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Difficulty: MediumTrauma and Burns

Match each classic burn trauma or post-resuscitation clinical presentation with its most appropriate immediate diagnostic or therapeutic next step in management.

  • A patient rescued from a closed-space building fire presenting with soot in the oropharynx, persistent coughing, and hoarseness.Prophylactic endotracheal intubation
  • A patient with full-thickness, circumferential burns to the right upper extremity presenting with worsening hand paresthesias and an absent radial pulse.Immediate bedside escharotomy
  • A patient with extensive high-voltage electrical burns presenting 24 hours later with dark brown urine, oliguria, and markedly elevated serum creatine kinase.Aggressive intravenous fluid administration to achieve a high target urine output
  • A patient with 55% total body surface area burns undergoing massive fluid resuscitation who develops a tense abdomen, oliguria, and elevated peak airway pressures.Measurement of intra-abdominal pressure via a bladder catheter

Answer

Inhalational injury requires prophylactic endotracheal intubation. Circumferential limb burns require immediate bedside escharotomy. Electrical burns causing rhabdomyolysis require aggressive intravenous fluid administration. Massive fluid resuscitation leading to abdominal compartment syndrome requires measurement of intra-abdominal pressure via a bladder catheter.
Each presentation describes a critical complication of severe burns requiring specific management. Inhalation injuries risk rapid airway loss and require early intubation. Circumferential limb burns cause compartment syndrome, relieved by escharotomy. Electrical burns cause deep muscle necrosis and rhabdomyolysis, managed with aggressive fluid diuresis. Massive fluid resuscitation causes third-spacing into the bowel, leading to abdominal compartment syndrome, diagnosed by measuring intra-abdominal pressure.

Step-by-Step Solution

1
Evaluate the airway of the patient from the enclosed fire.
Identify signs of inhalation injury (hoarseness, soot in the oropharynx).
Inhalation injuries can cause rapid and unpredictable airway edema, necessitating securement before complete obstruction occurs.
2
Assess the right upper extremity of the patient with circumferential burns.
Identify an absent radial pulse and paresthesias, indicating extremity compartment syndrome.
Circumferential eschar restricts swelling, increasing compartment pressure which must be promptly released via escharotomy to save the limb.
3
Evaluate the patient with high-voltage electrical burns and dark brown urine.
Recognize severe rhabdomyolysis and impending myoglobinuric acute kidney injury.
Electrical burns cause hidden deep muscle damage; treatment requires flushing the kidneys with aggressive intravenous fluid therapy.
4
Assess the massively resuscitated patient with a tense abdomen and elevated airway pressures.
Suspect secondary abdominal compartment syndrome due to massive third-spacing.
Intra-abdominal hypertension compresses organs and the diaphragm, and is diagnosed by measuring bladder pressure.

Key Concept

Management of severe burns requires recognizing critical complications: airway edema from inhalation injury, extremity compartment syndrome from circumferential eschar, rhabdomyolysis from electrical injury, and abdominal compartment syndrome from massive fluid resuscitation.
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Topics

Trauma and Burns

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