Burns injury - PACT - ESICM

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performed in this setting. If prognosis appears poor and palliation seems to be the best choice after an overall evaluation, the decision to terminate active treatment should be made as early as possible in the treatment course. For further reading see the PACT modules on Ethics and Communication. Cole P, Stal D, Hollier L. Ethical considerations in burn management. J Craniofac Surg 2008; 19(4): 895–898. PMID 18650707 Young AE. The Laing essay 1998: ethical issues in burn care. Burns 1999; 25(3): 193–206. PMID 10323603 Platt AJ, Phipps AR, Judkins K. Is there still a place for comfort care in severe burns? Burns 1998; 24(8): 754–756. PMID 9915678 Burn care research Although the research activities have increased in the burn care community throughout the years, a significant portion of usual burn care practices still lack a strong scientific basis. Despite this, mortality has decreased significantly, length of stay has dramatically been shortened and long-term outcome assessed as health related quality of life has improved. However, mainstream burn care does still not fulfill the highest evidence-based medicine (EBM) criteria. At the same time, it is important to realise that a significant amount of knowledge used in burn care and other care specialties, especially trauma and critical care, are based on early experiences in the care of the burn injured. This applies especially to fluid therapy, knowledge on the trauma response and the complications in the post trauma care period and the nutritional support. Lately, important research within burn care has been conducted in the field of modification to the trauma response - such as pharmacological modulation of this specific trauma response. Within the burns specialty, the focus is now directed at improving research quality and there is a strong demand for more randomised controlled trials supporting present care and identifying better care strategies. http://www.elsevier.com/wps/find/journaldescription.cws_home/30394/description #description) and the journal of Burn Care Research http://journals.lww.com/burncareresearch/pages/default.aspx Herndon DN, Hart DW, Wolf SE, Chinkes DL, Wolfe RR. Reversal of catabolism by beta-blockade after severe burns. N Engl J Med 2001; 345(17): 1223– 1229. PMID 11680441 Herndon DN, Tompkins RG. Support of the metabolic response to burn injury. Lancet 2004; 363(9424): 1895–1902. PMID 15183630 Jeschke MG, Kulp GA, Kraft R, Finnerty CC, Mlcak R, Lee JO, et al. Intensive insulin therapy in severely burned pediatric patients: a prospective randomized trial. Am J Respir Crit Care Med 2010; 182(3): 351–359. PMID 20395554 46
CONCLUSION In patients with burns covering more than 10–15 % of TBSA, fluid resuscitation should be initiated early. Administer the fluid orally or intravenously. Fluid resuscitation in the initial phase is dynamic. Nurse driven protocols may reduce the susceptibility to over-resuscitation. Aim for a urinary output of ½–1 mL/kg/hr in adults. Never use thermodilution techniques to measure fluid needs in the initial phase (0–24 hrs) as it causes fluid over-resuscitation. Fluid induces oedema, and facial burns may necessitate early orotracheal intubation to secure the airway. Impaired ventilation and/or compromised peripheral circulation due to deep or circumferential burns should be managed by early escharotomy at the primary hospital. Respiratory distress is most often due to vigorous fluid resuscitation, secretions, pneumonia and-/or other cause of systemic sepsis. Fibre optic bronchoscopy may reveal inhalation injury and enables removal of sequestered material or retained secretions from the airways. In the acute, initial phase, hypotension is usually caused by hypovolaemia. Subsequently a massive inflammatory response (SIRS) causes vasodilatation and hypotension despite an increased cardiac output. Wound and airway infections are common. SIRS may cause CRP levels above 100 mg/L and a body temperature of 38– 39 C which makes it difficult to define the precise onset of infection and to identify the right time to start antibiotic treatment. Prophylactic use of antibiotics is not encouraged. Definitive surgery, excision and grafting, should be performed early, preferably within the first week. Patients with large burns should be treated according to general principles for intensive medical care, preferably in units with special experience in treatment of burns. 47
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 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: 8/ OUTCOME, ETHICS & RESEARCH In a
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

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