Item:

a. ld : 4550
~'?Mark ~
PreVIOUS
f>
Next
a
lab Values
~
Notes
~
Calculator
,
Reverse Color
GJIIA)
Text Zoom

A 62-year-old man is evaluated in the burn unit due to progressive confusion, lethargy,
and reduced urine output. Five days ago, the patient was hospitalized for a 20% body
surface area burn and mild inhalation injury after his house caught fire. He is receiving
analgesics, enteral feedings, and intravenous fluids. Temperature is 35.5 C (96 F), blood
pressure is 100/60 mm Hg, pulse is 120/min, and respirations are 26/min. Physical
examination shows third-degree burns on sections of the bilateral legs and a
second-degree burn on the torso. Some areas of partial-thickness injury appear to have
progressed to full-thickness necrosis. Laboratory results are as follows:

Platelets 80,000/mm'
Leukocytes 16,000/mm'
Blood glucose 230 mg/dL

Which of the following is the most likely cause of this patient's current condition?

0 A. Carbon monoxide poisoning

0 B. Gram-negative sepsis
0 C. Hypermetabolic state
0 D. Myocardial injury
0 E. Renal tubular injury

Submit

~
----------------- ------------------------------
Feedback Su~nd EnQ ock
Item:
a. ld : 4550
~'?Mark ~
PreVIOUS
f>
Next
a
lab Values
~
Notes
~
Calculator
,
Reverse Color
GJIIA)
Text Zoom

A 62-year-old man is evaluated in the burn unit due to progressive con fusion, lethargy,
and reduced urine output. Five days ago, the patient was hospitalized for a 20% body
surface area burn and mild inhalation injury after his house caught fire. He is receiving
analgesics, enteral feedings, and intravenous fluids. Temperature is 35.5 C (96 F), blood
pressure is 100/60 mm Hg, pulse is 120/min, and respirations are 26/min. Physical
examination shows third-degree burns on sections of the bilateral legs and a
second-degree burn on the torso. Some areas of partial-thickness injury appear to have
progressed to full-thickness necrosis. Laboratory results are as follows:

Platelets 80,000/mm'
Leukocytes 16,000/mm'
Blood glucose 230 mg/dL

Which of the following is the most likely cause of this patient's current condition?

A Carbon monoxide poisoning [4%)

B. Gram-negative sepsis [51%)
C. Hypermetabolic state [26%)
D. Myocardial injury [1%)
_· E. Renal tubular injury [19%)

Proceed to Next Item

Explanation: User
Severe burns disrupt the skin barrier and create an avascular, immunologically poor,
protein-rich substrate for the growth and proliferation of bacteria and fungus.
Immediately after a severe burn, gram-positive organisms (eg, Staphylococcus aureus)
from hair follicles and sweat glands dominate; after more than 5 days, most infections are
due to gram-negative organisms (eg, Pseudomonas aeruginosa) or fungi (eg, Candida).

Wound infections are common, and patients with large surface area (>20%) burns are at
highest risk. The earliest sign is usually a change in appearance (partial-thickness
injury turns into a full-thickness injury) of the wound or the loss of a viable skin graft.
Burn wound sepsis can develop rapidly and is associated with some or all of the
following systemic findings:
-- - - -- - ·- -
Feedback EnQ ock
-----------------
Item:
a. ld : 4550
~'?Mark ~
PreVIOUS
f>
Next
a
lab Values
~
Notes
~
Calculator
,
Reverse Color
GJIIA)
Text Zoom

Explanation: User
Severe burns disrupt the skin barrier and create an avascular, immunologically poor,
protein-rich substrate for the growth and proliferation of bacteria and fungus.
Immediately after a severe burn, gram-positive organisms (eg, Staphylococcus aureus)
from hair follicles and sweat glands dominate; after more than 5 days, most infections are
due to gram-negative organisms (eg, Pseudomonas aeruginosa) or fungi (eg, Candida).

Wound infections are common, and patients with large surface area (>20%) burns are at
highest risk. The earliest sign is usually a change in appearance (partial-thickness
injury turns into a full-thickness injury) of the wound or the loss of a viable skin graft.
Burn wound sepsis can develop rapidly and is associated with some or all of the
following systemic findings:
• Temperature <36.5 C (97.7 F, as in this patient) or >39 C (1 02.2 F)
• Progressive tachycardia (>90/min)
• Progressive tachypnea (>30/min)
• Refractory hypotension (systolic blood pressure <90 mm Hg)

Oliguria, unexplained hyperglycemia, thrombocytopenia, and mental status changes are

also common. Diagnosis requires quantitative wound culture (>10• bacteria/g of
tissue) and biopsy for histopathology (to determine tissue invasion depth). Treatment
involves empiric, broad-spectrum intravenous antibiotics (eg, piperacillin/tazobactam,
carbapenem) with the addition of potential coverage for methicillin-resistant
Staphylococcus aureus (eg, vancomycin) or multidrug-resistant Pseudomonas
aeruginosa (eg, an aminoglycoside). Local wound care and debridement are usually
necessary.

(Choice A) Carbon monoxide poisoning due to fire exposure can sometimes cause a
delayed neuropsychiatric syndrome (eg, altered mental status) but would not explain the
hypothermia, laboratory abnormalities, or change in wound appearance seen in this
patient.
(Choice C) The metabolic rate drastically increases after a large surface area burn due
to the release of inflammatory mediators; this may cause increased basal temperature (to
38.5 C [1 01.3 F)), tachycardia, tachypnea, and hyperglycemia. However, this patient has
hypothermia, a change in wound appearance, reduced urine output, and confusion,
making sepsis more likely.

(Choices 0 and E) Myocardial infarction can complicate burn injuries, and this patient
may be at risk for renal tubular injury due to sepsis or hypotension. However, change in
wound appearance, thrombocytopenia, and hypothermia are more consistent with sepsis.

Feedback EnQ ock

-----------------
Item:
a. ld : 4550
~'?Mark ~
PreVIOUS
f>
Next
a
lab Values
~
Notes
~
Calculator
,
Reverse Color
GJIIA)
Text Zoom

Wound infections are common. and patients with large surface area (>20%) burns are at
highest risk. The earliest sign is usually a change in appearance (partial-thickness
injury turns into a full-thickness injury) of the wound or the loss of a viable skin graft.
Burn wound sepsis can develop rapidly and is associated with some or all of the
following systemic findings:
• Temperature <36.5 C (97.7 F. as in this patient) or >39 C (1 02.2 F)
• Progressive tachycardia (>90/min)
• Progressive tachypnea (>30/min)
• Refractory hypotension (systolic blood pressure <90 mm Hg)

Oliguria. unexplained hyperglycemia. thrombocytopenia, and mental status changes are

also common. Diagnosis requires quantitative wound culture (>10; bacteria/g of
tissue) and biopsy for histopathology (to determine tissue invasion depth). Treatment
involves empiric. broad-spectrum intravenous antibiotics (eg. piperacillin/tazobactam.
carbapenem) with the addition of potential coverage for methicillin-resistant
Staphylococcus aureus (eg. vancomycin) or multidrug-resistant Pseqdomonas
aeruginosa (eg. an aminoglycoside). Local wound care and debridement are usually
necessary.
(Choice A) Carbon monoxide poisoning due to fire exposure can sometimes cause a
delayed neuropsychiatric syndrome (eg. altered mental status) but would not explain the
hypothermia. laboratory abnormalities. or change in wo.und appearance seen in this
patient.
(Choice C) The metabolic rate drastically increases after a large surface area burn due
to the release of inflammatory mediators; this may cause increased basal temperature (to
38.5 C [1 01 .3 F]). tachycardia. tachypnea. and hyperglycemia. However. this patient has
hypothermia. a change in wound appearance, reduced urine output. and confusion,
making sepsis more likely.

(Choices 0 and E) Myocardial infarction can complicate burn injuries. and this patient
may be at risk for renal tubular injury due to sepsis or hypotension. However. change in
wound appearance. thrombocytopenia, and hypothermia are more consistent with sepsis.
Educational objective:
Severe burns are often complicated by wound infections and sepsis. Risk is increased
with large burns (>20% body surface area). Gram-positive organisms are common soon
after injury; gram-negative organisms and fungi are more common after 5 days. A
change in burn wound appearance. or the loss of skin graft is often the first sign of a burn
wound infection.

Time Spent 2 seconds Copyright © UWorld Last updated: [08/23/2016)

Feedback EnQ ock

-----------------