Burns injury - PACT - ESICM

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2/ HOSPITAL ADMISSION – THE FIRST 24 HOURS Initial hospital management When the patient is admitted to hospital, the primary (ABC) survey is re-checked and a secondary survey is performed. Emergency medicine physicians/intensivists, surgeons, anaesthesiologists and nurses work together to provide optimum initial care and to chart the injury and the condition of the patient. Clothes and bandages are removed, and the wounds are washed with tap water and soap or with sterile saline [Video of wound cleaning in interactive version]. A central venous catheter (preferred in adults with burns >20 %TBSA and in children with burns >15 %TBSA depending on hospital practice), arterial catheter and urinary catheter are positioned after the cleaning (preferably catheters placed before cleaning should be removed). Secure all lines carefully. Bloods for haemoglobin, electrolytes, creatinine, creatinine kinase, liver function tests and blood gas analyses are obtained and many units take swabs for microbiology, and blood cultures from the outset. It is important that the temperature in the admittance area be adjusted to above 30 C to prevent hypothermia. Burn centre referral criteria Management of patients with large burns (Table in interactive version) is resource demanding. A team of intensivists, surgeons, anaesthesiologists, dedicated ICU nurses, physiotherapists and social workers are involved in the collaborative management of these patients to achieve the best cosmetic and functional result. It has long been demonstrated that patients benefit from a specialised burn centre if certain criteria are present. The patient should then be referred as soon as possible to such a centre. The ABA has defined transfer criteria for burn patients: Second degree burns >10% TBSA Third degree burns Burns that involves face, hands, feet, genitalia, perineum and major joints Chemical burns Electrical burns including lightening injuries Any burn with concomitant trauma in which the burn injuries pose the greatest risk to the patient Inhalation injury Patients with pre-existing medical disorders that could complicate management, prolong recovery or affect mortality Hospitals without qualified personnel or equipment for care of critically burned children. Herndon DN, editor. Total Burn Care. 3rd edition. Edinburgh: Saunders-Elsevier; 2007. ISBN 978-1416032748 6
Fluid resuscitation (0–24 hrs) Burns exceeding 20% TBSA (10% TBSA in children) are characterised by an early phase of massive capillary hyperpermeability proportional to the extent of the burn injury. [Images in interactive version] The transient increase in permeability is caused by the massive liberation of numerous substances such as histamine, serotonin, cytokines, prostaglandins, leukotrienes, lipid peroxides, free radicals, myeloperoxidase, and complement. Studies in animals show that the leakage lasts 24–72 hrs, peaking between 12 and 24 hrs. The only similar clinical condition is anaphylaxis. The resultant fluid leak causes an interstitial extravasation of intravascular fluid, potentially resulting in hypovolaemic shock which requires sodium containing isotonic crystalloids for treatment. During the first 24–48 hrs, molecules up to 100 kdalton in size escape into the interstitium. Colloids are discouraged in the early phase after injury because they will remain dispersed in the interstitium at the end of the hyperpermeability phase (their removal being dependent on an effective lymphatic transport). According to recommendations, one should fluid resuscitate the burn patient with 2–4 mL/kg/%TBSA (the Parkland formula) using crystalloids. As a small burn size is frequently overestimated on scene, this formula may cause pre-hospital fluid overload. Other factors that contribute to the fluid creep (see Complications of fluid management) are over-sedation and volume guided fluid therapy. Dynamic protocols for fluid resuscitation managed by nurses may reduce fluid overload in the early phase. The primary goal of fluid resuscitation is to maintain adequate tissue perfusion to the end-organs and the skin in an effort to conserve organ function/skin survival and to avoid ischaemic injury. Some supplementary critical care signs of fluid overload Polyuria > 1.0 mL/kg/hr cardiac preload (elevated CVP or ITBVI and PAOP if invasive monitoring instituted) PaO2/FiO2 ratio Intra-abdominal pressure >20 mmHg Abdominal compartment syndrome manifested by - Acute kidney injury - Visceral ischaemia CVP: Central venous pressure, ITBVI intrathoracic blood volume index, PAOP Pulmonary artery occlusion pressure Remember, CVP (and PAOP) are more useful when used dynamically rather than as single stand alone measurements – see PACT module on Haemodynamic monitoring. 7
Page 1 and 2: AN ESICM MULTIDISCIPLINARY DISTANCE
Page 3 and 4: Pathophysiology ...................
Page 5 and 6: INTRODUCTION Most emergency medical
Page 7 and 8: 1/ PRE-HOSPITAL/IMMEDIATE CARE Prio
Page 9: Intravenous cannulae/needles and fl
Page 13 and 14: Fluid resuscitation in patients wit
Page 15 and 16: Electrical burn injury is addressed
Page 17 and 18: Haberal M. Guidelines for dealing w
Page 19 and 20: Early tangential excision was first
Page 21 and 22: performed for these individuals and
Page 23 and 24: 4/ MANAGING CONCURRENT INJURIES AND
Page 25 and 26: Clinical signs of CO poisoning rela
Page 27 and 28: Although diagnosing CN poisoning is
Page 29 and 30: Electrical injuries Electrical inju
Page 31 and 32: 5/ CRITICAL CARE CONSIDERATIONS SPE
Page 33 and 34: Pruitt BA Jr. The diagnosis and tre
Page 35 and 36: Lam NN, Tien NG, Khoa CM. Early ent
Page 37 and 38: Sheridan RL, Yu YM, Prelack K, Youn
Page 39 and 40: hydromorphone) is preferred. In the
Page 41 and 42: 6/ PERIOPERATIVE MANAGEMENT OF INTE
Page 43 and 44: Know your hospital guidelines for t
Page 45 and 46: 7/ BURNS IN CHILDREN Epidemiology a
Page 47 and 48: One can also use a modified Parklan
Page 49 and 50: 8/ OUTCOME, ETHICS & RESEARCH In a
Page 51 and 52: CONCLUSION In patients with burns c
Page 53 and 54: Initial resuscitation specific to b
Page 55 and 56: With due preparation and skilled as
Page 57 and 58: After wound debridement and escharo
Page 59 and 60: Sepsis diagnosis Catheter-related i

Burns injury - PACT - ESICM

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