Burns injury - PACT - ESICM

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Bak Z, Sjoberg F, Eriksson O, Steinvall I, Janerot-Sjoberg B. Hemodynamic changes during resuscitation after burns using the Parkland formula. J Trauma 2009; 66(2): 329–336. PMID 19204504 Holm C, Melcer B, Horbrand F, von Donnersmarck GH, Muhlbauer W. The relationship between oxygen delivery and oxygen consumption during fluid resuscitation of burn-related shock. J Burn Care Rehabil 2000; 21(2): 147–154. PMID 10752748 Samuelsson A, Steinvall I, Sjoberg F. Microdialysis shows metabolic effects in skin during fluid resuscitation in burn-injured patients. Crit Care 2006; 10(6): R172. PMID 17166287 Vlachou E, Gosling P, Moiemen NS. Microalbuminuria: a marker of endothelial dysfunction in thermal injury. Burns 2006; 32(8): 1009–1016. PMID 16884855 18
4/ MANAGING CONCURRENT INJURIES AND POISONING Inhalation injury Incidence and diagnosis The incidence of inhalation injury ranges from 5% to 30% of ICU admissions after burn injury and is suggested by the history and the examination of the patient. Hot gases can damage the lung as far as the terminal bronchioles, while smoke injury can extend more distally. The reflex vocal cord closure is not always sufficient to prevent penetration. The chemical products harm the respiratory mucosa. Diagnosis of the extent of the inhalation injury should be carried out on admission to the specialised burn facility with a separate Ear, Nose and Throat (ENT) specialty evaluation of the oro-pharynx and tracheobronchial tree – overlooking an ENT injury carries the risk of inappropriate early extubation. Standardising the description of inhalation injury – a descriptive score (See Ikonomidis C et al. 2012 below) Signs and symptoms Facial burns Hoarseness Singed nasal vibrissae and oropharynx Carbonaceous deposits and sputum Cough, stridor Wheeze Loss of consciousness Depressed mental status Mucosal airway appearance at the oro-pharyngeal and/or tracheobronchial levels Grade I: Erythema + mucosal oedema Grade II: Bullous mucosal detachment, erosions, exudates Grade III: Stenosis, profound ulcers, partial necrosis NB! Presence or absence of soot with any grade Airway management and ventilator treatment Immediate action: Any evidence of inhalation injury should prompt tracheal intubation – in controlled circumstances. Delay in securing the airway can potentially compromise oxygenation and access to the airway very rapidly, rendering intubation impossible due to the development of facial and upper airway oedema during fluid resuscitation. Suxamethonium (together with sedation/anaesthesia) can be used safely to facilitate intubation until 48 hrs after a major burn injury. In patients with deep injuries and/or oedema, intubation may be impossible. Case reports indicate that both percutaneous and surgical tracheostomy are safe in the acute setting when performed by skilled doctors. Importantly, in oedematous patients, the conventional tracheostomy tube might be too short, so that a tube with a adjustable flange will be required. There is no clear consensus on indications or the correct timing of tracheostomy in patients with large burns. Inhalation injury prolongs time on mechanical ventilation and distal injury to the tracheobronchial tree has a major effect on the duration of intubation. No mechanical ventilation technique has proven superior: local team competencies being the most important determinant in the choice of the mode. 19
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 and 10: Intravenous cannulae/needles and fl
Page 11 and 12: Fluid resuscitation (0-24 hrs) Burn
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: performed for these individuals 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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