Deipan - 2003886 - CWU - Emergency Medicine RI

M Kandiah Faculty of Medicine and Health Sciences, UTAR
Score sheet for CASE Write-Up

Emergency Medicine
Year 4
Student Name: Deipan A/L Arjunan

ID No: 20UMB03886 Year:2023/2024
Name of lecturer: Prof Dr Rosidah Ibrahim
Marks allocation for Case Write-up

Chief complaints and triage 2.5/5 Report on emergency care 5/10
process management and progress of the
patient in the emergency
department / ward
Focused History taking with 15/20 Subsequent management and 5/10

relevant positive & negative investigations done (their indications,
findings. results and interpretations) including
Emergency treatment management referral to relevant discipline
Physical Examination findings 12/15 Discussion on final diagnosis and 4/6

clearly documented with relevant Disposition of patient
positive and negative findings
including lifesaving interventional Critical discussion of the case (such 7 /10
procedures and resuscitation as learning issues, evidence-based
management, prognosis,
Summary of case clear and concise 3/5 communication, ethical issues and
professionalism.
Discussion 7/10 Proper use of English language, and 3/4

on Diagnosis/Differential write-up is clear & logical
diagnosis based on clinical
findings
Initial investigations in ED (with 4/5 Total score 67.5/100

indications, results and
interpretation)
Lecturer’s Signature: ____ _____________ Date: ____01/3/2024_______

PATIENT IDENTIFICATION
Patient’s initial: Mr A Date of admission:
9/1/2024
R/N: AM 00860617 Date of discharge:
Age: 37 y/o Date of clerking: 9/1/2024
Gender: Male Source of history: Patient
Ethnic group: Burmese
CLINICAL CASE
Chief Complaint
Mr A, a 37-year-old gentleman presented with alleged burn injury.
History of Presenting Illness
Mr A is a 37-year-old Burmese gentleman was involved in an alleged fire accident 6 pm a day

before admission (8/1/2024). Patient is a durian farmer in Raub, Pahang and was cleaning the
farm he is currently working and was burning rubbish and dried leaves which caused the fire
accident. He used petrol as fuel to burn the rubbish and dried leaves. A sudden explosion
occurred while using petrol and the flames from the explosion and hit him in his face and entire
body. His friend was also involved in the same fire accident, but he sustained burns only over his
right lower limb and currently receiving treatment in the green zone.
After sustaining the injury, both he and his friend went home. He felt moderate pain shortly
after the injury and rated it 4/10. He noticed his hair, eyebrows and moustache were burned. He
noticed his limbs and face were starting to swell. When his condition became worse, he and his
friend took a taxi from Raub to Ampang as they have a friend here that can provide financial
support. Subsequently, that friend brought them to the emergency department of Hospital
Ampang around 4 pm on day of admission (20 hours post injury) and he was then triaged to
resus non-SARI.
Systemic Review
General Conscious, alert, no fever, no chills, no rigors

Cardiovascular No palpitations, no syncope, no chest pain, no
dizziness
Respiratory No haemoptysis, no shortness of breath, no
stridor, no wheezing
Nervous Loss of sensation in injury areas, no slurred
speech, no hearing impairment, no blurry
vision, no altered mental status, no headache,
no bleeding from ear and nose, no fitting
episodes
Gastrointestinal No heartburn, no constipation, no abdominal
pain, no nausea, no vomiting, no bowel
incontinence
Genitourinary No increased urinary frequency, no oliguria,
polyuria, dysuria, haematuria or frothy urine, no
abnormal urine smell or colour, no urinary
incontinence
Musculoskeletal No problem walking in short distance, no
myalgia or arthralgia
Endocrine No excessive thirst, excessive sweating, no heat
or cold intolerance.
Past Medical, Surgical and Hospitalisation History
Mr A does not have any past medical, surgical or hospitalisation history.
Drug and Allergy History

Mr A is not on any long-term medications. He has no known food or drug allergies.
Family History
Mr A is single. He is the eldest of 2 siblings, he has 1 sister. His parents and sister are healthy
with no chronic diseases.
Social History
Mr A is a durian farm worker in Raub, Pahang. He is a nonsmoker and non-drinker. His diet is
normal, and he is not a vegan. His work involves a lot of physical exertion. He has no recent
travel history.
PHYSICAL EXAMINATION
Anthropometric Measurement
Weight: 53 kg
Height: 165 cm
Body Mass Index: 19.46 kg/m2
Interpretation: Mr. A is in normal range (18.5-24.9)
Vital Signs
Vital signs Results Interpretation

Temperature 36.9℃ Afebrile
Blood Pressure 160/95 mmHg Hypertensive
Pulse Rate 114 beats per minute Tachycardic
Respiratory Rate 38 breaths per minute Tachypnoeic
SpO2 100% under room air Normal
Interpretation: Mr A was tachycardic, tachypnoeic, and hypertensive

Primary Survey: ABCDE Approach
Airway Mr A was able to talk and there was no noisy breathing such as stridor and
gurgling sound. He was also able to swallow his own saliva. Facial hair singed.
No soot seen. Airway is patent.
Breathing Mr A was tachypnoeic. Respiratory rate was 38 breaths/min, SpO2 was 100%
under room air. Equal chest was observed. On auscultation, air entry was equal
on both lungs and there were no crepitations. Trachea was central. On inspection,
burn injuries were seen on his chest. Palpation was unremarkable. Percussion
revealed resonance over all lung fields. Lung fields were clear on auscultation.
Circulation Pulse rate was 114 beats/min, capillary refill time was less than 2 seconds and
blood pressure was 160/95 mmHg. On auscultation, both S1 and S2 were heard,
and no gallop sounds were heard.
Disability Patient was conscious and alert. GCS was 15. Pupils were 3mm in size and
reactive to light.
Exposure Body temperature was 36.9 °C. There were burn injuries on his back
Rule of Nines Burn Chart

General Examination
On general inspection at the end of the bed, Mr. A was lying supine at a 30-degree angle with
his head rested on a pillow. He was alert, well-orientated, pink, and not irritable. He was
tachypnoeic. There were 2 branulas attached on his right forearm and left calf.
On inspection of his hand, there were circumferential burns over bilateral upper limbs and
shoulder. The burns were a mix of deep partial thickness and full thickness burns. His upper
limbs had leathery skin appearance and some parts of the skin had a red appearance with body
hair burned away. Capillary refill time was less than 2 seconds. Radial pulse had regular rhythm
with normal volume and character. Total body surface area (TBSA) burned on his bilateral upper
limbs were mixed deep partial and full thickness burn of 14%. His hair appeared singed.
On examination of face, there was no scleral icterus or conjunctival pallor. Bilateral pinna had
deep partial thickness burns. There were no nasal deformities or discharge. Gums were healthy.
There were no abnormalities on the tongue. No central cyanosis can be seen from the tongue.
There was no fetor hepaticus, aphthous ulcers or noticeable tooth decay. The tonsils were not
enlarged. Both upper and lower lips appear swollen. His eyebrows and moustache were singed.
His face appeared darker due to the burns.
On inspection of the neck, there was almost circumferential mixed deep partial thickness and
full thickness burns sparing the right lateral side of his neck. The neck skin had leathery
appearance and some parts of the skin had a red appearance. TBSA burned on his neck, head and
face were mixed deep partial and full thickness burn of 6%.
On examination of lower limbs, circumferential full thickness burns were seen over bilateral
lower limbs from thigh up to foot. Skin had leathery appearance and some parts of the skin had a
red appearance. Posterior tibialis and dorsalis pedis pulsations can be felt with regular rhythm
and good volume and character. TBSA burned on his bilateral lower limbs were mixed deep
partial and full thickness burn of 30%
On examination of his back and trunk, deep partial thickness and full thickness burns were
noticed. Skin had a leathery appearance, and some parts of the skin had a red appearance. TBSA
burned on his trunk and back were mixed deep partial and full thickness burn of 34%.
Lymph node examination could not be carried out.
Hydration Status
His eyes were not sunken. Oral mucosa was moist. Skin turgor test could not be carried out.
Respiratory Examination
Patient was examined in lying position with head of bed raised to 30° with neck and chest
exposed.
Inspection- Patient was tachypnoeic and under high flow mask 15L/min. Anterior trunk had
circumferential deep partial thickness and full thickness burns extending to the neck.
Palpation: No tracheal deviation. Apex can be felt at 5th intercostal space midclavicular line.
Chest expansion was normal and equal on both sides. Vocal fremitus could not be carried out.
Percussion: Resonance all over the lung fields
Auscultation: Vesicular breath sounds were heard and equal air entry on both sides
Cardiovascular Examination
Patient was examined in lying position with head of bed raised to 30° with neck and chest
exposed.
Inspection- Patient was tachypnoeic and under high flow mask 15L/min. Anterior trunk had
circumferential deep partial and full thickness burns extending to the neck. His chest was
symmetrical. Apex beat was not visible.
Palpation- Radial pulse present with regularly regular rhythm, normal character, and good pulse
volume. No radio-radial delay, radio-femoral delay or collapsing pulse. Carotid pulse was felt on
both sides. Apex beat was not palpable. No parasternal heaves or palpable thrills in the mitral,
tricuspid pulmonary and aortic regions. No sacral oedema.
Auscultation- S1 and S2 were heard over mitral, tricuspid, pulmonary and aortic regions, with
no additional heart sounds or murmurs. No neck bruits.
Abdominal Examination
Inspection: Deep partial thickness and full thickness burns were seen on the abdomen. Skin had
leathery appearance. Axillary hair appeared singed. The umbilicus was centrally located and
inverted. Hernia orifices were intact.
Palpation: Abdomen was soft. His liver and spleen were not palpable, and kidneys are not
ballotable.
Percussion: Fluid shift was negative. Shifting dullness could not be assessed.
Auscultation: Normal bowel sounds were heard. No liver, aortic or renal bruits.
Neurological Examination
Patient was examined in sitting position, conscious, alert and well communicative.
Inspection: There was no winging of scapula, no upward or downward drift, no deformities, no
muscle wasting or fasciculations of both upper and lower limbs.
Palpation: There were no changes in temperature over both upper and lower limbs. Some parts
of his bilateral upper and lower limbs were tender to touch.
Sensory, motor coordination and reflex: Could not be assessed.
Musculoskeletal Examination
Inspection: Swelling were noted on bilateral upper and lower limbs. No deformities were
observed on bilateral upper and lower limbs.
Palpation: Range of motion could not be assessed.
SUMMARY OF CASE
Mr A, a 37-year-old Burmese gentleman was involved in an alleged fire accident 6 pm a day
before admission. Patient used petrol to burn rubbish and dried leaves. A sudden explosion
occurred while using petrol and the flames from the explosion and hit him in his face and entire
body. Patient came to ED department 20 hours post injury.
Upon arrival at ED, he was tachycardic (114 beats per minute), tachypnoeic (38 breaths per
min) and hypertensive (160/95 mmHg). Mr A was alert and well-oriented with GCS full score of
E4V5M6. He had extensive mixed deep partial and full thickness burns on his bilateral lower
limbs, bilateral upper limbs, anterior trunk, back, neck and face. TBSA burned was estimated to
be 84%.
PROVISIONAL DIAGNOSIS
Alleged burn injury with 84% TBSA with deep and partial and full thickness burns secondary to
fire accident, 20 hours post exposure.
Evidence for Evidence against

History
 Involved in alleged fire accident
 Fire caused by explosion from using petrol
 Fire hit patient in face and entire body
 Came in for treatment 20 hours post exposure
Physical Examination
 Hypertensive
 Tachypnoea
 Tachycardic
 TBSA of mixed deep partial and full thickness of 84% on his bilateral
lower limbs, bilateral upper limbs, anterior trunk, back, neck and face
INVESTIGATIONS IN EMERGENCY DEPARTMENT
Investigation Indication
Full Blood Count  As baseline for monitoring and management

 To screen for anaemia, thrombocytopenia, and bleeding
disorders
 To screen for leucocytosis that can be caused by
infection or inflammation
 To screen for haemoconcentration/ haemodilution
Chest X-ray  Baseline evaluation to detect any changes of diffuse or

focal infiltrates or pulmonary oedema
Venous Blood Gas  To assess the intravascular status and presence of acid
base disturbance (by looking at pH, HCO3, PaCO2)
 To monitor efficacy of oxygenation and ventilation
Renal Profile  As baseline investigation to assess renal function

 To detect any electrolyte imbalance
 To detect signs of kidney injury
Liver Function Test  As baseline investigation to assess liver function
Random Blood Glucose  To detect hyperglycaemia/ hypoglycaemia
Cardiac Biomarkers  To detect post-burn cardiac injury
Creatine Kinase  To detect muscle breakdown
Coagulation Profile  As a baseline investigation

 To detect any underlying coagulopathy
Full Blood Count and White Cell Differential Counts

Blood Components Reference Range Result Interpretation
Red blood cell (106/µL) 4.53-5.95 7.38 High
Haemoglobin (g/dL) 13.5-17.4 20.9 High
Haematocrit (%) 30.1-50.6 60.9 High
Mean cell volume (fl) 80.6-95.5 82.5 Normal
Mean cell haemoglobin (pg) 26.9-32.3 28.3 Normal
Mean cell haemoglobin concentration (g/dL) 31.9-35.3 34.3 Normal
Platelet (K/μL) 142-350 374 High
Red cell distribution width (%) 12.0-14.8 16.8 High
White blood cells (K/µL) 4.1-11.4 21.7 High
Nucleated red blood cells (%) 0.0 0.11 High

Absolute neutrophils (K/µL) 3.9-7.1 18 High
Absolute lymphocytes(K/µL) 1.8-4.8 1.9 Normal
Absolute monocytes(K/µL) 0.4-1.1 1.7 High
Absolute eosinophils (K/µL) 0.0-0.8 0.0 Normal
Absolute basophils (K/µL) 0.0-0.1 0.1 Normal
Interpretation: Mr A has several higher-than-normal values in blood parameters. This could be

due to haemoconcentration that happens during acute phase of thermal injuries where there is
increased blood viscosity.
Venous Blood Gas

Parameters Reference Range Results Interpretation
pH 7.35 – 7.45 7.14 Low
PCO (mmHg)
2 35.0 – 45.0 31 Low
PO (mmHg)
2 30 - 40 38 Normal
HCO (mmol/L)
3
-
22 -26 10.6 Low
Interpretation: Patient has a low blood pH indicating acidosis and a low PCO This indicates a
2.
metabolic acidosis. Using Winter’s formula, predicted PCO value should fall between 21.9-25.9
2
mmHg. Since measured PCO value is higher than predicted value, this indicates that there is a
2
concurrent respiratory acidosis present. This patient has both metabolic acidosis and respiratory
acidosis.
Renal Profile and Serum Electrolytes

Urea (mmol/L) 2.80-7.20 12.3 High
Sodium (mmol/L) 136-146 130 Low
Potassium (mmol/L) 3.4-4.5 5.1 High
Chloride (mmol/L) 101-109 97 Low
Creatinine (mmol/L) 59-104 355 High
Calcium (mmol/L) 2.08-2.65 1.86 Low
Magnesium (mmol/L) 0.85-1.1 0.45 Low
Phosphate Inorganic (mmol/L) 0.78-1.65 2.38 High
Interpretation: Patient has hyponatremia due to sodium exciting extracellular space due to
increased vascular permeability. Hyperkalaemia present due to leakage of potassium from cell
lysis and tissue necrosis. This indicates patient is in acute phase of burn injury.
Liver Function Test
Parameter Reference Range Results Interpretation
Total bilirubin(µmol/L) 5.0-21.0 8.9 Normal
Total protein (g/L) 66.0-83.0 35 Low
Alkaline phosphatase (U/L) 0-104 37 Normal
Albumin (g/L) 35.0-52.0 18 Low
Globulin (g/L) 20-35 17 Low
Albumin/Globulin Ratio - 1.05 Normal
Alanine transaminase (U/L) 10-49 65 High
Aspartate Transaminase (U/L) 0-33 190 High
Interpretation: Patient has decreased protein and albumin levels indicating patient is in acute
phase of burn injury. Increased AST and ALT indicates hepatocyte necrosis which might
represent cellular damage due to the burns.
Creatine Kinase
Reference Range Results Interpretation
55-170 (U/L) 3510 High
Interpretation: Elevated CK level indicates extensive muscle damage due to the burn injury.
Troponin-I (hsTnI)
<14 (ng/L) 390.4 High
Interpretation: Elevated hsTnI indicates post-burn cardiac injury.
Coagulation Profile
Prothrombin Time (s) 10 – 14 22.8 Prolonged
Activated Partial Thromboplastin Time (s) 28 - 38 45.2 Prolonged
International Normalized Ratio <1.1 1.49 Increased
Interpretation: Patient has prolonged PT and aPTT. This indicates traumatic coagulopathy due
to the burn injuries.
Random Blood Glucose

7.8-11.1 (mmol/L) 9.2 Normal
Interpretation: Patient has normal blood glucose level

Chest Radiograph
Interpretation: This chest plain radiography was taken in a semi erect position using a mobile
X-ray equipment. No abnormalities are detected but an X-ray done in an anteroposterior position
is needed for definitive interpretation.
MANAGEMENT AND PROGRESS OF THE PATIENT

In Emergency Department (ED)
Patient presented to primary triage. He was triaged to resus zone non-SARI.
Management and Progress in ED
9/1/2024 2:54 pm
Day 1 Management
 Started high flow mask 15L/minute

 Prop up patient
 Vital signs and SpO monitoring
2
 IVD Hartmann’s Solution 1L bolus

 IV Cefuroxime 1.5 g stat
 IV Flagyl 500 mg stat
 IV Fentanyl 50 µg stat
 Refer ORL
 Refer Surgical
 IV Dexamethasone 8 mg (as planned by ENT)
 Start IV infusion Fentanyl 3mL/hour
 Insert continuous bladder drainage (CBD)
 Strict intake/ output charting
 Keep urine output at 1-2mL/kg/hour
Progress
 FBC: Hb 20.7/ TWC 23.3/ Hct 62/ Platelets 311
 ABG: pH 7.1/ PCO 22/ PO 403/ K 4/ HCO 6.8
2 2 3
-
 CBD: 100 mL, clear

5:41pm
Management
 Bactigras dressing
 Change to nasal prong 3L/minute
 Start IV Cefobid 2g stat
 Start IV Omeprazole 40mg 2 times a day
 Continue IV infusion fentanyl 3mL/hour
 IVD 2L Hartmann’s Solution bolus
 Repeat blood gas
 Renal profile post bolus
 Awaiting input from plastic surgery
Progress
 BP 160/95 PR 114 RR 18 SpO 99% on HFM
2
 CCTVR good
 No shortness of breath, chest pain or palpitations
 No abdominal pain
 No GI losses
 Completed 2L bolus
 GCS full, pink, not tachypnoeic, good perfusion
 ABG on HFM 15L/minute: pH 7.2/ PO 403/ PCO 22/HCO 6.8/ Na 124/ K
2 2 3
-
4/ Ca 1.06/ Glucose 9.2/ Lactate 7.4

 Coagulation profile: aPTT 45.2/ PT 22.8/ INR 1.77
 FBC: NRBC% 0.5%/ RBC 7.38/ Hb 20.9/ Hct 60.9%/ MCV 82.5/ MCH
28.3/ MCHC 34.3/ Platelet 374/ RDW 16.8%/ NRBC 0.11
 Troponin I (hsTnI): 390.4
9:26 pm
Management
 Keep nasal prong
 Keep MAP >65mmHg
 Close vital signs monitoring
 Continue current medications
 Another 2L bolus over 2 hours
 Awaiting surgical admission
Progress
 BP 153/82, PR 100, RR 19, SpO 100% on nasal prong 3L/minute
2
 CCTVR good
 Complete 3.5L bolus
 Noted branula over right hand dislodged
 Bactigras dressing done
 No abdominal pain
 Alert, pink, speaking in full sentences, good perfusion, moist oral mucosa
 Explained to patient he needs aggressive fluid resuscitation but no vascular
access
 Will be inserting triple lumen
 Risk of procedure explained (hematoma, infection, neurovascular injury,
catheter dislodgement and bleeding)
 Patient understood and asked no further questions
 Right inguinal area cleaned and draped
 Area of interest infiltrated with lignocaine
 Femoral vein identified through ultrasound and large bore needle advanced
into right femoral vein
 Guide wire inserted and needle removed
 Insertion site dilated
 Triple lumen advanced easily through guide wire
 Guide wire removed
 Good outflow and inflow of all lumen
 Catheter anchored to skin using brilon 2/0
 Dressing applied
 CBD: 200cc concentrated urine
 VBG post 3.5L bolus: pH 7.14/ HCO 10.6/ Na 123/ K 4.7/ Ca 0.84/ Glucose
3
-
6.8/ Lactate 8.4/ Base excess: -17.1
11:52 pm
Management
 Keep nasal prong
 Close vital signs monitoring
 Continue IV infusion fentanyl 5mL/hour
 Another 2L bolus Hartmann’s Solution over 2 hours (total 7L)
 Then IVD 6 pints of normal saline maintenance as per surgical plan
 Aim urine output 0.5-1 mL/kg/hour
 Awaiting surgical admission
Progress
 BP 153/82, PR 100, SpO 100% on nasal prong
2
 GCS full
 Warm peripheries
 Good pulse volume
 Good pulse volume
 CRT <2 seconds
 CBD total drain: 300cc urine until 10:30 pm
 VBG post 6.5L bolus: pH 7.17/ HCO 16/ Glucose 5.9/ Lactate 6.8
3
-
Critical Care Review

9/1/202 7:01 pm
4
Day 1 Management
 Not for ICU admission
 To admit to ward for now
 Aggressive fluid resuscitation
 Low threshold for intubation
 To inform if respiratory distress or condition worsens
 For anaesthesiology team to review
 To inform if admitted to ward
 Continue primary team plan
Progress
 BP 120/80, PR 102, SpO 100% on high flow mask
2
 Afebrile
 Saturating under high flow mask 15L/minute
 Alert, conscious, not tachypnoeic, not tachycardic
Otorhinolaryngology (ORL) Review

9/1/2024 3:01 pm
Day 1
Management
 IV Dexamethasone 8mg three times a day
 To intubate if patient stridulous or worsening shortness of breath
 Jelonet and normal saline dressing over bilateral pinna and neck
 Continue surgical plan
 ORL to review daily
Progress
 No odynophagia or dysphagia
 No drooling, able to take own saliva
 Normal voice, talk in full sentences
 Alert, full GCS
 Comfortable under high flow mask 15L/minute
 Not tachypnoeic, no stridor
 Facial burn injury
 Singed eyebrow and hairs
 Bilateral pinna 2nd degree burns with blisters
 No abnormality detected on bilateral mastoid
 Otoscope: No abnormality detected on bilateral external auditory canal, no
abnormality detected on bilateral tympanic membrane
 Airway patent
 Upper and lower lips swollen
 No abnormality detected on tongue
 Floor of mouth not raised
 No abnormality detected on palate
 Uvula not oedematous
 No abnormality detected on bilateral anterior and posterior pillars
 Bilateral tonsils grade 1
 Posterior pharyngeal wall clear and no oedema seen
 Neck: Almost circumferential 2nd degree burn injury of the neck(sparring right
lateral side of neck)
 Laryngeal framework palpable
 Trachea is central
 Flexible Nasopharyngoscopy: Singed vibrissae, anterior of bilateral IT
inflamed, nasopharynx clear, no abnormalities detected on bilateral ET/FOR,
no abnormalities detected on base of tongue, no abnormalities detected on
bilateral aryepiglottic folds, arytenoids, and pyriform fossa, bilateral vocal
cords mobile and symmetric, no oedema or pooling of saliva, no soot seen
Surgical Review
9/1/2024 4:05 pm
Day 1
Management
 Nil by mouth with IVD 6 pints of normal saline
 Run bolus 2 pints of Hartmann’s Solution each over 1 hour
 Central venous line insertion (informed ED team as existing peripheral line at
left calf not functioning)
 Refer anaesthesiology for ICU admission
 IV Flagyl 500mg stat and thrice daily
 IV Cefobid 2g stat and 1g twice daily
 IV Pantoprazole 40mg twice daily
 RT FF and 4 hourly aspirate
 Strict intake/ output charting
 Refer HKL plastic surgery team
 IV Tramadol 50mg 4 times a day
 IV Paracetamol 1g 4 times a day
 Keep in view for subcutaneous morphine if pain score not controlled
 IV Pethidine 50mg stat 30 minutes before dressing
 Jelonet and normal saline dressing over burn wound
 Upper and lower limbs circulation dressing
 Refer ophthalmology
 Vital signs hourly monitoring
 Urine output hourly charting
 Trace pending blood investigation sent
Progress
2
 Alert, GCS full, not tachypnoeic, tachycardic

 No fever
 No GI losses
 Having chills
 On 2 branula (Right forearm, left calf)
 Ongoing IV Flagyl
 Generalised deep partial and full thickness burn
 Face/head/neck- Deep partial thickness burn TBSA 6%
 Trunk and back- Mix of deep partial and full thickness burn TBSA 34%
 Upper limb- Mix of deep partial and full thickness burn TBSA 14%
 Lower limb- Mix of deep partial and full thickness burn TBSA 30%
 Distal pulses: Bilateral dorsalis pedis and radial arteries palpable
6:24 pm
Management
 For ICU admission as planned
 Not for HKL takeover as bed unavailable
 For elective intubation for protection of airway (possibility of respiratory
distress and developing acute pulmonary oedema is high)
 Warm wash of chlorhexidine with Jelonet dressing over trunk and back
 Warm wash of normal saline and Jelonet dressing over face (to be done under
OT if possible, for pain control and without hypothermia)
 Continue IVD 6 pints of normal saline for maintenance
 Strict intake/output charting
 Ensure urine output 1-2 cc/kg/hour
 If require escharotomy, to proceed in HA
 If require escharotomy over upper and lower limbs, to refer Orthopaedic
Surgery
 To update plastic surgery team everyday regarding patient progress
10/1/2024 1:12 am
Day 2
Management
 For ICU admission if possible
 For elective intubation to secure airway
 IVD 5 pints of normal saline D5 for maintenance
 Close monitoring of vital signs
 Adequate analgesia
 Ensure urine output 1-2 cc/kg/hour (bolus fluids as necessary)
 IV Pantoprazole 40mg once daily
 Keep normothermia (apply bear hugger, blanket, radiant farmer)
 Hourly monitoring of all 4 limbs
 Watch out for signs of abdominal/ limbs compartment syndrome, respiratory
alkalosis- for escharotomy if deemed necessary
 Scrub down burn areas with chlorhexidine, apply Jelonet/wet gauze over face,
Jelonet/chlorhexidine dressing over other wounds
 Daily dressing of wounds
 Pending ophthalmology review
 Update daily regarding condition of patient
Management and Progress in Surgical Ward

10/12/202 6:02 am
4
Day 2 Management
 For ICU admission if possible
 For elective urgent intubation to secure airway
 IVD 5 pints of normal saline D5 for maintenance
 Close monitoring of vital signs
 Adequate analgesia
 Ensure urine output 1-2 cc/kg/hour (bolus fluids as necessary)
 IV Pantoprazole 40mg once daily
 Keep normothermia (apply bear hugger, blanket, radiant farmer)
 Hourly monitoring of all 4 limbs
 Watch out for signs of abdominal/ limbs compartment syndrome, respiratory
alkalosis- for escharotomy if deemed necessary
 Scrub down burn areas with chlorhexidine, apply Jelonet/wet gauze over
face, Jelonet/chlorhexidine dressing over other wounds
 Daily dressing of wounds
 Pending ophthalmology review
 Update daily regarding condition of patient
 To follow up with employer regarding insurance/ spikpa/ financial status
12:45 pm
Management
 For IV Magnesium Sulphate 1 ampoule
 IV Lytic cocktail stat
 IV Unasyn 3g twice daily
 Insert Ryle’s tube
 Start feeding today
 Allow clear fluids, if tolerating for nourishing fluids
 Distal circulation charting every 2 hours
 Check blood glucose every 8 hours
 Vital signs and urine output monitoring
 Continue IVD normal saline D5 5 pints every 24 hours
 Continue analgesia
 Daily dressing of wounds (aseptic technique)
 High protein diet
 Not for NSAIDS (AKI)
 Investigations: FBC, RP, LFT, VBG, Blood C&S
Progress

2

 No fever
 No GI losses
 Having chills
 On 2 branula (Right forearm, left calf)
 Ongoing IV Flagyl
 Completed 2 pints gelafundin and 1 pint of Hartmann’s Solution
 Doppler limb- present, triphasic
6:14 pm
Management
 Increase IVD normal saline D5 to 6 pints per 24 hours
 Keep nil by mouth at 4am
 Aim for wound debridement in OT
 Watchout for respiratory distress
 Keep SpO >95%
2
 If desaturate to inform MO and anaesthesiology team

 Keep in view for intubation
 Continue feeding today
 Investigations: FBC, RP, LFT, VBG, Blood C&S
Progress
 BP 147/73, PR 112, SpO 98% on nasal prong 3L/minute
2

 No fever
 No GI losses
 Tolerable pain
 Urine output 35cc/hour
10:59 pm
Management
 Keep nil by mouth at 4am
 Aim for wound debridement in OT
 Watchout for respiratory distress
 Keep SpO >95%
2
 If desaturate to inform MO and anaesthesiology team

 Keep in view for intubation
 Continue feeding today
 Investigations: RP, VBG
Progress
 Vital signs stable
 Saturating under nasal prong 3L/min
 No fever
 No GI losses
 Tolerable pain
 On IVD normal saline D5 6 pints per 24 hours
11/1/2024 2:17 pm
Day 3 Management
 IVD Hartmann’s Solution 1L over 2 hours
 Repeat VBG, RP, lactate
 To transfuse 4 units of platelet, standby another 4 units of platelet in blood
bank
 Aim urine output >70cc/hour
 Escalate to IV Tazocin 2.25g four times a day
 Keep nil by mouth with IVD 6 pints (3 pint normal saline D5, 3 pints
sterofundin)
 Aim for wound debridement and dressing in OT once platelet and acidosis
optimised
 Trace blood C&S
Progress
2
 No fever
 No GI losses
 Tolerable pain
 On Ryle’s tube
 Right femoral triple lumen
 Worsening AKI with metabolic acidosis
 Creatine kinase 3640
 On IV Unasyn 3g stat- Day 1
7:02 pm
Management
 IVD Hartmann’s Solution 1L over 2 hours
 Repeat VBG, RP, lactate
 To transfuse 4 units of platelet, standby another 4 units of platelet in blood
bank
 Aim urine output >70cc/hour
 Escalate to IV Tazocin 2.25g four times a day
 Keep nil by mouth with IVD 6 pints (3 pint normal saline D5, 3 pints
sterofundin)
 Aim for wound debridement and dressing in OT once platelet and acidosis
optimised
 Trace blood C&S
Progress
2

 No fever
 No GI losses
 Tolerable pain
 Worsening AKI with metabolic acidosis
 Creatine kinase 3640
 On IV Unasyn 3g stat- Day 1
12/1/2024 3:23 pm
Day 4
Management
 Dressing bedside today
 Syrup morphine/ fentanyl during dressing
 IV Lasix 40mg once daily for 3 days
 Reduce IVD to 4 pints (2 normal saline, 2 D5)
 Start nourishing fluid
 Oralise paracetamol
 Not to transfuse platelet first
 Aim urine output>70cc/hour
 Continue IV Tazocin 2.25g 4 times a day
 Trace blood C&S
Progress
2
 Alert, GCS full,

 No fever
 No GI losses
 Tolerable pain
 Intake/output: +1902
 Urine output: 60-200/ hour
8:24 pm
Management
 Patient unable to press PCA fentanyl
 Fentanyl 25mcg stat
 Oral nutrition 4 scoops thrice daily
 IV Lasix 40mg once daily for 3 days
 Reduce IVD to 4 pints (2 normal saline, 2 D5)
 Start nourishing fluid
 Oralise paracetamol
 Not to transfuse platelet first
 Trace blood C&S
Progress
2

 No fever
 No GI losses
 Tolerable pain
13/1/2024 3:07 am
Day 5 Management
 Continue IVD
 Trace blood C&S
Progress
2
 No fever
 No GI losses
 Tolerable pain
 Maggots noted over bilateral lower limbs
 Urine output: 40-50 cc/hour
14/1/2024 11:40 am
Day 6 Management
 Continue IVD
 Keep in view for turpentine dressing if maggots present
 Trace blood C&S
Progress
 BP 170/101, PR 100, SpO 99% on nasal prong 3L/minute
2
 Alert, GCS full

 No fever
 No GI losses
 Tolerable pain
15/1/2024 2:14 am
Day 7
Management
 Continue IVD
Progress
 Vital signs stable
 Alert, GCS full, mildly tachypnoeic, speaking in full sentences
 No fever
 No GI losses
 Tolerable pain
 On Ryle’s tubeRight femoral triple lumen
Summarize the progress and management accordingly- not copy paste all written in case
notes eg Day 1 in ED, Day 2 ? ward etc
What about secondary injuries due to explosion?
SUBSEQUENT INVESTIGATIONS DONE
Full Blood Count and White Cell Differential Count
Indications  As baseline for monitoring and management

:
 To screen for anaemia, thrombocytopenia, and bleeding disorders
 To screen for leucocytosis that can be caused by infection or
inflammation
 To screen for haemoconcentration/ haemodilution
Result
Blood Components Reference 10/1 11/ 11/1 13/1 14/ 15/1
Range 1 1
Red Blood Cell (10⁶ / µL) 4.53-5.95 6.42 5.97 5.14 4.14 3.43 3.38
Haemoglobin (g / dL) 13.5 - 17.4 18.1 16.8 14.4 11.7 9.7 9.6
Haematocrit (%) 30.1 - 50.6 51.7 47.6 40.3 33.2 27.3 27.5
Mean Cell Volume (fL) 80.6 – 95.5 80.5 79.7 78.4 80.2 79.6 81.4
Mean Cell Haemoglobin (pg) 26.9 - 32.3 28.2 28.1 28.0 28.3 28.3 28.4
Mean Cell Haemoglobin 31.9 - 35.3 35.0 35.3 35.7 35.2 35.5 34.9
Concentration (g / dL)
Platelet Count (K / µL) 142 - 350 80 44 40 19 48 57
Red Cell Distribution Width (%) 12.0 - 14.8 14.5 14.7 14.7 15.3 15.1 15.7
White Blood Cell Count (K / µL) 4.1 - 11.4 6.6 8.4 3.2 2.3 5.1 5.2
White Cell Component Reference 10/5 11/ 12/5 15/5 16/ 17/5
Range 5 5
Absolute Neutrophil (K/µL) 3.9 - 7.1 5.7 7.4 2.8 1.8 4.1 4.3
Absolute Lymphocyte (K/µL) 1.8 - 4.8 0.4 0.3 0.2 0.3 0.7 0.5
Absolute Monocyte (K/µL) 0.4 - 1.1 0.5 0.5 0.2 0.2 0.3 0.3
Absolute Eosinophil (K/µL) 0.0 - 0.8 0.0 0.0 0.0 0.0 0.0 0.0
Absolute Basophil (K/µL) 0.0 - 0.1 0.0 0.0 0.0 0.0 0.0 0.0
Interpretation: Patient initially haemoconcentration but slowly shows signs of anaemia over
subsequent days. Anaemia could be explained by from erythrocyte extravasation and destruction.
Venous Blood Gas
Indications  To assess the intravascular status and presence of acid base disturbance
: (by looking at pH, HCO3, PaCO2)
 To monitor efficacy of oxygenation and ventilation
Result
Parameters Reference 11/1 11/1 11/1 12/1 13/1
Range
pH 7.35 – 7.45 7.27 7.29 7.4 7.45 7.35
PCO 2 35.0 – 45.0 29 37 34 31 45
(mmHg)
PO 2 30 - 40 149 49 171 186 34
(mmHg)
HCO 3
-
22 -26 13.3 17.8 21.1 21.5 24.8
(mmol/L)
Lactate 0.5-2.2 3.3 3,6 3,0 - -
(mmol/L)
Interpretation: Patient’s VBG shows normalisation over his hospital stay
Renal Profile and Serum Electrolytes
Indications  As baseline investigation to assess renal function

:  To detect any electrolyte imbalance
 To detect signs of kidney injury
Result
Component Reference 10/ 11/1 11/1 11/ 12/1 13/1 14/ 15/1
Range 1 1 1
Urea (mmol / L) 2.8 – 7.2 17.5 21.8 21.0 18.7 18.3 17.5 12.6 9.2
Sodium (mmol / L) 136 – 146 134 132 136 138 138 148 153 165
Potassium (mmol / L) 3.4 – 4.5 4.9 5.7 4.7 4.3 4.2 3.7 3.1 3.1
Chloride (mmol / L) 101-107 103 105 109 109 114 119 116 110
Creatinine (mmol / L) 59 – 104 374 356 280 210 224 145 87 77
Calcium (mmol / L) 2.08 – 2.65 1.89 1.82 - - 2.14 2.14 2.04 2.02
Magnesium (mmol / L) 0.85 – 1.1 0.87 0.7 - - 1.08 1.06 0.91 0.93
Phosphate inorganic 0.78 – 1.65 1.83 1.99 - - 1.61 1.77 0.84 0.99
(mmol / L)
Interpretation: Patient has deranged parameters in his renal profile and serum electrolytes
pointing towards acute kidney injury (AKI)
Creatine Kinase
Indications  To detect muscle breakdown

:
Result
Reference Range 11/1 11/1
55-170 (U/L) 3640 2037
Interpretation: Patient has extensive muscle damage
Liver Function Test
Indications  As baseline investigation to assess liver function

:
Result
Parameter Reference Range 10/1 11/1
Total bilirubin(µmol/L) 5.0-21.0 20.8 16.4
Total protein (g/L) 66.0-83.0 41 49
Alkaline phosphatase (U/L) 0-104 82 61
Albumin (g/L) 35.0-52.0 20 23
Globulin (g/L) 20-35 21 26
Albumin/Globulin Ratio - 0.88 0.95
Alanine transaminase (U/L) 10-49 72 83
Aspartate Transaminase (U/L) 0-33 257 139
Interpretation: Patient has damage to hepatocytes, as indicated by low level of proteins and
increased ALP and AST.
Coagulation Profile
Indications  As a baseline investigation

:  To detect any underlying coagulopathy
Result
Parameters Reference 10/1 11/1 12/1

Range
Prothrombin Time (s) 10 – 14 20 17.9 12.6
Activated Partial Thromboplastin Time (s) 28 - 38 35.4 42.7 41.6
International Normalized Ratio <1.1 1.54 1.37 0.95

Interpretation: Patient’s coagulation profile points towards consumptive coagulopathy.
DISCUSSION ON FINAL DIAGNOSIS
The final diagnosis of Mr A is Alleged burn injury with 84% TBSA with deep and partial and
full thickness burns secondary to fire accident, 20 hours post exposure.
Signs and symptoms of deep partial thickness burns include:
- Vesicles/bullae
- Mottled coloration of skin with red/and or white patches
- Intact pain perception (pain typically felt on applying pressure)
- Wound not blanchable/ very slow refill
Signs and symptoms of full thickness burn include:

- Tissue necrosis with black, waxy-white, or gray leather-like skin (eschar)
- Skin appears dry and elastic (leathery skin)
- Pain perception not intact (perception of deep pressure intact)
- Wound not blanchable
In the case of Mr. A, he had a mix of deep partial thickness and full thickness burns. Some of
the burn wounds had a whitish appearance and some of them had a leathery appearance. He also
felt only moderate pain which he gave a pain rating of 4/10.
Total body surface area (TBSA) is the total area of skin involved in an injury or disease.
TBSA calculated using methods such as the Wallace’s rule of nines, Lund-Browder chart, or
palmar method. In this case, Wallace’s rule of nines method was used to measure the TBSA
involved in the burn injury.
In this case, Mr. A had a total TBSA of 84%:
- Face/Head/Neck: TBSA 6%
- Trunk and Back: TBSA 34%
- Upper Limbs: TBSA 14%
- Lower Limbs: TBSA 30%
Mr. A fulfilled the criterion for classification of major burn according to American Burn
Association Burn Classification. The criterion is:
- Partial thickness >25% TBSA, age 10-50 years old
- Partial thickness >20% TBSA, age <10 or >50 years old
- Full thickness >10% TBSA in anyone
- Burns involving hands, face, feet, or perineum
- Burns crossing major joints
- Circumferential burns of an extremity
- Burns complicated by inhalational injury
- Electrical burns
- Burns complicated by fracture or other trauma
- Burns in high-risk patients
Mr. A has partial thickness >25% TBSA, aged 37 years old and burns involving hands, face
and feet, burns crossing major joints and circumferential burns of extremities. Thus, he is
classified as a major burn patient. ? inhalational injury?
Critical Discussion
Skin has 2 layers, epidermis, and dermis. The thickness of skin is variable depending on age
and location. Based on the age factor, skin is thinner at extremes of ages. Based on location
factor, skin is thicker on palms, soles, and upper back as these are areas of maximum frictional
force.
The skin has several functions such as being a semipermeable barrier to evaporative water loss,
protection against assault from the environment and plays a role in the control of the temperature
of the body, sensation, and excretion.
Thermal injury results in a spectrum of local and systemic homeostatic disorders such as
disruption of sodium pump, intracellular influx of sodium and water, extracellular efflux of
potassium, depression of myocardial contractility (>60% TBSA burned), increased systemic
vascular resistance, metabolic acidosis, increase in haematocrit, increase in viscosity of blood,
secondary anaemia from erythrocyte extravasation and destruction, local tissue injury and release
of histamines, kinins, serotonins, arachidonic acids, and free oxygen radicals. As seen in this
patient, there was metabolic acidosis present, increase in blood pressure signalling increased
systemic vascular resistance, and there was increase in haematocrit in the early stages and
anaemia in the subsequent days.
Inhalational injury has become the main cause of mortality in burn patients and most deaths
are due to smoke inhalation. Direct thermal injuries usually are limited to the upper airway.
Smoke contains small particles that may reach to the terminal bronchioles. This can initiate
inflammation that will progress to bronchospasm and oedema. In this patient, an ORL
examination was done, and no soot was found.
Evidence-Based Management
Initial Assessment
Immediate management of moderate and major burns should prioritize the ABCDE approach.
 Airway
o Early intubation is indicated if an inhalation injury is suspected prior to airway
oedema or if burns involve > 30% TBSA.
o Do not delay intubation if needed, as fluid resuscitation can increase laryngeal
swelling.
 Breathing
o Administer 100% oxygen, if carbon monoxide poisoning is suspected.
o Escharotomy is indicated in circumferential burns of the trunk and neck
 Circulation: Fluid resuscitation with crystalloids is indicated to ensure
sufficient perfusion in patients with major burns.
o Hartmann’s Solution is preferred over hypertonic saline (HTS) because HTS may
cause hyperchloremic metabolic acidosis.
o The volume for 24 hours of initial fluid therapy with Hartmann’s Solution is
calculated using the Parkland formula:
 Because of the risk of serious complications from over resuscitation
(e.g., pleural effusion and compartment syndrome), current ATLS and
American Burn Association guidelines recommend adjusting the Parkland
formula as follows:
 Individuals ≥ 14 years of age: half the volume calculated using
the Parkland formula
 Individuals < 14 years of age who are ≥ 30 kg: initial fluid
therapy with LR for a 24-hour period using 3 mL x [%
of TBSA affected by 2nd- and 3rd-degree burns] × weight (in kg)
 Children < 30 kg: 24 hours of initial fluid therapy followed by 24
hours of maintenance fluid therapy with a glucose-
containing solution is required.
 Half of the recommended fluid volume should be administered within the
first 8 hours and the remaining half over the course of the next 16 hours.
o Combining crystalloids with colloids (e.g., albumin, plasma) or high-dose vitamin
C can reduce fluid requirements.
o After initial stabilization, patients who require aggressive fluid
resuscitation should undergo urethral catheterization to monitor urine output and
adjust fluids accordingly.
 Management of the burn area
o Remove clothing, dirt, and debris.
o Cool the burnt area with room-temperature or cool running water or saline-
soaked gauze and cover the wound with a sterile dressing.
 Core body temperature should be monitored for hypothermia; if body
temperature is < 35°C, warm IV fluids can be given.
 Cool with caution or not at all in patients with burns >10% TBSA because
of the high risk of hypothermia.
Subsequent Management
 Indications for treatment in a special burn unit
o 2nd-degree burns involving > 10% of TBSA or 3rd-degree burns involving >
5% of TBSA
o Inhalation injury
o Burns involving the hands, feet, genitalia, or major joints
o High-voltage electrical burns and chemical burns
 Wound care
o Early debridement of necrotic tissue
o Wound dressing depends on specific burn characteristics. Options include:
 Free-skin grafts (split thickness or full thickness)
 Flap reconstruction with free or pedicled flaps
o Topical antibiotics (e.g., silver sulfadiazine, bacitracin, neomycin)
 Nutritional support
o Enteral feeding via a nasogastric or nasoduodenal feeding tube is preferred over
parenteral.
o Early initiation of nutritional support helps to control the hypermetabolic
response.
 Pain management: NSAIDs, opioids
 Anxiety management: benzodiazepines
 Prophylaxis
o Proton pump inhibitors or H2 antagonists: curling ulcer prophylaxis
o Vaccination: tetanus prophylaxis
o Antibiotic therapy: Routine prophylactic systemic antibiotic therapy is not
recommended.
 If infection or sepsis occur, treat empirically (e.g., with vancomycin)
until MRSA can be ruled out.
 Treat for Pseudomonas (e.g. with cefepime) if suspected.
 Supportive measures: physical therapy
Eschar
 Circumferential eschar: Perform a Doppler test and check capillary refill time,
peripheral pulses, sensation, and pulse oximetry in the limb hourly for 24–48 hours to
assess for vascular/respiratory compromise or compartment syndrome.
o No vascular/respiratory compromise or compartment syndrome
 Raise the legs or upper body
 Perform a range-of-motion exercises as tolerated
o Vascular/respiratory compromise or compartment syndrome
 Escharotomy: an incision of the burnt necrotic tissue to prevent
constriction of the skin
 Fasciotomy is indicated if compartment syndrome develops.
 Chest/neck eschars: escharotomy in impending or active respiratory compromise
In this case Mr A was started on high flow mask 15L/minute. He was resuscitated with
Hartmann’s Solution. He was given IV cefuroxime and IV flagyl as he presented to the ED 20
hours post injury which increases the risk of wound contamination. He was also given fentanyl to
provide analgesia. A CBD was also inserted to measure urine output to monitor the resuscitation.
Dressing was then done with bactigras dressing which is a medicated paraffin gauze. He was
then started on IV omeprazole as prophylaxis for curling ulcer.
Prognosis
Important prognostic factors in thermal injuries are severity of burn, presence of inhalational
injury, associated injuries, age of patient, comorbid conditions, and acute organ system failure.
This patient fulfils criteria for major burns and has a low chance of survival according to
research done in November 2023.
Complications
 Shock, sepsis, and respiratory failure
o Most common causes of death from burns.
o Common causative organisms of sepsis include Staphylococcus
aureus (including MRSA), Enterococcus (including VRE), and Pseudomonas.
 Circumferential burns may lead to:
o Compartment syndrome
o Acute limb ischemia (e.g., weak/absent pulse, paraesthesia, pallor in the affected
limb)
o Abdominal compartment syndrome
o Increased intraabdominal pressure (e.g., jugular venous
distension, hypotension, tachycardia)
 Curling ulcers
 Keloid formation, contractures
 Marjolin ulcer
In this case, Mr A has circumferential burns. This increases the risk of him developing
compartment syndrome, acute limb ischemia, abdominal compartment syndrome and increased
intraabdominal pressure. He is also at risk of developing curling ulcers, keloid formation and
contractures.
DISCUSSION ON PATIENT SAFETY AND PROFESSIONALISM
Before taking the history from Mr. A, I approached him and introduced myself as a 3rd year
medical student from UTAR. I asked for permission to take history from him and informed him
that I will be jotting down the information that he tells me. I also assured him that all information
shared will be confidential and will not be misused in any shape or form. After gaining consent, I
moved on to my clerking. I ensured that Mr. A was in a comfortable position and made sure to
not interrupt his chain of conversation and let him finish his sentences. Before performing
physical examination, I explained briefly to him about the examination that will be done, and I
asked him if it is fine with him to be examined without the curtains on as there were no curtains
around his bed. I then sanitized my hands with alcohol hand rub and wore gloves and wore
medical gown to prevent cross contamination. I enquired about any pain present before touching
the patient. I also made sure to keep an eye on the patients face to see if he was in any
discomfort. Upon completing my examination, I covered up the patient, thanked the patient for
his cooperation and time. I then sanitized my hand before leaving the patient. I then disposed my
gloves and medical gown in the biohazard bin.
REFERENCES
Burns - AMBOSS. (n.d.). Retrieved January 16, 2024, from

https://next.amboss.com/us/article/Jh0sUf?q=burns
Cartotto, R., Greenhalgh, D. G., & Cancio, C. (2017). Burn state of the science: Fluid
resuscitation. Journal of Burn Care and Research, 38(3), e596–e604.
https://doi.org/10.1097/BCR.0000000000000541
Greenhalgh, D. G. (2019). Management of Burns. New England Journal of Medicine, 380(24),

2349–2359. https://doi.org/10.1056/NEJMRA1807442
Hettiaratchy, S., & Papini, R. (2004). Initial management of a major burn: II—assessment and
resuscitation. BMJ, 329(7457), 101–103. https://doi.org/10.1136/BMJ.329.7457.101
Hettiaratchy, S., & Dziewulski, P. (2004). Pathophysiology and types of burns. BMJ, 328(7453),
1427. https://doi.org/10.1136/BMJ.328.7453.1427
Overview of the management of the severely burned patient - UpToDate. (n.d.). Retrieved
January 16, 2024, from https://www.uptodate.com/contents/overview-of-the-management-of-the-
severely-burned-patient/print
Tintinalli’s Emergency Medicine A Comprehensive Study Guide.

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M Kandiah Faculty of Medicine and Health Sciences, UTAR

Score sheet for CASE Write-Up

Student Name: Deipan A/L Arjunan

Name of lecturer: Prof Dr Rosidah Ibrahim

Marks allocation for Case Write-up

Focused History taking with 15/20 Subsequent management and 5/10

Physical Examination findings 12/15 Discussion on final diagnosis and 4/6

Discussion 7/10 Proper use of English language, and 3/4

Initial investigations in ED (with 4/5 Total score 67.5/100

Lecturer’s Signature: ____ _____________ Date: ____01/3/2024_______

Mr A, a 37-year-old gentleman presented with alleged burn injury.

History of Presenting Illness

Mr A is a 37-year-old Burmese gentleman was involved in an alleged fire accident 6 pm a day

General Conscious, alert, no fever, no chills, no rigors

Past Medical, Surgical and Hospitalisation History

Mr A does not have any past medical, surgical or hospitalisation history.

Drug and Allergy History

Vital signs Results Interpretation

Interpretation: Mr A was tachycardic, tachypnoeic, and hypertensive

Rule of Nines Burn Chart

Evidence for Evidence against

Full Blood Count  As baseline for monitoring and management

Chest X-ray  Baseline evaluation to detect any changes of diffuse or

Renal Profile  As baseline investigation to assess renal function

Liver Function Test  As baseline investigation to assess liver function

Random Blood Glucose  To detect hyperglycaemia/ hypoglycaemia

Cardiac Biomarkers  To detect post-burn cardiac injury

Creatine Kinase  To detect muscle breakdown

Coagulation Profile  As a baseline investigation

Full Blood Count and White Cell Differential Counts

Red blood cell (106/µL) 4.53-5.95 7.38 High

Haemoglobin (g/dL) 13.5-17.4 20.9 High

Haematocrit (%) 30.1-50.6 60.9 High

Mean cell volume (fl) 80.6-95.5 82.5 Normal

Mean cell haemoglobin (pg) 26.9-32.3 28.3 Normal

Mean cell haemoglobin concentration (g/dL) 31.9-35.3 34.3 Normal

Platelet (K/μL) 142-350 374 High

Red cell distribution width (%) 12.0-14.8 16.8 High

White blood cells (K/µL) 4.1-11.4 21.7 High

Nucleated red blood cells (%) 0.0 0.11 High

Absolute lymphocytes(K/µL) 1.8-4.8 1.9 Normal

Absolute monocytes(K/µL) 0.4-1.1 1.7 High

Absolute eosinophils (K/µL) 0.0-0.8 0.0 Normal

Absolute basophils (K/µL) 0.0-0.1 0.1 Normal

Interpretation: Mr A has several higher-than-normal values in blood parameters. This could be

Venous Blood Gas

Renal Profile and Serum Electrolytes

Urea (mmol/L) 2.80-7.20 12.3 High

Sodium (mmol/L) 136-146 130 Low

Potassium (mmol/L) 3.4-4.5 5.1 High

Chloride (mmol/L) 101-109 97 Low

Creatinine (mmol/L) 59-104 355 High

Calcium (mmol/L) 2.08-2.65 1.86 Low

Magnesium (mmol/L) 0.85-1.1 0.45 Low

Phosphate Inorganic (mmol/L) 0.78-1.65 2.38 High

Interpretation: Elevated hsTnI indicates post-burn cardiac injury.

Parameters Reference Range Results Interpretation

Prothrombin Time (s) 10 – 14 22.8 Prolonged

Activated Partial Thromboplastin Time (s) 28 - 38 45.2 Prolonged

International Normalized Ratio <1.1 1.49 Increased

Random Blood Glucose

Interpretation: Patient has normal blood glucose level

MANAGEMENT AND PROGRESS OF THE PATIENT

Lecturer’s Signature: ___ Date: 01/3/2024_