General Surgery · Year 3 · from General Surgery

Case 1: Major Thermal Burn

Patient Demographics

  • Age: 32 years
  • Sex: Male
  • Occupation: Firefighter

Chief Complaint

Patient brought by EMS after house fire rescue

History of Present Illness

The patient was injured while rescuing a child from a house fire. His protective gear was partially compromised when a ceiling collapsed. He was trapped briefly before being extracted by colleagues. He was awake at the scene but confused. His clothing was smoldering on arrival of backup. EMS initiated cooling and fluid resuscitation.

Prehospital Management

  • Removal from fire environment
  • Removal of smoldering clothing
  • Cooling with room temperature water (stopped to prevent hypothermia)
  • Supplemental oxygen 100% via non-rebreather
  • Large-bore IV access, LR initiated

Primary Survey

  • A: Hoarse voice, soot in mouth and nares, singed facial hair - HIGH RISK FOR AIRWAY COMPROMISE
  • B: RR 28, bilateral rhonchi, no stridor yet
  • C: BP 108/68, HR 124, 2 large-bore IVs
  • D: GCS 14 (confused)
  • E: Extensive burns (see burn assessment below)

Immediate Airway Management

Given hoarseness, facial burns, and soot in airway:

  • Early intubation performed (anticipating airway edema)
  • Laryngoscopy: Supraglottic edema and carbonaceous material
  • Successfully intubated with 7.5 ETT
  • If delayed, airway edema would have made intubation impossible

Burn Assessment

Rule of Nines Calculation:

  • Face/head: 4.5% (partial thickness)
  • Anterior trunk: 18% (mixed partial and full thickness)
  • Both arms: 18% (9% each, circumferential, mixed depth)
  • Right leg: 9% (partial thickness)
  • Total Body Surface Area (TBSA): ~50%

Burn Depth Assessment:

  • Superficial partial thickness: Face, right leg
  • Deep partial thickness: Anterior trunk (portions), arms
  • Full thickness: Portions of anterior trunk, bilateral forearms

Inhalation Injury Assessment

  • Clinical signs: Facial burns, singed nasal hair, carbonaceous sputum
  • Bronchoscopy performed after intubation: Carbonaceous deposits, erythema, edema of bronchial mucosa
  • Confirmed inhalation injury

Fluid Resuscitation (Parkland Formula)

4 mL × body weight (kg) × %TBSA

  • Weight: 80 kg
  • TBSA: 50%
  • Total 24-hour crystalloid: 4 × 80 × 50 = 16,000 mL
  • First 8 hours: 8,000 mL (half)
  • Next 16 hours: 8,000 mL
  • Give half in first 8 hours from time of injury (not from arrival)
  • Target urine output: 0.5-1.0 mL/kg/hr

Initial Laboratory Results

  • Carboxyhemoglobin: 18% (significant exposure)
  • Lactate: 4.2 mmol/L
  • Hemoglobin: 16.8 g/dL (hemoconcentration)
  • Creatinine: 1.4 mg/dL
  • CK: 2,400 U/L (elevated - rhabdomyolysis risk)

Carbon Monoxide Poisoning Treatment

  • 100% FiO2 via ventilator
  • Consider hyperbaric oxygen if available and patient stable for transport
  • COHb half-life: ~320 minutes on room air vs. ~80 minutes on 100% O2

Escharotomy

  • Bilateral upper extremity circumferential burns
  • Compartment pressures elevated
  • Bedside escharotomies performed on both arms
  • Restored distal pulses and improved perfusion

Burn Center Admission

  • Burn ICU
  • Continuous fluid titration to urine output
  • Mechanical ventilation with lung-protective strategy
  • Early enteral nutrition (started within 24 hours)
  • Infection prevention protocols

Wound Care

  • Initial: Cleansing and debridement of loose tissue
  • Topical antimicrobial: Silver sulfadiazine
  • Daily wound assessment

Surgical Planning

  • Early excision and grafting planned for deep partial and full thickness burns
  • First surgery: Day 3-5 (after stabilization)
  • Staged procedures given large TBSA

Operative Procedure (Day 4)

  • Tangential excision of anterior trunk and bilateral arms
  • Split-thickness skin grafting (autograft from thighs)
  • Temporary coverage of remaining areas with allograft (cadaveric skin)
  • Estimated blood loss: 1.2L (replaced with blood products)

Hospital Course

  • Multiple staged grafting procedures
  • Tracheostomy Day 14 (prolonged ventilation)
  • Weaned from ventilator Day 21
  • Aggressive physical/occupational therapy
  • Nutritional support throughout (high-protein, high-calorie diet)
  • Discharged to rehabilitation Day 45

Teaching Points

  1. Early intubation for airway concerns (edema peaks at 24-48 hours)
  2. Parkland formula guides initial fluid resuscitation
  3. Urine output is the best guide for adequate resuscitation
  4. Escharotomy for circumferential burns with compartment syndrome
  5. Early excision and grafting improves outcomes
  6. Inhalation injury significantly increases morbidity and mortality
  7. Burn care requires multidisciplinary approach

Clinical Image

Image Description: Rule of Nines diagram used for rapid estimation of total body surface area (TBSA) affected by burns. This standardized assessment tool divides the adult body into regions representing 9% (or multiples thereof) of total body surface area.

Attribution: Image from Wikimedia Commons, Category:Burns. Source: https://commons.wikimedia.org/wiki/Category:Burns

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