Case Study 1: Major Burn Injury
Chief Complaint: 14-year-old boy admitted after suffering 45% total body surface area
(TBSA) deep-partial thickness and full thickness burns following him rescue from a
burning house.
History: Steven Smith a 14-year-old white male, was transported by ambulance to the
emergency room after being rescued from his burning house. He was asleep at night
when lightning struck the house and started a fire, leaving him trapped in him bedroom.
By the time the fire rescue squad arrived, he had suffered severe burns and excessive
smoke inhalation.
In the emergency room, Steven was unconscious. He had partial thickness burns over
25% of his body and full thickness burns over 20% of his body -- both covering his
chest- thoracic and abdominal regions and his right knee. His vital signs were quite unstable:
blood pressure = 55 / 35 (MAP 41.7); heart rate = 210 beats / min.; and respiratory rate
= 40 breaths / min. He was quickly deteriorating from circulatory failure. Two IVs were
inserted and fluids were administered through each. His vital signs stabilized and he
was transported to the pediatric intensive care unit (ICU).
Steven regained consciousness the following morning, surprisingly complaining of
severe pain over his abdomen and trunk. Following debridement of his burns and
application of a broad-spectrum, topical antibiotic, dressings were applied over the
wounds. Despite treatment with silver sulfadiazine (Silvadene), a broad-spectrum
antibiotic, he developed a systemic staphylococcal infection, necessitating a switch to a
different antibiotic.
Steven began a long, slow recovery. His position in bed had to be changed every 2
hours to prevent the formation of decubitus ulcers (i.e. bedsores). He lost 12 pounds
over the next 3 weeks, despite nasogastric tube feeding of 6500 calories ("Kcals") per
day. After 9 weeks, sheets of autografted material were grafted to him regenerating
dermal layer. By the 15th week of his hospitalization, his epidermal graft was complete,
and he was back on solid foods, his antibiotics were discontinued, and he was
discharged from the hospital with a rehabilitation plan for both physical and occupational
therapy at home, as well as twice-weekly visits by a nurse.
1. Briefly describe the three major layers that make up
healthy skin.
2. Briefly describe the extent of damage and
characteristics seen in superficial thickness,
superficial partial thickness, deep partial thickness
and full thickness
3. What would the best method of pain control for
Steven. (Please provide a rationale for your answer)
4. Explain why this patient's blood pressure was so low
and his heart rate so high upon arrival at the
emergency room.
5. Why was it important to immediately administer
intravenous fluids to Stephen?
6. What potential complication did Steven’s thoracic burn
injury predispose him to? What actions might be
necessary to correct this problem?
7. What is Silvadene and why did Steven need it. Is
healthy skin normally colonized by bacteria?
8. Why was skin-grafting necessary in this patient? (Why
not just let the skin heal on its own?)
9. Why did the patient lose so much weight despite
being on a very high-calorie diet?
10. What long-term problems may the patient have as a
result of extensive scar tissue formation over him
trunk and him right knee?
1. epidermis
dermis: have to have some left to regenerate
subcutaneOUS (fat)
2.
Superficial red, sunburn appearance, skin intact,
-
no
scarring, heal spontan, painful
superficial blisters, link or red, mildedema, blanches,
painful, no scarring, heal spontan.
partial
closed or opened blisters, cherry red,
painful
partial mottled, waxy, nonplanchable,
around edges
fUl
-dry, thick, leathern, eschar, no pain,
deep
-
thickness
3. In
sensitive to pressure, do not heal spon
meds: fentanly, morphine, dilaudid, Ketamine,
PCA PUMP
Y.
dUetObloodLOSS,MASSIVEfIUidshiftPtIEAR
3. restore intravascular
volume;
give
lacted
ringers
HOB
Infection; ARDS: escharl fasciotomy, intubate,
100% NRBM, humidified
comp.Sundrome
3.
7.
broad spectrum antibiotic, treats bacterial
-
&
fungal
Yes
8. Missing enough dermis
5 interventions for skin grafts
Ino
2.
3.
bubbles underneath, roll out air
on
fluid pockets
Hourly neurovascular checks to limb a pulses
Position
elevate limb to level of heart. NO DEPENDENT
pressure
n. minimize
3.
9.
extremity
dress, splint and/or immobilize
hypermetabolic state when TBSA-20%
contractures
10. hypertrophic scarring,
adequate fluid resu. Uo, sustolic BP>100
adequate nutrition & protein level
=
=
normal
-
Protein 6-8
=
albumin=3.4-5.U