Brokenshire Integrated Health Ministries

Incorporated
Department of General Surgery

A CASE PRESENTATION ON BURNS

PRESENTED BY:
PGI BELUAN, CHARLES GERARD B.
August 4, 2019
 OBJECTIVES

 To present a case of a 9 month old male who came in

with a chief complaint of burns.

 To be able to come up with an impression based on the

patient’s history and physical examination

 To discuss on burns and correlate it with the case

 GENERAL DATA

9 months
O.J.
Child

Filipino

Roman Catholic

Calinan,
Davao City
CHIEF COMPLAINT

BURNS
 HISTORY OF PRESENT ILLNESS

Patient was placed in his crib, then while playing accidentally grabbed the
wire of the electric kettle, which contained hot water. Upon grabbing the
water was poured unto the childs body sustaining burn injuries on his Right
Hours Prior Upper and Lower Extremities and also the Right side of his torso. Mother
to Admission promptly rushed the patient to the nearest hospital. Hence admission.
 PAST MEDICAL HISTORY

• Born to a 29 y.o. G1P1 mother with no known obstetrical

complications during pregnancy.
• Exclusively breastfed.
• Stand alone - 8 months
• Can sit alone - 7 months
• Rolls back to stomach - 6 months
• Able to pick up small objects - 8 months
• Complete Immunization
 FAMILY HISTORY

No known he Paternal No known heredo-

redo-familial Maternal
familial diseases
diseases
 REVIEW OF SYSTEMS

GIT:
HEENT:
GENERAL:
RESPIRATORY: CARDIOVASCULAR: (-) vomiting,
(-) headache,
(-) weight loss, (-) diarrhea,
(-) visual disturbances, (-) cough, (-) orthopnea,
(-) body malaise/ (-) constipation,
(-) dizziness, (-) hemoptysis, (-) exertional dyspnea,
fatigue, (-) epigastric pain,
(-) mucosal bleeding, (-) dyspnea (-) palpitations
(-) loss of appetite (-) melena,
(-) epistaxis
(-) hematochezia
 REVIEW OF SYSTEMS

MUSKULOSKELETAL: ENDOCRINE:
GUT: (-) hot/cold
(-) numbness of both upper and lower intolerance,
(-) bloody/watery vaginal discharges extremities (-) tremors
 PHYSICAL EXAMINATION

GENERAL SURVEY

• Patient is awake, conscious, afebrile, and not in respiratory distress

Vital Signs Weight 9.55 kgs

Heart Rate 142 bpm
Height 72 cm
Respiratory Rate 29 cpm
No wasting No stunting
Temperature 36.6° C
O2 Sat 99 %
 PHYSICAL EXAMINATION

SKIN: (+)partial-thickness burn lesions right upper and lower extremities and right abdomen ,(+)
blisters right upper extremities and right abdomen, warm to touch, good turgor

HEENT: pink palpebral conjunctivae, (-) nasoaural discharges

NECK: supple, (-) neck vein engorgement; (-) lymphadenopathy

CHEST and LUNGS: equal chest expansion, clear breath sounds

HEART: Adynamic precordium, distinct heart sounds, normal rate, regular rhythm, (-) murmurs
 PHYSICAL EXAMINATION

Abdomen: protuberant, (+) partial-thickness burn lesions on the right abdomen,

normoactive bowel sounds, soft , non tender

Anus/Rectum: not assessed

 PHYSICAL EXAMINATION

EXTREMITIES: (+)partial-thickness burn lesions right upper and lower extremities,(+)

blisters right upper extremities, (-) cyanosis, (-) clubbing, strong peripheral pulses, CRT < 2
seconds

NEUROLOGIC: intact, no deficits

CRANIAL NERVES: CN I-XII intact

MUSCLE STRENGTH: 5/5 Upper and Lower Extremities

REFLEXES: 2+
 WORKING IMPRESSION

SCALD BURN, 11% TBSA, RIGHT UPPER

AND LOWER ARM, RIGHT ABDOMEN
COURSE AT THE ER (07/25/2019)

Subjective Objective ADMISSION Assessment Plan

(+)burns V/S: SCALD BURN, 11% TBSA,  admit patient
(+)irritability HR: 140 RIGHT UPPER  TPR q 4 hours
 I n O q shift
(-) fever RR: 24 AND LOWER ARM, RIGHT  Diet: Diet for age
(-)dyspnea T: 36.5 ABDOMEN  IVF: PLR 1L @ 40 gtts/min as
O2: 99% at room air maintenance rate.
 Diagnostics:
1. CBC
2. UA
3. BUN
4. CREA
5. Na, K, Cl
6. CXR

SKIN: (+)partial-thickness burn lesions right Meds:

upper and lower extremities and right 1. PCM 100/ml 1.5 ml q 6 hours
abdomen ,(+) blisters right upper extremities 2. flammazine ointment OD
and right abdomen, warm to touch, good
turgor
GS: conscious, not in respiratory distress,
irritable
C/L: Equal chest expansion, Clear breath sounds
CVS: Distinct heart sounds, normal, regular
rhythm, no murmurs
ABD:protuberant, normoactive bowel sounds, (+)
partial-thickness burn lesions on the right
abdomen
Ext: CRT<2 seconds, storng peripheral pulses, (-)
edema
COURSE AT THE WARD HD1 (07/26/19)

Subjective Objective ADMISSION Assessment Plan

(+)burns V/S: SCALD BURN, 11% TBSA,  TPR q 4 hours

(+)irritability HR: 140 RIGHT UPPER  I n O q shift
 Diet: Diet for age
(-) fever RR: 24 AND LOWER ARM, RIGHT  FD PLR 120 cc now IVF TF D5LR
(-)dyspnea T: 36.5 ABDOMEN 1L @80cc/hr x 4 hours, then
O2: 99% at room air regulate to 1L @40cc/hr
 CBG monitoring q 8h
 for unroofing of bullae and
dressing of burn wound with
flammazine treatment
 for debridement of burn wound
under sedation

SKIN: (+)partial-thickness burn lesions right 1. PCM 100/ml 1.5 ml q 6 hours

upper and lower extremities and right 2. flammazine ointment OD
abdomen ,(+) blisters right upper extremities 3. Ampicillin-Sulbactam 475 mg
IVTT q 6h
and right abdomen, warm to touch, good
turgor
GS: conscious, not in respiratory distress,
irritable
C/L: Equal chest expansion, Clear breath
sounds
CVS: Distinct heart sounds, normal, regular
rhythm, no murmurs
ABD:protuberant, normoactive bowel
sounds, (+) partial-thickness burn lesions on
the right abdomen
 COMPLETE BLOOD COUNT
07/26/2019 WBC 17.6 4.0-10.0
LABORATORIES: RBC 4.3 4.5-6.2
Hemoglobin 11.2 13.0-18.0
Hematocrit 0.33 0.40-0.50
Chest X-ray RESULT (July 26, 2019) MCV 76.5 78.0-100.0
MCH 26.3 27.0-34.0
Impression: Bronchopneumonia with MCHC 33.3 30.0-35.0
hilar adenopathies RDW-CV 12.5 11.5-14.5
Platelet Count 209 150-400
Crea: 29.7L
Differential Count
Na:136.7
K:3.96 Neutrophil 0.42 0.55-0.65
Cl:104.5 Lymphocytes 0.48 0.35-0.55
BUN:3.96
Monocytes 0.09 0.02-0.09
Eosinophil 0.00 0.02-0.04
Basophil 0.01 0.00-0.02
COURSE AT THE WARD HD2 (07/26/19)1AM

Subjective Objective ADMISSION Assessment Plan

(+)burns V/S: SCALD BURN, 11% TBSA,  TPR q 4 hours

(+)irritability HR: 138 RIGHT UPPER  I n O q shift
 NPO
(-) fever RR: 22 AND LOWER ARM, RIGHT  CBG monitoring q 8h
(-)dyspnea T: 36.7 ABDOMEN  for debridement of burn wound
O2: 99% at room air under sedation
 administer salbutamol 1 nebule
prior to OR

SKIN: (+)partial-thickness burn lesions right 1. PCM 100/ml 1.5 ml q 6 hours

upper and lower extremities and right 2. flammazine ointment OD
abdomen ,(+) blisters right upper extremities 3. Shift Ampicillin-Sulbactam to
Piperacillin-Tazabactam 770mg
and right abdomen, warm to touch, good
q 8hours
turgor 4. Salbutamol nebule q 8hours
GS: conscious, not in respiratory distress,
irritable
C/L: Equal chest expansion, Clear breath
sounds
CVS: Distinct heart sounds, normal, regular
rhythm, no murmurs
ABD:protuberant, normoactive bowel
sounds, (+) partial-thickness burn lesions on
the right abdomen
Ext: CRT<2 seconds, storng peripheral
pulses, (-) edema
COURSE AT THE WARD HD2 (07/26/19)5pM

Subjective Objective ADMISSION Assessment Plan

(+)irritability V/S: SCALD BURN, 11% TBSA,  TPR q 4 hours

(-) fever HR: 135 RIGHT UPPER  I n O q shift
 NPO
(-)dyspnea RR: 22 AND LOWER ARM, RIGHT  CBG monitoring q 8h
T: 36.6 ABDOMEN  scheduled for burn dressing
O2: 99% at room air S/P Burn wound dressing under sedation 7/29/19
under sedation

SKIN: (+)partial-thickness burn lesions right 1. PCM 100/ml 1.5 ml q 6 hours

upper and lower extremities and right 2. flammazine ointment OD
abdomen ,(-) blisters right upper extremities 3. Shift Ampicillin-Sulbactam to
Piperacillin-Tazabactam 770mg
and right abdomen, warm to touch, good
q 8hours
turgor 4. Salbutamol nebule q 8hours
GS: conscious, not in respiratory distress,
irritable
C/L: Equal chest expansion, Clear breath
sounds
CVS: Distinct heart sounds, normal, regular
rhythm, no murmurs
ABD:protuberant, normoactive bowel
sounds, (+) partial-thickness burn lesions on
the right abdomen
Ext: CRT<2 seconds, storng peripheral
pulses, (-) edema
COURSE AT THE WARD HD2 (07/26/19)5pM

Subjective Objective ADMISSION Assessment Plan

(+)irritability V/S: SCALD BURN, 11% TBSA,  TPR q 4 hours

(-) fever HR: 138 RIGHT UPPER  I n O q shift
 NPO
(-)dyspnea RR: 22 AND LOWER ARM, RIGHT  CBG monitoring q 8h
T: 36.7 ABDOMEN  scheduled for burn dressing
O2: 99% at room air S/P Burn wound dressing under sedation 7/29/19
under sedation

SKIN: (+)partial-thickness burn lesions right 1. PCM 100/ml 1.5 ml q 6 hours

upper and lower extremities and right 2. flammazine ointment OD
abdomen ,(-) blisters right upper extremities 3. Shift Ampicillin-Sulbactam to
Piperacillin-Tazabactam 770mg
and right abdomen, warm to touch, good
q 8hours
turgor 4. Salbutamol nebule q 8hours
GS: conscious, not in respiratory distress,
irritable
C/L: Equal chest expansion, Clear breath
sounds
CVS: Distinct heart sounds, normal, regular
rhythm, no murmurs
ABD:protuberant, normoactive bowel
sounds, (+) partial-thickness burn lesions on
the right abdomen
Ext: CRT<2 seconds, storng peripheral
pulses, (-) edema
COURSE AT THE WARD HD2 (07/27/19)5pM

Subjective Objective ADMISSION Assessment Plan

(-) fever V/S: SCALD BURN, 11% TBSA,  DAT

(-)dyspnea HR: 140 RIGHT UPPER  Cont Present management
 scheduled for burn dressing
RR: 20 AND LOWER ARM, RIGHT under sedation 7/29/19
T: 37.1 ABDOMEN  D/C hgt monitoring
O2: 99% at room air S/P Burn wound dressing  D/C Nebulizations
under sedation (7/26/19)

SKIN: (+)partial-thickness burn lesions right 1. PCM 100/ml 1.5 ml q 6 hours

upper and lower extremities and right 2. flammazine ointment OD
abdomen ,(-) blisters right upper extremities 3. Shift Ampicillin-Sulbactam to
Piperacillin-Tazabactam 770mg
and right abdomen, warm to touch, good
q 8hours
turgor
GS: conscious, not in respiratory distress,
irritable
C/L: Equal chest expansion, Clear breath
sounds
CVS: Distinct heart sounds, normal, regular
rhythm, no murmurs
ABD:protuberant, normoactive bowel
sounds, (+) partial-thickness burn lesions on
the right abdomen
Ext: CRT<2 seconds, storng peripheral
pulses, (-) edema
 COMPLETE BLOOD COUNT
07/27/2019 WBC 11.6 4.0-10.0
LABORATORIES: RBC 3.7 4.5-6.2
Hemoglobin 10.0 13.0-18.0
Hematocrit 0.29 0.40-0.50
Crea: 28 MCV 77.5 78.0-100.0
Na:137.3 MCH 26.5 27.0-34.0
K:3.93
Cl:108.8H MCHC 33.3 30.0-35.0
BUN:1.75 RDW-CV 12.5 11.5-14.5
Platelet Count 278 150-400
Differential Count
Neutrophil 0.17 0.55-0.65
Lymphocytes 0.73 0.35-0.55
Monocytes 0.10 0.02-0.09
Eosinophil 0.01 0.02-0.04
Basophil 0.00 0.00-0.02
COURSE AT THE WARD HD2 (07/28/19)

Subjective Objective ADMISSION Assessment Plan

(-) fever V/S: SCALD BURN, 11% TBSA,  DAT

(-)dyspnea HR: 140 RIGHT UPPER  Cont Present management
 scheduled for burn dressing
RR: 20 AND LOWER ARM, RIGHT under sedation 7/29/19
T: 37.1 ABDOMEN
O2: 99% at room air S/P Burn wound dressing
under sedation (7/26/19)

SKIN: (+)partial-thickness burn lesions right 1. PCM 100/ml 1.5 ml q 6 hours

upper and lower extremities and right 2. flammazine ointment OD
abdomen ,(-) blisters right upper extremities 3. Shift Ampicillin-Sulbactam to
Piperacillin-Tazabactam 770mg
and right abdomen, warm to touch, good
q 8hours
turgor
GS: conscious, not in respiratory distress,
irritable
C/L: Equal chest expansion, Clear breath
sounds
CVS: Distinct heart sounds, normal, regular
rhythm, no murmurs
ABD:protuberant, normoactive bowel
sounds, (+) partial-thickness burn lesions on
the right abdomen
Ext: CRT<2 seconds, storng peripheral
pulses, (-) edema
COURSE AT THE WARD HD2 (07/29/19)5pM

Subjective Objective ADMISSION Assessment Plan

(-) fever V/S: SCALD BURN, 11% TBSA,  DAT

(-)dyspnea HR: 140 RIGHT UPPER  Cont Present management

RR: 20 AND LOWER ARM, RIGHT

T: 37.1 ABDOMEN
O2: 99% at room air S/P Burn wound dressing
under sedation (7/26/19);
S/P Burn wound dressing
under sedation (7/29/19)

SKIN: (+)partial-thickness burn lesions right 1. PCM 100/ml 1.5 ml q 6 hours

upper and lower extremities and right 2. flammazine ointment OD
abdomen ,(-) blisters right upper extremities 3. Shift Ampicillin-Sulbactam to
Piperacillin-Tazabactam 770mg
and right abdomen, warm to touch, good
q 8hours
turgor
GS: conscious, not in respiratory distress,
irritable
C/L: Equal chest expansion, Clear breath
sounds
CVS: Distinct heart sounds, normal, regular
rhythm, no murmurs
ABD:protuberant, normoactive bowel
sounds, (+) partial-thickness burn lesions on
the right abdomen
Ext: CRT<2 seconds, storng peripheral
pulses, (-) edema
COURSE AT THE WARD HD2 (07/29/19)5pM

Subjective Objective ADMISSION Assessment Plan

(-) fever V/S: SCALD BURN, 11% TBSA,  MGH

(-)dyspnea HR: 135 RIGHT UPPER
RR: 20 AND LOWER ARM, RIGHT
T: 37.1 ABDOMEN
O2: 99% at room air S/P Burn wound dressing
under sedation (7/26/19);
S/P Burn wound dressing
under sedation (7/29/19)

SKIN: (+)partial-thickness burn lesions right 1. Azithromycin 200/5, 2.5ml OD x

upper and lower extremities and right 2 days
abdomen ,(-) blisters right upper extremities 2. Co-Amoxiclav 457/5, 3ml BID x 3
days
and right abdomen, warm to touch, good
turgor
GS: conscious, not in respiratory distress,
irritable
C/L: Equal chest expansion, Clear breath
sounds
CVS: Distinct heart sounds, normal, regular
rhythm, no murmurs
ABD:protuberant, normoactive bowel
sounds, (+) partial-thickness burn lesions on
the right abdomen
Ext: CRT<2 seconds, storng peripheral
pulses, (-) edema
 FINAL DIAGNOSIS

SCALD BURN, 11% TBSA

Pediatric Community Acquired Pneumonia C ( Moderate risk )
 Burns

Initial Evaluation
• Airway Management
• Evaluation of other injuries
• Estimation of burn size
• Diagnosis of CO and Cyanide Poisoning
Large-bore peripheral intravenous (IV) catheters should be placed
and fluid
resuscitation should be initiated; for a burn larger than 40% total
body surface area (TBSA), two large-bore IVs are ideal

Pediatric patients with burns larger than 15% may

require IO access in emergent situations if venous access cannot
be attained.
Burn Classification

1. thermal
2. electrical
3. chemical
 Resuscitation

• Parkland or Baxter formula

• 3 to 4 mL/kg per % burn
• Lactated Ringer’s
• half is given during the first 8 hours after burn
• remaining half is given over the subsequent
• 16 hours
 Treatment

• Silver sulfadiazine
• Dakin’s solution (0.5% sodium hypochlorite solution)
• SURGERY