Resident Readiness General Surgery (29 page)

4.
Yes; because this second-degree burn involves the face, this patient should be transferred to a burn center. According to the American Burn Association the following 10 items require transfer to a burn center:

1.
Partial thickness burns greater than 10% TBSA.

2.
Burns that involve the face, hands, feet, genitalia, perineum, or major joints.

3.
Third-degree burns in any age group.

4.
Electrical burns, including lightning injury.

5.
Chemical burns.

6.
Inhalation injury.

7.
Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality.

8.
Any patient with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality. In such cases, if the trauma poses the greater immediate risk, the patient may be initially stabilized in a trauma center before being transferred to a burn unit. Physician judgment will be necessary in such situations and should be in concert with the regional medical control plan and triage protocols.

9.
Burned children in hospitals without qualified personnel or equipment for the care of children.

10.
Burn injury in patients who will require special social, emotional, or rehabilitative intervention.

5.
Escharotomy: A circumferential second- or third-degree burn, on extremities or digits, has the potential to compromise circulation. A significant burn on the anterior torso has the potential to compromise ventilation. Prompt attention to such burns can prevent serious complications. The appropriate anatomic sites for escharotomies vary; however, a proper escharotomy should extend into normal skin on either end of the incision and penetrate through the dermis up to the subcutaneous tissue. The ultimate goal is decompression, while at the same time minimizing exposure of, or damage to, neurovascular structures. When possible, escharotomies should be located at the sites of standard fasciotomy incisions. This facilitates evaluation and treatment of compartment syndrome, which may accompany a massive fluid resuscitation.

TIPS TO REMEMBER

Rule of 9’s: head 9%, each upper extremity 9%, each lower extremity 18%, anterior chest + abdomen 18%, and back 18%.

First-degree burns are not included in TBSA calculations.

<20% TBSA does not require large-volume resuscitation (ie, Parkland formula).

Parkland formula = 4 mL × % TBSA × weight/kg; give one half in the first 8 hours post injury.

Burn depth often progresses over the first 24 hours post burn.

Massive fluid resuscitation has the potential to cause secondary compartment syndrome, that is, orbital, abdominal, extremity. Treatments include increasing colloid as fluid, lateral canthotomy, paralysis, abdominal decompression, and escharotomy/fasciotomy.

COMPREHENSION QUESTIONS

1.
A 33-year-old man is noted to have first-degree burns to his entire left leg, third-degree burns to his entire right leg, as well as second- and third-degree burns to his entire anterior chest and abdomen. Which of the following statements is
false
?

A. He may require escharotomies to his chest.

B. He will require large-volume resuscitation (ie, Parkland formula).

C. He has a 54% TBSA burn.

D. He fulfills the ABA criteria for transfer to a burn center.

2.
A 20-year-old female is seen in the emergency department after scalding herself with hot soup. She is noted to have blistering of her anterior thigh with involvement of her genitals. Which of the following is most likely true?

A. She has an 18% TBSA burn.

B. She may require large-volume resuscitation (ie, Parkland formula).

C. She fulfills the ABA criteria for transfer to a burn center.

D. She should be resuscitated with albumin.

3.
A 50-year-old male electrical worker was involved in a high-voltage electrical injury at approximately 8
AM
. He was intubated in the field by EMS and transferred to the local emergency department where he was given 4 L of lactated Ringer’s solution and quickly transferred to a regional verified burn center. The patient arrived to the burn center at 1
PM
and is noted to have a 40% TBSA burn. He is 100 kg. What should his initial fluid rate on arrival to the burn center be?

A. 1000 cm
³
/h

B. 1333 cm
³
/h

C. 800 cm
³
/h

D. 500 cm
³
/h

Answers

1.
C
. Only second- and third-degree burns are included in calculations of TBSA. Leg (18%) + anterior chest (9%) + anterior abdomen (9%) = 36% TBSA.

2.
C
. Burns that involve the genitalia, perineum, face, hands, or feet fulfill criteria for burn center transfer.

3.
B
. Total fluid requirement first 24 hours = 4 (40 × 100) = 16,000 cm
³
. Therefore, 8 L (one half the total resuscitation volume) must be given in the first 8 hours. The patient has already received 4 L in the first 5 hours; therefore, he requires an additional 4 L over the next 3 hours: 1.33 L/h.

SUGGESTED READING

Herndon D.
Total Burn Care
. 4th ed. Philadelphia, PA: Elsevier, Inc; 2012.

A 56-year-old Man 6 Days Status Post Colectomy With New Pelvic Discomfort

Michael F. McGee, MD and Brian C. George, MD

You evaluate an otherwise healthy 56-year-old man in the emergency department with a 4-day history of worsening left lower quadrant abdominal pain and fever. He has no evidence of peritonitis or sepsis. Computed tomography (CT) imaging of the abdomen and pelvis reveals sigmoid diverticulitis without abscess. The patient is admitted for a trial of bowel rest and broad-spectrum intravenous antibiotics. After 48 hours, the patient worsens clinically and undergoes sigmoid colectomy, end colostomy, and oversewing of the distal rectal stump (Hartmann procedure).