue? - A current favorite of burn treatment is the concept of early excision and
grafting. After fluid resuscitation the typical burn patient spends two weeks in the hospital
consuming thousand of dollars of health care every day, getting topical treatment to the burn areas
and intensive nutritional support in preparation for skin grafting. In most cases there is no
alternative. But less extensive burns can be taken to the O.R., excised and grafted on day one,
saving tons of money. You will not be asked to provide the fine judgement call for the borderline
case that might be done that way, but the vignette is a classical one where the decision is easy:
very small and clearly third degree.
Answer: Early excision and grafting.