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SU4.1-4 | Burns — PBL Case

CLINICAL SETTING

A 45-year-old male factory worker is brought to a rural district hospital by his colleagues four hours after an industrial accident in which a boiler exploded and he was engulfed in flames and superheated steam in an enclosed room. He weighs 80 kg. On arrival he is restless, his voice is hoarse, there is soot in his mouth and singed nasal hair, and he has extensive deep burns over both upper limbs, the front and back of his trunk, and the front of both lower limbs. No fluids have yet been started. The nearest specialist burns unit is three hours away by road. Your group is asked to work through his resuscitation, transfer and longer-term recovery, and to reason explicitly about how the delay between the burn and arrival affects management.

Trigger 1: The first hour — airway, breathing and the enclosed-space burn

The patient is restless with a hoarse voice, soot in the mouth and singed nasal hair after a burn sustained in an enclosed room with steam. His oxygen saturation reads normal on the monitor, but his breathing is becoming laboured.

DISCUSSION POINTS

  • Why does the history of an enclosed-space burn with steam, soot and a hoarse voice raise immediate concern, and what is the priority action?
  • Why can a 'normal' pulse-oximeter reading be falsely reassuring in this setting?
  • How does approaching this patient along ABCDE change what you do in the first few minutes compared with simply dressing the wounds?
Click to reveal Trigger 2: Calculating and timing the fluid resuscitation (discuss previous trigger first!)

Trigger 2: Calculating and timing the fluid resuscitation

The team estimates the burn extent and prepares to start fluids. Four hours have already passed since the burn, and no fluid has yet been given. The group must calculate the requirement and decide how to deliver it given the delay and the long transfer ahead.

DISCUSSION POINTS

  • Estimate this patient's %TBSA using the Rule of Nines and calculate his 24-hour Parkland requirement, showing your working.
  • Given that four hours have already elapsed since the burn, over what period must the first half of the fluid now be given, and why?
  • What end point will you use at the bedside to confirm the resuscitation is adequate, and how will you adjust the rate?
Click to reveal Trigger 3: Transfer and the road to rehabilitation (discuss previous trigger first!)

Trigger 3: Transfer and the road to rehabilitation

The patient is stabilised for a three-hour transfer to the burns unit. His family asks what his recovery will be like and whether he will be able to return to work. He has deep circumferential burns of one forearm and the hand is becoming cool.

DISCUSSION POINTS

  • What must be assessed and acted upon before and during transfer, including the cooling, pulseless forearm?
  • What are the two arms of burn rehabilitation, and what would you tell the family honestly and empathically about his likely recovery?
  • How would you counsel the patient about contracture prevention and return to work without giving false reassurance?

Group Task Assignments

  • Construct a timeline of the first 24 hours for this patient, marking the burn time, arrival time, the Parkland clock, and exactly how much fluid should be running at each stage.
  • Produce a labelled Rule-of-Nines body diagram for this patient and tabulate the %TBSA contribution of each burned region.
  • List the indications for, and the technique and warning signs that mandate, an escharotomy of the circumferentially burned forearm.
  • Draft a structured, empathic counselling script for the family covering both the physical and psychological arms of rehabilitation.

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [SU4.1] What is the pathophysiology of a major burn, including burn shock and the systemic effects that make early trauma-based assessment essential?
  2. [SU4.2] How are the depth and extent (%TBSA) of a burn diagnosed, and how is fluid resuscitation calculated and timed using the Parkland formula from the time of the burn?
  3. [SU4.2] What are the indications for and technique of escharotomy in a circumferential full-thickness burn?
  4. [SU4.4] How should outcome and rehabilitation be communicated to a burn patient and family, addressing both physical and psychological recovery with empathy?