A 36-year-old man is brought to the burn center after being trapped in a structural fire. … — USMLE Step 3

A $36$ -year-old man is brought to the burn center after being trapped in a structural fire. He sustained deep partial-thickness and full-thickness thermal burns involving the entire anterior trunk, posterior trunk, and circumferentially around his left upper extremity and both lower extremities. The total body surface area burned is estimated at $60\%$ . He was intubated in the field for inhalation injury and is currently receiving aggressive intravenous lactated Ringer resuscitation. Vital signs are temperature $36.2^\circ\text{C}$ ( $97.2^\circ\text{F}$ ), heart rate $132$ /min, and blood pressure $88/55\text{ mmHg}$ . Mechanical ventilation settings are volume control, tidal volume $450\text{ mL}$ , respiratory rate $18$ /min, $\text{FiO}_2$ $0.80$ , and positive end-expiratory pressure (PEEP) $5\text{ cm H}_2\text{O}$ . Over the last hour, the ventilator has alarmed continuously for high peak airway pressures, which have risen from $25$ to $55\text{ cm H}_2\text{O}$ . His oxygen saturation has declined from $98\%$ to $86\%$ . Breath sounds are present but diminished bilaterally. The left hand is cool to the touch, and radial and ulnar pulses are no longer detectable by handheld Doppler. Which of the following are the most appropriate immediate interventions? (Select all that apply)

Bedside escharotomy of the anterior chest wallCevap
Bedside escharotomy of the left upper extremityCevap
C
Bedside fasciotomy of the left upper extremity
D
Bilateral needle thoracostomy
E
Computed tomography angiography of the left upper extremity

Cevap

The correct immediate interventions are bedside escharotomy of the anterior chest wall and bedside escharotomy of the left upper extremity.

This patient is experiencing two severe complications of massive, circumferential full-thickness thermal burns: thoracic restriction and peripheral vascular compromise. The inelastic, leathery burn eschar acts like a tourniquet as the underlying tissues develop massive edema from burn shock and aggressive fluid resuscitation. On the chest, this prevents the lungs from expanding, manifesting as elevated peak airway pressures and profound hypoxia. On the extremity, it compresses the vasculature, resulting in a pulseless, cool hand. The definitive procedural intervention for both issues is an emergent bedside escharotomy. Surgical incisions are made through the burned skin into the underlying subcutaneous fat to release the tension, allowing the chest wall to expand adequately for ventilation and restoring arterial perfusion to the distal extremity.

Adım Adım Çözüm

Identify the etiology of the rising peak airway pressures and hypoxemia.

The circumferential full-thickness burns on the trunk are acting as an inelastic, restrictive band (burn eschar), preventing adequate chest wall excursion during mechanical ventilation.

Airway pressures are rising and oxygen saturation is falling despite intubation, without clinical evidence of a pneumothorax.

Identify the etiology of the pulseless, cool left hand.

The circumferential burns on the left arm are causing vascular compromise due to massive underlying tissue edema that cannot expand past the leathery eschar.

Doppler pulses have been lost and the extremity is cool, indicating an acute lack of perfusion.

Select the appropriate procedural interventions to address both life- and limb-threatening complications.

Emergent bedside escharotomies must be performed on both the chest wall and the affected upper extremity.

Incising the eschar down to the subcutaneous fat releases the mechanical tension, allowing the chest to expand for ventilation and restoring arterial flow to the hand.

Anahtar Kavram

Circumferential full-thickness thermal burns can rapidly cause thoracic restriction leading to respiratory failure, and limb constriction leading to acute vascular compromise. Both conditions are surgical emergencies requiring prompt bedside escharotomy.

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Cevap

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