1. Assistant lecturer of Anaesthesia and Intensive Care
Case
Presentation By
Eeman Abou Bakr
Assistant lecturer of Anaesthesia and Intensive Care

2. You have been called to anesthesia and emergency department to provide anesthesia for reduction of a colle’s fracture.
The patients is a 68 years old, heavy smoker and drinker who has been involved in a fire she has burns to her face, chest and arms.

3. Questions What assessment of the patients would you make?
Discuss airway assessment,
The significance of perform SaO2 and other investigations you would perform (COHb).
What are the indications for intubations.
What fluid requirements will patients have ?
What fluid would you give, when you give, and why ?
Discuss analgesia, are burns painful ?
Would you give an anesthetic for the fracture ?
Where should the patient be looked after ?

4. What assessment of the patient would you make?

5. Step 1: Initial Assessment
Assessment of the burn patient follows the standard EMS assessment pattern:
Airway: does the patient have a patent airway?
Breathing: is the patient breathing adequately?
Circulation: Is the patient’s circulatory and cardiac status stable?
Neurological status: AVPU
Note: burns do NOT alter mentation—if the patient is un-alert or disoriented, something else is going on!
Expose the patient, and treat for hypothermia

6. Secondary Survey History: obtain burn specific history
How did the burn occur?
Did the patient’s clothing ignite?
Were accelerants involved?
Was patient found in smoke-filled room?
Did the patient leap from a window, fall, or roll a vehicle?
Are the purported circumstances of the injury consistent with the burn characteristics? Is abuse a possibility?

7. Secondary Survey (Cont’d.)
Head-to-toe: look carefully for injuries other than the actual burn
Start detailed physical examination
Establish an adequate IV access
Burn injuries are not considered immediate life threats, but they do often accompany traumatic injuries that are life threats!

8. Step 2: Determining Burn Severity
Burn severity is determined primarily by assessing the extent of the burn as percentage of total body surface area, and its depth
‘Partial/full thickness’ and ‘1st/2nd/3rd degree’ are acceptable terminology
First and second degree burns are partial thickness burns
Third degree burns are full thickness burns

9. The Rule of Nines

10. Determining Burn Severity (Cont’d)
First degree burns (epidermal burns) are red,
appear DRY, blanch when pressed upon,
and blister mildly.
Second degree (dermal) burns tend to
be red or yellowish, appear WET, usually
blister, and may or may not blanch
Third degree (subcutaneous) burns
appear very DRY, may be yellow, gray or
black, do not blanch, and are ‘leathery’ to touch.

11. Patient is: 68 yrs old. Fire – burns to face, chest and arms.
Colle’s fracture.
Heavy smoker.
Drinker.
First of all trauma patient !!

12. Discuss Airway Assessment

14. This patient at RISK of developing inhalational injury due to
Unable to escape fire due to
Extremes of age
Immobility due to other trauma
Reduction of level of consciousness: alcohol, drugs, effects of smoke.
Lack of functional smoke detector
Chronic pulmonary disorders: asthma, COPD morbidity of smoke inhalation increased.

15. Airway assessment (Cont’d)
History
- Was the fire in an enclosed space.
- Duration of exposure.
-What type of material burned, e.g., paints, chemicals.
- Level of consciousness on scene.

16. Airway assessment (Cont’d)
Burns and smoke inhalation victims should be treated as a “trauma” patient, with trauma protocol being followed as routine. This includes cervical immobilization until injury is excluded.

17. Airway assessment (Cont’d)
Examination
- Stridor: indicates severe laryngeal edema and the possibility of imminent airway obstruction
- Voice hoarseness—an excellent warning sign
- Tachypnea
- Use of accessory muscles
- Persistent cough
- Soot in oropharynx
- Singed nasal hair

18. Carbonaceous particles staining a patient’s face after a burn in an enclosed space. This suggests there is inhalational injury

19. Airway assessment (Cont’d)
Laryngoscopy detect edema to the pharynx or larynx or vocal cords.
Bronchoscopy
Airway edema
Mucosal slouging
Charring or soot

21. Discuss the significance to perform SaO2 and other investigations you would perform as(COHb).

22. Oxygen saturation(SaO2)
SaO2 is inaccurate in the presence of significant carboxyhemoglobin (COHb) or methemoglobinemia.

23. Carbon Monoxide Poisoning
Asphyxiation and/or carbon monoxide poisoning causes most fire scene fatalities
Inhaled carbon monoxide bonds to hemoglobin in the blood, taking the place of oxygen with approximately 200 times greater affinity.
The pulse oximiter, which measures bonded hemoglobin, will deliver a normal reading, even when the patient is hypoxic, or dead

24. Carbon Monoxide Poisoning
Cherry-red lips, skin and nail beds occur in only 50% of patients with severe carbon monoxide poisoning and are not a clinically reliable indicator
If sufficient carbon monoxide is inhaled, tissue perfusion WILL cease, and the patient WILL die
CO2 removal is not affected, so ET capnography does remain an accurate indicator of ET placement
The only accurate assessment is blood level carboxyhemoglobin, which must be assessed at the hospital

25. Signs of Carboxyhaemoglobinaemia
COHb levels
Symptoms
0-10%
Minimal (normal level in heavy smokers)
10-20%
Nausea, headache
20-30%
Drowsiness, lethargy
30-40%
Confusion, agitation
40 -50%
Coma, respiratory depression
>50%
Death
COHb = Carboxyhaemoglobin

26. Investigations for major burns
General
Full blood count, packed cell volume, urea and electrolyte concentration, clotting screen, liver enzymes
Blood group, and save or crossmatch serum
12 lead electrocardiography
Cardiac enzymes

27. Investigations for major burns
For inhalational injury:
Arterial Blood Gases—mandatory
Chest x-ray—Frequently normal initially but essential nonetheless as baseline assessment and to exclude trauma.

28. What are the indications of intubation?
Early intubation required to treat “4” causes of respiratory dysfunction:
1. CO poisoning
2. Upper airway edema
3. Subglottic thermal and chemical burns
4. Chest wall restriction

29. What fluid requirement will patient have ?
What fluid would you give when you give and why ?

30. Fluid Resuscitation Related to:
extent of burn (rule of nines)
body size (pre-injury weight estimate)
Delivered through large bore peripheral IV
Attempt to avoid overlying burned skin
Can use venous cut down or central line

31. Fluid Resuscitation Goal: Maintain perfusion to vital organs
Fluid requirement calculations for infusion rates are based on the time from injury, not from the time fluid resuscitation is initiated.

32. Resuscitation Fluid Needs: First 24 Hours
Parkland Formula:
Adults: ml RL x Kg body weight x % burn
First half of volume over first 8 hours, second half over following 16 hours
Hypovolemia, decreased CO
Increased capillary permeability
Crystalloid fluid is keystone, colloid not useful

33. Lactated Ringers - preferred solution
Fluid resuscitation
Lactated Ringers - preferred solution
Contains Na+ - restoration of Na+ loss is essential
Free of glucose – high levels of circulating stress hormones may cause glucose intolerance

34. Resuscitation Fluid Needs: Second 24 Hours
Capillary permeability gradually returns to normal
30–50% burn: 0.3 mL/kg body weight per % burn
50–70% burn: 0.4 mL/kg body weight per % burn
>70% burn: 0.5 mL/kg body weight per % burn
Usually check for BP, CVP and urinary output.

35. Resuscitation endpoints

36. Fluid resuscitation Over resuscitation Results in:
Pulmonary edema
3rd spacing of tissues of chest—escharotomies
Prolonged ventilation
Source of morbidity—monitor U/O closely

38. Discuss analgesia, are burns painful ?

39. Analgesia Pain management is indicated for most burns.
First degree and superficial second degree burns are generally painful.
Full thickness burns are not painful due to destruction of the dermis.

40. Morphine is the drug of choice for pain
Analgesia
Morphine is the drug of choice for pain
Should be titrated intravenously only.
Subcutaneous and intramuscular routes become trapped in tissues by edema and can induce respiratory arrest as the edema resolves which may kill the patient.
Morphine is of choice for (background pain).

41. For extremely painful procedures in both emergency and acute phase, Fentanyl has a major advantage.
It is shorter acting (procedural pain).
It avoids over sedation following a procedure.
Other drugs as Benzodiazepines may be indicated to clam patients in anxiety induced hyperventilations.

42. Would you give an anesthetic for the fracture ?
To answer this question we must know what is the pathophysiology of burn injury

43. Fluid and Electrotype Shifts—Emergent Phase
Generalized dehydration
Reduced blood volume and hemoconcentration
Decreased urine output
Trauma causes release of potassium into extracellular fluid: hyperkalemia
Sodium traps in edema fluid and shifts into cells as potassium is released: hyponatremia
Metabolic acidosis

44. Fluid and Electrolyte Shifts—Acute Phase
Fluid reenters the vascular space from the interstitial space
Hemodilution
Increased urinary output
Sodium is lost with diuresis and due to dilution as fluid enter vascular space: hyponatremia
Potassium shifts from extracellular fluid into cells: potential hypokalemia
Metabolic acidosis

45. Three variables estimate a high probability of death
Age > 60
Burn more than 40% TBSA
Presence of inhalational injury
Other variables include:
Presence of coexisting disease
Delay in resuscitation

46. Anesthetic management for this patient
Give anesthesia for patients as soon as hemodynamics are stabilized.
Regional anesthesia can be used effectively in small burns or patients undergoing reconstructive procedures.
For upper extremity procedures brachial plexus block may be considered as primary anesthetic or as an adjunct for postoperative pain control.
In this patient as there is injury to both the arms and chest regional anesthesia would be a difficult choice.

47. Remember also: Casts over burn must be avoided.
Avoid prolonged immobilization of joints in burn area.
Therefore external and internal fixation techniques are of choice.

48. Operative management
Ketamine has many advantages for burn patients as an induction and maintenance agent.
Induction dose mg/Kg.
Ketamine preserves hemodynamics compared to other IV anesthetics.
Airway reflexes remain more intact with small risk of aspiration
Maintenance can be done by volatile agents opioid nitrous oxide.

49. Muscle relaxants
Succinylcholine is contraindicated un the first 24 hours (cardiac arrest)
Burn patients require higher than normal doses of non depolarizing muscle relaxants duet o altered protein binding and increase in extrajunctional acetyl choline receptors.
Note :
Consider alcoholic liver cirrhosis
Consider COPD patient

50. Where would the patient be looked after ?

51. This patient should be admitted to ICU
Second and third degree ≥ 20% TBSA.
Second and third degree burns that involve face, hands, genitalia perineum and major joints.
Full thickness burn ≥5% TBSA.
Inhalational injury.
Burn in patient with pre-existing medical conditions alcoholic smoker.

52. Discuss your management in this critical situation
what would you do if an anesthetized patient suddenly became hard to ventilate?
Discuss your management in this critical situation
What are the signs of pneumothorax?
How should a pneumothorax be treated?

53. Ventilation may be difficult because of a problem with one of three sites:
Anesthetic equipment (ventilator, anesthetic breathing system)
Airway device (endotracheal tube, laryngeal mask, face mask)
The patient.

54. Management
The anesthetist should immediately look for obvious causes. Airway pressure may be high immediately after intubation, when neuromuscular blockade has decreased and if the airway is kinked.
If there is no obvious cause, the anesthetist should have a systematic approach to the diagnosis of high airway pressure

55. Management
Gas supply
Breathing circuit: (hand ventilate the patient with a selfinflating resuscitation bag)
Airway: not kinked or obstructed(suction catheter)
Lungs: Look for bilateral chest expansion and listen to both sides of the chest. endobronchial intubation (withdraw the endotracheal tube 2cm and reassess) or pneumothorax (check the heartrate and blood pressure, feel to see if the trachea is central and percuss the chest).

56. Management
If wheezes are present, consider bronchospasm, aspiration or pulmonary oedema
The surgical procedure or the position of the patient may also make ventilation difficult

57. Pneumothorax A pneumothorax may occur for many reasons including :
Insertion of intercostal nerve blocks or
Placing a central venous catheter.
It can happen spontaneously or because of chest trauma or high ventilation pressure during general anesthesia.

58. Signs and Symptoms
The awake patient may complain of dyspnoea, chest pain, and be tachypnoeic and hypoxic.
In the anaesthetized patient, it can be very difficult to diagnose a pneumothorax.
The patient may be hypoxic and have raised inspiratory airway pressures. A large pneumothorax or a tension pneumothorax will cause hypotension, tachycardia and may cause death.

59. Signs and Symptoms
On examination the patient may have reduced or absent breath sounds on one side, increased resonance to percussion, tracheal deviation or subcutaneous emphysema.
The anesthetist must always consider a pneumothorax in their diagnosis, especially if the patient is at increased risk
(central venous catheter inserted, chest trauma, asthma, high airway pressure).

60. Signs and Symptoms
A pneumothorax may be present with signs and symptoms similar to several other problems, including aspiration of gastric contents, endobronchial intubation, a blocked endotracheal tube and bronchospasm.
An erect chest x-ray will help with the diagnosis (a pneumothorax can be very difficult to see on a supine chest x-ray).

61. Chest X-Ray

62. Management
Always ensure that the patient is well oxygenated and ventilating
Turn off the nitrous oxide and give 100% oxygen (70% nitrous oxide will rapidly increase the size of a pneumothorax by 100% in 10 minutes).
Check the blood pressure and pulse rate.

63. Management
If the blood pressure is low and there is no other cause for a low blood pressure, treat the patient as if they have a tension pneumothorax. A tension pneumothorax can rapidly cause death and must be treated as an emergency.
Inform the surgeon and call for help.

64. Management
Insert a large intravenous catheter into the pleural space to aspirate the pneumothorax.
The intravenous catheter should be placed in the second intercostal space above the rib in line with the middle of the clavicle, to avoid damaging the intercostal nerves and blood vessels.
A chest tube must be inserted following insertion of an intravenous catheter.

65. THANK YOU