Burns injury - PACT - ESICM

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Q. If bleeding continues despite an absence of a surgical bleeding site, what is the approach? A. Check platelet and coagulation indices (in the aftermath of a substantial fluid/blood transfusion) and prescribe therapy (usually fresh frozen plasma and platelets) as indicated. Old hydroxyethyl starch HES solutions are associated with long lasting pruritus. After surgery she is hypothermic and hypotensive, but after some hours of fluid management she stabilises. On day four, temperature approaches 40 C, CRP is 300 mg/L and PCT is 10 µg/L. Blood pressure is normal. PaO 2 /FiO 2 ratio is declining (20 kPa). Q. Sepsis is the apparent cause of this deterioration. What is the likely aetiology? A. In view of her deteriorating respiratory state, a pulmonary source is likely but, in patients with thermal injuries, a wound infection is always a possibility. Differentiation will require clinical evaluation. Sepsis Burn wound infection Respiratory infection Q. In your search for the source of infection, what will be the target(s) of your clinical evaluation? A. The search for a source of sepsis will include: respiratory and urinary systems; operative site, (in this case extensive burn wounds); indwelling catheters including CVC access and arterial access and other bloodstream infections (including cardiac valves). Other possibilities are acalculous cholecystitis, Clostridium difficile infection (particularly if the patient has been on antibiotics and/or has diarrhoea), sinusitis, otitis media, and decubitus ulcers. If, on clinical examination there is no other evident source for the sepsis, and CRI (catheter-related infection) is suspected, the CVC, arterial catheter or other intravascular device is removed or changed (and catheter tip and blood cultured). 54
Sepsis diagnosis Catheter-related infection (CRI) See PACT modules on Sepsis and MODS, Severe infection and Pyrexia (for diagnosis of CRI). Specimen from a protected brush, (large volume of purulent sputum noted), urine, blood and swabs from burn sites have been sent to lab for microscopy, culture and sensitivity (MCS) analysis. Apart from an increasing leukocytosis, all other bloods including liver function tests are unremarkable. The first of three faecal samples for C. difficile toxin has been collected. All catheters have been changed. CXR shows a new left-sided consolidation; she now requires FiO 2 >80% to maintain saturation and she has become hypotensive despite increasing doses of vasopressor. Q. She has an evident respiratory infection. How will you treat it? A. Once the diagnosis of sepsis is made, immediate empirical antibiotic therapy is indicated pending laboratory results from the diagnostic specimens sent at the time of the septic work-up. Augmented supportive respiratory therapy will likely also be required. Q. Given that this is a nosocomial pneumonia, what will be your approach to antimicrobial therapy? A. Antibiotic therapy may be guided by urgent sputum microscopy or by recent microbial surveillance data, but should be broad and incorporate good Gram-negative cover. If resistant organisms such as MRSA are common in the unit, then antibiotics active against these organisms should be considered. Fungal infection is common in burn patients, usually several days post injury. Q. Although, a pulmonary infection is the apparent cause of this deterioration, what other infections may co-exist in this burn injury patient? A. In burn injury patients, always consider a wound infection and see that all necrotic tissue is excised. If there is clinical evidence or suspicion of C. difficile infection, oral metronidazole is indicated, pending toxin results. PACT module Sepsis and MODS PACT module Severe infection She was commenced on piperacillin/tazobactam together with fluconazole and oral metronidazole and rapidly improved in the following 48 hours. Cultures from the protected brush specimen showed a heavy growth of sensitive Pseudomonas sp. as did her burn site 55
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 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: After wound debridement and escharo
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