Management of the Patient with Thermal Injuries

2016 ◽  
Author(s):  
Michael J. Mosier ◽  
Nicole S. Gibran
Keyword(s):  
Carbon Monoxide ◽  
Carbon Monoxide Poisoning ◽  
Fluid Management ◽  
Clinical Manifestations ◽  
Injured Patient ◽  
Inhalation Injury ◽  
Burn Patients ◽  
Burn Care ◽  
Burn Resuscitation ◽  
Burn Patient

Optimal care of the burn patient requires not only specialized equipment but also, more importantly, a team of dedicated surgeons, nurses, therapists, nutritionists, pharmacists, social workers, psychologists, and operating room staff. Burn care was one of the first specialties to adopt a multidisciplinary approach, and over the past 30 years, burn centers have decreased burn mortality by coordinating prehospital patient management, resuscitation methods, and surgical and critical care of patients with major burns. This review covers where to treat burn patients, fluid management, airway management, temperature regulation, airway control, nutrition, anemia, pain management, deep vein thrombosis prophylaxis, and putting it all together: an algorithmic approach to early care of the burn-injured patient. Figures show that the size of a burn can be estimated by means of the Rule of Nines, which assigns percentages of total body surface to the head, the extremities, and the front and back of the torso, the approach to the burn patient in the first 24 hours, and the approach to the burn patient during the second to fifth days after burn injury. Tables list American Burn Association criteria for burn injuries that warrant referral to a burn unit, criteria for outpatient management of burn patients, acute physiologic changes during burn resuscitation, acute biochemical and hematologic changes during burn resuscitation, measures of pulmonary function, mechanisms of pulmonary dysfunction and indications for mechanical ventilation, clinical manifestations of carbon monoxide poisoning, half-life of carbon monoxide–hemoglobin bonds with inhalation therapy, increased acute kidney injury in patients treated with hydroxocobalamin for suspected inhalation injury, clinical findings associated with specific inhaled products of combustion, bronchoscopic criteria used to grade inhalation injury, and formulas for estimating caloric needs in burn patients. This review contains 3 highly rendered figures, 12 tables, and 134 references

Management of the Patient with Thermal Injuries

2016 ◽  
Author(s):  
Michael J. Mosier ◽  
Nicole S. Gibran
Keyword(s):  
Carbon Monoxide ◽  
Carbon Monoxide Poisoning ◽  
Fluid Management ◽  
Clinical Manifestations ◽  
Injured Patient ◽  
Inhalation Injury ◽  
Burn Patients ◽  
Burn Care ◽  
Burn Resuscitation ◽  
Burn Patient

Optimal care of the burn patient requires not only specialized equipment but also, more importantly, a team of dedicated surgeons, nurses, therapists, nutritionists, pharmacists, social workers, psychologists, and operating room staff. Burn care was one of the first specialties to adopt a multidisciplinary approach, and over the past 30 years, burn centers have decreased burn mortality by coordinating prehospital patient management, resuscitation methods, and surgical and critical care of patients with major burns. This review covers where to treat burn patients, fluid management, airway management, temperature regulation, airway control, nutrition, anemia, pain management, deep vein thrombosis prophylaxis, and putting it all together: an algorithmic approach to early care of the burn-injured patient. Figures show that the size of a burn can be estimated by means of the Rule of Nines, which assigns percentages of total body surface to the head, the extremities, and the front and back of the torso, the approach to the burn patient in the first 24 hours, and the approach to the burn patient during the second to fifth days after burn injury. Tables list American Burn Association criteria for burn injuries that warrant referral to a burn unit, criteria for outpatient management of burn patients, acute physiologic changes during burn resuscitation, acute biochemical and hematologic changes during burn resuscitation, measures of pulmonary function, mechanisms of pulmonary dysfunction and indications for mechanical ventilation, clinical manifestations of carbon monoxide poisoning, half-life of carbon monoxide–hemoglobin bonds with inhalation therapy, increased acute kidney injury in patients treated with hydroxocobalamin for suspected inhalation injury, clinical findings associated with specific inhaled products of combustion, bronchoscopic criteria used to grade inhalation injury, and formulas for estimating caloric needs in burn patients. This review contains 3 highly rendered figures, 12 tables, and 134 references

scholarly journals A History of Fluid Management—From “One Size Fits All” to an Individualized Fluid Therapy in Burn Resuscitation

Medicina ◽  
2021 ◽  
Vol 57 (2) ◽  
pp. 187
Author(s):  
Dorothee Boehm ◽  
Henrik Menke
Keyword(s):  
Fluid Therapy ◽  
Point Of Care ◽  
Fluid Management ◽  
Point Of Care Ultrasound ◽  
Burn Patients ◽  
Starting Point ◽  
History Of ◽  
Definition Of ◽  
Historical Developments ◽  
Burn Resuscitation

Fluid management is a cornerstone in the treatment of burns and, thus, many different formulas were tested for their ability to match the fluid requirements for an adequate resuscitation. Thereof, the Parkland-Baxter formula, first introduced in 1968, is still widely used since then. Though using nearly the same formula to start off, the definition of normovolemia and how to determine the volume status of burn patients has changed dramatically over years. In first instance, the invention of the transpulmonary thermodilution (TTD) enabled an early goal directed fluid therapy with acceptable invasiveness. Furthermore, the introduction of point of care ultrasound (POCUS) has triggered more individualized schemes of fluid therapy. This article explores the historical developments in the field of burn resuscitation, presenting different options to determine the fluid requirements without missing the red flags for hyper- or hypovolemia. Furthermore, the increasing rate of co-morbidities in burn patients calls for a more sophisticated fluid management adjusting the fluid therapy to the actual necessities very closely. Therefore, formulas might be used as a starting point, but further fluid therapy should be adjusted to the actual need of every single patient. Taking the developments in the field of individualized therapies in intensive care in general into account, fluid management in burn resuscitation will also be individualized in the near future.

scholarly journals Acute respiratory distress syndrome caused by carbon monoxide poisoning and inhalation injury recovered after extracorporeal membrane oxygenation along with direct hemoperfusion with polymyxin B-immobilized fiber column: a case report

2021 ◽  
Vol 15 (1) ◽  
Author(s):  
Ji Hoon Jang ◽  
Hang Jea Jang ◽  
Hyun-Kuk Kim ◽  
Jin Han Park ◽  
Hyo-Jung Kim ◽  
...  
Keyword(s):  
Carbon Monoxide ◽  
Acute Respiratory Distress Syndrome ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Distress Syndrome ◽  
Carbon Monoxide Poisoning ◽  
Polymyxin B ◽  
Inhalation Injury ◽  
Cytokine Storm ◽  
Direct Hemoperfusion

Abstract Background Inhalation injury from smoke or chemical products and carbon monoxide poisoning are major causes of death in burn patients from fire accidents. Respiratory tract injuries from inhalation injury and carbon monoxide poisoning can lead to acute respiratory distress syndrome and cytokine storm syndrome. In the case of acute respiratory failure needing mechanical ventilation accompanied by cytokine storm, mortality is high and immediate adequate treatment at the emergency department is very important. Case presentation This report describes a case of acute respiratory distress syndrome and cytokine storm followed by carbon monoxide poisoning in a 34-year-old Korean male patient who was in a house fire, and was successfully treated by extracorporeal membrane oxygenation and direct hemoperfusion with polymyxin B-immobilized fiber column at emergency department. Conclusions To prevent mortality in acute respiratory distress syndrome with cytokine storm from inhalation injury and to promote a better prognosis, we suggest that early implication of extracorporeal membranous oxygenation along with direct hemoperfusion with polymyxin B-immobilized fiber column even at the emergency department should be considered.

scholarly journals Nebulized Heparin in Burn Patients with Inhalation Trauma—Safety and Feasibility

2020 ◽  
Vol 9 (4) ◽  
pp. 894 ◽  
Author(s):  
Gerie J. Glas ◽  
Janneke Horn ◽  
Jan M. Binnekade ◽  
Markus W. Hollmann ◽  
Jan Muller ◽  
...  
Keyword(s):  
Primary Outcome ◽  
Inhalation Injury ◽  
Current Data ◽  
Burn Patients ◽  
Heparin Group ◽  
Double Blind ◽  
Respiratory Problems ◽  
Burn Care ◽  
Secondary Outcomes ◽  
International Multicenter

Background: Pulmonary hypercoagulopathy is intrinsic to inhalation trauma. Nebulized heparin could theoretically be beneficial in patients with inhalation injury, but current data are conflicting. We aimed to investigate the safety, feasibility, and effectiveness of nebulized heparin. Methods: International multicenter, double-blind, placebo-controlled randomized clinical trial in specialized burn care centers. Adult patients with inhalation trauma received nebulizations of unfractionated heparin (25,000 international unit (IU), 5 mL) or placebo (0.9% NaCl, 5 mL) every four hours for 14 days or until extubation. The primary outcome was the number of ventilator-free days at day 28 post-admission. Here, we report on the secondary outcomes related to safety and feasibility. Results: The study was prematurely stopped after inclusion of 13 patients (heparin N = 7, placebo N = 6) due to low recruitment and high costs associated with the trial medication. Therefore, no analyses on effectiveness were performed. In the heparin group, serious respiratory problems occurred due to saturation of the expiratory filter following nebulizations. In total, 129 out of 427 scheduled nebulizations were withheld in the heparin group (in 3 patients) and 45 out of 299 scheduled nebulizations were withheld in the placebo group (in 2 patients). Blood-stained sputum or expected increased bleeding risks were the most frequent reasons to withhold nebulizations. Conclusion: In this prematurely stopped trial, we encountered important safety and feasibility issues related to frequent heparin nebulizations in burn patients with inhalation trauma. This should be taken into account when heparin nebulizations are considered in these patients.

Obesity Paradox in the Burn Patient

2020 ◽  
Vol 41 (1) ◽  
pp. 30-32
Author(s):  
Erica L W Lester ◽  
Justin E Dvorak ◽  
Patrick J Maluso ◽  
Samy Bendjemil ◽  
Thomas Messer ◽  
...  
Keyword(s):  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
Obesity Paradox ◽  
Class I ◽  
Burn Patients ◽  
Obesity Class ◽  
Burn Care ◽  
Significant Difference ◽  
Underweight Patients ◽  
Burn Patient

Abstract Despite the fact that obesity is a known risk factor for comorbidities and complications, there is evidence suggesting a survival advantage for patients classified by body mass index (BMI) as overweight or obese. Investigated in various clinical areas, this “Obesity Paradox” has yet to be explored in the burn patient population. We sought to clarify whether this paradigm exists in burn patients. Data collected on 519 adult patients admitted to an American Burn Association Verified Burn Center between 2009 and 2017 was utilized. Univariable and multivariable logistic regression were used to determine the association between in-hospital mortality and BMI classifications (underweight <18.5 kg/m2, normal 18.5 to 24.9 kg/m2, overweight 25–29.9 kg/m2, obesity class I 30 to 34.9 kg/m2, obesity class II 35 to 39.9 kg/m2, and extreme obesity >40 kg/m2). For every kg/m2 increase in BMI, the odds of death decreased, with an adjusted odds ratio of 0.856 (95% confidence interval [CI] 0.767 to 0.956). When adjusted for total BSA (TBSA), being obesity class I was associated with an adjusted odds ratio of mortality of 0.0166 (95% CI 0.000332 to 0.833). The adjusted odds ratio for mortality for underweight patients was 4.13 (95% CI 0.416 to 41.055). There was no statistically significant difference in odds of mortality between the normal and overweight BMI categories. In conclusion, the obesity paradox exists in burn care: further investigation is needed to elucidate what specific phenotypic aspects confer this benefit and how these can enhance the care of burn patients.

Burns

2019 ◽  
Author(s):  
Edward A. Bittner ◽  
Connie W. Chaudhary
Keyword(s):  
Pain Management ◽  
Burn Injury ◽  
Anesthetic Management ◽  
Injured Patient ◽  
Inhalation Injury ◽  
The Body ◽  
Temperature Management ◽  
Burn Patients ◽  
Optimal Care ◽  
Injured Patients

Anesthetic management of burn-injured patients can be particularly challenging. Burn-injured patients exhibit pathophysiologic changes that can affect nearly all the organs in the body. Challenges the anesthesiologist may encounter when caring for burn patients include difficult airway management, impaired lung function, vascular access issues, hypothermia, pharmacokinetic and pharmacodynamic alterations, and pain management. Other important considerations that could affect the condition of burn patients include blood loss, hypermetabolism, pain control, and temperature management.  Anticipating appropriate precautions can change the clinical outcome of these patients.  Optimal care requires a full understanding of the unique preoperative, intraoperative, and postoperative issues of the burn-injured patient. This review contains 2 figures, 3 tables, and 77 references. Key Words: anesthetic management of acute burns, burn injury, electrical injury, fluid resuscitation, inhalation injury, Parkland formula, pain management

519 The Routine Addition of Maintenance IV Fluid is Not Warranted during all Pediatric Burn Resuscitation: A Retrospective Study

2021 ◽  
Vol 42 (Supplement_1) ◽  
pp. S106-S107
Author(s):  
Prabhu Senthil-Kumar ◽  
Madeline Zieger ◽  
Brett C Hartman
Keyword(s):  
Oral Intake ◽  
Inhalation Injury ◽  
Smoke Inhalation ◽  
Wound Complications ◽  
Burn Patients ◽  
Smoke Inhalation Injury ◽  
Resuscitation Fluid ◽  
Pediatric Burns ◽  
Age Range ◽  
Burn Resuscitation

Abstract Introduction Pediatric burn resuscitation has improved dramatically over the years with improved survival and outcomes. Recent studies have shown the amount of fluid given (ml/kg/%TBSA) has direct correlation to the outcomes. Over resuscitation (fluid creep) results in multiple systemic and wound complications. We hypothesize the addition of maintenance IV fluid with Parkland resuscitation fluid in younger pediatric burns (< 30kg) may not be needed to achieve adequate end points of resuscitation. Methods We performed a retrospective chart analysis of our pediatric burn patients at our institution by categorizing younger patients (< 30kg) into two groups: The maintenance IV fluid (MF) group and the resuscitation fluid (RF) only group. We identified 18 patients that met the criteria with 9 patients in each group. All of the patients in both groups were under 30kg, age range 2-8yrs, and TBSA: 16–50 %. We included 3 patients under 20% TBSA that were resuscitated due to full thickness burns and smoke inhalation injury. We analyzed their hourly and 24-hour fluid administration including all oral intake and tube feeds as well as their hourly vitals, urine output, and laboratory values during the resuscitation. Results We found that the RF group received 1.311+/- 1.295 cc/kg cc less fluid compared to the MF group without any hypoglycemic events or deleterious hemodynamic effects. The patients who had good oral intake or received tube feeds during resuscitation resulted in significantly less resuscitation volume than the estimated resuscitation volume in both groups. Conclusions We conclude that resuscitation can be safely done in pediatric burn patients under 30 kg without adding routine maintenance IV fluid. Early oral and enteral feeding is very critical in all burn patients. The volume that was administered enterally should also be considered in hourly fluid titration rates to reduce the resuscitation fluids given thereby preventing fluid creep and ensuing deleterious complications.

Inhalation Injury Does Not Influence the Amount of Blood Transfused to Major Burn Patients: A Secondary Analysis from the Transfusion Requirement in Burn Care Evaluation Study

2019 ◽  
Vol 40 (6) ◽  
pp. 757-762
Author(s):  
Robert Cartotto ◽  
Sandra L Taylor ◽  
James H Holmes ◽  
Brett Arnoldo ◽  
Michael Peck ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Blood Transfusion ◽  
Transfusion Requirement ◽  
Secondary Analysis ◽  
Inhalation Injury ◽  
Burn Patients ◽  
Burn Care ◽  
Major Burn ◽  
Multivariable Regression ◽  
Care Evaluation

Abstract Patients with major burn injuries typically require numerous blood transfusions. It is not known if an inhalation injury (INHI) directly influences the need for blood transfusion. The purpose of this study was to determine whether INHI increases the amount of blood transfused to major burn patients. A secondary analysis from the Transfusion Requirement in Burn Care Evaluation (TRIBE) study was conducted. Patients with INHI were compared with patients without INHI. The number of red blood cell (RBC) transfusions per day (RBC per day) between INHI and No INHI was analyzed with a multivariable regression. Patients with INHI (n = 78) had significantly larger burns (P = .0004), larger full-thickness burns (P = .0007), greater admission APACHE score (P < .0001), higher admission multiple organ dysfunction scores (P < .0001), and were transfused more RBC per day (P = .009) than No INHI patients (n = 267). In the multivariable regression analysis, RBC per day was significantly associated with the %TBSA burn (P < .0001), age of the patient (P = .004), the need for more than 1 day of mechanical ventilation (P < .0001), the occurrence of at least one blood stream infection (BSI; P = .044), and being assigned to the liberal transfusion arm of TRIBE (P < .001) but not the presence of INHI (P = .056). The null hypothesis that INHI exerts no influence on the amount of blood transfused could not be rejected. Larger burn size, advanced patient age, mechanical ventilation, and BSIs are important determinants of the blood transfusion rate in major burn patients.

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