Question: Kevin Lewis, 21 Years Old, Was Involved In An Industrial Fire. Mr. Lewis Was Welding A Steel Structure When A Spark From His Torch Ignited A Barrel Of Flammable Material That Was Inadvertently Placed In His Work Area. Mr. Lewis Sustained Full-thickness Burns Over The Upper Half Of His Chest And Circumferential Burns To Both Arms. He Also Sustained Superficial…

Kevin Lewis, 21 years old, was involved in an industrial fire. Mr. Lewis was welding a steel structure when a spark from his torch ignited a barrel of flammable material that was inadvertently placed in his work area. Mr. Lewis sustained full-thickness burns over the upper half of his chest and circumferential burns to both arms. He also sustained superficial partial- thickness burns to his face, neck, and both hands. His entire abdomen, upper half of his back, and front of his upper legs sustained deep partial-thickness burns. He was transported to a small community hospital where two intravenous lines were started, a Foley catheter and nasogastric tube was inserted, and humidified oxygen at 3 L/min was started through a nasal cannula. He was given mannitol 12.5 g IV before being transported to a major burn center. Vital signs immediately before transport were as follows: BP 136/84 mm Hg HR 96 bpm Respirations 24 breaths/min Temperature 37.2°C (99° F) Mr. Lewis’s preborn weight was 72 kg (160 lb). He was received in the burn unit 4 hours after sustaining the burn injury. At admission to the burn unit, Mr. Lewis was alert and oriented, and his vital signs were as follows: BP 140/90 mm Hg HR 110 bpm Respirations 24 breaths/min Temperature 36.1°C (97°F) Mr. Lewis’s lungs were clear in all fields on auscultation, and he had an occasional productive cough of a small amount of carbon-tinged sputum. His voice was becoming hoarse. No bowel sounds were heard, and the nasogastric tube was draining dark yellow-green liquid. Peripheral pulses were obtained with a Doppler stethoscope because they could not be palpated manually. The Foley catheter was draining burgundy-colored urine. Urine output totaled 280 ml since insertion of the Foley catheter 4 hours before. Fluid resuscitation efforts since the burn injury included 4 L of Lactated Ringer’s solution through the IV lines. The following laboratory results were determined after Mr. Lewis’s arrival in the Burn Unit: Complete Blood Count WBCS RBCS 12 x 103/mm3 34.8 x 103/mm3 12.8 g/dL 52% HGB HCT Arterial Blood Gases (on 3L of oxygen) рн 7.37 PCO2 35 mm Hg 105 mm Hg PO2 HCO3 18 mmol/L SaO2 99% SMAC 20 Na+ 151 mmol/L K+ 5.2 mmol/L cr BUN 112 mmol/L 22 mg/dL 1.6 mg/dL Creatinine Additional Bloodwork Myoglobin (RIA) Carboxyhemoglobin 90 ng/ml 6% Urinalysis revealed the following Specific gravity 1.040 Glucose Ketones Trace Blood Trace Protein Trace The burn unit physician performed a fiberoptic bronchoscopy, which showed minimal redness of the glottis and no edema. Escharotomies were performed on both arms immediately after admission to the burn unit. Mr. Lewis was bathed, his scalp was shaved, and his burns were dressed in occlusive silver sulfadiazine (Silvadene) dressings. His burns were then dressed twice a day with silver sulfadiazine. The following regimen was prescribed: rantadine 150 mg IV push every 12 hours; antacid 30 ml every hour instilled through the nasogastric tube and clamped for 15 minutes for the first 48 hours after the burn; and morphine sulfate 3 mg IV push every hour as needed for pain. Bowel sounds returned on day 3, the nasogastric tube was removed, and high-calorie, high-protein diet was begun. On day 5 of the hospital stay, Mr. Lewis was taken to the OR for the first of a series of surgical procedures to excise and graft the area of full-thickness injury with split-thickness autografts. The donor sites included his buttocks and the backs of his legs. Mr. Lewis was discharged from the hospital after a 65-day hospital stay with follow-up and rehabilitation scheduled. 1. Discuss the pathophysiology of burns, including the classification of burn depth and severity of burn injury. 2. Using the rule of nines, calculate the 1. Discuss the pathophysiology of burns, including the classification of burn depth and severity of burn injury. 2. Using the rule of nines, calculate the percentage of total body surface area (TBSA) burned. Based on the TBSA percentage and depth of burn, how would you classify Mr. Lewis’s burn? 3. Describe the initial assessment and stabilization of a burn victim at the scene of the injury and in the ED. 4. Describe the effects of the burn on the following systems during the emergent and acute phases of burn injury: cardiovascular, respiratory, immune system, gastrohepatic, genitourinaru, and neurologic. 5. Based on Mr. Lewis’s preborn weight, use the Parkland formula to calculate the fluid requirement for adequate resuscitation. 6. What significance, if any, would the administration of mannitol have on fluid resuscitation? 7. What assessment findings are critical to establishing the presence of an inhalation injury? Which of Mr. Lewis’s assessment findings warrant concern? 8. Describe the treatment protocol of a burn patient with an inhalation injury or suspected inhalation injury. 9. What is the purpose of escharotomies? 10. Discuss pain management in the treatment protocol for the burn patient?