Case Study - Burns in Disasters and Conflicts

Original Editors - Naomi O'Reilly

Top Contributors - Naomi O'Reilly, Kim Jackson, Chelsea Mclene and Olajumoke Ogunleye      

Title

Face, Neck, Trunk and Arm Burns following a cooking fire in a Temporary Camp post Earthquake

Thanks to Humanity and Inclusion for Case Study taken from Early Rehabilitation in Conflicts and Disasters.

Abstract

Mrs T is a 35-year-old female who presented to a healthcare facility four hours post burns to the face, neck, trunk and arms after a cooking fire in a temporary camp post earthquake that destroyed her house. Mrs T was breathing spontaneously showed signs of superficial burn around the nose and mouth, which may be indicative of toxic smoke inhalation and suggest need for oxygen therapy. Required escharotomy to the chest and upper arms.

Key Words 

Burns, Fire, Earthquake, Disasters,

Patient Characteristics

Background

Mrs T is a 35-year-old lady who was cooking over a fire in a temporary camp following an earthquake that destroyed her house. The fire was put out with a bucket of cold water and she presented to your facility four hours later. There is no history or additional trauma and you do not suspect C-spine injury, so she does not require neck collar/sandbags and tape.

Examination Findings

A: Airway and C-spine Control

• Is patient maintaining airway? Yes, Mrs T is maintaining her airway.
• However, there are burns to face and neck, so we are concerned that the airway may be at risk due to swelling and/or inhalation injury.
• Sit patient up
• Medical Management
  • There is a need for oxygen
  • Link with medical team

B: Breathing

• Spontaneously breathing with normal breath sounds throughout
• RR of 16BPM, breathing is a little shallow.
• Evidence of burns to her chest and upper back
  • Burns appear deep, so patient may require escharotomy
  • Link with medical team
• Signs of superficial burn round nose and mouth (may be indicative of toxic smoke inhalation)

C: Circulation

• Patient is not haemorrhaging from anywhere
• Pulse is 110, BP 100/70: likely to be dehydrated, but not in shock
• Hands are cold with poor capillary return in fingers
  • Burns on the upper arm are deep and circumferential
• Medical team to insert cannulas and start fluid therapy and carry out escharotomy to both arms and chest

D: Disability

• Mrs T is conscious and talking when spoken to
  • V on the AVPU Scale
• Examination of her pupils are equal and responsive to light
• There appears to be no neurological concerns
• Patient able to sit up independently, so you do not need to log roll her

E: Exposure

• Patient needs to be kept warm to prevent hypothermia

F: Fluid Resuscitation

• Crucial in Acute Burns Management: Medical team to lead on this
• Important to monitor Urine Output, Pulse, BP and Capillary Refill
• Continue to assess her airway and swelling due to oedema

Pain Management

• Ensure pain management is covered, to include pre-change of dressings / therapy analgesia

Wound Care

• Discuss the plan for Mrs T’s wound care
• Therapy ties in well to change of dressings and is a chance to check on wound healing and assess for complications

Rehabilitation

Concerns

• Oedema
• Respiratory
• Joints Affected
  • REMEMBER – Maintain correct position, splint to prevent contracture and mobilise to encourage normal function

Treatment

• Nurse Mrs T sitting up due to inhalation injury risk – add breathing exercises and if required, chest physiotherapy (as with any other condition). Keeping the patient well-hydrated is important, so that secretions don’t dry up
• NB, post-SSG to the chest area vibrations and percussion should be left for five days if possible, and if necessary, done over Gamgee (absorbent cotton between gauze) dressings/pads
• Elevate her arms gently and keep them abducted and extended at rest, as safely appropriate
• Keep monitoring fingers to check on her circulation
• Splint neck and axilla and, if needed, mouth
• Teach ROM and stretching (avoiding overstretch) exercises
• Assess and advise on mobilisation
• Ensure patient is feeding with her own participation as safely able, and monitor pain levels
• Document everything clearly and COMMUNICATE everything clearly to patient and her family

Goals

Short-term

• Encourage Activity from day one.
• Aim is to prevent contracture and maximise return to function – initial movements can be limited if patient has had to undergo any skin grafts, but once surgeon allows it, movement must be encouraged.
• Outcome assessment to include measurement of active and passive ROM and also chin-to-sternal notch measurement and commenting on mouth opening (limited/full), as well as contours of the face, neck and trunk.

Long-term

• Expected management and outcome
• Assess stage of scar maturation and patient’s acceptance of altered body image and function.

Resources

Early Rehabilitation in Conflict and Disasters, Humanity and Inclusion