Surgery Essay

Discuss briefly the physiological implications in the

management of a 50-year-old female who has
sustained a full thickness burn to 30% of the body
surface.

Burns should be treated like any traumas, and hence the

airway, breathing and circulation should be assessed first. A
full-thickness burn will result in a massive leak of protein-rich
material from capillaries into surrounding tissues, to cause
oedema and swelling. If this happens in the airway, obstruction
may occur. This must be suspected if there is strider or
hoarseness. Other signs that lead to suspicion include facial
burns, singeing of eyebrows and nasal hairs, carbonaceous
smell, altered consciousness and a history of a long exposure
to gasses or an explosion. In this case the anaesthetist must be
called to do an endotracheal intubation.

Breathing is obstructed due to chemical trachobronchitis and

pneumonia due to toxic fumes. CO poisoning is also possible.
Haemoglobin has 240 times more affinity to CO than O2, and
the oxygen dissociation curve is displaced to the left. The signs
are Headache, nausea, vomiting and cherry-red discoloration of
the skin. Giving 100% oxygen will aid in the quick displacement
of CO by oxygen due to shortening of CO’s half life.

Since a lot of fluid is lost from capillaries, both to surrounding

tissues but also to the outside, the patient may become quickly
hypovolemic. IV assess is important to obtain FBC, U&E,
glucose, X-match and carboxyhaemoglobbin tests. The IV
access is used to administer fluids. This should be started
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immediately, and the best assessment of the hypovolemia is

the urine output and more than 20-30ml/h should be the aim.
The burn depth and body surface area should be assessed to
allow modification of fluid given. In general 2-4l of crystalloid
solution should be given for each kilogram body weight per
burn percentage. One half this amounts has to be given within
8hours of the burn. Colloids may be given according to the
Muir and Barcley Formula.

Vol of colloid (per unit time) = body weight (kg) x % burns/2

This amount is given in the 1st 4 hours. The same amount is

then given after 4, 4, 6, 6 and 12 hours.

If the patient has circumferential burns in her limbs, the

oedema and swelling in a confined space might result in
ischemia lower down. A full-thickness circumferential torso burn
may prevent chest expansion. Escharotomies along the full
length of the burn are to be considered in this case.

Full-thickness burns reach the dermis and damage the nerves,

so the patient is painless. Theoretically therefore analgesia is
not needed. However, in some areas, the burn may be of partial
thickness, were there are kinins released and pain is felt, so
opiates are given

Other associated injuries, obtained from the history are

assessed. For example jumping out of a window to prevent a
fire. The burns are coverered with sterile Clingfilm. No
antiseptics are used or blisters pierced. Burns are covered as
infection is very likely with the amount of caseous necrotic

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tissue and proteinaceous material released. The patient should

be transferred to the burns unit.

07/02/09