It is a surgical case write up, written by Nathasa Paiyo Health Science student of Divine Word University, Madang, Papua New Guinea.

1. SURGICAL WARD_#3___
CASE WRITE UP !!!!!!!!!
ID# 190408 _NATASHA PAIYO_RURAL HEALTH_YEAR 4_ 2022

3. Patient Identification
Name: CG
Sex/Age: M/36
Place of origin: Madang
Place of residence: Wali
Denomination: Catholic
Marital status: Married
SOI: Guardians
DOA: 10/ 04/ 2022
TOA: 9: 45pm
BGH of Psychosis

4. Presenting symptoms
Fire burns ………1/7

5. History of the Presenting symptoms
 Patient has a BGH of Psychosis and admitted to Medical ward #2 in 2017, was
well and improved then discharged home.
 However, until 1/7 ago, he tried to hung himself and set fire on his house. He
was saved by his big brother, who ran into the house and untie the rope
around his neck and dragged him outside.
 Then he was rushed to ED and admitted to surgical ward for further
management.

6. Specific Interrogation
 Unable to talk
 Very irritable
 No SOB
 Was not coughing when the incident happened

7. Systemic review
CNS
 Confused
 BGH of psychosis
Other systems
 NAD

8. Past Medical History
 Known psychosis patient, not on any treatment.
 Admitted at Medical ward previously in 2017.
 2nd admission now
 No past surgical or allergy history

9. Social History
 Married with one kid, wife took the child away to Bogia when psychosis
started.
 Does chew betel nut.
 Does consume alcohol
 Does smoke, unable to differentiate whether he takes marijuana or not.

10. Family History
 No history of psychosis in the family
 Nil other illness in the family.

11. On Examination
Patient lying supine on bed, not in any
respiratory distress, had obvious
bandages around the hands, feet and
head.
 Vitals:
Temperature:36.8 degree celsius
Blood pressure:152/110 mmHg
Pulse: 102bpm
Spo2:97%
Respiratory rate: 32bpm

12. Local examination
 Obvious facial swelling and bandages in place.
 Neck swelling
 Full thickness burn to face
 Face = 8-9%
 Limbs partial thickness
 Limbs = 5-6%
 Total body surface area < 20%
 Wound infected slightly.
 Other systems = NAD

13. Findings
Subjective
 Unable to talk
 Very irritable
 No SOB
 No cough
Objectives
 Confused
 Infected wound
 Psychosis
 BP=152/110mmHg
 Respiration = 32bpm

14. Summary
Adult M/36 from Wali in Madang, has a BGH of Psychosis and got treated in 2017.
Until 1/7 ago was presented fire burn, TBSA<20%. Was admitted to surgical ward
for further investigation and proper management.

15. Diagnosis
Provisional diagnosis
 Thermal (Fire) Burn
Differential diagnosis
 Psychosis

16. Plan of Management
1. Admit to ward 3
2. Hb = 12 g %
3. Daily COD
4. Keep close watch to the patient
5. Advice on high protein diet
1. Flucloxacillin 1g QID
2. Crystapen 2ml IV QID
3. Diazepam 4ml IV prn
4. Hydrocortisone 100mg IV QID
5. Ceftriaxone 1g IV BD.
6. Flagyl 800mg TDS
7. Panadol 1g QID
8. Tetox stat.

17. Learning objectives
1. Definition
2. Epidemiology
3. Signs & symptoms
4. Causes
5. Classification of burns
6. Pathophysiology
7. Risk factors
8. Complications
9. Management

18. Definition
 A burn is a type of injury to the
flesh or skin which can be caused
by heat, electricity, chemicals, or
radiation
 The destruction of tissue by dry
heat where as scald is by moist
heat such as boing water or steam.

19. Epidemiology
 It is estimated that 90% of the burns occurs in low middle income countries,
regions that generally lack the infrastructure to reduce the incidence and
severity of burns.
 The vast majority are children, old age group, adult in working environment
or in the kitchen at homes, and people with underlying conditions; such as
psychosis.
 Rate of deaths in children is over 7 times higher in low middle income
countries compared to high middle income countries.
 Deaths from burns is one of the leading cause of morbidity, including
prolonged hospitalization, disfigurement and disability.

20. Signs & Symptoms
 Swelling
 Pain
 Blisters
 White or charred (black) skin
 Peeling skin
 Dizziness
 Loss of consciousness
 Hypotension/hypertension
 Scars
 Shock
 Airway compromise/ distress
 Hoarseness/ wheezing
 Death

21. Causes
 Thermal burns
Burns that result from an external heat source
like; flame, liquid, solid object or gases
 Radiation burns
Burns that occurs due to prolong exposure to
ultraviolet radiation (sunburn) or exposure to
sources of x-ray or other non-solar radiation
 Chemical burns
Burns that results from strong acids or alkalis
like; phenol, gasoline, cresols, mustard gas,
or phosphorus.
 Electrical burns
Burns that result from electrical generation of
heat. May cause extensive deep tissue damage
despite minimal apparent cutaneous injury.
 Friction burns
A friction burn is a type of abrasion that
occurs when the skin rubs against another
surface. Friction burns aren't really burns, but
since friction generates heat, extreme cases
can cause the outer layers of the skin to burn.

22. Classification of burns
1. First degree (partial superficial) –
erythema, sometimes painful, absence of
blisters or if blisters present, take about 2
weeks to heal
2. Second degree (partial deep) – burns to
the bottom of sweat glands, red, very
painful, swollen, blisters. Pin prick test is
felt as a sharp pain.
3. Third degree (full thickness) - painless,
pin prick test produce no pain and is felt
as a pressure sensation, with the skin
dark, leathery or waxy white, and is
usually dry.

23. Pathophysiology
 Heat immediately destroys cells or disrupts their metabolic functions so
completely cellular death occurs.
 The burn wound swells rapidly secondary to release of chemical mediators
 Causes an increase in capillary permeability and a fluid shift from the
intravascular space into the injured tissues
 Injury to the sodium pump in the cell walls accentuates the increased
permeability
 As sodium moves into injured cells it causes an increase in osmotic pressure
that increases the inflow of vascular fluid into the wound
 Finally, the normal process, evaporative loss of water into the environment is
dramatically accelerated (5 to 15 times that of normal skin) through the
burned tissue
Excessive Fluid Shift  Less Fluid in Blood Vessels  Shock (Hypovolemic
Shock)

24. Risk factors
 Modifiable
 Careless smoking: Cigarettes are the leading cause of house fires.
 Use of wood stoves
 Exposed heating sources or electrical cords
 Unsafe storage of flammable or caustic materials
 Substance abuse: Use of alcohol and illegal drugs increases risk.
 Non-modifiable
 Age: Children who are poorly supervised are at high risk.
 Gender: Males are more than twice as likely to suffer burn injuries.
 Epilepsy: Burn injury is unavoidable for epileptic person.

25. Complications
Immediate Complications
 Hypovolemic Shock
 Hypothermia
 Pulmonary complications due to Inhalation Injury
Intermediate Complications
(By Day 5 up to 2 or 3 wks)
 Acute Renal Failure
 Infections & Sepsis
 Curling’s Ulcer in large burns > 30% usually after 9th day
 Long Term Complications
• Scars
• Contractures
• Amputations
• Cancer called Marjolin’s ulcer, up to 21 years to develop
• Functional sequels
• Deformity
• Psychological Disorders

26. Burn Area Assessment
 Rule of seventh for children under 3 years  Rule of nines
Fluids required in:
 Children with >10% BSA
 Adults with burns>15% BSA both in 1st & 2nd degree.
 Children <3 years of age with >5% BSA.
Body Surface Area 0-3
years
Over
3
years
Head & neck 18% 12%
Trunk & groin 32% 38%
Both arms 20% 20%
Both legs 30% 30%
Head & neck 9%
Each arm 9%
Each leg 18%
Back & buttocks 18%
Front of the chest &
abdomen
18%
Genitalia 1%

28. Criteria for Hospitalization
 20% or greater TBSA
 10% or greater TBSA in child or
older adult
 5% or greater full thickness burn
 Burns to any of the 4 specific areas
(face, hands, feet, groin)
 Inhalation injury.
 Circumferential burns.
 Burns to the eyes or ears
 Burns with associated medical
condition (eg; diabetes, pregnancy,
or other trauma)
 Significant chemical burns

29. Management
Initial procedures
 Fluid infusion must be started immediately
 NGT insertion to prevent gastric dilatation,
vomiting & aspiration
 Urinary catheter to measure urine output
 Weight important & has to be taken daily
 Local treatment delayed until respiratory
distress & shock is controlled
 Tetanus prophylaxis
Laboratory investigations
• Hemoglobin / Hematocrit
• Urea / Creatinine
• Electrolytes
• Urine microscopy

30. Management
Outpatient management
 For 1st and 2nd degree burns < 10% BSA
 Blisters should be left intact & dressed
with silver sulfadiazine (SSD) cream
 Dressings should be changed daily &
washing with warm water to remove any
cream left.
 Splint all burn areas that overlap joints
Hospital management
• General assessment & cardiopulmonary
stabilization
• Resuscitation
• Establishment of IV lines & Blood studies
• Wound care and infection control
• Pain relief & Psychological Support
• Nutritional Support
• Physiotherapy/Occupational Therapy

31. Fluid calculation
Parklands rule (for the 1st 24 hours)  Fluid maintenance
100/50/20 per 24 hours; eg,pts wt
60kg.
100ml/kg 1st 10kg = 1000ml
50ml/kg 2nd 10kg = 500ml
20ml/kg the rest 40kg = 800ml
2300ml/24hours = 96ml/hr.
Adults 4ml x weight in Kg x BSA
Children 3ml/kg x weight in kg x BSA
½ volume over the first 8 hours
½ volume over next 16 hours
Lactate Ringers is the fluid of choice

32. References
1. The Global Burden of Disease: A Comprehensive Assessment of Mortality and
Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020,
Murray CJL, Lopez AD (Eds), World Health Organization, Switzerland 1996.
2. Surgery for Primary Health Care Workers in PNG_2013_Jerzy Kuzma.pdf,MD,PhD.
Specialist General & Orthopeadic Surgeon_Modilon General Hospital, Professor of
Surgery, Faculty of Heath Sciences, Divine Word University.
3. Standard Treatment Guidelines for Adult, National Department of Health, Papua
New Guinea, 6th Edition 2012. retriever from:
https://www.google.com/search?q=standard+treatment+book+for+adults&client=fi
refox-b-d&tbm=isch&so
4. Lecture notes_Dr J. Benjamin, Burns & Its Management_HE
Department.2020_DWU.