
Presentation
It is 6pm on a Saturday evening. Liam B, an 18 year
old male, is brought to Barcaldine Base Hospital with
severe burns to his body.
Hypothesis
Flames
Sun
Thermal
Radiation
Chemical
Electrical
Friction
Scalds
Mechanism
Functions of skin
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Barrier (entry of infection, fluid loss)
Sweating/Temperature regulation
Appearance
Sensation
Vit D synthesis
Fat storage
Further info
How long
Infection?
Where?
How much?
Cause? Mechanism?
First aid?
Thickness/depth?
Pain?
Dehydration?
Function?
Consciousness?
Who else?
GCS?
Airway? Burns in
mouth/lungs?
Other skin conditions
Other injuries
FQs
Function of skin
Types of burns. Grades
and severity and
degrees.
First aid for burns

Emergency Management
The paramedics state that Liam was at a party when he threw a can
of kerosene on a bonfire which exploded, burning himself and five
friends. His shirt and jeans caught alight and he ran around for about
a minute before the flames were extinguished.
Liam denies any loss of consciousness and is alert and oriented on
presentation but is clearly in a lot of pain. He states his pain as being
worst in his neck and right arm with 8/10 pain. Liam is given IV
morphine titrated to effect.
He is noted to have cool extremities but all pulses are present.
RR: 20/min normal
HR: 140bpm regular tachycardia
T: 35°C low
BP: 140/70 hypertensive/normal
SaO2: 94% 6L via mask low (6-8L/min is normal)
Wt: 75kg
Although Liam is talking in full sentences without stridor, his voice is
hoarse and upon indirect laryngoscopy, he is found to have glottic
swelling and carbonaceous sputum. He is intubated with a 7.0
endotracheal tube.
A central venous line is placed in Liam's right subclavian vein. Blood
is taken for investigations.
Liam's % total body surface area (%TBSA) of burn is calculated using
a Lund-Browder chart to be 62% with 59% full thickness burns, 2%
deep dermal and 1% partial thickness burns. Both his arms have
suffered circumferential burns from shoulder tip to hands. His neck,
back and posterior legs have also been badly burnt with his face
sustaining partial thickness burns from nose down.
It is quickly realised that Liam's injuries are too severe to be
managed in a small rural hospital. Following the ANZBA guidelines,
transfer to the Burns Unit in Brisbane is arranged. Liam's burns are
covered with gladwrap in preparation for transport.
Hypothesis
Breathing troubles
Near shock
Hypothermic
Mechanism
Further info
Alcohol?
Drugs?
What happened to
friends?
Clothes?
FQs
Healing of burns?
Foreign bodies?
Compartment
syndrome? Scarring?
Cosmetics?
Lungs affected by
burns
Smoke inhalation
ANZBA guidelines for
burns management?
Clingwrap? Positioning
of pt
Lund-Browder chart
What comprises a
burns unit?
Trigger 1.3

Liam arrives in Brisbane and handover is given to the burns unit team.
He is given morphine stat and the pain team is called to advise on the
best way to manage his pain. He is also written up for regular
paracetamol.
The resident looking after Liam uses the Parkland formula to calculate his
fluid requirements as 18.6L over 24hrs. After contemplating which fluid
replacement would be best, she decides on Hartmanns and write up orders
to have half of this administered in the first 8hrs.
Whilst the resident is stabilising Liam, she becomes concerned that his
arms and left leg are becoming increasingly oedematous and calls her
consultant to advise on performing an escharotomy.
She make plans to have Liam admitted to the intensive care unit and
checks the blood results that have come through from Barcaldine.
Parameter
pH
PaCO 2
HCO 3K+
Na+
ClAnion gap
Glucose
Hb
Albumin
WBC
Value
7.32 low
28 low
18 low
4.6 high
142 normal
111 high
17.6 high
8.1 high
160 normal
24 low
8.6 normal
Normal Range
7.36-7.44
35-45 mm Hg
22-32 mmol/L
3.4-4.5 mmol/L
135-145 mmol/L
95-110 mmol/L
8-16 mmol/L
3.0-7.7 mmol/L (random)
130-180 g/L
32-45 g/L
4.5-11 x 10 9/L
The dietetics team is called to review Liam and a nasogastric tube is placed
to facilitate feeding.
Hypothesis
Compartment
syndrome
Acidotic. Metabolic.
Compensated.
Cell damage (K+
high)
 Urea and
creatinine will
probably be high
Mechanism
Further info
Kidneys?
What is causing
metabolic acidosis?
MHx
Consultant’s thoughts
Changes in blood
results
Monitor
Check fluids, O2, vital
signs
Gladwrap
FQs
Synergy between
paracetamol and
opioids.
Parkland formula.
Fluids for fluid
replacement
(Hartmanns, Ringers,
etc). Principles of
fluid balance. Colloid
Vs crystalloid. How
Glucose released due
to adrenaline and
cortisol/steroids 
anti-insulin effect
Albumin has leaked
due to inflammation
(serous fluid)
Check for infection
Prophylactic a/b
much do we need to
give. Replacement
and maintenance.
Silvazine
Pain management
Problems associated
with
oedema/compartment
syndrome (ischaemia,
loss of blood supply,
thrombosis, etc)
Role of silvazine

ICU
In the ICU, escharotomies are performed on both of Liam's upper
limbs (see photograph) and his right lower limb.
For the rest of the evening, the ICU staff keep a very close eye on
Liam's urine output, biochemistry and haematology parameters and
his wounds are dressed in silver sulfadiazine cream.
In the morning, Liam is taken to theatre for debridement of his injuries
with split skin grafts applied to his hands, arms, face, neck, back and
legs over several days. His scalp and chest are used as donor sites.
A skin substitute, Integra, is also utilised. The theatre is kept at a
target temperature of 37°C.
Two days later, Liam's temperature is 37.9°C and his glucose levels
have dropped. There are fears that, despite rigorous infection control
procedures, Liam may have developed an infection and a complete
septic screen is carried out. On removal of his dressings, it is
discovered that the wound on Liam's right lower limb has a greenish
tinge and an extremely pungent smell. A chest X-ray, FBC, two sets
of paired blood cultures, urine MCS, and line and wound swabs are
ordered. Liam is commenced on Timentin (ticarcillin/clavulanate) and
given a single dose of vancomycin while his samples are processed.
Hypothesis
Mechanisms
Further info
Swab results.
FQs
Skin grafts. Site of
donation. Methods.
septic screens.

Laboratory results
Liam's chest X-ray shows no abnormalities. 12 hours after samples
were collected, pathology results reveal that swabs from all his lines
and his urine sample are negative for bacterial growth. However the
wound swab is positive for Gram-negative rods.
In the meantime, Liam's condition is worsening. He develops a
temperature of 38.4°C, HR 130, RR 26 and BP 120/50. His WCC has
risen to 18.4 x 10 9/L (reference range: 4.5 - 11 x 10 9/L).
After a further 12 hours, the lab reports that the wound organism is an
isolate of Pseudomonas aeruginosa. It is another 24 hours before
sensitivity results are available. These show that the isolate is resistant
to Ticarcillin but sensitive to Meropenem. The blood cultures also return
positive for the same isolate
Hypothesis
Septic shock
Mechanism
Further info
FQs
Sepsis
P. aeruginosa
Prescribing antibiotics
1.
2.
3.
4.
KISS commonly available first
Use the correct a/b for the correct site  what organisms do we expect at that location? Eg. Gram
negative Vs gram positive
Culture wherever possible. want the results asap and not to have to make a second guess.
If in doubt, ask
Focus Questions:
o
Skin as a multifunctional organ (revision from year 1) (Skye)
Functions of skin.
o
Assessment and types of burns (Pete)
Types of burns. Grades and severity and degrees. Lund-Browder chart. ANZBA guidelines for burns
management?
o
Acute management of burns (Andy)
First aid for burns. Synergy between paracetamol and opioids. Parkland formula. Pain
management. Role of silvazine
o
Fluid balance (Arthur)
Fluids for fluid replacement (Hartmanns, Ringers, etc). Principles of fluid balance. Colloid
Vs crystalloid. How much do we need to give. Replacement and maintenance.
o
Long-term management and complications (Jackie)
Clingwrap? Positioning of pt. What comprises a burns unit? Problems associated with
oedema/compartment syndrome (ischaemia, loss of blood supply, thrombosis, etc). Skin grafts.
Site of donation. Methods.
o
Opportunistic and health-care associated infections (Alex)
o
Factors determining appropriate antibiotic choice (Shannon)

o
P. aeruginosa
SIRS, sepsis and septic shock (Royd)
septic screens. Sepsis. Systemic inflammatory response syndrome
o
Wound healing and scarring (Sonya)

Healing of burns? Foreign bodies? Compartment syndrome? Scarring? Cosmetics?