# Clinical Cases: Burn 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
![Burn TBSA Assessment](case_01_image.jpg)

**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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## Case 2: Electrical Burn

### Patient Demographics
- **Age:** 45 years
- **Sex:** Male
- **Occupation:** Electrician

### Chief Complaint
Found unresponsive after workplace electrical accident

### History of Present Illness
The patient was working on a high-voltage power line (7,200 volts) when contact occurred. Coworkers witnessed him being thrown from the utility pole. CPR was initiated at the scene for approximately 2 minutes before return of spontaneous circulation. He has entrance wounds on his right hand and exit wounds on his left foot.

### Prehospital Information
- Witnessed cardiac arrest (ventricular fibrillation)
- Defibrillated x2 with ROSC
- Intubated for airway protection
- C-spine immobilized (fall from height)

### Primary Survey
- **A:** Intubated, secured
- **B:** Bilateral breath sounds
- **C:** BP 92/58, HR 116, irregular rhythm
- **D:** GCS 3T (sedated)
- **E:** Entrance and exit wounds, fall-related injuries

### Burn Assessment

**Visible Burns:**
- Right hand: Full thickness contact burn (entrance)
- Right forearm: Deep partial thickness
- Left foot: Full thickness (exit wound)
- **Surface TBSA appears small (~5%)**

**However:** External appearance underestimates severity in electrical burns

### Cardiac Monitoring
- ECG: Sinus tachycardia with occasional PVCs
- Troponin: 2.4 ng/mL (elevated - myocardial injury)
- Continuous telemetry monitoring required

### Laboratory Results
- CK: 28,000 U/L (markedly elevated - severe rhabdomyolysis)
- Myoglobin: Markedly elevated
- Creatinine: 1.8 mg/dL
- Potassium: 5.8 mEq/L
- Lactate: 5.2 mmol/L
- Urinalysis: Tea-colored urine, positive for myoglobin

### Rhabdomyolysis Management
- Aggressive IV fluid resuscitation (goal UOP 1-2 mL/kg/hr)
- Urine alkalinization (sodium bicarbonate)
- Monitor for compartment syndrome
- Monitor renal function closely
- Avoid nephrotoxins

### Compartment Syndrome Evaluation
- Right forearm: Tense, painful with passive stretch
- Compartment pressures measured: 42 mmHg (elevated)
- **Fasciotomy indicated**

### Fasciotomy
- Right forearm fasciotomy performed
- All compartments released
- Muscle appeared partially necrotic
- Wound left open with planned return to OR

### Trauma Workup (Fall from Height)
- CT head: No intracranial hemorrhage
- C-spine CT: No fracture
- CT chest/abdomen/pelvis: No traumatic injury
- Thoracolumbar spine: No fracture
- Pelvis X-ray: Intact

### Operative Management
**First surgery (Day 0):**
- Right forearm fasciotomy
- Debridement of necrotic tissue

**Second surgery (Day 2):**
- Further debridement of right forearm (necrotic muscle excised)
- Left foot debridement
- Wound VAC placement

**Third surgery (Day 5):**
- Delayed primary closure of forearm fasciotomy
- Right hand debridement - partial amputation of digits 3 and 4 required
- Split-thickness skin grafting to left foot

### Hospital Course
- ICU x 7 days
- Renal function recovered (avoided dialysis)
- Cardiac enzymes trended down
- No further arrhythmias
- Extensive physical and occupational therapy
- Psychological support for traumatic injury and digit loss
- Discharged to rehabilitation Day 18

### Teaching Points
1. Electrical burns: "Tip of the iceberg" - external burns underestimate internal injury
2. High-voltage injuries cause deep tissue damage along current path
3. Cardiac monitoring essential (arrhythmia risk)
4. Rhabdomyolysis management: Aggressive fluids, alkalinization
5. High risk for compartment syndrome - low threshold for fasciotomy
6. Multiple debridements often required
7. Fall-related injuries must be evaluated (secondary trauma)

### Clinical Image
![Electrical Burn Injury](case_02_image.jpg)

**Image Description:** Clinical photograph of an electrical burn showing the characteristic entry wound with full-thickness tissue destruction. The surface injury often appears smaller than the extensive underlying tissue damage caused by electrical current passing through the body.

**Attribution:** Image from Wikimedia Commons, Category:Electrical burns. Source: https://commons.wikimedia.org/wiki/Category:Electrical_burns

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## Case 3: Chemical Burn

### Patient Demographics
- **Age:** 28 years
- **Sex:** Female
- **Occupation:** Laboratory technician

### Chief Complaint
"Acid spilled on my arm and face during an experiment."

### History of Present Illness
The patient was working in a chemistry laboratory when a container of concentrated sulfuric acid (98%) broke, splashing onto her right arm, chest, and face. Coworkers immediately initiated emergency eyewash and shower protocols. She was under running water for approximately 20 minutes before EMS arrival. She reports severe pain in the affected areas. She was wearing safety glasses, which partially protected her eyes.

### Prehospital Care
- Continued water irrigation during transport
- Removal of contaminated clothing
- Dry chemical brushed off before water (standard protocol)

### Primary Survey
- **A:** Patent, speaking clearly, no oral involvement
- **B:** Normal respiratory effort, no chest involvement affecting breathing
- **C:** BP 142/88, HR 108 (pain response), stable
- **D:** GCS 15, alert and oriented
- **E:** Chemical burns to right arm, right chest, right face

### Burn Assessment

**Areas Affected:**
- Right forearm and hand: 4.5% TBSA
- Right chest (lateral): 4.5% TBSA
- Right face: 2% TBSA (spared central face/eyes due to glasses)
- **Total TBSA: ~11%**

**Burn Depth:**
- Face: Superficial partial thickness
- Chest: Deep partial thickness
- Forearm: Mixed partial and full thickness

**Chemical Identification:**
- Agent: Sulfuric acid (strong acid)
- Concentration: 98%
- Mechanism: Coagulation necrosis (acids cause protein denaturation)

### Eye Examination
- Visual acuity: Intact bilaterally
- Slit lamp: Minor conjunctival irritation, no corneal burns
- Continued irrigation with normal saline

### Decontamination
- Continued copious water irrigation in ED
- pH monitoring of skin surface
- Irrigation until pH normalizes (approximately 30 minutes additional)
- No neutralizing agents used (exothermic reaction risk)

### Wound Care
- After adequate decontamination:
  - Gentle cleansing
  - Debridement of loose tissue
  - Topical antimicrobial (silver sulfadiazine)
  - Sterile dressings

### Pain Management
- IV opioids for initial pain control
- Tetanus prophylaxis updated

### Hospital Admission
- Burn unit admission for wound monitoring
- Fluid resuscitation (modified Parkland - smaller TBSA)
- Daily wound assessments

### Wound Evolution
- Day 3: Face burns healing well (superficial)
- Day 5: Chest burns showing epithelialization
- Day 7: Forearm burns delineating - areas of full thickness confirmed

### Surgical Management (Day 10)
- Forearm: Tangential excision of full-thickness areas
- Split-thickness skin grafting
- Face and chest: Healed with conservative management

### Hospital Course
- No infection
- Grafts take: 100%
- Physical therapy for hand function
- Scar management education
- Discharged Day 14

### Follow-up Care
- Compression garments for hypertrophic scar prevention
- Silicone gel sheets
- Moisturization
- Sun protection
- Scar massage

### Long-term Considerations
- Psychological support (facial scarring)
- Occupational safety review
- Return to work planning with safety modifications

### Teaching Points
1. Immediate copious water irrigation is the priority for chemical burns
2. Continue irrigation until pH normalizes (may take hours)
3. Do NOT use neutralizing agents (risk of exothermic reaction)
4. Acids cause coagulation necrosis (limits depth of penetration somewhat)
5. Alkali burns often more severe (liquefaction necrosis, deeper penetration)
6. Identify the chemical agent when possible
7. Eye involvement requires aggressive irrigation and ophthalmology consult
8. Chemical burns may evolve over 24-72 hours

### Clinical Image
![Chemical Burn Injury](case_03_image.jpg)

**Image Description:** Clinical photograph demonstrating a chemical burn with characteristic demarcated borders following the splash pattern of the caustic agent. The wound shows coagulation necrosis typical of acid burns with varying depths of tissue injury.

**Attribution:** Image from Wikimedia Commons, Category:Chemical burns. Source: https://commons.wikimedia.org/wiki/Category:Chemical_burns