The initial resuscitation of the burn patient in icu

The initial resuscitation of the Burn Patient in icu

DR GHALEB ALMEKHLAFI CONSULTANT MEDICINE AND CRITICAL CAREPSMMC AUG 2014

Introductionover the last half century have resulted in; improved survival rates shorter hospital stays decreases in morbidity and mortality rates Factors development of resuscitation protocols, improved respiratory support support of the hypermetabolic response, infection control early burn wound closure early enteral nutrition.

MANAGEMENT

IMMEDIATE CARE

• STOP THE BURNING PROCESS

• ABC

• COOL THE BURN WOUND

• WASH THE WOUND

• COVER WITH BLANKET

• CHECK FOR OTHER INJURIES

1-PRE-HOSPITAL CARE

2-HOSPITAL CARE

A AIRWAYB BREATHING AND VENTILATIONC CIRCULATIOND DISABILITY_ NEUROLOGICAL STATUS

E EXPOSURE WITH ENVIRONMENTAL CONTROL

F FLUID RESUSCITATION

A-AIRWAY Early intubation

Emergency cricothyroidotomy

Thracheostomy

B-BREATHING AND VENTILATIONMECHANICAL BLOCK TO BREATHING - Eschar - Escharotomy

INHALATIONAL INJURY - Soot in nose and oropharynx - Warm humified 100% oxygen CO POISONING - Carboxy haemoglobin level > 10% - ABGs - Oxygen

Inhalation Injury• marked increase in mortality and morbidity.• associated with a 44% increase in fluid requirements• Acute upper airway obstruction occurs in 20% to 33% of burn

patients with inhalation injury• Patients presenting with stridor should be intubated on

presentation• Even the gold standard of bronchoscope within the first 24 hrs

of admission cannot accurately predict the severity of inhalation injury

• 70% of patients with inhalation injury will develop ventilator-associated pneumonia-VAP prevention

Darling GE, Keresteci MA, Ibañez D, et al: Pulmonary complications in inhalation injuries with associated cutaneous burn. J Trauma 1996; 40:83–89

CIRCULATION

MAINTAIN AN I/V LINE - Two wide bore cannula peripherally - One in the centre

ESCHAROTOMY circumferential burns of - extremities

ASSESSMENT OF THE BURN WOUND

ASSESSING THE SIZE AND SITE Lund and browder chart Rule of nine Palm sizeASSESSING DEPTH Superficial burns

Partial thickness burns

Full thickness burn

CRITERIA FOR ADMISSION

• 15% Partial or full thickness burn in adults and 10% in Extremes of ages

• Suspected airway or inhalational injury• Significant burns of hands, face, feet or perineum• Chemical burns• High tension Electric burns• Major associated life threatening injuries

Vascular Access/Other Tubes and Catheters

• Ideally, obtain peripheral intravenous access away from burned tissues.

• intraosseous catheters may safely be placed in patients of any age.

• Foley catheter .u/o is imp. for mgt• NGT should be considered in patients with >

20% TBSA burns, as they will experience Gastroparesis and probable emesis.

First-line Monitoring

URINE OUTPUT AND HEART RATE - the primary modalities for monitoring, - not supported by data. URINE OUTPUTThe American Burn Association Practice Guidelines for Burn Shock

Resuscitation recommend - 0.5 mL/kg/hr urine output in adults - 0.5–1.0 mL/kg/hr in children weighing < 30 kg HEART RATE:• < 110 beats/min in adults usually indicates adequate volume• rates > 120 beats/min usually indicative of hypovolemia. • Narrowed PP is an earlier indication of shock than SBP alone

invasive monitoring

• Noninvasive BP measurements by cuff are inaccurate

• An arterial catheter placed in the radial artery is the first choice, followed by the femoral artery

• Less invasive cardiac output monitoring and EVLW are useful

• PAC/CVP not recommended

RESUSCITATIONFLUID

Resuscitation• one of the cornerstones of modern burn care• The intervention most directly improves patient

survival.• hypovolemia/shock will develop if the burns involve

> 15% to 20% total body surface area (TBSA)• The obvious challenge is to

provide optimal fluid replacement to maintain perfusion without causing fluid overload.

excessive resuscitation

as deleterious as those of under-resuscitation:

pulmonary edemamyocardial edemaconversion of superficial into deep burnsPredispose to limbs, and abdominal

compartment syndrome

Resuscitation Formulas

• Formulas :none is optimal • fluid administration has to be individualized• Factors that influence fluid requirements besides TBSA

burn include:o burn depth o inhalation injury o associated injuries o age.• delay in resuscitation, need for escharotomies /

fasciotomies

Parkland formula for burns resuscitation

Total fluid requirement in 24 hours =4 ml×(total burn surface area (%))×(body weight (kg))

• 50% given in first 8 hours• 50% given in next 16 hoursChildren receive maintenance fluid in addition, at hourly rate of• 4 ml/kg for first 10 kg of body weight plus• 2 ml/kg for second 10 kg of body weight plus• 1 ml/kg for > 20 kg of body weightEnd point• Urine output of 0.5-1.0 ml/kg/hour in adults• Urine output of 1.0-1.5 ml/kg/hour in children

Resuscitation fluid

• LR solution most closely match NL body fluids. • There has not been a clinical advantage with colloids.• comparing albumin to crystalloid showed 2.4-fold increased risk of death with albumin.• Hypertonic saline: 4-fold increase in renal failure and twice the mortality of patients given LR solution• Fresh frozen plasma should not be used as a volume

expander American Burn Association Practice Guidelines for Burn Shock Resuscitation

Permissive hypovolemia

• The most recent iteration of this concept is the ‘Rule of 10’ developed at Fort Sam Houston (Texas, USA). The authors propose a three-step approach:

• the 1st step is to estimate burn size to the nearest 10% TBSA,

• 2nd step is to multiply this number by ten to derive the initial fluid rate in mL/hr (for every 10 kg body weight over 80 kg add 10 mL/h to this rate), and

• 3rd is to adapt the fluid rate to the signs of organ underperfusion.

resuscitation protocols

•there are many resuscitation protocols

vitals

Urine output over one hour

Fluid adjustment

Urine output over one hour/targets

Further management

University of Utah protocol

J Burn Care Res 2007; 28:382–392

A protocol for resuscitation of severe burn patients guided by transpulmonary thermodilution and lactate levels

A decision tree for the adjustment of fluid and catecholamine therapy according to a permissive hypovolemia protocol with lower preload targets and lactate measurements to ensure tissue perfusion is shown

Sánchez et al. Critical Care 2013, 17:R176

Vitamin C Resuscitation

The landmark study by Tanaka et al showed that high dose ascorbic acid 66mg/kg/hr during the initial24 hrs post burn reduced

fluid requirements by 40%, reduced burn tissue water content 50%, and reduced ventilator days.

Tanaka H, Matsuda T, Miyagantani Y, et al: Reduction of resuscitation fluid volumes in severely burned patients using ascorbic acid administration. Arch Surg 2000; 135:326–331Dubick MA, Williams C, Elgjo GI, et al: High-dose vitamin c infusion reduces fluid requirements in the resuscitation of burn-injured sheep. Shock 2005; 24:139–144

Hypothermia

• Metabolic responses can be minimized by treating the patient in a thermo-neutral environment (32°C).

• During hydrotherapy, in the operating room, and in the burn unit, keep the room temperature at ≥30°C to minimize heat loss and decrease metabolic rate.

Judkins K: Current consensus and controversies in major burns management. Trauma 2000; 2:239–251

Compartment Syndromes• Abdominal compartment syndrome (ACS) is a life-threatening complication

caused by high-volume resuscitation Curr Opin Anaesthesiol 2001; 14:431–435] • ACS is defined as IAP ≥20 mm Hg plus at least one new organ dysfunction.

Intensive Care Med 2006; 32:1722–1732• Simply monitoring urine output is insufficiently sensitive or specific to diagnose

ACS.• Bladder pressure monitoring should be initiated in every patient with >30%

TBSA burn.• Patients who receive > 250 mL/kg of crystalloid in the first 24 hrs will likely

require abdominal decompression. Ann Surg 2007; 245:622–628• Percutaneous abdominal decompression is a minimally invasive procedure that

should be performed before resorting to laparotomy. J Burn Care Res 2007; 28:708–714

• The reported mortality rates for decompressive laparotomy for ACS can be as high as 88%[71] to 100%. J Burn Care Rehabil2002; 23:190–195

Infection/Inflammation/Sepsis• patients with large burns are in a state of chronic systemic

inflammatory stimulation(SIRS) for months.Clues to infection include : increased fluid requirements, decreasing platelet counts > 3 days after burn injury, altered mental status, worsening pulmonary status, and impaired renal function.• Any infection in a burn patient should be considered to be from

the central venous catheter until proven otherwise. Change to a new site every 3 days to minimize bloodstream infections.

• topical antimicrobial therapy is efficacious

Enteral Nutrition• Burn causes hypermetabolism, • enteral nutrition should be started as soon as

resuscitation is underway• Patients with burns > 20% TBSA will be unable to

meet their nutritional needs with oral intake alone. • Early feeding enhanced wound healing and shorter

hospital stays.• PN should be used only if the GI tract is not

functioning.

Anabolic Steroids

• Severe burn injuries induce a hypermetabolic response, which leads to catabolism.

• Anabolic steroids such as oxandrolone promoteprotein synthesisnitrogen retention skeletal muscle growthwound healing . • Burn patients receiving oxandrolone regain weight and

lean mass two to three times faster than with nutrition alone.Demling RH, Desanti L: Oxandrolone induced lean mass gain during recovery from severe burns is

maintained bafter discontinuation of the anabolic steroid. Burns 2003; 29:793–797

β-Blockade• β-blockers after severe burns decrease heart rate, resulting in reduced cardiac index supraphysiologic thermogenesis.• In children, treatment with propranolol attenuates

hypermetabolism and reverses muscle-protein catabolism.

• Propranolol is given to achieve a 20% decrease in heart rate of each patient compared with the 24-hr average heart rate immediately before administration.

Pain Management• intravenous opioids should be administered.• Background pain is best managed with long-acting

analgesic agents.• Breakthrough pain is addressed with short-acting agents• Ketamine can be used for extensive burn dressing

changes and procedures such as escharotomies. • Anxiolytics such as benzodiazepines decrease

background and procedural pain.• For patients requiring mechanical ventilation, a Propofol

infusion will provide sedation but not analgesia..

Wound Management• The primary goal is to close the wound as soon as possible, beginning

at the time of injury. • daily, hydrotherapy is routine, involving washing the entire patient

with chlorohexidine and warm tap water. • The practice of immersion has fallen out of favor. • Once the wound is clean, use topical antimicrobial agents, Silver

sulfadiazine is the most commonly used • Silver containing sheets and compounds that may be placed on partial

thickness burns and remain in place for up to 7 days• patients with full-thickness burns, prompt surgical excision of the

eschar and allografting in patients with large burns, or auto grafting in patients with smaller burns, contributes to reduced morbidity and mortality.

GUIDELINES• This guideline provides a template

for the initial resuscitation of patients with acute major burn injury encompassing 10% total body surface area (TBSA) or more.

Guidelines Acute Burn Resuscitation 2013,Department of Surgical Education, Orlando Regional Medical Center Approved 12/04/2013

GUIDELINES-LEVEL OF RECOMMENDATION DEFINITIONS

• Level 1: Convincingly justifiable based on available scientific

information alone.

• Level 2: Reasonably justifiable based on available scientific evidence

and strongly supported by expert opinion.

• Level 3: Supported by available data, but scientific evidence is lacking.

GUIDELINES

RECOMMENDATIONS

• Level 1 None

GUIDELINES

RECOMMENDATIONS----Level 21. Estimate initial fluid requirements with the Parkland

formula (4 mL/kg/% TBSA burned).2. Give ½ of the fluid volume calculated over the first 8

hours from the time of the burn3. Give the remaining half of the fluid volume over the

next 16 hours4. For ≥ 30% TBSA burns, Vitamin C infusion should be

considered..5. Avoid the use of hypertonic saline.

GUIDELINES

RECOMMENDATIONS-----Level 3

1-Avoid oversedation. Consider non-narcotic analgesia such as ketorolac, ibuprofen, or Ketamine.

2-In patients with burns ≥ 20% TBSA:• Insert a central venous catheter, • Insert a urinary (Foley) catheter, • Monitor intra-abdominal (bladder) pressure q 4 hours

during the initial resuscitation, • Consider invasive hemodynamic monitoring to guide

resuscitation

GUIDELINES• RECOMMENDATIONS-----Level 3

3-Resuscitation endpoints in the first 24 hours post-burn injury:

Monitor arterial lactate q 4 hours until < 2 mMol/L, Maintain urine output at 30-50 ml/hr (50-100 ml/hr if

receiving Vitamin C) In electrical injury or rhabdomyolysis patients, serial

creatinine kinase levels should be, checked daily until < 2500 mcg/L, Monitor hemoglobin to ensure that it is not trending upward

GUIDELINES

• RECOMMENDATIONS-----Level 3• If the patient requires ≥ 1.5 times the calculated Parkland

formula volume (6 ml/kg/TBSA), consider colloid rescue: 5% albumin at 1/3 Parkland rate + 2/3 Parkland rate of Lactated Ringers OR,25% albumin at 1/15th the Parkland rate + 2/3 Parkland rate of Lactated Ringers,

• Fresh frozen plasma may be used as an efficacious alternative to albumin for colloid rescue

• If the patient has received > 250 mL/kg of fluid resuscitation, intraocular pressure should be measured.

questions?