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A pt. sustained 3rd degree burn on his both arms when his shirt caught on fire while he was lightning the backyard barbecue. the burned areas r dry, white, leathery, anaesthetic n circumferential all around the arms n forearms. which of the following parameters should b very closely monitored?
A) blood gases
B) body weight
C) carboxyhemoglobin levels
D) myoglobinemia n myoglobinuria
E) peripheral pulses n capillary filling
source: kaplan qbook
its easy question but i wanna have discussion on management of this case.
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E) peripheral pulses n capillary filling
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ANS:E
What will be further management?
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E....... also look out for pain on passive stretching as this is circumferential burn with most likely eshar formation........thus watch out for compartment syndrome......any pain on passive stretching of muscles........then go for escharotomy and if still does not resolve then fasciotomy
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well, the ans is "E"
now where i got confused is when we get such a case, do we directly go for escharotomy or wait for signs for compartment syndrome to develop?
in this case, how to differentiate a case of compartment syndrome with impending disaster ahead from just a case of 2nd degree circumferential burn?
physical examination?
pain on passive stretching : present in both.
peripheral pulses: compartment syndrome can set in the presence of "normal" palpable pulses. pressure as much as 30 mm hg is enough to kill the muscles while pressure somewhere around the systolic pressure is required for pulses to b occluded
doppler/ duplex? same as peripheral pulses
so only definitive diagnosis is the frequent measurement of pressure in the compartment. then do we go for this frequent measurement wid keen observation or we straight away go for escharotomy in a circumferential burn?
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circumferential burns are prone to develop compartment syndrome and thats when they r dangerous..........so pain on passive stretching is the most important and sensitive clinical parameter to monitor alongwith compartment pressure monitoring...........if it develops then go for escharotomy if pressures are better with just that then no need for fasciotomy
doppler wud monitor blood flow in the extrimity
so full thickness circumferential burns lead to compartment syndrome.......no need to differentiate them..........its cause and effect.........we rx the effect ie compartment syndrome
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thanx guys. help appreciated
@ waynerooney: we need to differentiate coz we dont do escharotomy untill pt. develops compartment syndrome. or do we do escharotomy straight away when we see a full thickness circumferential burn?
frequent measurement of pressure within the compartment doesnt look feasible n with 2nd degree burn with already tender tissue, passive extension will anywaz produce pain. so it looks difficult to diagnose compartment syndrome in this setting.
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we dont do it straight away.......we monitor compartment pressures and then if need arises we go for it........if escharotomy also doesnt bring the pressure down then fasciotomy wud also be needed
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well, thats the answer i was looking for coz in these materials for step 2 prep, itz nowhere mentioned about measurement of compartment pressure. itz from the knowledge of orthopaedics acquired during MBBS that i was talking about it.
thanks. got my answer
