Surgery for PLAB 1

A 34 year old man weighing 80 kg is rescued from a house fire. He has burns to his entire right arm, the front of his torso and the front of his right leg, which are red, blistered, moist and very painful. He has no facial burns, a clear voice and no soot in his mouth. Using the rule of nines his burn is estimated at 27% of his body surface area. What is the SINGLE most likely diagnosis?

1. Deep partial-thickness burn Less painful, with reduced feeling and a blotchy colour, at risk of scarring. Here, a 27% partial-thickness burn with no airway signs points elsewhere.
2. Airway burn Facial burns, singed nose hairs, soot and a hoarse voice, threatening the airway. It does not fit a 27% partial-thickness burn with no airway signs.
3. Full-thickness burn Painless, white or leathery skin that does not go pale when pressed, needing a skin graft. That does not match a 27% partial-thickness burn with no airway signs.
4. Scald A burn from hot liquid, the commonest cause in children and something to think about for safeguarding. But a 27% partial-thickness burn with no airway signs does not point to it.
5. Superficial partial-thickness burn correct Correct. Red, blistered, moist, painful skin is a superficial partial-thickness burn. The depth matters for healing and grafting, but the size of the area is the main concern here.

The point: Judge a burn by how deep it is, how much of the body it covers, and whether the airway is involved. Superficial burns are red and painful. Superficial partial-thickness burns blister and are painful. Deep partial-thickness burns hurt less and feel less because the nerve endings are damaged. Full-thickness burns are painless and look white or leathery. Work out the area with the rule of nines in adults, or use the patient's own palm as about 1% of their body, and do not count plain redness with no blister. Give fluid through a drip using the Parkland formula for adults with over 15% of their body burned and children with over 10%: 4 mL times the weight in kg times the percentage burned, given as plain fluid (crystalloid) over 24 hours, half in the first 8 hours from the time of the injury, adjusted to keep the urine output at 0.5 to 1 mL/kg an hour. Suspect an airway burn with facial burns, singed nose hairs, soot in the mouth, a hoarse voice or a harsh breathing sound (stridor), and put in a breathing tube early, before swelling closes the airway off completely. A burn that goes all the way round a limb or the chest and is full-thickness may need a cut through the burnt skin to relieve the pressure (escharotomy). Refer to a specialist burns unit using the set criteria.

Source: British Burn Association / referral criteria British Burn Association · tier 2, specialty society or college

A 34 year old man weighing 80 kg is rescued from a house fire. He has burns to his entire right arm, the front of his torso and the front of his right leg, which are red, blistered, moist and very painful. He has no facial burns, a clear voice and no soot in his mouth. Using the rule of nines his burn is estimated at 27% of his body surface area. What is the SINGLE most appropriate immediate management?

1. Escharotomy for a constricting circumferential burn A cut through the burnt skin to bring back blood flow to a limb or let the chest move to breathe. But a 27% partial-thickness burn with no airway signs does not point to it.
2. Early excision and skin grafting For deep partial-thickness and full-thickness burns that will not heal on their own. Here, a 27% partial-thickness burn with no airway signs points elsewhere.
3. Secure the airway early for suspected airway burns Put in a breathing tube before swelling closes the airway, because doing it later becomes impossible. It does not fit a 27% partial-thickness burn with no airway signs.
4. Parkland formula fluid resuscitation correct Correct. At 27% he is well over the 15% mark. The Parkland sum gives 4 mL times 80 kg times 27, which comes to about 8,640 mL over 24 hours, half in the first 8 hours from the injury, adjusted to the urine output.
5. Analgesia and tetanus prophylaxis Burns are painful and prone to tetanus, and both are dealt with early. That does not match a 27% partial-thickness burn with no airway signs.

The point: Judge a burn by how deep it is, how much of the body it covers, and whether the airway is involved. Superficial burns are red and painful. Superficial partial-thickness burns blister and are painful. Deep partial-thickness burns hurt less and feel less because the nerve endings are damaged. Full-thickness burns are painless and look white or leathery. Work out the area with the rule of nines in adults, or use the patient's own palm as about 1% of their body, and do not count plain redness with no blister. Give fluid through a drip using the Parkland formula for adults with over 15% of their body burned and children with over 10%: 4 mL times the weight in kg times the percentage burned, given as plain fluid (crystalloid) over 24 hours, half in the first 8 hours from the time of the injury, adjusted to keep the urine output at 0.5 to 1 mL/kg an hour. Suspect an airway burn with facial burns, singed nose hairs, soot in the mouth, a hoarse voice or a harsh breathing sound (stridor), and put in a breathing tube early, before swelling closes the airway off completely. A burn that goes all the way round a limb or the chest and is full-thickness may need a cut through the burnt skin to relieve the pressure (escharotomy). Refer to a specialist burns unit using the set criteria.

Source: British Burn Association / referral criteria British Burn Association · tier 2, specialty society or college

A 34 year old man weighing 80 kg is rescued from a house fire. He has burns to his entire right arm, the front of his torso and the front of his right leg, which are red, blistered, moist and very painful. He has no facial burns, a clear voice and no soot in his mouth. Using the rule of nines his burn is estimated at 27% of his body surface area. What is the SINGLE most appropriate definitive management?

1. Escharotomy for a constricting circumferential burn A cut through the burnt skin to bring back blood flow to a limb or let the chest move to breathe. But a 27% partial-thickness burn with no airway signs does not point to it.
2. Refer to a specialist burns unit by the criteria correct Correct. A burn this size meets the referral rules and needs specialist care for the wound and possibly a skin graft.
3. Secure the airway early for suspected airway burns Put in a breathing tube before swelling closes the airway, because doing it later becomes impossible. Here, a 27% partial-thickness burn with no airway signs points elsewhere.
4. High-flow oxygen for smoke inhalation For carbon monoxide poisoning, which shortens how long the poisoned form of haemoglobin stays in the blood. That does not match a 27% partial-thickness burn with no airway signs.
5. Safeguarding assessment for a suspicious burn For a burn in a child where the history does not add up or the pattern looks suspicious. It does not fit a 27% partial-thickness burn with no airway signs.

The point: Judge a burn by how deep it is, how much of the body it covers, and whether the airway is involved. Superficial burns are red and painful. Superficial partial-thickness burns blister and are painful. Deep partial-thickness burns hurt less and feel less because the nerve endings are damaged. Full-thickness burns are painless and look white or leathery. Work out the area with the rule of nines in adults, or use the patient's own palm as about 1% of their body, and do not count plain redness with no blister. Give fluid through a drip using the Parkland formula for adults with over 15% of their body burned and children with over 10%: 4 mL times the weight in kg times the percentage burned, given as plain fluid (crystalloid) over 24 hours, half in the first 8 hours from the time of the injury, adjusted to keep the urine output at 0.5 to 1 mL/kg an hour. Suspect an airway burn with facial burns, singed nose hairs, soot in the mouth, a hoarse voice or a harsh breathing sound (stridor), and put in a breathing tube early, before swelling closes the airway off completely. A burn that goes all the way round a limb or the chest and is full-thickness may need a cut through the burnt skin to relieve the pressure (escharotomy). Refer to a specialist burns unit using the set criteria.

Source: British Burn Association / referral criteria British Burn Association · tier 2, specialty society or college