Burns injury - PACT - ESICM

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Another important complication during burn surgery is the septic effects on the circulation and haemostasis. Such effects may be significant but are most common in large burns and later during the course of treatment. In such cases infection surveillance and diagnosis and the choice of appropriate antibiotics are essential. Active temperature control during surgery One very important topic in burn surgery is temperature control. The patient is losing heat for several reasons: evaporative losses as dressings are removed; a nonfunctional skin barrier for temperature control; and cooling as surgical washing of the skin is made. These reasons make it mandatory to have a close temperature surveillance (e.g. via bladder catheter) and using active heating devices, the most successful being convective heat devices. Other means are keeping the operating room warm, warming the ventilator breathing system (circuit), warming all fluids given to the patient and limiting the amount of time in the operating room. Hypothermia prevention: give this high priority! Hypothermia favours coagulation disorders with bleeding and worsens outcome! Increased mortality has been shown in patients with delayed recovery of normothermia after surgery! See PACT module on Bleeding and thrombosis. Yowler CJ. Recent advances in burn care. Curr Opin Anaesthesiol 2001; 14(2): 251–255. PMID 17016410 Berger MM, Bernath MA, Chioléro RL. Resuscitation, anaesthesia and analgesia of the burned patient. Curr Opin Anaesthesiol 2001; 14(4): 431–435. PMID 17019126 MacLennan N, Heimbach DM, Cullen BF. Anesthesia for major thermal injury. Anesthesiology 1998; 89(3): 749–770. PMID 9743414 Janzekovic Z. A new concept in the early excision and immediate grafting of burns. J Trauma 1970; 10(12): 1103–1108. PMID 4921723 Kjellman BM, Fredrikson M, Glad-Mattsson G, Sjöberg F, Huss FR. Comparing ambient, air-convection, and fluid-convection heating techniques in treating hypothermic burn patients, a clinical RCT. Ann Surg Innov Res 2011; 5(1): 4. PMID 21736717 40
7/ BURNS IN CHILDREN Epidemiology and prevention Burns are the most common cause of accidental death in children 0-14 years of age in the United States after car accidents and drowning. In the western world, scald is the most common reason [images in interactive version]. In 1946 Emlyn Lewis, Gloucester City General Hospital, wrote in the British Medical Journal urging legislative interventions to prevent burn injuries in small children from electric fires and gas stoves, a matter still in focus today. Measures to prevent burn injury in children are to teach children about fire prevention and to keep dangerous materials out of reach in particular in the kitchen. Supervision during fireworks is critical. Child abuse Distinguishing intentional injuries from accidents is challenging. Maguire and colleagues performed a systematic review to characterise whether the mechanism of injury in burns was suspected abuse. Dipping injuries caused by hot tap water which were identified in children with intentional scalds, were symmetrical and with distinct upper margins, located on extremities and/or buttocks. Unintentional scalds were most often localised in the upper right part of the body, i.e. the face, neck and right upper extremity. Typically these wounds had irregular margins and depths (see figs 3,4,5 in second Maguire reference, below) Maguire S, Moynihan S, Mann M, Potokar T, Kemp AM. A systematic review of the features that indicate intentional scalds in children. Burns 2008; 34(8): 1072–1081. PMID 18538478 Maguire S. Which injuries may indicate child abuse? Arch Dis Child Educ Pract Ed 2010; 95(6): 170–177. PMID 20926622. http://ep.bmj.com/content/95/6/170.long How does burn care in children differ from burn care in adults? Airway and intravenous access The smallest children often need general anaesthesia (with or without intubation) if central venous access is needed. Most experts advocate a CVC in burns >15%–20% of TBSA or if peripheral venous access is difficult. Further, the airway is small and if the burn is located in the face, neck and upper part of the trunk, the child is often intubated. If one suspects a compromised airway, intubation should be performed without delay. However, it is important to be aware that children that stay intubated are easily overhydrated as they have an increased production of antidiuretic hormone (ADH). SIADH (syndrome of inappropriate anti diuretic hormone secretion) may occur. Fluid overload often leads to respiratory failure and ventilator-associated pneumonia 41
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 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: Know your hospital guidelines for t
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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