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. Burns Thermal, chemical, electrical or radiation injury to the skin and deeper tissues. A 27% partial-thickness burn with no airway signs fits.
2. Airway burn Facial burns, singed nasal hairs, soot and a hoarse voice, threatening the airway. A 27% partial-thickness burn with no airway signs makes it the emergency.
3. Deep partial-thickness burn Less painful with reduced sensation and mottled colour, at risk of scarring. A 27% partial-thickness burn with no airway signs points to it.
4. Full-thickness burn Painless, white or leathery and non-blanching, needing grafting. A 27% partial-thickness burn with no airway signs raises it.
5. Superficial partial-thickness burn correct Correct. Red, blistered, moist and painful skin is superficial partial-thickness. The depth matters for healing and grafting, but the priority here is the large area.

The point: Assess a burn by its depth, its total body surface area, and the presence of airway involvement. Superficial burns are red and painful; superficial partial-thickness blister and are painful; deep partial-thickness are less painful with reduced sensation; and full-thickness are painless, white or leathery. Estimate the area with the rule of nines in adults or the patient's palm as about 1%, not counting simple erythema. Fluid resuscitation with the Parkland formula is for adults with over 15% and children with over 10% surface area: 4 mL times weight in kg times percentage burn of crystalloid over 24 hours, half in the first 8 hours from the time of injury, titrated to a urine output of 0.5 to 1 mL/kg/h. Suspect airway burns with facial burns, singed nasal hairs, soot in the mouth, a hoarse voice or stridor, and intubate early before oedema closes the airway. Circumferential full-thickness burns of a limb or the chest may need escharotomy. Refer to a burns unit by the 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 initial investigation?

1. Urine output monitoring The endpoint of fluid resuscitation, titrated to 0.5 to 1 mL/kg/h. A 27% partial-thickness burn with no airway signs makes it decisive.
2. Assess depth, total body surface area and airway The three assessments that drive management: fluid, referral and the need to secure the airway. A 27% partial-thickness burn with no airway signs makes them first.
3. Look for airway involvement Facial burns, singed nasal hairs, soot in the mouth, a hoarse voice or stridor mandate early intubation. A 27% partial-thickness burn with no airway signs makes it necessary.
4. Assess for circumferential burns and distal perfusion Circumferential full-thickness burns can impair perfusion or ventilation and need escharotomy. A 27% partial-thickness burn with no airway signs makes it important.
5. Estimate the burn area with the rule of nines or the palm correct Correct. The 27% estimate is what determines the fluid resuscitation and the referral, so accurate area assessment is essential.

The point: Assess a burn by its depth, its total body surface area, and the presence of airway involvement. Superficial burns are red and painful; superficial partial-thickness blister and are painful; deep partial-thickness are less painful with reduced sensation; and full-thickness are painless, white or leathery. Estimate the area with the rule of nines in adults or the patient's palm as about 1%, not counting simple erythema. Fluid resuscitation with the Parkland formula is for adults with over 15% and children with over 10% surface area: 4 mL times weight in kg times percentage burn of crystalloid over 24 hours, half in the first 8 hours from the time of injury, titrated to a urine output of 0.5 to 1 mL/kg/h. Suspect airway burns with facial burns, singed nasal hairs, soot in the mouth, a hoarse voice or stridor, and intubate early before oedema closes the airway. Circumferential full-thickness burns of a limb or the chest may need escharotomy. Refer to a burns unit by the 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. Parkland formula fluid resuscitation correct Correct. At 27% he is well over the 15% threshold. Parkland gives 4 mL times 80 kg times 27, which is about 8,640 mL over 24 hours, half in the first 8 hours from injury, titrated to urine output.
2. Early excision and skin grafting For deep partial and full-thickness burns that will not heal spontaneously. A 27% partial-thickness burn with no airway signs meets that.
3. Secure the airway early for suspected airway burns Intubate before oedema closes the airway, because it becomes impossible later. A 27% partial-thickness burn with no airway signs demands it.
4. Refer to a specialist burns unit by the criteria A burn of this size meets the referral criteria and needs specialist care for wound management and possible grafting, and a 27% partial-thickness burn with no airway signs here points elsewhere.
5. Analgesia and tetanus prophylaxis Burns are painful and tetanus-prone, and both are addressed early. A 27% partial-thickness burn with no airway signs makes it necessary.

The point: Assess a burn by its depth, its total body surface area, and the presence of airway involvement. Superficial burns are red and painful; superficial partial-thickness blister and are painful; deep partial-thickness are less painful with reduced sensation; and full-thickness are painless, white or leathery. Estimate the area with the rule of nines in adults or the patient's palm as about 1%, not counting simple erythema. Fluid resuscitation with the Parkland formula is for adults with over 15% and children with over 10% surface area: 4 mL times weight in kg times percentage burn of crystalloid over 24 hours, half in the first 8 hours from the time of injury, titrated to a urine output of 0.5 to 1 mL/kg/h. Suspect airway burns with facial burns, singed nasal hairs, soot in the mouth, a hoarse voice or stridor, and intubate early before oedema closes the airway. Circumferential full-thickness burns of a limb or the chest may need escharotomy. Refer to a burns unit by the criteria.

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