christopher p. brandt m.d. associate professor of surgery case western reserve university burns...
TRANSCRIPT
Christopher P. Brandt M.D.Christopher P. Brandt M.D.
Associate Professor of SurgeryAssociate Professor of Surgery
Case Western Reserve UniversityCase Western Reserve University
BURNSBURNSInitial Evaluation & ManagementInitial Evaluation & Management
Joseph B.Joseph B.
Your patient is brought to the E.D. by the Your patient is brought to the E.D. by the EMS service.EMS service.
He is a 14 year-old male who was involved He is a 14 year-old male who was involved in a house firein a house fire
HistoryHistory
What other points of history do you What other points of history do you want to know?want to know?
History, Joseph B.History, Joseph B.
Neighbors heard an explosionNeighbors heard an explosion Patient found confused, outside of the housePatient found confused, outside of the house Cannot remember what occurredCannot remember what occurred Denies shortness of breathDenies shortness of breath Transport time of twenty minutesTransport time of twenty minutes PMH of ADHDPMH of ADHD Tetanus – up to dateTetanus – up to date
Physical ExaminationPhysical Examination
What would you look for?What would you look for?
Physical ExaminationPhysical Examination
VS T=96.5VS T=96.5 P=140 R=24 BP=90/60 P=140 R=24 BP=90/60 Awake; No hoarseness or stridorAwake; No hoarseness or stridor Soot in mouthSoot in mouth Clear breath soundsClear breath sounds Burns involving face, neck, trunk, arms and Burns involving face, neck, trunk, arms and
upper legs (see photos)upper legs (see photos) Doppler pulses in all extremitiesDoppler pulses in all extremities
Physical ExaminationPhysical Examination
How do you determine the extent and How do you determine the extent and depth of the burn injuries?depth of the burn injuries?
What findings suggest inhalation What findings suggest inhalation injury?injury?
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Extent of burn Extent of burn % total body % total body surface areasurface area
Burn DepthBurn Depth
ColorColor MoistnessMoistness Capillary refill/BlanchingCapillary refill/Blanching SensationSensation BlisteringBlistering
Superficial Second Degree
Deeper second degree
Third Degree
Inhalation injuryInhalation injury
Occurred in closed spaceOccurred in closed space
Cough, dyspnea, wheezing, hoarseness, Cough, dyspnea, wheezing, hoarseness, stridorstridor
Facial burns / Singed facial hairFacial burns / Singed facial hair
Carbonaceous sputumCarbonaceous sputum
HypoxiaHypoxia
IndicatorsIndicators
LabsLabs
What would you obtain?What would you obtain?
Lab ResultsLab Results
CBC - CBC - WBC-12.0 Hct-49%WBC-12.0 Hct-49% Electrolytes -Electrolytes -Na-147 Cl-100 K-4.5 BUN-12Na-147 Cl-100 K-4.5 BUN-12 ABG -ABG - 7.31/35/125 on 50%VM 7.31/35/125 on 50%VM Carboxyhemoglobin-Carboxyhemoglobin- 21% 21% Tox. ScreenTox. Screen - Negative - Negative U/AU/A - Normal - Normal
Interventions at this point?Interventions at this point?
Interventions at this point?Interventions at this point?
Assess airway; Intubation ?Assess airway; Intubation ?OxygenOxygenFluid resuscitationFluid resuscitationFoley CatheterFoley CatheterNG tubeNG tubeWound careWound carePain medicationPain medication
InterventionsInterventions
Why is fluid resuscitation important?Why is fluid resuscitation important?How do you estimate fluid requirements?How do you estimate fluid requirements?How do you monitor response to initial fluid How do you monitor response to initial fluid
therapy?therapy?What complications can occur from over- or What complications can occur from over- or
under- resuscitation?under- resuscitation?
Fluid ManagementFluid Management
Edema formationEdema formation Systemic inflammatory responseSystemic inflammatory response Capillary leak/ Increased vascular permeabilityCapillary leak/ Increased vascular permeability Loss of skin barrierLoss of skin barrier
Zones of injuryZones of injuryParkland formulaParkland formula
Crystalloid 4 x %TBSA x wt (kg)Crystalloid 4 x %TBSA x wt (kg) ½ of total in first eight hours½ of total in first eight hours Goal of ½ - 1 cc/kg/hr U.O.Goal of ½ - 1 cc/kg/hr U.O.
StudiesStudies
What further studies/tests would you What further studies/tests would you want at this time?want at this time?
StudiesStudies
CXRCXR – Basilar atelectasis – Basilar atelectasis
EKGEKG – Sinus tachycardia – Sinus tachycardia
? Bronchoscopy? Bronchoscopy
ManagementManagement
Low urine outputLow urine output
Loss of Doppler signals in the handsLoss of Doppler signals in the hands
Inadequate ventilation with high airway Inadequate ventilation with high airway
pressures?pressures?
What would you do in the following scenarios?What would you do in the following scenarios?
ManagementManagement
EscharotomyEscharotomy
ManagementManagement
What are the principles of management of What are the principles of management of
the inhalation injury?the inhalation injury?
What will be the basic strategies for What will be the basic strategies for
management of the burn wounds?management of the burn wounds?
Questions?Questions?
Acknowledgment The preceding educational materials were made available through the
ASSOCIATION FOR SURGICAL EDUCATIONASSOCIATION FOR SURGICAL EDUCATION
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