A 46-year-old man is brought to the emergency department after a burn injury. The patient is a cook and spilled hot oil on his trunk and legs 30 minutes ago. The patient has no significant medical history. Temperature is 36.2 C (97.2 F), blood pressure is 140/90 mm Hg, pulse is 102/min, and respirations are 20/min. On physical examination, the patient appears distressed and in pain. Partial- to full-thickness burns cover approximately 25% of the body surface area, including the lower abdomen, genitalia, and lower extremities. Intravenous fluids are begun after access is obtained with 2 large-bore peripheral catheters. Which of the following is the best immediate step in management of this patient?

Question

A 46-year-old man is brought to the emergency department after a burn injury.  The patient is a cook and spilled hot oil on his trunk and legs 30 minutes ago.  The patient has no significant medical history.  Temperature is 36.2 C (97.2 F), blood pressure is 140/90 mm Hg, pulse is 102/min, and respirations are 20/min.  On physical examination, the patient appears distressed and in pain.  Partial- to full-thickness burns cover approximately 25% of the body surface area, including the lower abdomen, genitalia, and lower extremities.  Intravenous fluids are begun after access is obtained with 2 large-bore peripheral catheters.  Which of the following is the best immediate step in management of this patient?

Quizplus · Accepted Answer

The first priorities of burn management are stabilization (eg, airway, breathing, circulation) and resuscitation (eg, intravenous fluids). Extensive burns can rapidly lead to hypovolemic shock due to a large release of proinflammatory mediators that increase vascular permeability and lead to third spacing of fluid. For this reason, patients with major burns (ie, >20% total body surface area [TBSA]) receive aggressive fluid resuscitation, which is usually begun based on a formula (eg, Parkland formula) and then titrated to maintain adequate urine output (goal: ≥0.5 mL/kg/hr), a marker of organ perfusion. For accurate monitoring of urine output in these patients, a urethral catheter (eg, Foley catheter) is required. In patients who have genital burns and other burns covering a large TBSA, a catheter should be placed as soon as possible; delay can lead to edema that obstructs visualization and catheterization of the urethra. In addition to facilitating measurement of urine output, the urinary catheter also ensures urinary continence so that urine does not soil burned areas or dressings. Following urethral catherization, treatment of this patient's burns involves copious irrigation and gentle gauze debridement of affected areas. This is followed by application of topical antimicrobial agents (eg, topical antibiotic) and nonstick dressings (Choice D). (Choice A) Cool, not cold, saline-soaked gauze is sometimes applied to burned tissues within the first few hours after injury to decrease pain. However, cold application (eg, ice) is discouraged because it can further injure (eg, frostbite) the burned tissues and/or cause systemic hypothermia. (Choice B) Endotracheal intubation is appropriate for patients with signs of smoke inhalation injury (eg, hoarse voice, singed nasal hair, carbonaceous sputum). Inhalational injury is unlikely in this patient who has none of these signs and who spilled hot oil directly onto his trunk, perineum, and legs. (Choice C) Sharp surgical debridement and skin grafting will likely be required for this patient's full-thickness burns. However, these surgical procedures are not performed until after approximately 72 hours, when burns have fully demarcated; partial-thickness burns at presentation may progress to become full-thickness over that time. Educational objective: After initial stabilization, burn patients who require aggressive fluid resuscitation (eg, due to burns covering a large total body surface area) should undergo urethral catheterization as soon as possible. References: ISBI practice guidelines for burn care (http://www.ncbi.nlm.nih.gov/pubmed/27542292) Management of genital burns: a review. (http://www.ncbi.nlm.nih.gov/pubmed/20666853)

A 46-Year-Old Man Is Brought to the Emergency Department After