Burn Management and Sepsis

Patient History

• 54 yo M, guard found unconscious after fire/blast
• Hemodynamically stable with constricted pupils, sedated and intubated in trauma bay
• 3rd degree burns to 40% BSA
• 4% CO, cyanide levels taken, thiosulfate administered
• Warmed, NGT placed, urine catheter red urine

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• No sig findings following ENT and Ophtho consults
• Fluids and albumin given per protocol
• Full body CT: small pneumothorax, pulmonary contusions, ICA dissection, manubrium fx with hematoma

Airway

Low threshold for endotracheal intubation

Stridor

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• Hypoxemia/Hypercapnea
• GCS
• Full thickness neck burns
• Oropharyngeal edema

Deep facial burns

So what happens in the airway?

Thermal Damage

ABOVE: most worried about swelling
Look listen: stridor, changes in voice

BELOW: sloughing of airway epithelium
Look listen: copious mucous secretions, coughing, wheezing

1.4% Bicarbonate

Chemical Damage

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• Vomiting, headache, hypotension, convulsions, coma
• Pulse oximeter vs. ABGs
• Rx: 100% O2, hyperbaric oxygen
• Suspect cyanide poisoning with unexplained persistent lactic acidosis

Breathing

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• Full thickness burns restrict chest movement
• Blast injury: tension pneumothorax, lung contusion, alveolar trauma -->ARDS

Circulation

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2 peripherally inserted large bore IVs

Warm

ImPORTANT POINTS

• Fluid resuscitation based on clinical picture, frequently reasses
• Pulse oximetry may be normal
• Don't wait, intubate!
• Early enteral nutrition may improve survival
• No prophylactic antibiotics, except in wound excision or manupulation

Sepsis

After initial resuscitation, 75% mortality associated with infection

How do we diagnose?

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IN ADDITION

• Procalcitonin superior to C-reactive protein
• Prevention is key

Early Surgery

Topical Antimicrobials

• Silver sulfadiazine: painless
• Cerium nitrate-silver sulfadiazine: may reduce or reverse immunosupression after injury
• Silver nitrate: sol'n soaked dressing, skin discoloration
• Mafenide: penetrates burn eschar, PAINFUL, potent carbonic anhydrase inhibitor

Tube Feeding

• Start early
• Nasojejunal bypasses gastric stasis
• Hypermetabolic state, high nutritional requirements when not satisfied may lead to impaired wound healing, susceptibility to infection, organ failure and death

Maintain tight glycemic control

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• Hyperglycemia leads to increased catabolism
• Increased bactermia/fungemia
• Higher chance of skin graft loss
• Death
• Insulin trophic effect mucosal and skin barriers

Oxandrolone

• Improves weight gain
• Urine nitrogen loss
• Decreased time to wound healing
• Significant decrease in hospital stay (45 vs 32 days)

Beta-Blockade

• Decreased supraphysiologic thermogenesis
• Decreased tachycardia, cardiac work, rest energy expenditure
• Muscle protein balance increased by 82% in propanolol group

refrences

• Snell, Jane A., Ne-Hooi W. Loh, Tushar Mahambrey, and Kayvan Shokrollahi. "Clinical Review: The Critical Care Management of the Burn Patient." Critical Care Crit Care 17.5 (2013): 241. Web. 22 Mar. 2016.
• Bishop, Sophie, and Simon Maguire. "Anaesthesia and Intensive Care for Major Burns." Contin Educ Anaesth Crit Care Pain Continuing Education in Anaesthesia, Critical Care & Pain 12.3 (2012): 118-22. Web. 22 Mar. 2016.
• Ansermino, M. "Intensive Care Management and Control of Infection." Bmj 329.7459 (2004): 220-23. Web. 22 Mar. 2016.

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• Ansermino, M. "Intensive Care Management and Control of Infection." Bmj 329.7459 (2004): 220-23. Web. 22 Mar. 2016.