You are on page 1of 10

CAGAYAN STATE UNIVERSITY

COLLEGE OF MEDICINE
Carig Campus, Tuguegarao City

SURGERY WARD

Submitted by: RAVICHANDRAN, RAVIKANTH


RAVICHANDRAN, SHAM BARATH
TOUNSI, RAMI T.
VALDEZ, HAZEL MAE
VEA, CASEY JON G.

3rd Year Medical Students

Submitted to: JHORELLE CADANG


SURGERY WARD PRECEPTOR

PATIENT PROFILE

Name : Z.M.
Age : 1 year and 1 month old
Gender : Female
Address : Atulayan Sur, Tuguegarao City
Marital Status : Single
Birthday : February 1, 2019
Birthplace : San Gabriel, Tuguegarao City
Religion : Catholic
Occupation : None
Date of Admission : March 13, 2019 @ 6:00 pm
Date of Interview : March 14, 2019 @ 10:30 am

Chief Complaint : Hot Water Burn


Nature of Incident : Heat exposure contact with hot water
Time of Incident : 5:30 pm
Place of Incident : Atulayan Sur, Tugueagarao City
Date of Incident : February 13, 2019

PRIMARY SURVEY
Airway : Patent airway
No injury to the spine

Breathing : RR: 30 CPM, regular rhythm, symmetrical chest expansion.


(-) Tracheal deviation

Circulation : CR: 95 bpm, regular rhythm.


no signs of hypovolemic shock.

Disability : PGCS: 14
Patient is awake and alert

1 | Page
Exposure/Environment : (See Figure 1 below)
Presence of hot water scald on:
- right cheek
- lips including the perioral area extending just
below the chin and under the mandible
- right shoulder and whole right upper extremity
- right half of both chest and abdomen
- anterior right thigh
- anterior right leg

Figure 1. Burn Size assessment

2 | Page
Assessment and Determination of Burn Size
For pediatric patients, an appropriate burn chart for different childhood age group should be used to
accurately estimate the extent of body surface area (BSA) burned. A correct estimation of the BSA is
important for the management as well as prognostication of the burn cases. According to Tintinalli et al.
(2016), a method of accurately determining the total body surface area (TBSA) involved in burn injury is the
Lund-Browder burn diagram (See Appendix). Based from the assessment of the patient on the day of the
interview, the following estimation of TBSA was computed using the Lund-Browder burn diagram in relation
with the patient’s age:
Table 1. Lind-Browder Relative Percentages of areas affected by growth (age in years)*
0 1 5 10 15 ADULT
HALF OF 9.5 8.5 6.5 5.5 4.5 3.5
HEAD
HALF OF 2.75 3.25 4 4.25 4.5 4.75
THIGH
HALF OF 2.5 2.5 2.75 3 3.25 3.5
LEG
*Lifted from Tintinalli's emergency medicine: a comprehensive study guide (p. 1399)
Table 2. Estimated Total Body Surface Area of the Patient (Age: 1 year and 1 month old)
BODY AREA SCORE
Right cheek 1
Lips + Perioral Area + chin andunder the mandible 1
Whole right upper extremity 8.5
1/2 right trunk 6.5
Anterior right thigh 3.25
Anterior right leg 2.5
TOTAL BODY SURFACE AREA 22.75%

Assessment and Determination of Burn Depth


Another crucial parameter in the management of burn injury is the depth. According to Marx et al
(2018), burn depth is most commonly determined thru clinical examination. The depth of burns has
traditionally been classified as first, second and third degree burn based on the degree of involvement of the
dermis. This classification can be clinically assessed and determined accordingly:
Table 3. Clinical Estimation of Burn depth**
DEPTH APPEARANCE BLANCHES SENSITIVITY PLIABILITY TIME OF NEED FOR
WITH TO HEALING EXCISION
PRESSURE PINCPRICK AND
GRAFTING
Superficial (1st Red, no blisters + ++ soft 1 week -
degree)
Superficial Red, blisters + ++ soft 1 to 2 -
partial thickness weeks
(2nd degree)
Deep partial Red or white, +/- + Slightly 2 to 3 +
Thickness (2nd no blisters tense weeks
degree)
Full thickness Leather like, - - Stiff, >3weeks +
(3rd degree) charred leather like
**Lifted from Rosen’s Emergency Medicine-Concepts and Clinical Practice (p. 716)

3 | Page
Based on the description of patient’s mother of the burnt area as well as on the physical exam done,
the burn depth can be classified as deep partial thickness-2nd degree burn because of the pink to white color
of the affected area as well as the absence of blister and the slight sensitivity to touch.

SECONDARY SURVEY
Allergies : No known allergy to drugs or any medication but mother
said that the patient has an allergy
towards fish and chicken

Medications : Not on any medication prior to hospitalization

Past Medical History : No recent hospitalization except for monthly checkup at


rural health unit

Family Medical History : No pertinent family history of diseases

Last Meal : Milk prepared at lunch time

Event 1 hour prior to admission, according to the mother,


she decided to prepare a meal for her daughter when
the patient started crying at around 5 o’clock in the
afternoon. The mother of the patient went to the kitchen
leaving her daughter in the living room. She started
measuring and pouring powdered milk formula in the milk
feeding bottle and after a while, she said, she got the
thermos and poured a little amount of hot water inside
the feeding bottle. As she needs to add room
temparature water to dilute and lower the temperature
of the solution, she left the thermos slightly sealed on the
table and went on to add water. Little did she know, her
daughter followed her to the kitchen and was right
behind her, the mother while adding water in the feeding
nbottle suddenly heard a shrill cry behind her. She looked
back and saw her daughter doused with hot water,
crying.
Panicked, the mother of the patient cried for help
and shouted for her husband while wiping the hot water.
Wearing just shorts and slippers, the patient’s father then
rushed her to daughter to City People’s General
Hospital. The mother said that upon arriving at the
hospital, the staff reluctantly declined to give treatment
to the patient as the father did not bring money with
them and cannot pay the amount the staff was asking.
The hospital then said that it was better to transfer the
patient to CVMC. The father did so and upon arriving at
CVMC, the patient was given first aid treatment, cleaned
her area affected and was later admitted.

4 | Page
TERTIARY SURVEY
VITAL SIGNS
Blood Pressure : -
Temperature : 38.0 degree Celsius
Cardiac rate : 95 bpm
Respiratory rate : 30 cpm
Oxygen saturation : -

PHYSICAL EXAM
GENERAL : The patient is awake, alert and febrile. She is irritable, crying
APPEARANCE and uncooperative at the time of the interview. She was lying on
the bed with an IV Fluid of lactated ringer’s solution hooked to
her right foot. All of the scalded sites are covered with bandages
except affected areas on her face.

VITAL SIGNS Blood Pressure: -


Temperarure: 38.0 degree celsius
Cardiac rate: 95 bpm
Respiratory Rate: 30 cpm
Oxygen Saturation: -

HEENT : Head
Normocephalic head with symmetry with no obvious scalp lesions
noted. Pinkish to white area on the right cheek and perioral area
extending to the chin and under the mandible. Affected area
looks wet and shiny without blisters.

Eyes
Pink conjunctivae, intact extraocular muscle

Ears
Symmetric with no obvious swelling, redness or discharges

Nose
Septum is midline, clear viscous mucus discharge observed

Throat/Mouth
Oral mucosa is pink with no swelling noted. Lips and buccal
mucosa are moist. Tongue is in midline.

SKIN No palor, no cyanosis noted. Scalded areas are covered with


bandages except for affected areas on her face with no noted
blisters and swelling. No hematomas and no other skin changes
noted.

NECK & SPINE : Trachea and spine are both midline. Absence of tenderness,
masses or abrasions. No palpable lymph nodes noted.

CHEST & : Thorax is symmetric with regular breathing patterns.


RESPIRATION

5 | Page
HEART or : Heart rate within normal range with regular rhythm
CARDIOVASCULAR

ABDOMEN : Normoactive bowel sounds noted

GENITOURINARY : An indwelling urinary catheter is inserted; pale yellow urine in the


collection bag.

EXTREMITIES : Pink nail beds with absence of cyanosis and clubbing. Warm
extremities with edema noted on the right foot

NEUROLOGIC EXAMINATION
PEDIATRIC GLASGOW- 14/15
COMA SCALE
Cranial Nerves
I

II Blinks eye spontaneously. Stares at thermometer when moved


around. Visual Acuity not tested

III, IV, VI Extraocular muscle movement intact

V, VII, IX, X Patient can suck milk from feeding bottle and
can swallow with no difficulty

VII No facial asymmetry when crying

VIII Patient turns head and eyes towards mother when called

XII Tongue is midline

MOTOR No involuntary movements noted as well as atrophy. Patient


has good muscle bulk and tone

MISCELLANEOUS Babinski reflex not observed

IMPRESSION

22.75% TBSA Deep Partial-Thickness Burn


Secondary to Heat Exposure Contact with Hot Water

DISCUSSION
 Burns are a leading cause of unintentional injury in children, second only to motor vehicle
crashes. (Nelson)
 Types of burn injuries according to etiology
o Thermal Burn
o Chemical Burn
o Electrical burn
 Physiologic effects of Thermal Burn (Tintinallis)
o Disruption of sodium pump
o Intracellular influx of sodium and water
o Extracellular efflux of potassium
6 | Page
o Depression of myocardial contractility (>60% of body surface area burned)
o Increased systemic vascular resistance
o Metabolic acidosis
o Increase in Hematocrit and increased blood viscosity
o Secondary anemia from erythrocyte extravasation and destruction
o Local tissue injury
o Release of histamines, kinins, serotonins, arachidonic acid, and free oxygen radicals
 Classification of Burns

Figure 3. Burn depth Features Classified by Degree of Burn (Lifted from


Tintinalli's emergency medicine: a comprehensive study guide [p. 1400])

DIAGNOSTICS - LABORATORY
 CBC
 Fluids and Electrolytes
 BUN and Creatinine
 RBS
 ABG

EMERGENCY CARE
 Provide environmental temperatures of 28-33°C (82.4-91.4°F) by ensuring adequate covering during
transport
 Children with burns >15% of BSA require intravenous (IV) fluid resuscitation to maintain adequate
perfusion. If IV access is unattainable, an intraosseous line should be placed.
 Children with burns of >15% of BSA should not receive oral fluids (initially), because gastric distention
may develop. These children require insertion of a nasogastric tube to prevent aspiration.
 Foley catheter should be inserted to monitor urine output in all children who require IV fluid
resuscitation.
 All wounds should be wrapped with sterile dressings
 Review child immunization, burns under 10% BSA do not require tetanus prevention, burns over 10%
need tetanus immunization; use diphtheria, tetanus toxoids and acellular pertussis (DTaP) for tetanus
prophylaxis for ages <11 yr, and tetanus, diphtheria and pertussis (TdaP) for ages >11 yr

EMERGENCY CARE
 Fluid Resuscitation
o Parkland Formula for Children
o LR 3 mL x weight (kg) x % TBSA – over initial 24hours
o Half over the first 8 hours from the time of burn

7 | Page
o Other half over the subsequent 16 hours
o Computation: 3mL x 8kg x 22.75% = 546 mL
o 273mL for the first 8 hours
o 273mL for the next 16 hours
o Parameters for adequate fluid resuscitation:
1. PR and BP return to normal
2. adequate urine output (>1 mL/kg/hr in children)
3. Acid–base balance
4. Mental status
o 2nd 24 hours after burn - patients begin to reabsorb edema fluid and to experience diuresis
o 5% albumin infusion
- 30-50% of total BSA: 0.3 mL of 5% albumin/kg/% BSA burn is infused over 24 hr
- 50-70% of total BSA: 0.4 mL/kg/% BSA burn is infused over 24 hr
- 70-100% of total BSA: 0.5 mL/kg/% BSA burn is infused over 24 hr
o Sodium supplementation - Oral sodium chloride supplement of 4 g/m2 burn area/24 hr
divided into 4-6 equal doses
o KCl drip
 Nutrition
o Oral supplementation usually starts as early as 48 hours after burn
o Milk formula, soft foods gradually introduced; NGT feeding if not tolerated
o Burn injury produces a hypermetabolic response – protein and fat catabolism
o Caloric supplementation objective: maintain body weight and minimize weight loss by meeting
metabolic demands
o Calorie provision: 1.5 times the basal metabolic rate, with 3-4 g/kg of protein/day
o Multivitamins, particularly the B vitamin group, vitamin C, vitamin A, and zinc
 Pain Control
o Acute phase – Opioids via IV route
o Anxiolytics
 Prevention of Infection
o Penicillin IV or PO
o 2nd line: Erythromycin
o Dressings should ideally be changed twice daily,gently removing residual ointment, for as long
as the wounds continue to weep, then daily until healing is complete
o Topical treatment
Table 4. Topical Agents Used for Burn***
AGENT EFFECTIVENESS EASE OF USE
Silvadene Cream Good penetration Changed once daily
(Silver Sulfadiazene) Residue must be washed off with
each dressing change
Mafenide acetate cream Broad Spectrum, including Closed Dressings
(sulfamylon cream) Pseudomonas Changed twice daily
Rapid and deep wound
penetration Residue must be washed off with
each dressing changed
0.5% Silver Nitrate Solution Bacteriostatic Close bulky dressing soaked every
Broad Spectrum including some 2 hours and changed once daily
fungi
Superficial penetration
AQUACEL Ag Dressing impregnated with silver Applied directly to 2nd- degree
burn; occlusive dressing kept for
10 days
***Lifted from Nelson’s Textbook of Pediatrics (p. 573)

8 | Page
 Physical rehabilitation
o body and limb positioning
o exercises (active and passive movement)
o assistance with activities of daily living
o gradual ambulation

APPENDIX

Figure 2. Lund-Browder diagram for estimation of burn size (Lifted from


Tintinalli's emergency medicine: a comprehensive study guide [p. 1399])

Table 5. Pediatric Glasgow Coma Scale****


EYE OPENING (Total Possible Points 4)
Spontaneous 4
To voice 3
To pain 2
none 1
VERBAL RESPONSE - infants and young children (Total Possible Score 5)
Appropriate words; smiles, fixes and follows 5
Consolable crying 4
Persistently Irritable 3
Restlessly, agitated 2
None 1
MOTOR RESPONSE (Total Possible Score 6)
Obeys 6
Localizes Pain 5
Withdraws 4
Flexion 3
9 | Page
Extension 2
None 1
TOTAL SCORE 14
****Lifted from Nelson’s Textbook of Pediatrics (p. 491)

REFERENCES

Bickley, L., & Szilagyi, P. G. (2012). Bates' guide to physical examination and history-taking. Lippincott
Williams & Wilkins.

Billiar, T., Andersen, D., Hunter, J., Brunicardi, F., Dunn, D., Pollock, R. E., & Matthews, J. (2009). Schwartz's
principles of surgery. McGraw-Hill Professional.

Marx, J., Walls, R., & Hockberger, R. (9th ed.).(2018). Rosen's Emergency Medicine-Concepts and Clinical
Practice. Elsevier Health Sciences.

Tintinalli, J. E., Stapczynski, J. S., Ma, O. J., Cline, D., Meckler, G. D., & Yealy, D. M. (Eds.). (2016). Tintinalli's
emergency medicine: a comprehensive study guide (pp. 74-79). New York: McGraw-Hill Education.

10 | Page