In the spirit of roasts and fire-breathing dragons

    NextPrevious

    In the spirit of roasts and fire-breathing dragons

    You’re on a lovely amble through the backcountry when suddenly you see smoke rising nearby and catch a whiff of a familiar scent that throws you back to your med school OR days: burning flesh. You quickly find one obtunded, severely burned hiker who inadvertently set fire to his camp.

    After a quick airway assessment – no soot or burns in the oropharynx, thankfully, since you can’t intubate anyway – you astutely proceed to quantify the burns. The following image immediately comes to mind:

    As you proceed calculate the total body surface area burned (the entire front of the torso, back of the torso…that’s 36%) in order to apply the Parkland formula which you’d always committed to memory…

    4 x weight (kg) x %burned = total IVF in mL over 24 hrs (half over the first 8 hrs, half over the next 16) – our patient would be 4x70x36=10080mL or approx 10L total over 24 hrs

    …you note the patient’s respirations begin to become more shallow. Uh oh…this guy has a full-thickness circumferential chest wall burn! What are you gonna do?

    Chest escharatomy

    A consequence of full-thickness burns is the formation of an eschar, burnt tissue which is inelastic and constricting; in circumferential burns, along with tissue edema from the burn, this can lead to compartment syndrome – of the extremities, abdomen, and chest. In severe torso or neck burns, this constriction can cause respiratory or airway compromise requiring escharotomy.

    Fortunately, you always travel with a scalpel (though sadly you left the electrocautery at home) cause you’re that kinda guy. You make two lengthy incisions – just through the eschar; this is distinct from a fasciotomy – along the anterior or mid-axillary line bilaterally, and a transverse incision below the costal margin across the abdomen as seen below. The patient’s ventilation improves and you move onto figuring out an evacuation plan.

     

    References:

    Rice, P. Emergency care of moderate and severe thermal burns in adults. UpToDate. Accessed on June 3, 2019.

    Zhang L, Hughes PG. Escharotomy. [Updated 2019 Apr 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-.Available from: https://www.ncbi.nlm.nih.gov/books/NBK482120/

    Calculator: Adult burn injury fluid resuscitation (Parkland crystalloid estimate). UpToDate, accessed at https://www.uptodate.com/contents/calculator-adult-burn-injury-fluid-resuscitation-parkland-crystalloid-estimate

     

     

    • Welcome! This is the website for the Mount Sinai Emergency Ultrasound Division. It serves as an information resource for residents, fellows, medical students and others seeking information about point-of-care ultrasound. There is a lot ofRead more

    • renal handling of water

      If you were on a tea & toast diet, how much water would you need to drink before you develop hyponatremia? I haven’t seen anyone work out the numbers before so here are my calculations. AndRead more

    • acute acidemia physiology

      As alluded to in the first post, don’t be fooled by a “normal” potassium in the setting of DKA because osmotic diuresis and H+/K+ exchange means that total body potassium is actually LOW. You all knowRead more

    • renal handling of potassium

      the first symptom of hyperkalemia is death Earlier post covered temporizing measures to counter hyperkalemia — namely, intracellular shift, increasing cardiac myocyte threshold potential. Give furosemide if the patient still urinates and consider dialysis, but then askRead more

    • bicarbonate revisited

      Previous post reviewed the safety of balanced crystalloids in hyper K. But what was up with serum bicarbonate decreasing with saline administration? This post introduces a new way of looking at the anion gap to possiblyRead more

    • hyperkalemia and balanced crystalloids

      Is it safe to give LR or plasmalyte to a hyperkalemic patient (these balanced crystalloids have 4-5 mEq/L K as opposed to 0 mEq/L K in normal saline)? Postponing the discussion of renal handling of potassium toRead more

    • hyperkalemia physiology

      You’ll likely encounter hyperkalemia on your next Resus / Cardiac shift, and you’ll instinctively treat it. But take a moment to review the fascinating physiology behind the “cocktail”! First, consider how K+ is buffered byRead more

    • Slow down your tachycardia (but not really)

      You’re sitting in resus bemoaning the departure of your most beloved attending when suddenly a patient wheels in without warning. The patient looks relatively stable but the triage RN tells you her heart rate wasRead more

    • Otitis externa: use the ear wick!

      Acute otitis externa (AOE) is a common complaint seen in pediatric as well as adult emergency departments. AOE is typically not accompanied by acute otitis media, although concurrent cases are possible. Also called “swimmer’s ear”Read more

    NextPrevious