Department of Surgery

Name: Gotera, Chloe Lynn M.

Batch/Section: NMD 4 Group 4
Date: November 26, 2022
Preceptor: Dr. Angelica Mary Joan A. Labradores
DAY 2 ACTIVITY
Diagnosis and Managemenrt

Case:
Around 12AM, a 40/M was trapped for about 15 minutes inside his room in a burning building and was then rescued by 911 and brought to the Emergency room on a stretcher.
Past medical history: Unremarkable
Surgical history: Unremarkable
Family history: Unremarkable
Personal history: Computer programmer, 5-pack year smoker, alcoholic beverage drinker

General Survey Vital Signs Skin HEENT Neck

Physical GCS 15, Awake, ambulatory, in 130/80 Patient sustained burns on left upper Soot stained face with singed Trachea midline
Examination mild respiratory distress 105bpm extremity, circumferential and anterior eyebrows and nasal hair. No mass
Findings
21cpm surface of the left thigh was noted with Pinkish palpebral conjunctive No enlarged cervical nodes
Weight: 70 kg 36.7C weeping blisters and were very painful
Height: 167 cm 98% O2 saturation to touch. The cheeks, perioral areas,
neck and chest are noted to be
erythematous and tender.

Lungs Heart Abdomen Genitalia/Rectum Extremities Neuro

Equal chest Tachycardic, PMI at 4th ICS Non-distended, soft, no palpable No external lesions, Good tone, No edema, full pulses bilateral, no GCS 15 (E4V5M6)
expansion, Clear MCL, Distinct heart sound, mass, tenderness on palpation on no mass or lesion, No blood on limitation of movements of all 3mm EBRTL
Breath sounds, no no murmur right flank. examining finger extremities, (+)tenderness upon No localizing signs
wheezes, no stridor movement of the left upper No sensory cut off
extremity and left thigh, (-) 5/5 Motor strength
paresthesia

CTTO

1
 Department of Surgery
Patient was transferred to the burn unit by 6AM. Further evaluation of the patient revealed the following findings.

Video assisted laryngoscopy:

No laryngeal erythema and mucosal edema

Patient was complaining of extreme pain on the left upper extremity not relieved by pain medications.
On re-evaluation of the left upper extremity it revealed the following findings:
Increased swelling and tenderness on left forearm. Patient complained of extreme pain on passive movement of the fingers. Paresthesia was noted on the finger tips with decreased capillary refill.
Distal Pulses were not appreciated on the right upper extremity.

LABS InI

Hgb 10.0 g/dl 12.1-15.1 Decreased Interpretation:

HCT 39 38-46% Normal Anemia with predominance of neutrophils

Hypokalemia
WBC 12 4.5-11 x 10 3 Normal
mm3

Neu 80 50-65% Increased

Lympho 20 20-50% Normal

Eos 1 0-6% Normal

Mono 2 2-9% Normal

Baso 0 0-2% Normal

Na 145 135-145 mEq/L Normal

CTTO

2
 Department of Surgery
K 3.4 3.5-5.0 mEq/L Decreased

Crea 92 80-150 Normal

Instructions:
● Use Schwartz’s Principles of Surgery 11th edition, Sabiston Textbook of Surgery 21st Edition, MIMS, and Bate’s Guide to Physical Examination and History Taking as your reference for this case.
● Indicate the reference and page number in the column provided for your answers. Failure to indicate references will have corresponding deductions.

Question/Task Answer Reference

(Source, page no.)

What is your current impression? Schwartz 10ed Chap 8 p

Explain your answer. Flame Burn 13.5% TBSA Superficial to Deep partial thickness involving circumferential left upper 234
extremity and left anterior thigh; Acute compartment syndrome left upper extremity.

Acute compartment syndrome is suspected due to swelling and tenderness on the left upper
extremity. Paresthesia was also noted on the fingertips with decreased capillary refill.

Does this patient need surgical intervention? The patient needs surgical intervention. Acute compartment syndrome is a surgical emergency Schwartz 10ed Chap 8 p
What surgical intervention will you offer this patient? and the patient is warranted for possible fasciotomy. 234

What are common complications associated with treatment of ● Ventilator-associated pneumonia Schwartz 11ed Chap 8 p
burn patient? ● Abdominal compartment syndrome 258-259
○ Massive resuscitation of burned patients may lead to an abdominal compartment
syndrome characterized by increased airway pressures with hypoventilation and
decreased urine output and hemodynamic compromise.
○ Decompressive laparotomy is the standard of care for refractory abdominal
compartment syndrome but carries an especially poor prognosis in burn patients.
○ Adjunctive measures such as minimizing fluid, performing torso escharotomies,
decreasing tidal volumes, and chemical paralysis should be initiated before

CTTO

3
 Department of Surgery
resorting to decompressive laparotomy. Patients undergoing massive
resuscitation also develop elevated intraocular pressures and may require lateral
canthotomy
● Deep vein thrombosis (DVT) and prophylaxis
○ it appears that heparin prophylaxis is safe in burn patients and may help prevent
thrombotic complications
● Heparin-associated thrombocytopenia (HIT)
○ the use of both prophylactic and therapeutic heparin may be associated with
heparin-associated thrombocytopenia (HIT)

What topical therapy will you give for this patient? What are the ● Silver sulfadiazine 1%, cerium nitrate 2.2% (Flammacerium) Schwartz 11ed Chap 8 p
other topical treatment available for burn wound and what are ○ apply 2-3mm thick directly onto the wound or on a sterile gauze dressing and 257
their common complication? applied at least once 24 hourly after removal of the old cream
○ Complications:
■ causing neutropenia
■ destroys skin grafts and is contraindicated in burns or donor sites in
proximity to newly grafted area
■ may retard epithelial migration in healing partialthickness wounds.
● Mafenide acetate
○ Apply
○ cream or solution form
○ Complications:
■ Use of mafenide acetate may be limited by pain with application to
partial-thickness burns. As mafenide is a carbonic anhydrase inhibitor, a
historically described side effect is metabolic acidosis.
● Silver nitrate
○ Apply
○ topical solution
○ Complications:
■ prolonged topical application leads to electrolyte extravasation with
resulting hyponatremia
■ rare complication: methemoglobinemia
● bacitracin, neomycin, and polymyxin B
○ Apply
○ topical ointments
○ Complications:

CTTO

4
 Department of Surgery
■ cause nephrotoxicity and should be used sparingly in large burns.

How will you compute for the caloric requirements for this ● The Harris-Benedict equation may be inaccurate in burns of <40% TBSA, and in these Schwartz 11ed Chap 8 p
patient and what is this patient’s caloric needs? patients, the Curreri formula may be more appropriate 258
○ This formula estimates caloric needs to be 25 kcal/kg per d plus 40 kcal/%TBSA
per d

○
○ (25 kcal x 70kg) + (40 kcal x13.5%) = 1750 + 540 = 2290 kcal needed for
healing
● Micronutrient supplementation with antioxidant vitamins (vitamin E and ascorbic acid)
and trace minerals (selenium, zinc, and copper) optimizes wound healing, enhances
immune function, and fights oxidative stress
***Questions in this table will be about the History of Present Illness, PMH, PSH, FH, ROS and PE findings of the patient. See sample questions.

CTTO