A Case of Burns

Dhatchayani1, Kalaiselvi2, M.Subadhra Devi3, Maha Lakshmi4

1ER Nurse, Kauvery Hospital, Cantonment

2Nursing Supervisor, Kauvery Hospital, Cantonment

3Nurse Educator Kauvery Hospital, Cantonment

4Nursing Superintendent, Kauvery hospital, Cantonment

Abstract

Burns are complex injuries caused by heat, electricity, chemicals, light, or friction, resulting in skin damage and potential systemic complications. The severity of burns varies, ranging from mild to life-threatening. Severe burns can lead to fluid loss, infection, organ dysfunction, and long-term scarring. Prompt medical attention is essential to manage pain, prevent infection, and promote optimal healing. Understanding the causes, consequences, and treatment options for burns is crucial for providing effective care and improving patient outcomes. This overview highlights the importance of burn prevention, timely intervention, and comprehensive management to minimize morbidity and mortality.

Background

Burns are indeed a significant public health concern, impacting millions globally each year. They can result from various causes, including thermal injuries from flames, scalds, or contact with hot surfaces, as well as electrical, chemical, and radiation-related injuries. Such burns can cause damage to the skin and underlying tissues, leading to complications like infection, fluid loss, and organ dysfunction.

The severity of burns varies widely, from mild to severe, and is typically classified based on the depth and extent of the injury. Mild burns may heal without significant complications, whereas severe burns might require extensive medical treatment, including surgical interventions, wound care, and rehabilitation.

Understanding the causes, consequences, and treatment options for burns is essential for providing effective care and improving patient outcomes. Burn prevention strategies, timely medical intervention, and comprehensive management can help minimize morbidity and mortality associated with burns.

 Case Presentation:

 The patient presented with mixed deep thermal third-degree burns covering 20% of the total body surface area, involving both upper limbs and the back. Following a comprehensive evaluation, including necessary investigations, a cardiologist’s opinion was obtained for cardiac assessment, and an echocardiogram (ECG) was performed. Due to the patient’s condition, an intensivist’s opinion was also sought. After discussing the prognosis and outcome with the patient’s attenders and obtaining their informed written consent, an anesthetic opinion was obtained. The patient underwent multiple wound debridement, left hand carpal tunnel release, median nerve intraneural neurolysis, and dressing changes. Post-operatively, pus culture was sent, and the patient was treated accordingly with IV fluids, analgesics, proton pump inhibitors (PPIs), anticoagulants, blood and blood products, and IV antibiotics. Upon admission, both upper limbs and back had blisters, with distal arm and proximal forearm digital pulses palpable. Although edema was present over the wrist, hand movement and sensation were normal, and the stretch sign was negative. Radial and ulnar pulses were also present.

Injuries:
Burns sustained over:

  • Both upper limbs
  • Back and middle trunk
  • Left gluteal region

Initial Treatment:
Treated at a private hospital for only pain management. Later presented with severe pain and signs of dehydration.

Allergies

No known drug or food allergies

Past Medical History:

Non-contributory

 Physical Examination:

Blood Pressure: 110/70 mmHg

Pulse Rate: 76/min

Respiratory Rate: 22/min

Temperature: 98.4°F

GCS: 15/15

Others: odor breath, dry mucous membranes

Investigations:

POCUS:

Grade one fatty liver

Mild splenomegaly

Markable investigations

Alanine Aminotransferase (ALT/SGPT)48.9 U/L
Bicarbonate28 mEq/L
Calcium Free Ionized1.27 mg/dL
Calcium Serum9.4 mg/dL
Chloride107 mmol/L
Creatine Phosphokinase (CPK)7487 U/L
Creatinine0.99 mg/dL
HbA1c5.70%
Indirect Bilirubin.0.74 mg/dL
Magnesium1.60 mg/dL
Phosphorous2.5 mg/dL
Potassium4.0 mmol/L
Sodium.137 mmol/L
Total Protein6.74 g/dl
Urea Serum19.26 mg/dL
Control (PT)11.5 Seconds
Haemoglobin13.7 g/dl
Platelet Count261000 Cells/Cumm
Test (PT)12.0 Seconds
Total RBC Count5.14 10^9/cmm
INR1.04 .
RDW - CV13.50%
Direct Bilirubin0.31 mg/dL
Total Bilirubin1.05 mg/dL

Pus Culture –No growth

Management:

Surgical Interventions

Day 1:

Wound debridement and scrubbing done under general anesthesia (GA)

Day 4:

Left hand:

Carpal tunnel release

Intraneural neurolysis of the median nerve

Dressing changed under GA

Intraoperative findings:

Incision made at the left wrist

Distal 4 cm of the median nerve found to be contused

Vasa nervorum at the distal segment was thrombosed

Intraneural neurolysis of the median nerve performed

Skin closed

Other burned areas:

Dressed with adicoat

Swab sent for culture

Plaster of Paris (POP) applied for immobilization

Strict limb elevation advised

Day 7:

Dressing changed under Total Intravenous Anesthesia (TIVA)

Initial Evaluation

Pain management

Fluid resuscitation

ECG

Echocardiogram

Ultrasonography (whole abdomen)

Blood investigations

Follow up treatment

Cap. Augmentin
Tab. Etoshine
Tab. Gabapentin
Limb Elevation
Intrasite Raw Area for Right Gluteal Region & Back Raw Areas

Postoperative Period

Uneventful recovery

Patient reported symptomatic relief from pain in the left hand

However, sensation remained diminished in the median nerve distribution area

 Skilled Nursing Care:

Fluid Replacement

The second major priority in burn care is the prevention of hypovolemic shock due to loss of intravascular fluid.

  • Established central IV access immediately.
  • Initiate intravenous fluid resuscitation, typically with Ringer’s lactate, as per the Parkland formula

Pain Management

Burn injuries cause severe and prolonged pain due to extensive tissue damage.

  • Intravenous opioids like fentanyl are commonly required, especially for major burns.
  • Non-pharmacologic measures such as relaxation techniques, music therapy, and positioning for comfort may also aid in pain relief and emotional support.

Nutritional Support

Due to the hypermetabolic state in burn patients, energy requirements are significantly increased.

  • Encourage early oral intake if possible.
  • Protein intake should constitute at least 23% of total calories to maintain body weight and muscle function.
  • Vitamin A and C supplementation is essential for wound healing.
  • Potassium and mineral supplements may also be necessary to correct electrolyte imbalances and support recovery.

Wound Care

Effective wound management is critical to prevent infection and promote healing.

  • Maintain strict hand hygiene at all times
  • Use clean and appropriate dressings as per wound type
  • Perform regular dressing changes following clinical guidelines
  • Adhere to prescribed antibiotic and topical treatments

Complications and Their Prevention
Skilled nurses are trained to identify and prevent common complications in burn patients, including:

  • Respiratory failure
  • Hypovolemic shock
  • Compartment syndrome
  • Renal failure
  • Paralytic ileus

Early identification and preventive interventions are key to avoiding these life-threatening issues.

Benefits of Skilled Nursing Care

Improved Outcomes

Skilled nursing care contributes significantly to improved patient outcomes by reducing complications and promoting faster recovery.

Reduced Hospital Stay

By delivering comprehensive care and preventing complications, skilled nurses help in minimizing the length of hospital stay and enhancing overall patient satisfaction.

Enhanced Quality of Life

Quality nursing care enhances the physical and emotional well-being of patients by:

  • Providing comfort
  • Reducing pain
  • Offering emotional support throughout the recovery process

Conclusion:

This case highlights the complexity and multidisciplinary management required in high-voltage electrical burn injuries. The patient, a 34-year-old male, sustained extensive burns involving critical areas including both upper limbs and trunk. Early fluid resuscitation, pain management, and thorough surgical interventions, including carpal tunnel release and neurolysis of the median nerve, were essential in stabilizing the patient and preventing complications.

Despite timely surgical decompression and wound care, residual neurological deficits such as blunted sensation in the median nerve territory persist, underscoring the need for long-term rehabilitation and follow-up. The absence of infection and the uneventful postoperative period reflect effective critical care and wound management protocols.

Electrical burns remain a serious clinical challenge due to their deep tissue involvement and systemic impact. Comprehensive and timely intervention can significantly improve outcomes and minimize long-term morbidity.

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