Chapter 24 (Burns) Unfolding Case Study

Chapter 24 (Burns) Unfolding Case Study

by Ginny Bayes

​Your Patient: Jay B.

​Jay B., a 45 year old avid "storm chaser", is brought into the ED via EMS with a severe electrical burn from a lightning strike. He was struck in the leg, collapsed and fell to the ground and briefly lost consciousness.

​Upon arrival to the ED Jay is strapped to a backboard with a cervical collar in place, there are no entry or exit wounds noted, however where the lightning strike occurred is obvious because of a singed hole in his pants. The only major abnormality seen by the naked eye is a prominent Lichtenberg figure on his back.

​Lichtenburg Figure

​Initial Presentation

​Upon arrival Jay is alert but confused. 12 lead ECG reveals tachycardia with peaked t-waves, a shortened QT interval and ST-segment depression. His blood pressure is 105/69, heart rate 115, RR 24, SpO2 93% on 6L/min via facemask. 2 large bore IVs are started and isotonic crystalloid infusion with LR is initiated. A full "rainbow" of labs are drawn and Jay is placed on continuous monitoring of all vital signs for close observation.

Multiple Choice

​In addition to the serum laboratory tests, a urine specimen is also ordered for Jay. The nurse knows that in a patient with an electrical burn it is important to monitor the urine specifically for: 

• Free iron and white blood cells

• Protein and red blood cells

• Potassium and Urea

• Hemoglobin and myoglobin

Multiple Select

When a patient incurs an electrical burn the electrical current takes the "path of least resistance" inside the body. Considering this information, what body tissues will be most affected by the lightning strike that Jay suffered?

SELECT THREE THAT APPLY

• Nerves

• Fat

• Blood vessels

• Muscles

• Bone

Multiple Select

Upon admission to the ED, why did Jay have a cervical collar in place?

SELECT TWO THAT APPLY.

• In case he sustained an injury when he lost consciousness after the strike

• EMS protocol - a cervical collar is placed on every trauma - regardless of MOI

• Electrical burns can cause severe muscle spasms that are strong enough to cause cervical vertebrae fractures

• Neutral neck positioning is essential in electrical injuries in order to facilitate venous drainage from the cerebral vessels

​Laboratory Results

​When Jay's labs come back the nurse reviews them carefully. There are several abnormal lab results but the abnormalities are expected and anticipated by the healthcare team because of their suspicion of the "iceberg" effect. They prepare for potential complications based on the results of the labs. Jay's heart rate remains high (112), blood pressure low and his ECG abnormalities persist. His mentation has slightly improved but he still has retrograde amnesia regarding the lightning strike event.

Multiple Select

Which laboratory values do you anticipate will be abnormal?

SELECT THREE THAT APPLY

• Magnesium

• Potassium

• Chloride

• Myoglobin

• Creatinine

Multiple Choice

An arterial blood gas is emergently drawn after the healthcare team analyzes Jay's lab results. What ABG results would you expect to see? 

• pH: 7.47 PaO2: 82 PaCO2: 47 HCO3: 23

• pH: 7.40 PaO2: 100 PaCO2: 38 HCO3: 24

• pH: 7.30 PaO2: 70 PaCO2: 49 HCO3: 22

• pH: 7.29 PaO2: 84 PaCO2: 32 HCO3: 21

​Conclusion

​Jay is admitted to the ICU for continued close monitoring and emergent treatment of his myoglobinuria, hyperkalemia, metabolic acidosis and acute tubular necrosis. 4 hours after admission he suffers a ventricular fibrillation cardiac arrest. He is resuscitated successfully but has to be mechanically ventilated and placed on emergency hemodialysis. After 2 weeks in ICU and 3 weeks at a rehab facility Jay has recovered enough to be discharged home. When asked by nursing staff about his plans for the future, Jay states that his storm chasing days of glory are over and he plans to take up bird watching instead.

​*Enjoy the following bonus burn questions*

Multiple Choice

True or False: A patient who experiences an alkali chemical burn is easier to treat because the skin will neutralize the chemical rather than with an acidic chemical burn.

• True

• False

Multiple Select

Select the patients below who are MOST at risk for complications following a burn.

SELECT TWO THAT APPLY

• A 42 year old male with partial-thickness burns on the front of the right and left arms and legs.

• A 25 year old female with partial-thickness burns on the front of the head and front and back of the torso.

• A 76 year old male with full-thickness burns on the front of the left arm.

• A 10 year old with superficial burns on the right leg.

• A 37 year old female patient with burns to the inner thigh and perineum

Multiple Choice

A patient has a burn on the back of the torso that is extremely red and painful but no blisters are present. When you pressed on the skin it blanches. You document this as a:

• 1st degree (superficial) burn

• 2nd degree (partial-thickness) burn

• 3rd degree (full-thickness) burn

• 4th degree (deep full-thickness) burn

Multiple Select

A patient arrives to the ER with full-thickness burns on the front and back of the torso and neck. The patient has no spinal injuries but is disoriented and coughing up black sooty sputum. Vital signs are: oxygen saturation 93%, heart rate 145, blood pressure 80/56, and respiratory rate 34. As the nurse you will:

SELECT ALL THAT APPLY.

• Initiate cautious fluid resuscitation by infusing NS at a slow, controlled rate

• Place the patient in High Fowler’s positon.

• Prep the patient for intubation.

• Obtain IV access at two sites.

• Prep the patient for escharotomy.

Multiple Select

A patient arrives to the ED due to experiencing burns while in an enclosed warehouse. Which assessment findings below demonstrate the patient may have experienced an inhalation injury? SELECT ALL THAT APPLY. 

• Hair singeing on the head and in the nose

• Bright red lips

• Hoarse voice

• Sputum that appears to contain soot (carbonaceous sputum)

• Bradycardia

Multiple Choice

Which meal would be most appropriate for a patient recovering from burns to 18% of their TBSA?

• Caesar salad, potato corn chowder with a cheddar bay biscuit and iced tea

• Over easy eggs, turkey sausage, whole grain toast with a glass of whole milk

• Low fat yogurt, granola and fresh fruit with herbal tea

• Vegetable barley soup and a side salad with a pumpkin spice latte