You are asked to review a 64-year-old male who has been brought to the Emergency Department having been burned in a house fire. He is drowsy and confused with a persistent cough and unable to give a coherent history. His heart rate is 120 beats/minute, blood pressure is 88/52 mmHg, respiratory rate is 28 breaths/min and oxygen saturation is 94% on high flow oxygen via a reservoir mask.
- a) List the initial priorities in this patient’s management.
- b) What features on history and examination would suggest a significant airway injury?
- c) List the differential diagnoses for his altered mental state.
Answer and interpretation
a) List the initial priorities in this patient’s management.
- Resuscitation including primary and secondary survey
- Assessment and management of potential airway burn (including early intubation, not cutting ETT, avoiding nasal tube)
- Obtain large bore IV access and administration of fluid bolus (20 ml/kg) for probable hypovolaemic shock (mention groins are usually spared in burns and are a good site for clean skin vascath access
- Look for signs of traumatic injury and assess extent of body surface area and depth of burn
- Risk of hypothermia
- Seek collateral history for past medical history, medication history and history of acute events
b) What features on history and examination would suggest a significant airway injury?
- Burns occurring in a closed space
- Cough, stridor, hoarseness of voice
- Burns to face, lips, mouth, pharynx or nasal mucosa
- Soot in sputum, nose or mouth
- Hypoxaemia or dyspnea
- Carboxyhaemoglobin levels >2%
- Acute confusional state or depressed conscious level
c) List the differential diagnoses for his altered mental state.
- Traumatic brain injury
- CO / Cyanide poisoning
- Alcohol intoxication / drug overdose
- Other pathology eg CVA, intracranial haemorrhage, seizure-related, hypoglycaemia