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BLASTS AND BURNS: Don’t Feel The Heat! Susan Marie Baro, DO, FACOS Associate Trauma and Surgical Critical Care Associate Director Surgical Critical Care.

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Presentation on theme: "BLASTS AND BURNS: Don’t Feel The Heat! Susan Marie Baro, DO, FACOS Associate Trauma and Surgical Critical Care Associate Director Surgical Critical Care."— Presentation transcript:

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2 BLASTS AND BURNS: Don’t Feel The Heat! Susan Marie Baro, DO, FACOS Associate Trauma and Surgical Critical Care Associate Director Surgical Critical Care Physician Director Blood Conservation Program

3 OBJECTIVES Understand the injuries that result from explosions and review current management and treatment of Blast Injuries Understand the injuries that result from explosions and review current management and treatment of Blast Injuries Review Burn Injury Classifications and Standard Treatments Review Burn Injury Classifications and Standard Treatments Calculate % TBSA in Burns Calculate % TBSA in Burns Calculate IV Fluid Requirements in Burns Calculate IV Fluid Requirements in Burns

4 AMERICAN BURN ASSOCIATION Burn Injury Severity Grading System Minor Burn Minor Burn –15% TBSA (Total Body Surface Area) or less in adults –10% TBSA or less in children and the elderly –2% TBSA or less full thickness burn in children or adults without cosmetic or functional risk to eyes, ears, face, hands, feet or perineum

5 AMERICAN BURN ASSOCIATION Burn Injury Severity Grading System Moderate Burn Moderate Burn –15 – 25% TBSA in adults with less than 10% full thickness burn –10 – 20% TBSA partial thickness burn in children 40 years of age with less than 10% full thickness burn –10% TBSA or less full thickness burn in children or adults without cosmetic or functional risk to eyes, ears, face, hands, feet, or perineum

6 AMERICAN BURN ASSOCIATION Burn Injury Severity Grading System Major Burn Major Burn –25% TBSA or greater –20% TBSA in children 40 years of age –10% TBSA or greater full thickness burn –All burns involving eyes, ears, face, hands, feet, or perineum that are likely to result in cosmetic or functional impairment

7 AMERICAN BURN ASSOCIATION Burn Injury Severity Grading System Major Burn (cont.) Major Burn (cont.) –All high voltage electrical burns –All burn injury complicated b y major trauma or inhalation injury –All poor risk patients with burn injury

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9 CLASSIFICATION OF BURNS Thermal Thermal Cold Exposure Cold Exposure Chemical Chemical Electrical Current Electrical Current Inhalation Inhalation Radiation Radiation

10 CLASSIFICATION BASED ON DEPTH OF TISSUE INJURY 1 st Degree – Superficial or Epidermal 1 st Degree – Superficial or Epidermal 2 nd Degree – Partial Thickness 2 nd Degree – Partial Thickness 3 rd Degree – Full Thickness 3 rd Degree – Full Thickness 4 th Degree – burns extending beneath the subcutaneous tissues involving the fascia, muscle, and /or the bone 4 th Degree – burns extending beneath the subcutaneous tissues involving the fascia, muscle, and /or the bone

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12 SUPERFICIAL BURN Epidermal layer (ex, sunburn) Epidermal layer (ex, sunburn) No Blisters No Blisters Red, painful, and dry Red, painful, and dry Epidermal layer peels away Epidermal layer peels away Blanches with pressure Blanches with pressure Subsides over 2 – 3 days and heals within 6 days without scarring Subsides over 2 – 3 days and heals within 6 days without scarring

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14 PARTIAL THICKNESS: SUPERFICIAL Between the epidermis and the dermis Between the epidermis and the dermis Forms blisters within 24 hours Forms blisters within 24 hours Painful, red, weeping Painful, red, weeping Blanches with pressure Blanches with pressure Pigment changes can occur Pigment changes can occur Usually heals in 7 – 21 days Usually heals in 7 – 21 days Scarring unusual Scarring unusual

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16 PARTIAL THICKNESS: DEEP Extends deep into the dermis Extends deep into the dermis Damages hair follicles and glandular tissue Damages hair follicles and glandular tissue Painful to pressure only Painful to pressure only Almost always blisters Almost always blisters Wet, waxy, or dry Wet, waxy, or dry Variable mottled coloration (Patchy cheezy white to red) Variable mottled coloration (Patchy cheezy white to red)

17 PARTIAL THICKNESS: DEEP (cont). Does not blanch Does not blanch Heals in 3 – 9 weeks if no grafting required Heals in 3 – 9 weeks if no grafting required Causes hypertrophic scarring Causes hypertrophic scarring If involves the joint, expect dysfunction even with aggressive physical therapy If involves the joint, expect dysfunction even with aggressive physical therapy Hard to differentiate from Full Thickness burn Hard to differentiate from Full Thickness burn

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19 FULL THICKNESS Extends through and destroys all layers of the dermis and often injures underlying subcutaneous tissue Extends through and destroys all layers of the dermis and often injures underlying subcutaneous tissue Burn eschar and denature dermis usually intact Burn eschar and denature dermis usually intact Eschar compromises viability of limb and torso if circumferential Eschar compromises viability of limb and torso if circumferential Anesthetic or hypoesthetic Anesthetic or hypoesthetic

20 FULL THICKNESS (cont.) Skin waxy white to leathery gray to charred and black Skin waxy white to leathery gray to charred and black Dry and inelastic Dry and inelastic Does not blanch Does not blanch No vesicles or blisters No vesicles or blisters

21 FULL THICKNESS (cont.) Eschar usually separates from the underlying tissue and reveals an unhealed bed of granulation tissue Eschar usually separates from the underlying tissue and reveals an unhealed bed of granulation tissue Without surgery – they heal by wound contracture with epithelialization around the edges Without surgery – they heal by wound contracture with epithelialization around the edges Scarring is severe with contractures Scarring is severe with contractures

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23 FOURTH DEGREE Deep Deep Potentially life threatening Potentially life threatening Extend through the skin to underlying structures Extend through the skin to underlying structures

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25 TOTAL BODY SURFACE AREA Size is usually underestimated Size is usually underestimated –Results in under resuscitation Lund-Browder Lund-Browder –Most accurate for both children and adults –Takes into account the relative % of body surface area affected by growth Kids have larger heads and smaller extremities Kids have larger heads and smaller extremities

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28 TOTAL BODY SURFACE AREA (cont). Rule of Nines (adults) Rule of Nines (adults) –Each leg represents 18% TBSA –Each arm represent 9% TBSA –Anterior and Posterior Trunk each represent 18% TBSA –Head represents 9 % TBSA

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30 TOTAL BODY SURFACE AREA (cont). Palm Method Palm Method –Used when the burn is irregular and/or patchy –Utilizes the surface area of the patients palm –Palm, excluding extended fingers = 0.5% patients TBSA –Palm, extending fingers = 1% of patients TBSA

31 INITIAL MANAGEMENT Essentially ATLS Essentially ATLS Special attention to respiratory distress and smoke inhalation Special attention to respiratory distress and smoke inhalation Remove clothing promptly Remove clothing promptly Consider early transfer to Burn Center Consider early transfer to Burn Center History is important History is important –Materials, chemicals, open vs closed space, explosion or blast involvement, associated trauma

32 AIRWAY Inhalation injury remains a leading cause of death in the adult burn victim Inhalation injury remains a leading cause of death in the adult burn victim Present in 2/3’s of patient with burns > 70% TBSA Present in 2/3’s of patient with burns > 70% TBSA Supplemental oxygen, maintain airway Supplemental oxygen, maintain airway Upper airway edema occurs rapidly Upper airway edema occurs rapidly

33 AIRWAY (cont.) RSI with Succinylcholine acceptable in the first 72 hours but no later secondary to the risk of severe hyperkalemia RSI with Succinylcholine acceptable in the first 72 hours but no later secondary to the risk of severe hyperkalemia Significant % develop ARDS Significant % develop ARDS

34 SIGNS OF SIGNIFICANT SMOKE INHALATION INJURY Persistent cough, stridor, or wheezing Persistent cough, stridor, or wheezing Hoarseness Hoarseness Deep facial or circumferential neck burns Deep facial or circumferential neck burns Nares with inflammation or singed hair Nares with inflammation or singed hair Carbonaceous sputum or burnt matter in the nose or mouth Carbonaceous sputum or burnt matter in the nose or mouth Blistering or edema of the oropharynx Blistering or edema of the oropharynx

35 SIGNS OF SIGNIFICANT SMOKE INHALATION INJURY (cont.) Depressed mental status Depressed mental status Respiratory distress Respiratory distress Hypoxia or Hypercapnia Hypoxia or Hypercapnia Elevated Carbon Monoxide and/or Cyanide levels Elevated Carbon Monoxide and/or Cyanide levels Inhalation injury from hot gasses usually occurs above the vocal cords Inhalation injury from hot gasses usually occurs above the vocal cords

36 CARBON MONOXIDE AND CYANIDE Check Carboxyhemaglobin level in all patients with moderate to severe burns Check Carboxyhemaglobin level in all patients with moderate to severe burns Standard Pulse-Ox not reliable Standard Pulse-Ox not reliable Treatment with high flow oxygen alone effectively removes CO Treatment with high flow oxygen alone effectively removes CO Hyperbaric Oxygen Treatment if increased CO or if treatment for Cyanide poisoning places patient at risk for hypoxemia Hyperbaric Oxygen Treatment if increased CO or if treatment for Cyanide poisoning places patient at risk for hypoxemia

37 CARBON MONOXIDE AND CYANIDE (cont.) Check Methemaglobin if Cyanide poisoning suspected Check Methemaglobin if Cyanide poisoning suspected Consider Cyanide toxicity in severe burn patients with unexplained lactic acidosis and declining EtCO 2 Consider Cyanide toxicity in severe burn patients with unexplained lactic acidosis and declining EtCO 2 Treatment: Hydroxocobalamin Treatment: Hydroxocobalamin

38 TREATMENT Supplemental Oxygen and Airway Protection Supplemental Oxygen and Airway Protection Bronchodilators when bronchospasm present Bronchodilators when bronchospasm present Avoid Corticosteroids Avoid Corticosteroids Fluid resuscitation with aggressive monitoring Fluid resuscitation with aggressive monitoring

39 TREATMENT (cont.) Vent Settings: low tidal volumes to minimize airway pressures and to reduce incidents of Ventilator Associated Acute Lung Injury (ALI) Vent Settings: low tidal volumes to minimize airway pressures and to reduce incidents of Ventilator Associated Acute Lung Injury (ALI) Inhaled Nitric Oxide – may increase hypoxic vasoconstriction Inhaled Nitric Oxide – may increase hypoxic vasoconstriction Aerosolized Heparin and N-Acetylcysteine (NAC) – may help to remove broncho- pulmonary casts Aerosolized Heparin and N-Acetylcysteine (NAC) – may help to remove broncho- pulmonary casts

40 FLUID RESUSCITATION Burn Shock – occurs within 24 – 48 hours Burn Shock – occurs within 24 – 48 hours Characterized by myocardial depression and increased capillary permeability Characterized by myocardial depression and increased capillary permeability Results in large fluid shifts and depletion of intravascular volume Results in large fluid shifts and depletion of intravascular volume Rapid, aggressive fluid resuscitation helps to reconstitute the intravascular volume and maintain end organ perfusion Rapid, aggressive fluid resuscitation helps to reconstitute the intravascular volume and maintain end organ perfusion

41 FLUID RESUSCITATION (cont.) A-line A-line Foley for accurate urine outputs Foley for accurate urine outputs Over-resuscitation leads to ARDS, pneumonia, MSOF, and compartment syndromes (including abdomen, limb, and orbit) Over-resuscitation leads to ARDS, pneumonia, MSOF, and compartment syndromes (including abdomen, limb, and orbit) Any patient with > 15% TBSA, nonsuperficial burns (2 nd /3 rd Degree) should receive formal fluid resuscitation Any patient with > 15% TBSA, nonsuperficial burns (2 nd /3 rd Degree) should receive formal fluid resuscitation

42 FLUIDS IV Crystalloid – typically Ringer’s Lactate IV Crystalloid – typically Ringer’s Lactate –helps to reduce incidence of hyperchloremic acidosis associated with large volumes of isotonic saline (NS) –Colloid and Hypertonic Saline for initial resuscitation not found to show any improvement in outcomes, are more expensive, and possibly increase renal failure and death

43 FLUIDS (cont.) Following initial resuscitation IV fluids need to meet baseline fluid needs and maintain Urine outputs Following initial resuscitation IV fluids need to meet baseline fluid needs and maintain Urine outputs IF UO < 0.5 ml/kg/hr – bolus with 500 to 1000 ml fluid and increase rate by 20 – 30% IF UO < 0.5 ml/kg/hr – bolus with 500 to 1000 ml fluid and increase rate by 20 – 30% If adequate resuscitation and patient stabilizes, change to D5 ½ NS with 20 mEq KCl per liter at maintenance to keep UO > 0.5 ml/kg/hr If adequate resuscitation and patient stabilizes, change to D5 ½ NS with 20 mEq KCl per liter at maintenance to keep UO > 0.5 ml/kg/hr

44 ESTIMATING INITIAL FLUID REQUIREMENTS Parkland Formula – utilized in initial 24 hrs Parkland Formula – utilized in initial 24 hrs Includes partial and full thickness burns Includes partial and full thickness burns 4 ml/kg for each % of TBSA burned over 15% TBSA 4 ml/kg for each % of TBSA burned over 15% TBSA ½ volume given in 1 st 8 hours and the remaining volume given over the next 16 hours ½ volume given in 1 st 8 hours and the remaining volume given over the next 16 hours

45 ESTIMATING INITIAL FLUID REQUIREMENTS (cont.) Modified Brooke Formula Modified Brooke Formula Given over initial 24 hours Given over initial 24 hours 2 ml/kg for each % TBSA 2 ml/kg for each % TBSA Likely reduces the overall volume Likely reduces the overall volume

46 BLOOD TRASFUSION Avoid if possible Avoid if possible Associated with increased mortality Associated with increased mortality Only if Hemoglobin < 8 gm/dL unless patient with acute coronary syndrome Only if Hemoglobin < 8 gm/dL unless patient with acute coronary syndrome If at risk for ACS – transfuse to 10 gm/dL If at risk for ACS – transfuse to 10 gm/dL

47 IMMEDIATE BURN CARE Remove clothing Remove clothing Cool burned area immediately using cool water or saline soaked gauze Cool burned area immediately using cool water or saline soaked gauze –can minimize the zone of injury in small burns Monitor cor body temp to prevent hypothermia, especially if >10% TBSA Monitor cor body temp to prevent hypothermia, especially if >10% TBSA Avoid temps below 35 o C/95 o F Avoid temps below 35 o C/95 o F Aggressive Pain control with Morphine and Benzo’s for anxiety Aggressive Pain control with Morphine and Benzo’s for anxiety

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49 CHEMOPROPHYLAXIS Extensive burns cause immunosuppression on basis of altered neutrophil activity, T lymphocyte dysfunction, and imbalance in production of cytokines Extensive burns cause immunosuppression on basis of altered neutrophil activity, T lymphocyte dysfunction, and imbalance in production of cytokines –Bacterial colonization of the burn eschar site can result Burns destroy physical barrier to tissue invasion Burns destroy physical barrier to tissue invasion –Permits spread of bacteria to the dermis and through the lymphatics along the fibrous septae

50 CHEMOPROPHYLAXIS (cont.) Once invasion occurs – organisms can invade the blood vessels producing secondary bacteremia Once invasion occurs – organisms can invade the blood vessels producing secondary bacteremia Topical antibiotics are given to all patients with nonsuperficial burns Topical antibiotics are given to all patients with nonsuperficial burns

51 TETANUS Update for any burns deeper than superficial Update for any burns deeper than superficial Tetanus Immune Globulin – if patient did not receive complete set of primary immunizations Tetanus Immune Globulin – if patient did not receive complete set of primary immunizations

52 ANTIBIOTICS Apply topically to all nonsuperficial burns Apply topically to all nonsuperficial burns If transferring to Burn Center – hold on topical coverage and cover with clean, dry, dressings If transferring to Burn Center – hold on topical coverage and cover with clean, dry, dressings No Prophylactic IV antibiotics No Prophylactic IV antibiotics Silver Sulfadiazine (SSD) Silver Sulfadiazine (SSD) –avoid near eyes and mouth, sulfonamide hypersensitivity, pregnant women, newborns, and nursing mothers Bacitracin as an alternative Bacitracin as an alternative

53 WOUND Wash with mild soap and water Wash with mild soap and water Remove debris Remove debris Avoid local anesthetics Avoid local anesthetics Never aspirate intact blisters Never aspirate intact blisters Burn wound debridement and excision and coverage is performed within the first 6 – 24 hours after local injury Burn wound debridement and excision and coverage is performed within the first 6 – 24 hours after local injury

54 DRESSINGS If transferring – clean, dry sheet If transferring – clean, dry sheet Non-adherent mesh gauze after cleaning with antibiotics ointment Non-adherent mesh gauze after cleaning with antibiotics ointment Avoid tape on skin Avoid tape on skin Tubular gauze or light circumferential wraps Tubular gauze or light circumferential wraps Deep wounds – biologic or biosynthetic dressings or bismuth impregnated petroleum gauze Deep wounds – biologic or biosynthetic dressings or bismuth impregnated petroleum gauze

55 ESCHAROTOMY Occurs with deep dermal and full thickness burns which are circumferential Occurs with deep dermal and full thickness burns which are circumferential Dermis can becomes stiff and unyielding – referred to as an eschar Dermis can becomes stiff and unyielding – referred to as an eschar Usually does not occur until 3 – 4 hours following initiation of fluid resuscitation Usually does not occur until 3 – 4 hours following initiation of fluid resuscitation Utilize scalpel or electrocautery (preferred) Utilize scalpel or electrocautery (preferred)

56 ESCHAROTOMY (cont.) Extend through the eschar to the fatty tissue beneath – no further Extend through the eschar to the fatty tissue beneath – no further Leaves fascia intact Leaves fascia intact If no improvement, may have developed compartment syndrome which could require fasciotomy, but this is a different entity If no improvement, may have developed compartment syndrome which could require fasciotomy, but this is a different entity If signs of ischemia or respiratory distress occur – need to perform prior to transfer If signs of ischemia or respiratory distress occur – need to perform prior to transfer

57 ESCHAROTOMY (cont.) Neck and Chest – can lead to respiratory compromise Neck and Chest – can lead to respiratory compromise Abdomen – leads to Abdominal compartment syndrome Abdomen – leads to Abdominal compartment syndrome Extremities – ischemia with decreased pulses, capillary refill, pulse-ox (if Pulse- Ox > 90%, likely does not need escharotomy) Extremities – ischemia with decreased pulses, capillary refill, pulse-ox (if Pulse- Ox > 90%, likely does not need escharotomy)

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62 GI Shock from thermal burn injuries results in mesenteric vasoconstriction predisposing to gastric distention, ulceration (Cushing’s Ulcer) and aspiration Shock from thermal burn injuries results in mesenteric vasoconstriction predisposing to gastric distention, ulceration (Cushing’s Ulcer) and aspiration NGT if > 20% TBSA NGT if > 20% TBSA Stress ulcer prophylaxis Stress ulcer prophylaxis

63 NUTRITION Early feeding: within 24 – 48 hours Early feeding: within 24 – 48 hours Meet basic patient energy needs to attenuate the catabolic response to burns Meet basic patient energy needs to attenuate the catabolic response to burns Hypermetabolic Hypermetabolic Enteral preferred Enteral preferred Indication for Nutritional Support – failure to maintain LBM (Lean Body Mass) and body weight (dry body weight on day 5 post burn) Indication for Nutritional Support – failure to maintain LBM (Lean Body Mass) and body weight (dry body weight on day 5 post burn)

64 HARRIS BENEDICT EQUATION Estimates basal energy expenditure Estimates basal energy expenditure For burn patients the BEE is multiplied by an arbitrary activity or stress factor of 1.2 to 2.0 (usually 1.2 to 1.5) For burn patients the BEE is multiplied by an arbitrary activity or stress factor of 1.2 to 2.0 (usually 1.2 to 1.5) Useful for initial estimate of energy demand Useful for initial estimate of energy demand Usually overestimates caloric requirements Usually overestimates caloric requirements

65 HARRIS BENEDICT EQUATION Females Females –BEE (Kcal/day) = 655 + (9.6) x Kg + (1.85) x Ht in cm – (4.68) x Age –Then multiply by 1.2 to 2.0 Males Males –BEE (Kcal/day) = 66.5 + (13.8) x Kg + (5) x Ht in cm – (6.76) x age –Then multiply by 1.2 to 2.0

66 CURRERI FORMULA Takes into account TBSA and Body Weight prior to burn Takes into account TBSA and Body Weight prior to burn Estimates the energy required by linear regression analysis based on the number of calories required to prevent weight loss Estimates the energy required by linear regression analysis based on the number of calories required to prevent weight loss Still likely overfeeds Still likely overfeeds

67 CURRERI FORMULA Age 16 – 59 Age 16 – 59 –Kcal/day = 25 kcal/Kg/day + 40 Kcal/%TBSA burned/day Age > 60 Age > 60 –Kcal/day = 25 Kcal/Kg/day + 65 Kcal/%TBSA burned/day

68 GOLD STANDARD Preferred method to estimate caloric requirements in burn patient is by Indirect Calorimetry (IDC) Preferred method to estimate caloric requirements in burn patient is by Indirect Calorimetry (IDC) Uses respiratory gas exchange to estimate fuel consumption Uses respiratory gas exchange to estimate fuel consumption Results affected by oxygen therapy, hemodynamic instability, fever, sepsis, ongoing procedures Results affected by oxygen therapy, hemodynamic instability, fever, sepsis, ongoing procedures

69 NUTRITION IN CHILDREN RDA (RDI) – recommended daily allowance (recommended daily intake) RDA (RDI) – recommended daily allowance (recommended daily intake) RDI Kcal/day = 37 x Kg RDI Kcal/day = 37 x Kg With a modifier based on age With a modifier based on age

70 NUTRITIONAL FORMULA At least 50% calories as Carbohydrates At least 50% calories as Carbohydrates 35% as Protein 35% as Protein No more than 15% as Fat No more than 15% as Fat Supplement with micro and macro nutrients Supplement with micro and macro nutrients Add Glutamine to standard formulas (decreased Gran Negative Bacteremia) Add Glutamine to standard formulas (decreased Gran Negative Bacteremia)

71 FORMULA (cont.) 1.5 to 2.0 grams protein/kg/day 1.5 to 2.0 grams protein/kg/day 5 to 7 mg/kg/min of glucose/day representing ~ 50% of total calories 5 to 7 mg/kg/min of glucose/day representing ~ 50% of total calories No more than 15% non-protein calories from fats No more than 15% non-protein calories from fats Vitamin A,C, and D Vitamin A,C, and D Trace Minerals (selenium, zinc, copper) Trace Minerals (selenium, zinc, copper) Glutamine Glutamine

72 THROMBOEBMOLIC PROPHYLAXIS Burn patients are at an increased risk for thromboembolic complications Burn patients are at an increased risk for thromboembolic complications Initial prophylaxis on arrival to ICU Initial prophylaxis on arrival to ICU –Enoxaparin 40 mg q day –Enoxaparin 30 mg q day if < 40 Kg or with creatinine clearance < 30 mL/min –Enoxaparin 40 mg q day if > 100 Kg –Enoxaparin 30 mg bid with associated lower extremity or pelvic orthopedic injuries or burn –Heparin 5000 mg q 8 if not a candidate for Enoxaparin

73 SEPSIS > 20% TBSA Burns – increased risk for an invasive burn wound infection > 20% TBSA Burns – increased risk for an invasive burn wound infection Referred to as “Burn Wound Sepsis” Referred to as “Burn Wound Sepsis” Often lead to MOF and death Often lead to MOF and death 75% of the mortality following thermal injuries is related directly to infection 75% of the mortality following thermal injuries is related directly to infection Different criteria than non-burn patients Different criteria than non-burn patients –Takes into account the changing metabolism and altered inflammatory response in burns

74 BACTERIAL BURN WOUND SEPSIS Non-Invasive burn wound infection Non-Invasive burn wound infection –> 10 5 bacteria per gram of tissue Invasive burn wound infection Invasive burn wound infection –Defined as the presence of micororganisms in the adjacent unburned tissue

75 FUNGAL BURN WOUND INFECTION Non-Invasive fungal infection Non-Invasive fungal infection –Defined as the recovery of mold or yeast by culture of a specimen obtained from a burn wound or eschar Invasive fungal infection Invasive fungal infection –Need to identify hyphae or melanized yeast-like forms utilizing histopath/cytopath, or by direct microscopic exam of a needle aspirate or biopsy specimen, or by associated tissue damage or recovery of mold/yeast by culture of a specimen from a normally sterile site

76 ABA CRITERIA FOR DEFINITION OF SEPSIS & INFECTION Most include three of the following Most include three of the following –Temp > 102.2 o F/39 o C –Progressive tachycardia –Progressive tachypnea –Refractory hypotension –Leukocytosis or Leukopenia –Thrombocytopenia –Hyperglycemia (in the absence of DM) –Inability to tolerate enteral feeds for > 24 hours (strict criteria for failure)

77 SEPSIS AND INFECTION (cont.) Requires infection be documented by one of the following Requires infection be documented by one of the following –Confirmed on cultures (wound, blood, urine) –Pathologic tissue source identified (> 10 5 bacteria on quantitative wound tissue biopsy or microbial invasion on surrounding tissue biopsy –Documentation of clinical response to antimicrobial administration

78 ORGANISMS IN BURNS Immediately following Immediately following –Predominately Gram Positive bacteria Staph aureus, Pseudomonas aeruginosa, Serratia marcescens Staph aureus, Pseudomonas aeruginosa, Serratia marcescens 2 – 4 days 2 – 4 days –Gram Negative bacteria Within 1 st week Within 1 st week –Burns colonized with GP’s, GN’s, Fungi > 5 days > 5 days –Gram Negatives with abx resistant traits

79 ORGANISMS IN BURNS Most Common Overall Most Common Overall –MSSA, MRSA, and Pseudomonas Most Predominate Gram Positives Most Predominate Gram Positives –Staph aureus and enterococcus Most Predominate Gram Negatives Most Predominate Gram Negatives –Pseudomonas and E coli Candida is the most common fungal infection (4 th most common cause overall) Candida is the most common fungal infection (4 th most common cause overall) HSV-1 – most common viral organism HSV-1 – most common viral organism

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81 BLAST INJURIES - PHYSICS Explosive detonations differ from collisions or impactsExplosive detonations differ from collisions or impacts High-order explosive detonations cause a near instantaneous transformation of the explosive material into a highly pressurized gasHigh-order explosive detonations cause a near instantaneous transformation of the explosive material into a highly pressurized gas Releases energy at supersonic speedsReleases energy at supersonic speeds Transient shock waves travel in excess of the speed of soundTransient shock waves travel in excess of the speed of sound Results in formation of a blast wave that travels out from the epicenter of the blastResults in formation of a blast wave that travels out from the epicenter of the blast

82 PHYSICS (cont.) Simply put - an explosion is caused by the rapid chemical conversion of a solid or liquid into a gas with resultant energy releaseSimply put - an explosion is caused by the rapid chemical conversion of a solid or liquid into a gas with resultant energy release An idealized free-field spherical blast creates a temporal pressure transient (Friedlander Function) that has a leading overpressure phase followed by an under pressure phase all occurring within millisecondsAn idealized free-field spherical blast creates a temporal pressure transient (Friedlander Function) that has a leading overpressure phase followed by an under pressure phase all occurring within milliseconds Rarely the common clinical explosion scenarioRarely the common clinical explosion scenario

83 PHYSICS (cont.) Explosives do not always combust instantaneously and multiple shock waves can occurExplosives do not always combust instantaneously and multiple shock waves can occur This is very frequent with improvised explosive devices (IED’s)This is very frequent with improvised explosive devices (IED’s) In addition, the blast wave is affected by reflection from nearby surfaces, potentially causing a merger of the initial pressure wave and the reflected wave or wavesIn addition, the blast wave is affected by reflection from nearby surfaces, potentially causing a merger of the initial pressure wave and the reflected wave or waves

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85 TYPES OF INJURIES Primary Blast Injury Primary Blast Injury Secondary Blast Injury Secondary Blast Injury Tertiary Blast Injury Tertiary Blast Injury Quaternary Blast Injury Quaternary Blast Injury Electromagnetic Perturbations Electromagnetic Perturbations Miscellaneous Effects from the explosion Miscellaneous Effects from the explosion

86 TYPES OF INJURIES Primary Blast Injury Primary Blast Injury Secondary Blast Injury Secondary Blast Injury Tertiary Blast Injury Tertiary Blast Injury Quaternary Blast Injury Quaternary Blast Injury Electromagnetic Perturbations Electromagnetic Perturbations Miscellaneous Effects from the explosion Miscellaneous Effects from the explosion

87 PRIMARY BLAST INJURY (PBI) Caused by the direct effect of the blast overpressure on organs Caused by the direct effect of the blast overpressure on organs Characterized by anatomical and physiological changes from the force generated by the blast wave impacting the body’s surface Characterized by anatomical and physiological changes from the force generated by the blast wave impacting the body’s surface Affect primarily gas-containing structures (lungs, GI tract, middle ear) Affect primarily gas-containing structures (lungs, GI tract, middle ear) Consequence of extreme pressure differentials developed at the body surfaces Consequence of extreme pressure differentials developed at the body surfaces Leading edge of a blast wave is call the “Blast Front” Leading edge of a blast wave is call the “Blast Front”

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91 SECONDARY BLAST INJURY Results from shrapnel, objects or materials hurled at the victim Results from shrapnel, objects or materials hurled at the victim Secondary missiles created by container fragments or nearby shattered objects have the longest range Secondary missiles created by container fragments or nearby shattered objects have the longest range Like sound waves, blast waves do not move mass, however, an additional “dynamic pressure” is created by the net motion of air molecules responding to blast-inducted differentials in static pressure Like sound waves, blast waves do not move mass, however, an additional “dynamic pressure” is created by the net motion of air molecules responding to blast-inducted differentials in static pressure Individuals far from the scene can be injured Individuals far from the scene can be injured Penetrating neck and torso trauma is common with this force Penetrating neck and torso trauma is common with this force

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94 TERTIARY BLAST INJURY Occurs when the victims are flung through the air and strike other objectsOccurs when the victims are flung through the air and strike other objects A blast causing peak static overpressures of 5 psi (strong enough to rupture ½ of exposed TM’s) can generate a “blast wind” of up to 145 mphA blast causing peak static overpressures of 5 psi (strong enough to rupture ½ of exposed TM’s) can generate a “blast wind” of up to 145 mph this can propel objects and people a considerable distancethis can propel objects and people a considerable distance The wind from a blast significant enough to cause Pulmonary PBI may exceed 831 mphThe wind from a blast significant enough to cause Pulmonary PBI may exceed 831 mph

95 QUATERNARY BLAST INJURY Characterized by burns produced from the thermal effects of the detonation itself Characterized by burns produced from the thermal effects of the detonation itself Adds difficulty to the resuscitation – requiring additional fluids not likely beneficial with PBI to the lungs Adds difficulty to the resuscitation – requiring additional fluids not likely beneficial with PBI to the lungs

96 ELECTROMAGNETIC PERTURBANCES These occur with some types of explosions, in particular, those generated by IED’s that have metallic casings These occur with some types of explosions, in particular, those generated by IED’s that have metallic casings These events result in the generation of small and brief radio-frequency pulses for which the physiologic impact is unclear These events result in the generation of small and brief radio-frequency pulses for which the physiologic impact is unclear

97 MISCELLANEOUS EFFECTS Inhalations of dust, smoke, carbon monoxide and other chemicals Inhalations of dust, smoke, carbon monoxide and other chemicals Burns from hot gasses or other fires Burns from hot gasses or other fires Crushing injuries from collapsed buildings Crushing injuries from collapsed buildings Accidental injuries not related to the explosion itself but to the rescue efforts still count as casualties Accidental injuries not related to the explosion itself but to the rescue efforts still count as casualties

98 PRIMARY BLAST INJURIES: LUNG Clinical diagnosis Clinical diagnosis Usually manifests as pulmonary contusions Usually manifests as pulmonary contusions Worse on the side of approach of open-air blastsWorse on the side of approach of open-air blasts B/l and diffuse in confined space blastsB/l and diffuse in confined space blasts Characterized as respiratory difficulty and hypoxia without evidence of obvious external trauma or injury to the chest Characterized as respiratory difficulty and hypoxia without evidence of obvious external trauma or injury to the chest

99 PBI LUNG (cont.) May be complicated by pneumothoraces and air emboli, as well as suffocation from massive hemoptysis May be complicated by pneumothoraces and air emboli, as well as suffocation from massive hemoptysis Can see pleural and subpleural petechiae and ecchymosis in parallel bands corresponding to intercostal spaces Can see pleural and subpleural petechiae and ecchymosis in parallel bands corresponding to intercostal spaces May be associated with multiple other injuries May be associated with multiple other injuries Presents with a variety of symptoms: dyspnea, chest pain, cough, hemoptysis Presents with a variety of symptoms: dyspnea, chest pain, cough, hemoptysis

100 PBI LUNG PHYSICAL EXAM May reveal tachypnea, hypoxia, cyanosis and decreased breath sounds May reveal tachypnea, hypoxia, cyanosis and decreased breath sounds Can have sub-pleural multifocal hemorrhages near the cheat wall, diaphragm, and mediastinum Can have sub-pleural multifocal hemorrhages near the cheat wall, diaphragm, and mediastinum Hemo-pneumothoraces, traumatic emphysema, alveolovenous fistulas from stress-induced tears of the air tissue interface Hemo-pneumothoraces, traumatic emphysema, alveolovenous fistulas from stress-induced tears of the air tissue interface Can lead to Broncho-Pleural fistulas (BPF) or Arterial Air Fistulas (AAE)Can lead to Broncho-Pleural fistulas (BPF) or Arterial Air Fistulas (AAE) Occurs following low vascular pressure after hemorrhage or high airway pressure during PPVOccurs following low vascular pressure after hemorrhage or high airway pressure during PPV

101 ARTERIAL AIR EMBOLISM (AAE) AAE – most common cause of rapid death solely caused by PBI in immediate survivors AAE – most common cause of rapid death solely caused by PBI in immediate survivors Occurs at first moment of PPV Occurs at first moment of PPV Pulmonary barotrauma, not from PBI, can lead to venous air emboli Pulmonary barotrauma, not from PBI, can lead to venous air emboli Long bone fractures lead to venous fat emboli Long bone fractures lead to venous fat emboli Both have same clinical picture as AAE: sudden hypoxemia and mental status changes Both have same clinical picture as AAE: sudden hypoxemia and mental status changes

102 ARTERIAL AIR EMBOLUS (AAE) Visualization of air in the retinal vessels, mottling of nondependent areas of skin, or demarcated tongue blanching are insensitive but rather specific indicators for systemic AAE Visualization of air in the retinal vessels, mottling of nondependent areas of skin, or demarcated tongue blanching are insensitive but rather specific indicators for systemic AAE No specific findings to detect MI and Coronary AAE other than profound shock and bradycardia with no other sources identified No specific findings to detect MI and Coronary AAE other than profound shock and bradycardia with no other sources identified

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106 LUNG PBI TREATMENT CXR, CT, ABG, etc…can assist in diagnosis but should not delay treatment CXR, CT, ABG, etc…can assist in diagnosis but should not delay treatment Tx: high flow oxygen, airway management, chest tubes if needed, mechanical vent if needed, permissive hypercapnia (provided no additional TBI), and judicious utilization of fluids Tx: high flow oxygen, airway management, chest tubes if needed, mechanical vent if needed, permissive hypercapnia (provided no additional TBI), and judicious utilization of fluids

107 PULM E & M Lung PBI acts like severe pulmonary contusions with impaired oxygen diffusion Lung PBI acts like severe pulmonary contusions with impaired oxygen diffusion Give highest FiO2 possibleGive highest FiO2 possible If problems soley with oxygenation and not ventilation – try NRB or CPAPIf problems soley with oxygenation and not ventilation – try NRB or CPAP No CPAP if suspect facial trauma/skull fx’sNo CPAP if suspect facial trauma/skull fx’s Spontaneous respirations desired for PBI lung to lessen likelihood of AAE, but may require PPV Spontaneous respirations desired for PBI lung to lessen likelihood of AAE, but may require PPV

108 PULM E & M (cont.) Poorly compliant blast-injured lungs need to be ventilated with techniques similar to those used with severe contusions or ARDS Poorly compliant blast-injured lungs need to be ventilated with techniques similar to those used with severe contusions or ARDS Pressure controlled ventilation with permissive hypercapnia to facilitate adequate oxygen exchange but keep transalveolar pressure less than 35 cm H 2 OPressure controlled ventilation with permissive hypercapnia to facilitate adequate oxygen exchange but keep transalveolar pressure less than 35 cm H 2 O Initial PEEP of 10 cm H 2 OInitial PEEP of 10 cm H 2 O Refractory hypoxemia or with associated bTBI Refractory hypoxemia or with associated bTBI Need to be managed with inverse I:E ratios, independent lung ventilation, high-frequency jet vent, and nitric oxide inhalation, even ECMO if neededNeed to be managed with inverse I:E ratios, independent lung ventilation, high-frequency jet vent, and nitric oxide inhalation, even ECMO if needed

109 PULM E & M (cont.) ABG ABG Check PaO 2 /FiO 2 rationCheck PaO 2 /FiO 2 ration Blast injury patients with initial ratio’s of > 200 mm Hg do not require mechanical vent for respiratory failure Blast injury patients with initial ratio’s of > 200 mm Hg do not require mechanical vent for respiratory failure Moderately impaired: PFR 60 – 200 mm Hg – generally require vent assistance for at least one day with PEEP > 5 cm H 2 O Moderately impaired: PFR 60 – 200 mm Hg – generally require vent assistance for at least one day with PEEP > 5 cm H 2 O PFR 10 cm H 2 O and unconventional vent strategies PFR 10 cm H 2 O and unconventional vent strategies

110 BLAST INDUCED TBI (bTBI) Most common cause of death Most common cause of death SAH and SDH – most common findings in fatalities SAH and SDH – most common findings in fatalities “Signature Wound” of the Afghanistan and Iraq wars “Signature Wound” of the Afghanistan and Iraq wars Vulnerable target, but the primary transduction pathway of blast energy to the brain is not well understood Vulnerable target, but the primary transduction pathway of blast energy to the brain is not well understood

111 PRIMARY bTBI 3 ways transduction can occur 3 ways transduction can occur Through direct transcranial propagationThrough direct transcranial propagation Via the vascular systemVia the vascular system From the CSF in the spinal cord to the Foramen MagnumFrom the CSF in the spinal cord to the Foramen Magnum (4 th Controversial mechanism – possible transmission via peripheral vasculature)

112 bTBI: EFFECTS OF EXPOSURE ON NEUROLOGIC FUNCTION Spectrum of injury severities ranging from mild effects to fatal injuries Spectrum of injury severities ranging from mild effects to fatal injuries Edema, contusions, DAI, hematoma, hemorrhage Edema, contusions, DAI, hematoma, hemorrhage Brain swelling occurs much soon after blasts (within hours) than routine trauma Brain swelling occurs much soon after blasts (within hours) than routine trauma Mortality decreased substantially with early decompressive craniectomiesMortality decreased substantially with early decompressive craniectomies

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114 bTBI: EFFECTS OF EXPOSURE (cont.) Persistent traumatic focal cerebral vasospasm Persistent traumatic focal cerebral vasospasm Worse outcomes notedWorse outcomes noted Also noted as a common and potentially underappreciated sequellae of cTBIAlso noted as a common and potentially underappreciated sequellae of cTBI

115 bTBI Milder end of the spectrum – “shell shock” or “blast concussion” Milder end of the spectrum – “shell shock” or “blast concussion” Symptoms include: physical (somatic), behavioral, psychological, and cognitive deficits Symptoms include: physical (somatic), behavioral, psychological, and cognitive deficits Symptoms often referred to as Post Concussive Syndrome or PCS Symptoms often referred to as Post Concussive Syndrome or PCS Includes retrograde amnesia, compromised executive function, headaches, confusion, amnesia, difficulty concentrating, mood disturbances, alterations in sleep patterns, and anxiety Includes retrograde amnesia, compromised executive function, headaches, confusion, amnesia, difficulty concentrating, mood disturbances, alterations in sleep patterns, and anxiety

116 cTBI and bTBI Similar symptoms as far as cognitive impairment Similar symptoms as far as cognitive impairment Disturbances in pain, balance, equilibrium, motor functioning, vision, depression or communicative abilities Disturbances in pain, balance, equilibrium, motor functioning, vision, depression or communicative abilities Frequently both occur at the same time secondary to event Frequently both occur at the same time secondary to event Can add penetrating trauma to the mix as well Can add penetrating trauma to the mix as well bTBI – increased risk for hearing loss and tinnitus as well as PTSD bTBI – increased risk for hearing loss and tinnitus as well as PTSD

117 PE FOR bTBI Subtle dysfunction to profound unresponsiveness Subtle dysfunction to profound unresponsiveness Causes of Altered Mental Status/Seizures Causes of Altered Mental Status/Seizures Hypoxemia from acute lung injuryHypoxemia from acute lung injury Shock from tension pneumo, hemorrhage or AAE induced MIShock from tension pneumo, hemorrhage or AAE induced MI Conventional blunt or penetrating head injuryConventional blunt or penetrating head injury Cerebral AAECerebral AAE Brain lesions resulting in focal deficits will most likely be related to severe intracerebral hemorrhage or AAE induced stroke Brain lesions resulting in focal deficits will most likely be related to severe intracerebral hemorrhage or AAE induced stroke

118 DIAGNOSITC APPROACH TO bTBI Significant correlation between tympanic membrane perforation and LOC Significant correlation between tympanic membrane perforation and LOC Also good correlation between occulo-motor dysfunction and bTBI Also good correlation between occulo-motor dysfunction and bTBI Biochemical markers being developed Biochemical markers being developed CT, MRI, DTI for diagnosis CT, MRI, DTI for diagnosis DTI – Diffusion Tensor Imaging – detects white matter damage by measuring diffusion of water in parallel tracts DTI – Diffusion Tensor Imaging – detects white matter damage by measuring diffusion of water in parallel tracts

119 CLINICAL CONSIDERATIONS IN bTBI More injuries with higher severity of injury noted in closed vs open blast settingsMore injuries with higher severity of injury noted in closed vs open blast settings Up to 36% can have delayed finding on CT scans 48 hours laterUp to 36% can have delayed finding on CT scans 48 hours later 30 – 44% have abdominal injuries as well30 – 44% have abdominal injuries as well Up to 50% have lung related PBIUp to 50% have lung related PBI Best practice guidelines difficult to follow with lung and brain injuries – contradictoryBest practice guidelines difficult to follow with lung and brain injuries – contradictory Rec’s: Inhaled Nitric Oxide to overcome severe hypoxemia and raise O2 saturation to at least 95% in brain injury patient while also ameliorating the inflammatory effects in the lungRec’s: Inhaled Nitric Oxide to overcome severe hypoxemia and raise O2 saturation to at least 95% in brain injury patient while also ameliorating the inflammatory effects in the lung Polytrauma likelyPolytrauma likely

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