Burns

A 32-year-old man is rescued from a warehouse fire. He has deep facial burns, soot in the oropharynx, progressive hoarseness, and increasing work of breathing. Oxygen saturation is 98% on high-flow oxygen. What is the most appropriate next step?

A 46-year-old woman presents 90 minutes after a flame burn involving the entire anterior trunk and the circumferential right upper limb. She weighs 60 kg. The burn is deep partial-thickness and full-thickness. Using 4 mL/kg/%TBSA for initial resuscitation, what approximate volume of crystalloid should be administered during the remaining 6.5 hours of the first 8-hour period?

A 41-year-old man has circumferential full-thickness burns of the left forearm. Four hours after admission, the hand becomes cool with delayed capillary refill, increasing pain on passive finger extension, and loss of previously audible digital Doppler signals. What is the most appropriate next step?

A 35-year-old electrician sustains a high-voltage injury. The entry wound is on the palm and the exit wound is near the elbow. The forearm is tense, pain is increasing despite analgesia, and passive finger extension causes severe pain. Radial and ulnar pulses remain palpable. What is the most appropriate management?

A 28-year-old woman presents after a deep partial-thickness scald burn to the dorsum of the hand. After 14 days of appropriate care, the wound remains pale, has minimal epithelial advancement, and is expected to take more than 3 weeks to heal. What is the most appropriate definitive management?

A 52-year-old man has circumferential full-thickness burns of the chest. He is intubated, but peak airway pressures are rising and bilateral chest expansion is markedly restricted. Breath sounds are equal, and the endotracheal tube is correctly positioned. What is the most appropriate next intervention?

A 7-year-old child sustains a hot-water scald. The burn involves the entire anterior trunk, the anterior surface of one arm, and the anterior surface of one thigh. Which method is most appropriate for estimating total body surface area?

A 44-year-old man is admitted after an enclosed-space fire. He is confused, tachypneic, and has a severe headache. Pulse oximetry reads 100% while receiving oxygen. What is the most appropriate immediate management?

A 31-year-old factory worker sustains a hydrofluoric acid burn to two fingers. The skin changes are initially mild, but he reports severe deep pain. What is the most appropriate initial specific treatment after copious irrigation?

A 38-year-old woman has a 20% TBSA deep dermal burn. During resuscitation, urine output is adequate, but she develops increasing generalized edema, tense extremities, elevated airway pressures, and rising intra-abdominal pressure. What is the most likely cause?

A 42-year-old man with a 28% TBSA flame burn is receiving crystalloid resuscitation. Eight hours after injury, his urine output is 40 mL/hour, blood pressure is stable, lactate is improving, but he has developed marked facial edema and increasing peak airway pressures. What is the most appropriate next step?

A 35-year-old woman has a circumferential deep burn of the neck and lower face. She was intubated early for progressive edema. Several hours later, venous congestion of the face worsens, and the neck eschar is tense. The endotracheal tube remains secure, and no hematoma is present. What is the most appropriate management?

A 51-year-old man sustains a 22% TBSA flame burn. On day 4, a previously clean full-thickness wound develops focal conversion to a dark purple color, increased pain at the margins, and rapidly spreading edema. He is febrile and tachycardic. What is the most appropriate next step?

A 28-year-old man has deep partial-thickness burns involving the palm and volar fingers. After 18 days, most of the palm has epithelialized, but a central area over the proximal interphalangeal flexion creases remains open and is unlikely to heal within the next week. What is the most appropriate management?

A 46-year-old woman undergoes tangential excision of a deep burn over the anterior thigh. During excision, the wound surface changes from pale, nonbleeding tissue to a uniformly punctate bleeding bed. What does this finding most strongly indicate?

A 39-year-old man undergoes split-thickness grafting of a deep burn across the anterior elbow. On postoperative day 5, the graft is adherent and viable. Which rehabilitation plan is most appropriate?

A 58-year-old man with a 40% TBSA burn develops increasing abdominal distension, oliguria, rising ventilatory pressures, and worsening metabolic acidosis despite escalating crystalloid administration. Bladder pressure is markedly elevated. What is the most likely diagnosis?

A 33-year-old woman sustains a deep facial burn involving both eyelids. Forty-eight hours later, increasing edema prevents complete eyelid closure, and the cornea is becoming exposed despite lubrication. What is the most appropriate next step?

A 30-year-old man sustains a deep circumferential burn of the penis after a chemical exposure. Several hours later, penile swelling increases, urinary catheterization becomes difficult, and distal tissue appears congested. What is the most appropriate management?

A 44-year-old man with a 32% TBSA burn is stable on day 2 after injury. Enteral feeding has not been started, and he is receiving maintenance intravenous glucose only. What is the most appropriate nutritional strategy?

A 45-year-old man presents with a 9% TBSA partial-thickness flame burn involving the face, both hands, and perineum. He is hemodynamically stable and has no signs of inhalation injury. What is the most appropriate disposition?

A 32-year-old woman has a deep partial-thickness burn of the ear after a house fire. The auricular cartilage is not exposed, but the ear is swollen and tender. Which management strategy best reduces the risk of suppurative chondritis?

A 54-year-old man undergoes tangential excision of a 35% TBSA full-thickness burn. Available autologous donor skin is insufficient to cover all excised areas during the same operation. What is the most appropriate temporary coverage for the remaining clean excised wound?

A 61-year-old woman undergoes split-thickness skin grafting of an excised thigh burn. On postoperative day 2, the graft is elevated by a tense dark collection and has become pale. What is the most appropriate next step?

A 7-year-old child with a 22% TBSA scald burn is undergoing resuscitation. Burn-replacement fluid has been calculated, but the child is becoming hypoglycemic. What additional fluid consideration is most appropriate?

A 40-year-old man sustains a hot tar burn to the forearm. The tar remains firmly adherent to the skin, and distal perfusion is intact. What is the most appropriate initial management?

A 37-year-old woman has a deep burn involving the axilla. After wound closure, she keeps the shoulder adducted because of pain. Four weeks later, abduction is becoming limited by scar tightening. What is the most appropriate management?

A 50-year-old man with extensive burns has undergone multiple grafting procedures. A previously harvested thigh donor site has fully re-epithelialized and is being considered for reharvesting. What is the most important prerequisite?

A 56-year-old man has a deep perineal burn with frequent stool contamination. The wound is not circumferential, and there is no rectal injury. What is the most appropriate initial wound-management principle?

A 43-year-old woman underwent grafting of a circumferential lower-leg burn 3 months ago. The grafts are healed, but the scars are raised, erythematous, pruritic, and becoming progressively firm. What is the most appropriate initial scar-management plan?

A 44-year-old man with a 38% TBSA flame burn undergoes staged tangential excision of the trunk. During excision, the surgeon reaches a uniformly punctate bleeding surface, but several central areas remain waxy and nonbleeding. What is the most appropriate next step?

A 37-year-old woman undergoes split-thickness skin grafting after excision of a deep burn across the anterior ankle. On postoperative day 4, the graft is adherent, but the ankle has been maintained in plantar flexion because of pain. What is the most appropriate rehabilitation strategy?

A 58-year-old man with a 45% TBSA burn develops progressive abdominal distension, oliguria, rising airway pressures, and worsening hypotension during aggressive fluid resuscitation. Bladder pressure is markedly elevated. What is the most appropriate next management step?

A 28-year-old woman has a deep facial burn involving the lower eyelids. Five days later, progressive lid retraction prevents complete eye closure despite lubrication and moisture chambers. What is the most appropriate next step?

A 49-year-old man with a 30% TBSA burn undergoes autografting of the back. On postoperative day 3, the graft is malodorous, greenish, and partially liquefied, with spreading erythema at the margins. What is the most appropriate management?

A 63-year-old man with a circumferential full-thickness burn of the lower leg undergoes escharotomy for worsening distal perfusion. After release, Doppler signals improve, but severe pain with passive toe extension and elevated compartment pressures persist. What is the most appropriate next step?

A 35-year-old woman sustains a deep burn across the first web space of the hand. After graft healing, the thumb is gradually being pulled into adduction despite routine dressing changes. What is the most appropriate management?

A 41-year-old man with a major electrical injury develops dark urine, hyperkalemia, and rapidly rising creatine kinase. Urine output remains below target despite initial fluid resuscitation, and the forearm is tense. What is the most appropriate combined management priority?

A 52-year-old man with extensive burns has insufficient donor skin for definitive closure after excision. Cadaveric allograft is applied to several clean wound beds. Which finding most strongly suggests that the excision beneath the allograft was adequate?

A 46-year-old woman with a 20% TBSA deep burn has undergone successful grafting. Six months later, the grafted anterior neck is thick, erythematous, pruritic, and beginning to limit extension despite consistent therapy. What is the most appropriate next step?

A 32-year-old woman undergoes excision of a deep facial burn involving the cheek and forehead. The wound bed is clean and viable, and sufficient donor skin is available. Which method of definitive coverage is most appropriate to optimize facial contour and minimize secondary contraction?

A 45-year-old man undergoes grafting of a circumferential deep burn of the forearm. The wound is clean, but donor skin is limited and moderate postoperative swelling is expected. Which graft configuration is most appropriate?

A 39-year-old woman has a deep full-thickness burn over the anterior knee with exposed patellar tendon after excision. The tendon lacks an intact paratenon. What is the most appropriate reconstructive approach?

A 56-year-old man recovering from extensive upper-extremity burns develops progressive loss of elbow motion 8 weeks after injury. Examination shows a firm end point, and radiographs demonstrate new bone formation in the soft tissues anterior to the elbow. What is the most likely diagnosis?

A 34-year-old man with a healed posterior elbow burn develops increasing pain and stiffness during rehabilitation. The elbow is warm and swollen, and range of motion has decreased rapidly over 10 days. What is the most appropriate next step?

A 68-year-old man presents with an ulcerated, foul-smelling mass arising within a burn scar that has been stable for more than 25 years. The lesion has enlarged over 6 months and bleeds easily. What is the most appropriate next step?

A 47-year-old woman undergoes excision of a full-thickness burn over the upper chest. The wound bed is clean, but the patient becomes hypothermic, coagulopathic, and hemodynamically unstable during surgery. What is the most appropriate operative decision?

A 29-year-old woman undergoes sheet grafting of a deep burn over the face. Six hours later, a localized bluish collection is visible beneath the graft, but the remainder of the graft remains adherent. What is the most appropriate management?

A 33-year-old man has a deep circumferential burn of the hand requiring excision and grafting. After surgery, which positioning strategy best protects function and minimizes contracture?

A 41-year-old man has a deep burn of the lower leg with exposed tibia after excision. The periosteum is absent over a 6-cm segment, and the surrounding tissue has been adequately debrided. What is the most appropriate definitive reconstruction?

A 43-year-old man presents 24 hours after a mixed-depth flame burn to the lower leg. Clinical examination cannot reliably distinguish deep partial-thickness areas that may heal spontaneously from areas requiring excision. The decision will determine whether early grafting is performed. What is the most appropriate adjunctive assessment?

A 29-year-old man has circumferential deep burns involving all fingers after grasping a burning object. Despite elevation, the digits become increasingly tense and cool, capillary refill is delayed, and digital Doppler signals are deteriorating. What is the most appropriate next step?

A 50-year-old woman sustains a deep anterior neck and upper chest burn. After wound closure, she is comfortable only when resting with the neck flexed over pillows. What positioning strategy is most appropriate to reduce future contracture?

A 36-year-old man with a 20% TBSA burn requires daily debridement and dressing changes. He experiences severe procedural pain despite adequate baseline opioid therapy and becomes unable to tolerate wound care. What is the most appropriate management?

A 25-year-old man presents with a contaminated partial-thickness burn after falling onto hot industrial equipment. His tetanus vaccination history is unknown. What is the most appropriate prophylactic management?

A 61-year-old man undergoes split-thickness grafting of a deep burn over the posterior trunk. The wound bed is clean, but its irregular contour makes conventional bolstering difficult. Which technique is most appropriate to improve stable graft contact and manage exudate?

A 48-year-old woman has a deep scalp burn after prolonged contact with a heated surface. Following excision, the outer table of the calvarium is exposed and has no viable pericranium. What is the most appropriate reconstructive principle?

A 40-year-old man with a 45% TBSA burn has persistent tachycardia, fever, and elevated inflammatory markers on day 3, but his wounds are unchanged, cultures are negative, perfusion is stable, and there is no organ dysfunction. What is the most appropriate interpretation?

A 33-year-old woman has a full-thickness burn over the breast and inframammary fold. After excision, adequate viable tissue remains, and definitive coverage is planned. Which reconstructive objective is most important for reducing later breast distortion?