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
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.