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

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Presentation on theme: "By Eeman Abou Bakr Assistant lecturer of Anaesthesia and Intensive Care By Eeman Abou Bakr Assistant lecturer of Anaesthesia and Intensive Care."— Presentation transcript:

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2 By Eeman Abou Bakr Assistant lecturer of Anaesthesia and Intensive Care By Eeman Abou Bakr Assistant lecturer of Anaesthesia and Intensive Care

3 You have been called to anesthesia and emergency department to provide anesthesia for reduction of a colles fracture. You have been called to anesthesia and emergency department to provide anesthesia for reduction of a colles 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. 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.

4 Questions What assessment of the patients would you make? Discuss airway assessment, The significance of perform SaO 2 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 ?

5 What assessment of the patient would you make?

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

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

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

9 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 1 st /2 nd /3 rd degree are acceptable terminology First and second degree burns are partial thickness burns Third degree burns are full thickness burns

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11 Determining Burn Severity (Contd) First degree burns ( First degree burns (epidermal burns) are red, appear DRY, blanch when pressed upon, and blister mildly. Second degree ( 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.

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

13 Discuss Airway Assessment

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15 This patient at RISK of developing inhalational injury due to Unable to escape fire 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 Lack of functional smoke detector Chronic pulmonary disorders: asthma, COPD morbidity of smoke inhalation increased. Chronic pulmonary disorders: asthma, COPD morbidity of smoke inhalation increased.

16 Airway assessment (Contd) 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.

17 Airway assessment (Contd) 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.

18 Airway assessment (Contd) Examination - Stridor: indicates severe laryngeal edema and the possibility of imminent airway obstruction - Voice hoarsenessan excellent warning sign - Tachypnea - Use of accessory muscles - Persistent cough - Soot in oropharynx - Singed nasal hair

19 Carbonaceous particles staining a patients face after a burn in an enclosed space. This suggests there is inhalational injury

20 Airway assessment (Contd) Laryngoscopy detect edema to the pharynx or larynx or vocal cords. Bronchoscopy Airway edema Mucosal slouging Charring or soot

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22 Discuss the significance to perform SaO 2 and other investigations you would perform as(COHb).

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

24 Carbon Monoxide Poisoning Asphyxiation and/or carbon monoxide poisoning causes most fire scene fatalities 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. 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 The pulse oximiter, which measures bonded hemoglobin, will deliver a normal reading, even when the patient is hypoxic, or dead

25 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 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 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 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 The only accurate assessment is blood level carboxyhemoglobin, which must be assessed at the hospital

26 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 %Coma, respiratory depression >50%Death COHb = Carboxyhaemoglobin

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

28 Investigations for major burns For inhalational injury: Arterial Blood Gasesmandatory Arterial Blood Gasesmandatory Chest x-rayFrequently normal initially but essential nonetheless as baseline assessment and to exclude trauma. Chest x-rayFrequently normal initially but essential nonetheless as baseline assessment and to exclude trauma.

29 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 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

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

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

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

33 Resuscitation Fluid Needs: First 24 Hours Parkland Formula: Parkland Formula: Adults: 2-4 ml RL x Kg body weight x % burn Adults: 2-4 ml RL x Kg body weight x % burn First half of volume over first 8 hours, second half over following 16 hours First half of volume over first 8 hours, second half over following 16 hours Hypovolemia, decreased CO Hypovolemia, decreased CO Increased capillary permeability Increased capillary permeability Crystalloid fluid is keystone, colloid not useful Crystalloid fluid is keystone, colloid not useful

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

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

36 Resuscitation endpoints

37 Fluid resuscitation Over resuscitation Over resuscitation Results in: Results in: Pulmonary edema Pulmonary edema 3 rd spacing of tissues of chest escharotomies 3 rd spacing of tissues of chest escharotomies Prolonged ventilation Prolonged ventilation Source of morbiditymonitor U/O closely Source of morbiditymonitor U/O closely

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39 Discuss analgesia, are burns painful ?

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

41 Analgesia Should be titrated intravenously only. 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. 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). Morphine is of choice for (background pain). Morphine is the drug of choice for pain

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

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

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

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

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

47 Anesthetic management for this patient Give anesthesia for patients as soon as hemodynamics are stabilized. Give anesthesia for patients as soon as hemodynamics are stabilized. Regional anesthesia can be used effectively in small burns or patients undergoing reconstructive procedures. 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. 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. In this patient as there is injury to both the arms and chest regional anesthesia would be a difficult choice.

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

49 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. 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.

50 Muscle relaxants Succinylcholine is contraindicated un the first 24 hours (cardiac arrest) 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. 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 alcoholic liver cirrhosis Consider COPD patient Consider COPD patient

51 Where would the patient be looked after ?

52 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. 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.

53 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? 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?

54 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. 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.

55 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. 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 If there is no obvious cause, the anesthetist should have a systematic approach to the diagnosis of high airway pressure

56 Management Gas supply Gas supply Breathing circuit: (hand ventilate the patient with a selfinflating resuscitation bag) Breathing circuit: (hand ventilate the patient with a selfinflating resuscitation bag) Airway: not kinked or obstructed(suction catheter) 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 heart rate and blood pressure, feel to see if the trachea is central and percuss the chest). 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 heart rate and blood pressure, feel to see if the trachea is central and percuss the chest).

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

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

59 Signs and Symptoms The awake patient may complain of dyspnoea, chest pain, and be tachypnoeic and hypoxic. 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. 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. 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.

60 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. 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). 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).

61 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. 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). An erect chest x-ray will help with the diagnosis (a pneumothorax can be very difficult to see on a supine chest x-ray).

62 Chest X-Ray

63 Management Always ensure that the patient is well oxygenated and ventilating 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). 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. Check the blood pressure and pulse rate.

64 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. 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. Inform the surgeon and call for help.

65 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. 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. A chest tube must be inserted following insertion of an intravenous catheter.

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