burns management

1. Futile medical care
‫المجدية‬ ‫غير‬ ‫الطبية‬ ‫الرعاية‬
Dr. Qutaiba Abdullah AlDoori
Burn & Reconstructive Surgery
AZADI Teaching Hospital

2. Futile medical
care
• The Word Futile• means unavailing , useless
• ‫جدوى‬ ‫ذي‬ ‫غير‬,‫تحته‬ ‫طائل‬ ‫ال‬
• unsuccessful, failing , fruitless,
• useless, ineffectual, vain, unfruitful,
unproductive,

3. Apoptosis and
Regeneration

4. Introduction
• Apoptosis ;
• (one of innate immune response)
• Apoptosis can be induced indirectly in response to
overwhelming physical injury.1
• Major burns associated with massive
inflammatory response can alter cellular
kinetics ,3

5. Introduction
• There is a ‘cytokine storm’ can lead to alterations
in Na+-K+ ATPases and thereby result in
electrophysiological membrane dysfunction .3

6. Introduction
Both
early apoptosis and delayed necrosis
are present in the zone of ischemia,
contributing to injury progression.4

7. • Approximately
• half {½} of the cells in the zone of
• stasis undergo apoptosis or necrosis as a result
of oxidative stress, ongoing inflammation, and
decreased blood flow due
• to microthrombosis.
• Andreas Bergmann1,* and Hermann Stelle
• Systemic factors such as advanced age, diabetes,
and other chronic illnesses increase risk for
“conversion from Partial T to FT Burn wound.”
Introduction

8. • calcium influx
• into the cytoplasm and triggers a subsequent
cascade leading to apoptosis.
• Greek prefix (apo) attached to a Greek stem (ptosis)
• “falling to death”
• Is it reversible ⁈ mitochondria if swell
• organelles that act like a digestive &respiratory
system in cells ,
Introduction

9. Futile medical care
• Is the continued provision of medical care or
treatment to a patient when there is no
reasonable hope of a cure or benefit.
• Some proponents of evidence-based
medicine suggest discontinuing the use of any
treatment that has not been shown to provide a
measurable benefit

10. A ‘do not
resuscitate’ (DNR)
order is not
the equivalent of a
‘do not care’ (DNC)
consideration.

11. Futile medical care
• Futile care is distinct from euthanasia because
• euthanasia involves active intervention to end life,
while withholding futile medical care does not
encourage or hasten the natural onset of death .
‫الشفقة‬ ‫بدافع‬ ‫قتل‬ =EEuthanasia

12. Arguments against providing
futile care include potential harm
to
• 1/ Patient , (Increasing duration of pain)
• 2/ Family members , (Fake hope )
• 3/ Caregivers with little or no likely
benefits,
• 4/ Diversion of resources to support the
futile care In spite to be directed to
provide care to patients that could
respond to care.

13. Futile medical care
• The issue of futile care in clinical medicine
generally involves two questions.
• The first concerns the identification of those
clinical scenarios where ? the care would be
futile.
• The second concerns the range of ethical options
when ? care is determined at which level of no
more improvement to be futile.

14. SCIENTIFIC CONSIDERATIONS
•

15. Pt. admitted over 7 years
(jan2012-dec.2018)
•2076 patients

16. 1640
adult
79%
435
pediatric
21%
2076 patient over 7 years
Every three hours one child dies from a burn
related accident
@ World Health Organization /Int J Burn Trauma 2018;8(1):6-16

17. 21%
Death
Suicides
Expected =
(435)
5%
(103)Death
un expected 2076
Total
No.
pt.
Discharged
Healthy
(1538)
74%
Number of patients over 6 years
538 dead
at hospital
Pt. admitted over 7 years (jan2012-dec.2018)

18. Dead patients
Sales
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
103=19%
Un expected
death,
Total death
over 7 year
538
patients
435 =81%
Expected death
Palliatve
care

19. Do-Not-Resuscitate Orders
• Two kinds of medical futility are often
distinguished:
• 1. Quantitative futility, where the likelihood
benefit of interventions to the patient is
exceedingly poor, (frequent dressing )
• 2. Qualitative futility, where the quality of benefit
an intervention will produce is exceedingly poor;
(isolation and surgical operations )

20. A ‘do not
resuscitate’ (DNR)
order is not
the equivalent of a
‘do not care’ (DNC)
consideration.

21. 95% OF THEM
SUICIDAL
ATTEPMPT
95 % BSAB
30 Yr
17 inh inj
Baux= 142 %
probability of death

22. Very limited CHANCES TO SAVE patient
attempted suicide by fire

23. “It is futile to continue to treat this patient,”
• Futility does not apply to treatments globally, to a
patient, or to a general medical situation. Instead,
• It refers to a particular intervention at a
particular time, for a specific patient.
80 % BSAB
27 YEARS
17 INH.INJURY+
Baux =124

24. But
sometime
can save
those with
specific
injury
specific
age 95%
BSAB
partial
thickness
95% BSAB
17 Yr
17 inh inj
Baux =129 probability of
death

26. How to decide
Many
prognostic
scoring systems
are available for
burn
patients.

27. Lunanaut
scoring system
• Mortality
• was seen in 94%
patients with
score >200.

28. Jabalpur prognostic scoring system
Cut off value of score ≥12 was associated
with significantly higher mortality

29. General prognostic indicators
• Clinical
indicators
• Baux 1949
• ABSI Tobiasen 1982
• many others
• Specific prognostic
indicators
• Creatin kinase CK Electrical injury
• C Reactive Protien SIR
• Procalcitonin SIR
• TNF @ was suppressed in nonsurvivors. SIR
• Interleukin 8 & 10 SIR
• S. Lactate global tissue hypoxia >4 Met.Acidosis
• Erythroblast HYPOXIA
• Platelet count Reduction associated with sepsis & bad
prognosis .

30. The Baux Score continues to provide a
simple logical Ratio of the
Risk of mortality & Survival after
major burn injury
AGE + BSAB% (+/0 ) Inh inj 17
It is increasingly common, and it can
be give decisions by nonspecialist
about initial triage , management
planning .

31. But futility of care should be
made after consultation with a
specialist burn service.

32. 30 % BSAB
40 Yr
17 inh inj
Baux= 87 %
probability of death

33. 35 % BSAB
30 Yr
17 inh inj
Baux= 82 %
probability of death

34. 25 % BSAB
40 Yr
17 inh inj
Baux= 82 %
probability of death

35. 35 % BSAB
20 Yr
17 inh inj
Baux= 72 %
probability of death

36. 20 % BSAB
30 Yr
17 inh inj
Baux= 67 %
probability of death

37. 23 % BSAB
30 Yr
17 inh inj
Baux= 60%
probability of death

38. 23 % BSAB
24 Yr
17 inh inj
Baux= 64 % probability
of death

40. First step Evaluation

42. Burns can be categorized into the following three main
types:
• 1• Those that can be treated with minimal efforts
• (e.g., by clean dressings and available analgesics).
• 2• Those that are not survivable without specialized
• care. Special care must be established, and success will
depend on the degree of medical care given .
Patients must be transported to facilities where
successful treatment can be performed and is funded..
• 3• Those that cannot be treated successfully even in a
specialized care centre .
• So those patients are deemed futile , and ‘comfort
care’ must be provided.

43. • End-of-life care
• should be a mutual and agreeable
choice by the patient/surrogate,
with the understanding by the
healthcare team that treatment
has become futile.

44. Palliative care
end-of-life care
• patients for whom survival is highly
unlikely.
• DIRECTED FOR

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