Management of the Burned Patient — MCQs
An anaesthetic agent with boiling temperature more than 75°C
Burns present as all the following EXCEPT
Which of the following statements regarding thermal injury is correct?
Which of the following is not true about resuscitation in burns patients?
What is the fluid of choice for resuscitation in a child with thermal burns within the first 24 hours?
All of the following are true regarding fluid resuscitation in burn patients except
In a post-burn patient, which of the following is true?
In a post-burn patient, which of the following is true?
Which of the following is NOT a recommended primary management option for a patient with a snake bite?
Patient in hospital was given IVF and patient develops hyperchloremic metabolic acidosis. Which fluid will cause this?
Management of the Burned Patient Indian Medical PG Practice Questions and MCQs
Question 1: An anaesthetic agent with boiling temperature more than 75°C
- A. Halothane
- B. Methoxyflurane (Correct Answer)
- C. Cyclopropane
- D. Ether
Explanation: ***Methoxyflurane*** - Methoxyflurane has a **boiling point of 104.7 °C**, making it the only agent listed with a boiling temperature above 75°C. - Its high boiling point and low vapor pressure necessitate the use of specialized **calibrated vaporizers** for safe administration [1]. *Halothane* - Halothane has a **boiling point of 50.2 °C**, which is significantly lower than 75°C [1]. - It was a commonly used inhalational anesthetic but has largely been replaced due to concerns about **hepatotoxicity**. *Cyclopropane* - Cyclopropane is a gas at room temperature and has a very low boiling point of **-32.9 °C**. - It is highly **flammable and explosive**, limiting its modern use in anesthesia. *Ether* - Diethyl ether (commonly known as simply "ether") has a boiling point of **34.6 °C**. - It was one of the earliest general anesthetics but is no longer used due to its **flammability** and slow induction/recovery.
Question 2: Burns present as all the following EXCEPT
- A. Acute kidney injury
- B. Shock
- C. Sepsis
- D. Air embolism (Correct Answer)
Explanation: ***Air embolism*** - **Air embolism** is a rare and severe complication, typically associated with central venous catheter insertion, lung trauma, or surgical procedures, not direct burn injuries [2]. - While burns can cause respiratory complications (e.g., **inhalation injury**), they do not directly cause **air embolism** [1]. *Acute kidney injury* - **Acute kidney injury (AKI)** can occur in severe burn patients due to several factors, including hypovolemic shock, rhabdomyolysis from muscle damage, and the formation of heme pigments [2]. - Decreased renal perfusion and the release of myoglobin/hemoglobin can lead to **acute tubular necrosis (ATN)**. *Shock* - **Hypovolemic shock** is a prominent and immediate concern in severe burn patients due to massive fluid loss from damaged capillaries and increased capillary permeability [3]. - This fluid shift, known as **burn shock**, results from third-spacing of fluids, leading to reduced intravascular volume. *Sepsis* - **Sepsis** is a major cause of morbidity and mortality in burn patients, especially after the initial resuscitative phase [1]. - The damaged **skin barrier**, along with immunosuppression caused by burns, makes patients highly susceptible to bacterial and fungal infections [1].
Question 3: Which of the following statements regarding thermal injury is correct?
- A. In child below 5 years, genitals form 1% of area
- B. Lund-Browder chart is the most accurate method for estimating TBSA in children (Correct Answer)
- C. Rule of nines is more accurate than Lund-Browder chart in children
- D. Burn index is the standard clinical method for assessing burn severity
Explanation: ***Lund-Browder chart is the most accurate method for estimating TBSA in children*** - The Lund-Browder chart is the **most accurate method** for estimating the **total body surface area (TBSA)** affected by burns, especially in children, due to its ability to adjust for age-related body proportion changes. - It assigns different body proportions based on age, making it superior to the Rule of Nines for pediatric patients. - This is the **CORRECT** statement. *Rule of nines is more accurate than Lund-Browder chart in children* - This is **FALSE**. The Rule of Nines is **less accurate in children** because their head and neck comprise a larger percentage of TBSA and their lower limbs a smaller percentage compared to adults. - The Lund-Browder chart is specifically designed to account for age-related differences and is therefore more accurate in pediatric burn assessment. *In child below 5 years, genitals form 1% of area* - While this statement is **technically true**, it is not the **most correct** answer in the context of thermal injury assessment methods. - In both adults and children, the **genitals and perineum** together typically account for **1% of TBSA**. - This is a specific anatomical fact but doesn't address burn assessment methodology, which is the main focus of the question. *Burn index is the standard clinical method for assessing burn severity* - This is **FALSE**. The **Burn Index** is not a commonly used term in standard clinical burn assessment. - Burn severity is assessed by considering both **depth** (superficial, partial-thickness, full-thickness) and **TBSA percentage**, along with other factors like location and patient age, but "Burn Index" is not the standard terminology or method used.
Question 4: Which of the following is not true about resuscitation in burns patients?
- A. Target mean arterial pressure in resuscitation is 60 mmHg.
- B. Ringer's lactate is the preferred crystalloid solution.
- C. Quantity of crystalloid needed is calculated using the Parkland formula - 6 mL/kg body weight per % of the total body surface area burnt. (Correct Answer)
- D. Fluid shift from intravascular to extravascular compartment in the burns patient is maximum in the first 24 hours.
Explanation: ***Quantity of crystalloid needed is calculated using the Parkland formula - 6 mL/kg body weight per % of the total body surface area burnt.*** - The **Parkland formula** is **4 mL/kg/%TBSA burned**, not 6 mL/kg/%TBSA. This formula is used to calculate the total fluid needed in the first 24 hours (half in the first 8 hours, remaining half in the next 16 hours). - This incorrect statement makes this the correct answer to the "not true" question. - The correct formula helps estimate intravenous fluid requirements to maintain adequate organ perfusion and prevent burn shock. *Target mean arterial pressure in resuscitation is 60 mmHg.* - This statement is TRUE. The target mean arterial pressure (MAP) in burn resuscitation is usually **60-70 mmHg** in adults to ensure adequate organ perfusion. - A MAP of ≥60 mmHg is the standard threshold for maintaining perfusion to vital organs during resuscitation. *Ringer's lactate is the preferred crystalloid solution.* - This statement is TRUE. **Ringer's lactate (Hartmann's solution)** is the preferred crystalloid for burn resuscitation due to its balanced electrolyte composition. - It closely mimics extracellular fluid and helps prevent hyperchloremic acidosis that can occur with large volumes of normal saline. *Fluid shift from intravascular to extravascular compartment in the burns patient is maximum in the first 24 hours.* - This statement is TRUE. The peak period for **capillary leak** and fluid shift into the extravascular space occurs within the first 8-24 hours post-burn. - This massive fluid shift leads to edema formation and is the reason aggressive fluid resuscitation is needed during this critical period.
Question 5: What is the fluid of choice for resuscitation in a child with thermal burns within the first 24 hours?
- A. Fresh frozen plasma
- B. Isolye-P
- C. Ringer lactate (Correct Answer)
- D. Platelet transfusion
Explanation: ***Ringer lactate*** - **Ringer lactate** is the preferred fluid for burn resuscitation in children due to its **isotonic nature** and buffering capacity which helps to correct acidosis. - It closely mimics the body's plasma electrolyte composition, effectively restoring circulating volume and addressing the **capillary leak** experienced in burn injuries. *Fresh frozen plasma* - **Fresh frozen plasma** is primarily used to replace **clotting factors** and **plasma proteins** in cases of severe bleeding or coagulopathy, not for initial fluid resuscitation. - Its high cost and potential for allergic reactions or **transfusion-related acute lung injury (TRALI)** make it unsuitable as a primary resuscitation fluid. *Isolye-P* - **Isolye-P** is a proprietary solution, and while some balanced electrolyte solutions may be used, it is not universally recognized as the **fluid of choice** for burn resuscitation over Ringer lactate. - Ringer lactate has a long-standing evidence base and widespread acceptance for managing burn shock. *Platelet transfusion* - **Platelet transfusions** are indicated for patients with **thrombocytopenia** or **platelet dysfunction** causing bleeding, which is not the primary concern in the initial phase of burn resuscitation. - Administering platelets without a specific indication is inappropriate and carries risks.
Question 6: All of the following are true regarding fluid resuscitation in burn patients except
- A. Most preferred fluid is Ringer's lactate
- B. Consider intravenous resuscitation in children with burns greater than 15% TBSA (Correct Answer)
- C. Oral fluids must contain salts
- D. Half of the calculated volume of fluid should be given in first 8 hours.
Explanation: ***Consider intravenous resuscitation in children with burns greater than 15% TBSA*** - This statement is incorrect because intravenous fluid resuscitation is typically initiated in children with burns involving **10% TBSA or more**, not 15%. - Children have a higher **basal metabolic rate** and **surface area to volume ratio**, making them more susceptible to dehydration with smaller burn percentages. *Most preferred fluid is Ringer's lactate* - **Ringer's lactate** is the preferred fluid for burn resuscitation due to its **physiologic electrolyte composition** which closely resembles plasma. - It helps to prevent **hyperchloremic acidosis**, which can occur with large volumes of normal saline. *Oral fluids must contain salts* - For minor burns or in situations where IV access is delayed, **oral rehydration solutions** containing salts are crucial to replace lost electrolytes. - Plain water alone without salts can lead to **hyponatremia** and fluid shifts. *Half of the calculated volume of fluid should be given in first 8 hours* - The **Parkland formula** dictates that half of the total calculated 24-hour fluid volume should be administered during the first 8 hours post-burn. - The remaining half is then given over the subsequent **16 hours** to ensure adequate resuscitation and prevent overhydration.
Question 7: In a post-burn patient, which of the following is true?
- A. Hyperkalemic acidosis
- B. Hypokalemic acidosis (Correct Answer)
- C. Hyperkalemic alkalosis
- D. Hypokalemic alkalosis
Explanation: ***Hypokalemic acidosis*** - Post-burn patients often experience significant fluid shifts and electrolyte imbalances, leading to **renal tubular dysfunction**. - This can result in excessive **potassium loss** in the urine (hypokalemia) and impaired acid excretion, leading to **metabolic acidosis** [1]. *Hyperkalemic acidosis* - While metabolic acidosis can occur post-burn, **hyperkalemia** is less common unless there's severe tissue destruction causing rapid cell lysis [1]. - Hyperkalemia usually results from **renal failure** or massive tissue breakdown from other causes, which is not the primary electrolyte derangement in uncomplicated burns. *Hyperkalemic alkalosis* - **Metabolic alkalosis** is rare in severe burns and is usually associated with conditions like **vomiting** or diuretic use from other causes. - **Hyperkalemia** is also not typical in metabolic alkalosis as the kidneys generally try to conserve potassium in such situations. *Hypokalemic alkalosis* - Although **hypokalemia** can occur post-burn, **metabolic alkalosis** is not the expected acid-base derangement in the acute phase. - Hypokalemic alkalosis is more commonly associated with conditions causing significant **volume contraction** and chloride loss, such as prolonged vomiting or loop diuretic use.
Question 8: In a post-burn patient, which of the following is true?
- A. Hypokalemic alkalosis
- B. Hyperkalemic alkalosis
- C. Hypokalemic acidosis
- D. Hyperkalemic acidosis (Correct Answer)
Explanation: ### Hyperkalemic acidosis - **Massive cell destruction** in severe burns leads to the release of intracellular potassium, causing **hyperkalemia** [1]. - **Metabolic acidosis** often results from tissue hypoperfusion, anaerobic metabolism, and accumulation of lactic acid due to shock and organ dysfunction [1]. *Hypokalemic alkalosis* - This condition is characterized by **low potassium levels** and **elevated pH**, which are not typical early responses to severe burns. - Would more likely be seen with significant **gastrointestinal losses** or certain diuretic use. *Hyperkalemic alkalosis* - While hyperkalemia can occur, the burn injury process typically leads to **acidosis** rather than alkalosis due to tissue damage and hypoperfusion. - This combination is generally contradictory as **severe hyperkalemia** is often accompanied by acidosis. *Hypokalemic acidosis* - **Hypokalemia** is not an immediate finding in severe burns; instead, **hyperkalemia** is expected due to cellular lysis. - Although **acidosis** is common, the potassium derangement described here is inconsistent with acute burn pathophysiology.
Question 9: Which of the following is NOT a recommended primary management option for a patient with a snake bite?
- A. Wash with soap and water (Correct Answer)
- B. Reassure the patient
- C. Splinting and immobilization
- D. Keep the site of bite below heart level
Explanation: ***Wash with soap and water*** - Washing the bite with soap and water is **NOT** a recommended primary management option for a snake bite as it can spread the **venom**, potentially worsening the local effects and systemic absorption [1]. - The focus should be on **immobilization and minimizing movement** to restrict venom spread [1], [3]. *Splinting and immobilization* - **Immobilization** of the bitten limb is crucial to reduce venom dissemination through the **lymphatic system** [1], [2]. - This helps to **slow the absorption** of venom into the systemic circulation [1], [3]. *Reassure the patient* - **Anxiety and panic** can increase heart rate and metabolism, potentially accelerating venom absorption. - **Reassurance** helps to calm the patient, which can slow the spread of venom and improve cooperation with treatment [1], [2]. *Keep the site of bite below heart level* - Keeping the affected limb **below heart level** helps to reduce blood flow and, consequently, the systemic spread of venom [1]. - This simple maneuver can **delay the onset** of systemic toxic effects [1].
Question 10: Patient in hospital was given IVF and patient develops hyperchloremic metabolic acidosis. Which fluid will cause this?
- A. RL
- B. 5 % dextrose
- C. NS (Correct Answer)
- D. DNS
Explanation: ***NS*** - **Normal Saline (0.9% NaCl)** contains a **chloride concentration of 154 mEq/L**, which is unphysiologically high (supranormal) compared to plasma (approx. 100 mEq/L). - Rapid infusion leads to the retention of excess chloride and dilution of serum bicarbonate, resulting in a **non-anion gap (hyperchloremic) metabolic acidosis**. *RL* - Ringer's Lactate (RL) is a **buffered solution** because it contains **lactate (28 mEq/L)**, which is metabolized by the liver into bicarbonate. - Because of the bicarbonate precursor (lactate) and a near-physiologic chloride concentration (109 mEq/L), RL tends to **prevent or correct** acidosis, rather than causing it. *DNS* - Dextrose Normal Saline (DNS) still contains the **supranormal chloride concentration** (154 mEq/L) from the normal saline component, posing a similar theoretical risk. - However, it is typically less associated with severe acidosis than pure NS in large volumes, and often the primary differentiating fluid in this context is the **buffered RL**. *5 % dextrose* - **5% Dextrose in Water (D5W)** contains no electrolytes (salt) and is only used to provide free water and small amounts of calories. - Rapid infusion of D5W results in dilution and can cause **hyponatremia** and free water excess, but it cannot precipitate hyperchloremic acidosis.
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