Burns Patient

Question 1

A 39-year-old male patient is admitted to the emergency department after a
house fire with burns to his chest, back and right arm.

How can you calculate the percentage of burns in this patient, and why is this important?

Answer 1

• A Lund-Browder chart can be used to calculate the total body surface area of burns.
• An alternative is to use the “Rule of Nines”:
• The head, right arm and left arm each account for 9%.
• The back, chest, right leg and left leg each account for 18%.
• The perineum counts for 1%.
• The percentage of burns will determine the management of the patient including the volume required for fluid resuscitation and the location of definitive care (e.g. tertiary burns unit for adults with >10% dermal or full-thickness burns).

Question 2

How much fluid does this patient require in the first 24 hours following the burn?

Answer 2

• The Parkland formula can be used to determine the fluid requirement in this patient and is calculated by multiplying the patient weight (kg) by the percentage burns by 4, to give a volume (mL).
• Half of the fluid should be given in the first 8 hours after the burn and the rest in the following 16 hours.
• Hartmann’s solution is the choice of fluid in burns patients in most units.

Question 3

One week following the initial burn, the patient is listed on the emergency list for wound debridement.

What are the anaesthetic concerns for this patient?

Answer 3

Preoperative:
* The patient’s cardiovascular and respiratory comorbidities may be exacerbated due to the burn injury, which can pose challenges for ventilation and maintenance of haemodynamic stability perioperatively. An assessment of current oxygen requirements and cardiovascular support will aid in the formulation of an anaesthetic plan.

• This patient has been in a house fire, suggesting that airway damage is possible. An airway assessment will help to determine the likelihood of a difficult intubation or ventilation.
• Preoperative investigations should be done to check for anaemia, deranged clotting and renal function.
• Intravenous access is likely to be difficult and limited due to the extent and location of the burns.

Question 4

What are the anaesthetic concerns for this patient?

Continued…

Answer 4

Intraoperative:
* Temperature: Patients with high percentage burns increase their baseline temperature, so need to be managed in a warm environment with heated blankets. Fluids and blood products should also be warmed.

• Monitoring can be challenging in burns patients, and alternative sites and means for monitoring may be required.
• Ventilation: Lung protective ventilation is routine, but note that high airway pressures are common in patients with chest and neck burns.
• Drugs: Suxamethonium should be avoided due to its effect on extra-junctional receptors.

Postoperative:
* The main postoperative concern is good pain management. A multimodal approach should be used with the early consideration of ketamine, neuropathic agents and opioid rotation.

Question 5

What are the common complications in burns patients?

Answer 5

Immediate complications:
* Airway obstruction.

Early complications:
* Sepsis.
* Oedema.
* Rhabdomyolysis and renal failure.
* Adult/acute respiratory distress syndrome.
* Venous thromboembolism.
* Malnutrition.

Late complications:
* Chronic pain.
* Anxiety and depression.
* Chronic lung disease.