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
CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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