 Welcome back to the emergency medicine video series. If you haven't done so already, please refer to part 1 and part 2 before this discussion. Remember our patient with the 36% burn? Now he has arrived in the emergency department. What is our management priority? How do we put all the things that we've learned in part 1 and 2 together to manage this sick patient? Well, like with all sick patients in the emergency department, we start with ABC. First, airway. What are some of the things that we're supposed to look for to look for an airway thermal burn? That's right. You want to inspect the mouth for signs of airway burns such as soot in the mouth, or sputum, singed nasal hair, voice changes, or strider, or an obvious facial burn. If he has any of the signs or physical findings, we should intubate him now because we know that edema will make intubation much harder with towing. Next, we'll go towards breathing. For breathing, you want to make sure that the patient is ventilating properly after the airway is secured. There are two potential problems with breathing. First, a tight eschar will cause ventilation to be difficult because of a constricted chest. The second, in terms of breathing, could be because of carbon monoxide that is competing with oxygen to bind to hemoglobin, making not the breathing itself, but the use of hemoglobin less efficient for the body. To fix a tight eschar in the chest as we talked about before, an escharotomy is done to release the constrictive chest wall, and that way the chest can rise when the patient is being ventilated. In terms of carbon monoxide toxicity, we put patient on 100% oxygen to decrease the half life of the carbon monoxide in the body. It can either be done at normal pressure, or it can be done with higher pressure, which is in a hyperbaric oxygen chamber. The next part is circulation. Remember how burn patient needs a lot and a lot of fluid because of capillary leak? Just to refresh your memory, we use the Parkland formula to estimate their fluid requirement. Remember this is a very rough guide for their fluid requirement, and we might have to adjust it based on how the patient is doing. In the first 24 hours, they should be getting 4cc times their weight in kilograms times percentage of the total body surface area that's burned over a secondary burn. That total number will be in cc, and half of that should be given 8 hours post burn, and the next half is given the next 16 hours. And we often put in a folic half that are to monitor the urine output to guide our fluid resuscitation. In terms of labs, what lab tests do you think will be helpful for us? A lot of these lab works are fairly routine, so cbc, electrolytes, bioncretin, will give us a very good baseline on what the patient is like. Specifically, the ck can be quite high because of lysis of the muscle cells, and because of that, that can cause myoglobinemia, and that in turn can cause renal failure, so you want to watch that with time. Atropone can increase based on carbon monoxide toxicity. Now you also want to draw blood gas, and you're looking for a specifically carboxy hemoglobin level. In a smoker, this level can be about 5% on a regular basis. In a patient with significant carbon monoxide exposure, it will be much higher. So this is a blood test you have to get. There's also now a way to measure this by a cooxymetry machine that is non-invasive that will also give your percentage reading. The second thing we look for in his blood gas is a metabolic acidosis, because as you remember that there are two chemicals that can cause a metabolic acidosis in the patient from a burn. So let's say this is his gas, and you can see the patient is acedotic, and the bicarb is low, so there is a metabolic acidosis, and the body is compensating by breathing out the CO2. So the patient has a metabolic acidosis. You also might recall those two chemicals that cause a metabolic acidosis will also cause an increased anion gap. So you want to go back to your electrolytes and try to calculate that. So you go on to go back to his electrolytes to see what his anion gap would be. So we said his bicarb is 15, let's say his sodium is 140, pretty typical, and his chloride is say 95. So this comes together, that becomes 110, and you have an ion gap of 30, which is high. So remember the two chemicals that cause the anion gap metabolic acidosis in the patient who are coming from a fire are carbon monoxide and cyanide. Now you probably would have gotten this number by either doing a blood gas or checking it by the non-invasive machine. To see if there is any cyanide on board, there isn't a quick way of doing this directly, and we do it indirectly by checking a lactate. And if the lactate is up, that usually means that there is cyanide on board, and this lactate usually is quite high, it's in the order of more than 9 or 10 in a patient with cyanide toxicity. We already talked about that for carbon monoxide, you would give 100% oxygen either at normal pressure or at higher pressure through the hyperbaric chamber. And for cyanide, there is a specific antidote which we will not get into here. Don't forget that burns are tetanus-prone wounds, and so patients should get to tetanus immunization. Burn is of course very painful, so patients should get adequate pain medication to control their pain. In terms of disposition, there are special burn units that are designed to look after burn patients, and there are criteria for referral to the specialized burn unit. They might vary among the places that you work at. However, these are the broad categories. First is the extent of the burn. Anyone who has any partial thickness burn, so a second degree and up, over 20% of the body, or if you're over the age of 50, remember the older the patient, the less well they do, or under the age of 10, and you have a partial thickness burn more than 10% of your body's service area. If you have a full thickness burn, that's a third degree burn, more than 5% of your body service area, and then there are criteria of where the burn is. So any specific area that is very functional to the patient, such as hands, feet, perineum, face, or a circumferential burn to the chest. The next is coexisting injury, so burn with significant inhalation injury, trauma, or lightning. And the last criteria is about the patient. So in terms of patient, the people you want to refer are children, and particularly if you suspect abuse. Those are the patients you should consider calling the burn unit for a referral. In summary, we discussed the approach to the patient with burn in the emergency department using a regular ABC approach. We hope you find it helpful and thank you for watching.