A 43-year-old female was admitted with a 31% TBSA mixed-depth flame burn to her left breast, abdomen and bilateral thighs (Figure 1). The patient had a prior history of depressive illness and dysfibrinogenaemia. This is an autosomal dominant condition, resulting in creation of defective fibrinogen, with impaired clotting function and a pre-disposition to bleeding. Tranexamic acid (TXA) is usually required when symptomatic, or as prophylaxis for some procedures, e.g. dental extraction.
Following presentation to the emergency department, intravenous fluid resuscitation was administered, using electrolyte and colloid fluids, according to a local hospital protocol. The burn was assessed and deemed suitable for enzymatic debridement. A pre-treatment plan was formulated, under guidance from haematology consultant colleagues. This included TXA pre-procedure (1  g, three times daily), continued until 48 hours post-application. If excessive bleeding was to occur, then human fibrinogen concentrate (RiaSTAP , CSL Behring, King of Prussia, PA, USA) would be required. Enzymatic debridement was performed on 25% TBSA in a single session, in an intensive care setting.
At 24 hours post-injury, the patient had an application of Nexobrid  (40 grams total) to all mid-dermal and deep-dermal burns. During the entire Nexobrid  treatment, cardiovascular monitoring was carried out. The clotting profile was recorded pre-treatment and post-treatment (Table 1). No adverse bleeding complications occurred and the clotting profile remained within the local normal range. No human fibrinogen concentrate or blood products were required at any point. The patient required split skin grafting (8% TBSA) to deeper areas overlying the abdomen, left upper chest and bilateral inner thighs. This took place without complication.