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
