Burns Patient Hot Case

GENERAL APPROACH

Phase of Burn

• Resuscitation (Day 1) – resuscitation, CO, CN, coagulopathy, compartment syndrome, management of traumatic injuries, co-morbidities
• Post-resuscitation (Day 2-6) – debridement and grafting, nutrition, fluid therapy, bleeding.
• Inflammatory/infective (Day 7) – differentiating sepsis from SIRS, extubation/tracheostomy.

INTRODUCTION

CUBICLE

• isolation
• increased temperature
• fibre optic bronchoscope in room for assessment of airway burn and for bronchial toileting

INFUSIONS

• analgesia (narcotic, ketamine)
• sedation
• feeding
• fluids (Parkland formula, multiply by 2 if inhalational injury present)
• albumin to maintain albumin > 20g/L
• hypertonic saline to minimise volume resuscitation
• later require free H2O replacement
  -> free water loss (mL/hr) = (25 + %TBSA burn) x BSA
  -> BSA use 2m2 as a rule of thumb
• blood product use
• insulin infusion
• antibiotics: prophylactic for OT or complication
• CN poisoning: hydroxocobalamin, sodium thiosulphate

VENTILATOR

• mode
• level of oxygenation: FiO2, PEEP (high with aspiration, nosocomial pneumonia, ARDS, restricted chest wall motion, inhalational injury, fluid overload, associated chest trauma)
• metabolic cart to ventilator: tailored nutrition
• nebulised heparin or NAC for inhalational injury

MONITOR

• fever: sepsis or burns related SIRS
• tachycardia: may be elevated for 6-12 months

EQUIPMENT

• bladder transducer for the measurement of intra-abdominal pressures
• CRRT: myoglobinuria and ARF

QUESTION SPECIFIC EXAMINATION

• difficult as often heavily dressed
• state you would like to review all body surfaces and burn wounds at the time of dressing changes
• ask to see photographs
• look for signs of burn infection
• clarify extent of burn wound and how much has been treated
• compartment assessment
• examine mouth with a tongue depressor
• eye examination when oedema subsides
• inhalational injury: carbonaceous sputum, facial burns, singed eyelashes, eyebrows, nasal hairs, upper airway obstruction.
•  hands/arms -> head -> chest -> abdo -> legs/feet -> back

-> general:
-> cardiovascular:
-> respiratory:
-> abdominal:

• neurological: as able

• all lines sites
• other sites in case they need replacement
• look for nosocomial infection
• look at neck for possible tracheostomy
• secondary survey
• urine output: > 0.5-1mL/kg/hr, myoglobinuria

RELEVANT INVESTIGATIONS

• ABG: lactate and gas exchange
• trend in haematocrit
• bronchoscopy
• burn biopsy and culture result
• current surgical plan

OPENING STATEMENT

• Burn
• Site
• Depth
• Extent
• Phase of Burn
  — Resuscitation
  — Post-resuscitation
  — Inflammatory/Infective
• Complications