Holley on Burns
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Anthony Holley's fantastic presentation on burns injuries that he gave at the Bedside Critical Care Conference 2012. Go to www.IntensiveCareNetwork.com for the unmissable talk.
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Holley on Burns
- 1. Burns Anthony Holley Intensivist RBWH Bedside Critical Care 2012
- 2. Acknowledgement Prof. Jeff Lipman Bedside Critical Care 2012
- 3. Large tertiary ICU Only burns referral centre 40 months n = 158 Bedside Critical Care 2012
- 4. Patient % Bu 10 15 20 25 30 35 40 0 5 rn :0 -9 Bu % rn :1 0- 19 % Bu rn :2 0- 29 Bu rn :3 0- 39 Bu rn :4 0- 49 Bu rn :5 Bedside Critical Care 2012 0- 59 Bu rn Burn % :6 0- n =158 69 Bu rn :7 0- 79 Body Surface Area Burn Distribution Bu rn :8 0- 89 Bu rn :9 Bu 0- rn 10 of 0 o ro ph ar ynx
- 5. Mortality 8.22% mortality But …….0.68% in those with intention “to cure” Bedside Critical Care 2012
- 6. Wallace’s Rule of Nine Bedside Critical Care 2012
- 8. First 24 HOURS A Airway assessment B Burn assessment C Circulation assessment Bedside Critical Care 2012
- 9. AIRWAY 60% of flame facial burns will have inhalational injury Bedside Critical Care 2012
- 10. Early Bronchoscopy Nebulised heparin for inhalation injury and to ??prevent VAP Bedside Critical Care 2012
- 11. Alveolar Ridge/Maxillary Screws for ETT Fixation Bedside Critical Care 2012
- 12. •Resuscitation •Assessment •Heated rooms •Theatre Bedside Critical Care 2012
- 13. Adult Burn Resuscitation Formulae (first 24 h) Formula Crystalloid Colloid Other Evans (1952) 1 ml/kg/%burn(N/S) 1 ml/kg/%burn 2000ml D5W Brooke (1953) 1.5ml/kg/%burn(LR) 0.5 ml/kg/%burn 2000ml D5W Parkland (1968) 4 ml/kg/%burn(LR) — — Modified Brooke (’71) 2 ml/kg/%burn(LR) — — Hypertonic saline1 250 mEq Na/L — Titrate to UO Modified hypertonic2 180 mEq Na/L — Titrate to UO (first 8 h) then LR Dextran3 LR (titrate to UO) 2 ml/kg/h 0.5 ml/kg/h (first 8 h) then… FFP 1Monafo (1970) 2Warden (1992) 3Demling (1985) Bedside Critical Care 2012
- 14. FORMULAE Formulas should be regarded as a resuscitation guideline Lactated Ringer’s (Hartmans) solution most closely resembles normal body fluids, note NaCl -> hyperchloraemia The Parkland formula - renamed the Consensus formula - because it is the most widely used guideline 4 mL/kg/% TBSA ½ in first 8 hrs rest over the next 16 hrs Bedside Critical Care 2012
- 15. RESUSCITATION Hypovolaemic State: 0-48 hours Rapid fluid shifts Metabolic acidosis Intense inflammatory response Protein loss Capillary permeability Oliguria 3rd spacing Haemoconcentration Fluid loss deep in wounds Hyponatraemia circulating blood Hyperkalaemia volume Bedside Critical Care 2012
- 16. Consequences of fluid overload Airway oedema Compartment syndromes Bedside Critical Care 2012
- 17. Dulhunty et al Burns 2008;34:1090-7 Bedside Critical Care 2012
- 18. ESCHAROTOMIES Bedside Critical Care 2012
- 19. ESCHAROTOMIES How not to do it! Bedside Critical Care 2012
- 20. THE THREE MOST IMPORTANT ISSUES IN BURNS CARE 1. Debridement and get early coverage 2. Debridement and get early coverage 3. Debridement and get early coverage Bedside Critical Care 2012
- 21. Coverage Xenograft (Pig skin) Allograft (cadarver skin) Biosynthetics and Synthetics (biobrane, integra) Cultured epithelial autograft Bedside Critical Care 2012
- 22. Intensive Care Complications Ventilator associated pneumonia TACO/TRALI/ARDS CRBSI Pancreatitis Acalculous cholecystitis Ischaemic enterocolitis Gastritis Cardiomyopathy Bedside Critical Care 2012
- 23. OTHER EARLY MANAGEMENT TIPS 1. Head position to reduce oedema 2. Ears: avoid pressure/chondritis 3. Graft tracheostomy site and central line sites first Bedside Critical Care 2012
- 24. Nose: avoid notching from NG tube Bedside Critical Care 2012
- 25. Eyes: avoid corneal ulceration Bedside Critical Care 2012
- 26. EARLY ENTERAL FEEDING Repeated theatre trips don’t require cessation of feeds. “Do not stop feeds....” unless: a) prone position b) airway manipulation Bedside Critical Care 2012
- 27. RBWH FEEDING PROTOCOL 10-20% FTB/DPT: 125 - 145kJ/kg and 1.2 - 1.5g/kg protein >20% FTB/DPT: 145 - 160kJ/kg and 20% energy as protein Bedside Critical Care 2012
- 28. Principles of Burn Management: Secondary survey The ultimate distracting injury Bedside Critical Care 2012
- 29. The ultimate distracting injury Bedside Critical Care 2012
- 30. RBWH PEARLS 1. Nebulised heparin for inhalation injury and to ??prevent VAP 2. ETT wiring 3. Feeding throughout 4. 1st area grafted is over trachea Bedside Critical Care 2012
- 31. Thank you Thank you Bedside Critical Care 2012