Question 30

Created on Thu, 05/21/2015 - 16:47
Last updated on Sun, 01/10/2016 - 15:43
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Highest mark: ?

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You are asked to review a 64 year old man who has been brought to the emergency department having been burned in a house fire.  There is no coherent history available from the patient  and you observe that he is drowsy and confused, and, has a persistent cough.   His heart rate is 120 bpm, blood pressure 88/52 mmHg, respiratory rate 28 and oxygen saturations are 94 % on high flow oxygen via a non re-breather mask.

30.1     List the initial priorities in management.

30.2     What features on history and examination would suggest a significant airway injury?

30.3     Give a differential diagnosis for his conscious level.

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College Answer

You are asked to review a 64 year old man who has been brought to the emergency department having been burned in a house fire.  There is no coherent history available from the patient  and you observe that he is drowsy and confused, and, has a persistent cough.   His heart rate is 120 bpm, blood pressure 88/52 mmHg, respiratory rate 28 and oxygen saturations are 94 % on high flow oxygen via a non re-breather mask.

30.1     List the initial priorities in management.

1)  Resuscitation including primary and secondary survey
2)  Assessment and management of potential airway burn injury – mention consideration of early intubation, not cutting ET tubes and avoiding nasal tubes.
3)  Obtain large bore iv access and administration of fluid bolus (20mls/kg) for probable hypovolaemic shock- mention that groins are usually spared in burns and are a good site for clean skin vas cath access.
4)  Look for signs of traumatic injury and assess extent of body surface area and depth of burn
5)  Awareness of risk of hypothermia
6)  Seek collateral history for past medical history and medication history and history of acute events

30.2     What features on history and examination would suggest a significant airway injury?

1.  Burns occurring in a closed space
2.  Cough, stridor, hoarseness of voice
3.  Burns to face, lips, mouth, pharynx or nasal mucosa
4.  Soot in sputum, nose or mouth
5.  Hypoxaemia or dyspnoea
6.  Carboxyhaemoglobin levels > 2%
7.  Acute confusional state or depressed level of consciousness

30.3     Give a differential diagnosis for his conscious level.

1.  Traumatic brain injury
2.  Carbon monoxide / CN - poisoning
3.  Alcohol intoxication/drug overdose
4.  Other pathology precipitating loss of consciousness eg stroke, intracranial haemorrhage, seizure-related, hypoglycaemia

Discussion

This question is identical to Question 11 from the first paper of 2013, and closely resembles Question 28 from the second paper of 2010 (except in 2010 the 64 year old male mutated into a three year old child).