Chapter 8: Burns
A 22-year-old man is brought to the emergency room after a house fire. He has burns around his mouth and his voice is hoarse, but breathing is unlabored. What most appropriate next step in management?
A. Immediate endotracheal intubation.
B. Examination of oral cavity and pharynx, with fiberoptic laryngoscope if available.
C. Place on supplemental oxygen.
D. Placement of two large-bore intravenous (IV) catheters with fluid resuscitation.
With direct thermal injury to the upper airway or smoke inhalation, rapid and severe airway edema is a potentially lethal threat. Anticipating the need for intubation and establishing an early airway is critical. Perioral burns and singed nasal hair are signs that the oral cavity and pharynx should be further evaluated for mucosal injury, but these physical findings alone do not indicate an upper airway injury. Signs of impending respiratory compromise may include a hoarse voice, wheezing, or stridor; subjective dyspnea is a particularly concerning symptom, and should trigger prompt elective endotracheal intubation. In patients with combined multiple trauma, especially oral trauma, nasotracheal intubation may be useful but should be avoided if oral intubation is safe and easy. (See Schwartz 10th ed., p. 227.)
What percentage burn does a patient have who has suffered burns to one leg (circumferential), one arm (circumferential), and the anterior trunk?
A general idea of the burn size can be made by using the rule of nines. Each upper extremity accounts for 9% of the total body surface area (TBSA), each lower extremity accounts for 18%, the anterior and posterior trunk each accounts for 18%, the head and neck account for 9%, and the perineum accounts for 1%. Although the rule of nines is reasonably accurate for adults, a number of more precise charts have been developed that are particularly helpful in assessing pediatric burns. Most emergency rooms have such a chart. A diagram of the burn can be drawn on the chart, and more precise calculations of the burn size made from the accompanying TBSA estimates given.
Children younger than 4 years have much larger heads and smaller thighs in proportion to total body size than do adults. In infants the head accounts for nearly 20% of the TBSA; a child’s body proportions do not fully reach adult percentages until adolescence. Even when using precise diagrams, interobserver variation may vary by as much as ±20%. An observer’s ...