Department of Surgery

UPCM- PGH
CASE REPORT
Plimaco-Garcia, Jervy B.
PGI- Block T
June 4, 2020
QUESTION 1: Given the above information how would you initially manage this patient?
For burn patients, initial assessment is targeted on determining the need for immediate
resuscitation. Primary survey that examines A for airway, B for breathing, C for circulation, cervical,
compartment syndrome, D for deficit/deformities (neurologic), E for exposure and F for fluid
resuscitation is a systematic and concise method widely used. During assessment, sterile gloves should be
utilized to check for airway and breathing compromise. Since the patient is not in respiratory distress, no
immediate intervention is needed. After ensuring that the patient is stable, we may proceed with complete
physical examination including anthropometric measurements and taking note of other injuries sustained
such as fractures, lacerations or blunt abdominal trauma especially with the history of fall and loss of
consciousness. Burnt clothing must be removed and fluid resuscitation using 1-2 large bore intravenous
catheters immediately started. Since in this patient lines running Parklands was already noted, its
important to check whether the rate used was appropriate. For electrical burn injury, Plain Lactated
Ringers solution at 6ml x kg x %TBSA is advised instead of the usual 2-4ml x kg x %TBSA. Half of the
computed volume should be given in the first 8 hours while the other half in the next 16 hours and
subsequent Foley catheter insertion to monitor for the urine output and assess the hydration status.
Maintaining a urine output between 75-100ml/hr or until the urine color clears up is suggested.
Hemoglobinuria or myoglobinuria can be seen in electrical burn patients hence, a higher urine output
requirement to facilitate excretion is usually advised. Next, nasogastric tube insertion and IV PPI should
be started to avoid Curling’s ulcer.

Secondary survey with the investigation of AMPLE parameters is the next step. This includes
asking questions on allergies, medications and tetanus immunization, previous illnesses, last meal, events
surrounding the injury (such as cause of burn, did injury occur in a closed space, clues for possible
inhalational injury? Were chemicals involved? Was there related trauma?). Tetanus toxoid and/or tetanus
immunoglobulin should be administered as needed based on the vaccination history elicited. It is
important that pulses in all extremities and adequacy of chest expansion are assessed to rule out surgical
emergencies and the need for an escharotomy. Initial laboratory work-up for electrical burn patients
should also be sent at this time with additional CXR and pelvic x-ray due to the fall and plain cranial CT
scan to rule out traumatic brain injury or hemorrhage since the patient presented with loss of
consciousness. Initial wound dressing should also be done while ensuring pain management should with
opioid as the drug of choice.

QUESTION 2: How would you classify the patient according to injury severity? What disposition will you give
this patient?
In electrical burn injury such as in this case, the patient is classified as having Major type of
injury regardless of the depth and the total surface area of burns with16.9% partial thickness burn
sustained which technically falls under Moderate category (15-25% partial thickness burn in adults). In
addition, presence of fractures or other trauma secondary to the fall incident also places the patient at high
risk further qualifies him to be classified as Major. Involvement of primary areas such as hands, face, feet,
perineum and major joints, as well as involving chemical injury, suspicion of inhalational injury, and
presence of major associated medical illness warrant further classification of the patient as Major. The
patient will then require subsequent admission to the Burn Unit.

Primary Working Impression:

Electrical injury with 16.9% TBSA cutaneous burns
DPT - 11.9% posterior neck, anterior and posterior trunk, R upper arm, R thigh, R leg, R foot
SPT - 5.0% anterior trunk, L leg and L foot
r/o traumatic brain injury secondary to fall

QUESTION 3: Briefly discuss the special considerations in this case.

 There are three acute management concerns that is unique to patients with electrical injuries: which
patients require electrocardiographic monitoring; how should fluid resuscitation proceed; and which
patients may need surgical intervention for a possible compartment syndrome.
a) Cardiac abnormalities such as fatal arrhythmias are potentially lethal sequelae of electrical burn
injuries and therefore may require subsequent cardiac monitoring. Indications include: (1) loss of
consciousness, (2) ECG abnormality or evidence of ischemia, (3) documented dysrhythmia either
before or after admission to the emergency department, (4) cardiopulmonary resuscitation in the
field, and (5) patient with other standard indications.
b) Another important area of concern is fluid resuscitation especially in patients who present with
apparent grossly darkened urine (hematuria) that may suggest an ongoing significant muscle
damage secondary to rhabdomyolysis. This can progress to tubular obstruction and manifest as
acute renal failure. Thus, the goal would be to “clear” the urine by increasing urine output in the
several hours after the injury.
c) Lastly, the risk for developing compartment syndrome must be addressed. Patients who sustained
high-voltage electrical injuries must be monitored closely; they are the greater risk for developing
compartment syndrome as compared to those with low-voltage electrical injuries. Those who
develop clinical signs of compartment syndrome are recommended to undergo fasciotomy.

QUESTION 4: What are your contemplated initial management admitting orders. Please arrange as follows:
Diet/Nutrition, Resuscitation – IV fluids / need for central line insertion, Diagnostics, Pharmacotherapy,
Monitoring
Admitting Orders
 Admit to Burn Unit
 Secure line
 Insert NGT
 Insert Foley Catheter
 Diet: Blenderized Tube Feeding (2,500 kcal/day from 50% CHO, 30% CHOH, 20% CHON), add
6 egg whites/day
 IVF:
Day 1 - PLR 2.5 L x first 8 hours, then PLR 2.5 L x 16 hours
Day 2 - D5NR 1L @ 80 cc/hr as maintenance fluid
 Diagnostics:
o 12L-ECG stat
o Daily CBC
o Blood Typing
o BUN, Crea, Na, K, Cl, Alb, RBS
o Daily BUN, Crea, Na, K
o PT/PTT
o Urinalysis with urine pH
o Urine myoglobin
o CXR-PAL
o Pelvic X-ray APL
o Plain Cranial CT Scan
 Therapeutics:
o Give Tetanus Toxoid 0.5mL via deep IM over R deltoid now
o Give Anti-tetanus serum 3000 “u” via deep IM over L deltoid now
o Give NaHCO3 50 mEqs IV bolus now
o Incorporate NaHCO3 50 mEqs per 1L PLR; if with persistent myoglobinuria, may
increase up to 100-150 mEqs until without myoglobinuria
o Incorporate Mannitol 12.5 g per 1L of PLR
o Meperidine 50 mg IVTT q6h
o Pantoprazole 40 mg IVTT q24h
o Ascorbic Acid 0.5 g IVTT q24h
o Zinc SO4 45 mg effervescent tab PO to be dissolved in 1 glass H20 BID
 Monitor VS qhourly, NVS qhourly, I&O qhourly, check for urine color and document
 Check for pulmonary status q4h, refer if with DOB or desaturation
 Check for peripheral perfusion hourly, refer if CRT>2s or absent peripheral pulses
  Hook to Cardiac Monitor if with ECG abnormalities
 Complete bed rest without toilet privilege for the first 24 hours
 Weigh patient daily
 Wound Care BID, check wound status
 Refer to Ophthalmology

QUESTION 5: What wound dressings would you use for this patient? How long can we expect the wounds to
recover?
Initial wound debridement/dressing is done by sterile technique. The process includes cutting of
hair or items that may have contaminated the burned areas. Full body bath with soap and water is done
and subsequent debridement of burned areas to visualize all affected areas, as well to reassess depth and
%BSA of burn. Wash again with betadine soap, rinse with sterile water and wound dressing can be done.
Wound can be dressed by:
 Silver sulfadiazine has a wide range of antimicrobial activity, primarily as prophylaxis against
burn wound infections rather than treatment of existing infections. It is inexpensive, and easily
applied and has soothing qualities. Added to that, it is not significantly absorbed systemically
hence has minimal metabolic derangements. However, it can cause transient leukopenia. It also is
contraindicated in donor sites in proximity to newly grafted areas since it destroys skin grafts. It
can also retard epithelial migration in healing-partial thickness wounds can only be used for a
maximum of 2 weeks.
 Mafenide acetate is an effective topical antimicrobial, is effective even in presence of eschar, and
can be used in both treating and preventing wound infections. However, since it is a carbonic
anhydrase inhibitor, it may cause metabolic acidosis.
 Silver nitrate has a broad spectrum antimicrobial activity, however is not widely used due to
prolonged topical application leads to electrolyte extravasation with resulting hyponatremia, with
rare complication of methemoglobinemia. It also causes black stains in with anything it contacts
with.
 Dakin’s Solution (15mL sodium hypochlorite (Zonrox) + 985mL NSS) is an inexpensive topical
antimicrobial. It is used in preparing granulation tissue for grafting. It has bactericidal properties
against S. aureus, P. aeruginosa and other G(-) and G(+) bacteria
Healing of superficial partial thickness burns is usually observed within 2-3 weeks compared to 3-5
weeks with deep partial thickness burns which can result in hypertrophic scarring and potential
contracture. Partial thickness burns can convert to full thickness burns and is evidence of worsening
condition. Full thickness burns heal by granulation and will require future skin coverage. Healing with
skin graft may take up months to 2 years for the graft to mature.

QUESTION 6: What surgical management options can you offer the patient? How will you offer them to the
patient?
Once the initial resuscitation is complete and the patient is hemodynamically stable, attention
should be focused to excising the burn wound. Burn excision and wound coverage should ideally start
within the first several days. Early excision within 7 days post burn is suggested when the wound is not
yet colonized by microorganisms thereby reducing the chances of infection and followed by skin
grafting.

Excision
 Tangential Excision-excising the wound in thin layers using a blade held at a very acute angle
with the skin surface done to remove the nonviable tissue leaving as much dermis as possible.
 Fascial Excision-may be necessary in deeper burns and is best used when excising large flat
areas. It is less bloody than tangential excision but with cosmetic effect defects. It has limited use
in extremities due to problems of edema distal to the area of excision, presence of avascular
fascia and superficial nerves.

There are multiple options for wound coverage in burn patients depending on the site of the
injury, and the availability of donor sites, options include the following: Primary closure, Skin
grafting (Split-thickness autografting, full-thickness autografting, and use of skin substitutes), Tissue
expansion and Local and Regional Skin Flaps. In the case of our patient a split-thickness autograft
can be offered:
 Split-thickness autograft is the most frequently used in the management of acute burn wounds,
this involves harvesting the epidermis and a variable amount of dermis (ranging from 8/1000 of
 an inch and 12/1000 of an inch) from a chosen donor site, these donor sites are carefully chosen
with a mindset of a possible re-harvesting. Easy to harvest areas include the convex lateral and
anterior surface of the thigh.

QUESTION 7: What are the complications expected in cases such as these? When will you discharge the
patient?
 Primary and early complications are of renal, septic, cardiac, neurologic and ocular
manifestations.
 Cardiac and neurologic complications may be present at the time of receiving the patient.
o Cardiac: non-specific ST changes, cardiac dysrhythmia (atrial fibrillation; most common
cause of death at the scene: ventricular fibrillation, traumatic myocardial contusion,
myocardial infarction
o Neuropsychiatric
 May present with central or peripheral neurologic symptoms
 Early presentation- decreased sensorium, loss of complications
 Late complication (up to 2 years of injury)- neuromuscular defects such as
paresis, paralysis, GBS, transverse myelitis, amyotrophic lateral sclerosis)
 Neurologic symptoms commonly complained: numbness, weakness, memory
problems, paresthesia, chronic pain
 Psychological symptoms: anxiety, nightmares, insomnia, flashbacks
 Renal complication- myoglobinuria and hemoglobinuria secondary to rhabdomyolysis cause a
risk in acute renal failure (tubular obstruction)
o Ensure adequate resuscitation and continuous monitoring of urine output
 Extremities: direct tissue destruction
o Skeletal injury: indirectly- fractures secondary to falls or with forceful tetanic muscle
contraction
o Thermal burns: joint contractures, limited movement and function
o Heterotopic calcification or ossification in periarticular tissue especially on large joints or
at the cut ends of amputation
 Caused by forced passive mobilization, articular bleeding, calcium precipitation
and deposition by damaged muscle and connective
 Autonomic complex complication- sympathetic overactivity (changes in bowel habits, urinary
and sexual function)
o Unknown exact pathophysiology or mechanism not known, most likely related to direct
injury by the electrical current or a vascular cause
 Ocular complication- cataract formation (more frequently associated with head, neck and upper
trunk contact points)
o High rate of bilateral involvement, minimal association with the amount of voltage
o Mechanism: direct coagulative effect on the lens proteins and disturbance in its
nutritional mechanism secondary to inflammation and impaired circulation
 Patient can be discharged:
o Initial and life-threatening complications and resolved: Cardiac, neurologic (immediate)
o Damage of tissue, organs (renal, muscles and bones) addressed through appropriate
management- surgical
o Ensuring adequate follow-up resources- burn centers, rehabilitation and physical therapy,
psychiatric therapy
Clinical dilemma: Among patients with partial thickness burns, what therapies/measures can induce pain
reduction as well as hasten wound healing?

Journal: A Clinical Study of Collagen Dressing Over Silver Sulphadiazine Dressing in Partial Thickness
Burns

Population 60 Patients admitted with partial thickness burns, <40% BSA

and not older than 48 hours

Intervention Group I: collagen dressing, Group II: 1% silver sulphadiazine

Control 30 patients treated with conventional silver sulphadiazine

ointment

Outcome Pain control/reduction/ Faster wound healing time

Method Prospective randomized Comparative study

1. Were patients randomly assigned to treatment groups?

Yes.
2. Was allocation concealed?
Yes.
3. Were baseline characteristics similar at the start of the trial?
Yes. Inclusion and exclusion criteria were utilized in the selection of the patients and thus,
baseline characteristics were similar.
4. Were the patients, caregivers and outcome assessors blinded to the treatment?
Cannot tell. It was not stated in the journal whether the patients, caregivers and outcome
assessors were blinded to the treatment.
5. Were all patients analyzed in the groups where they were originally randomized?
Yes.
6. Was follow up adequate?
Yes. The patients were followed upon a daily basis in both test and control group until complete
epithelisation occurred. The control group was subjected to alternate day dressing by
conventional silver sulphadiazine dressing whereas the test group was subjected to collagen
dressings and was left undisturbed until complete epithelisation occurred. Dressings were replied
if any infection of collagen dressing occurred.
7. How large was the effect of treatment?
In this study patients with burns<40%BSA only were included. Majority of the patients
had 21-30% BSA burns. All patients in group I with collagen dressings required only one
dressing, except in one patient who required 2 dressings, as a result of infection. Pain, Pain
assessment was done using visual analogue scale, on day 1, day 2, day 7, day 14. Pain assessment
on day 1: After application of collagen dressing on day1, 80%of patients had pain scoreless than
5, whereas with SSD dressings, 43.3% of patients had painless than 5. Comparison of pain in
 both the groups on day 1 showed a significant difference with p value < .0001, inferring that pain
in collagen dressing is significantly less compared to that in silver sulphadiazine dressings on
day1. Wound healing time showed a significant difference with p value of 0.0001. Indicating
faster healing time in collagen dressing is statistically significant. 87% of patients with collagen
dressing had no infection. Infection collagen dressing is much lower than with SSD Patients in
Group1had good wound healing with healthy scar formation in 87% after 4weeks compared to
group II.
8. What are biologic issues affecting applicability?
Pain tolerance among subjects included in the study was not determined prior to giving of
the interventions which can somehow affect the results. The study also included patients ages 6
until 65 which influences differences in pain perception and interpretation especially in younger
subjects. The study also was conducted on patients who sustained flame burns which can differ
from electrical burns such as in our patient in terms of pain severity and rate of healing.
9. Socio-economic issues?
The cost of collagen dressing is less compared that of silver sulphadiazine group in a
patient with 30% burns but it is not statistically significant (p value > 0.05). In SSD Dressing in
addition to the actual dressing cost many other cost like, the prolonged hospital stay as a result of
delayed wound healing, the additional doses of analgesics and antibiotics needed with SSD group
as a result of increased pain, delayed wound healing and increased infections, loss of labour and
time and money spent every time for the accompanying person taking care of the patient, time
spent by the doctor to perform the dressing. If all these taken in to consideration collagen
dressing, is significantly more cost effective than SSD dressing.
10. What is the likely effect of the treatment on your individual patient?
Collagen dressing would be beneficial to the patient and among other patients with partial
thickness burs. In addition, pain can be significantly reduced when this dressing is used since it
forms a temporary barrier preventing any external source from stimulating nerve endings to cause
pain. Collagen dressings help to form a mechanical barrier between wound and environment thus
preventing infections. In this study, the rate of wound healing was significantly faster in collagen
dressing than SSD and this was mainly attributed to the proper ties of collagen proving an
optimum environment for early wound healing. The morbidity of patients too is less as the scar
formation is healthy in most of the patients using collagen owing to its properties of inducing
granulation and epithelialisation. The collagen dressing is more cost effective than SSD. SSD has
disadvantage of the large number of dressings, prolonged hospital stay, amount pain, loss of time
and labor of the patient and the accompanying person which makes collagen dressing more cost
effective as it is most of the time a single dressing.