1. BurnsAnthony HolleyIntensivistRBWH Bedside Critical Care 2012

2. Acknowledgement Prof. Jeff Lipman Bedside Critical Care 2012 3. Large tertiary ICUOnly burns referral centre40 monthsn = 158Bedside Critical Care 2012 4. Patient %Bu 1015 2025 3035 40 0 5rn:0-9Bu% rn :1 0-19%Burn:20- 29Burn:30- 39Burn:40- 49Burn:5Bedside Critical Care 20120- 59Burn Burn %:60- n =158 69Burn:70- 79Body Surface Area Burn DistributionBurn:80- 89 Bu rn :9Bu 0- rn10of 0 o ro phar ynx 5. Mortality 8.22% mortality But .0.68% in those with intention tocureBedside Critical Care 2012 6. Wallaces Rule of NineBedside Critical Care 2012 7. ClassificationBedside Critical Care 2012 8. First 24 HOURSAAirway assessmentBBurn assessmentCCirculation assessment Bedside Critical Care 2012 9. AIRWAY 60% of flame facial burns will have inhalational injuryBedside Critical Care 2012 10. Early BronchoscopyNebulised heparin for inhalation injury and to ??prevent VAPBedside Critical Care 2012 11. Alveolar Ridge/Maxillary Screws for ETT Fixation Bedside Critical Care 2012 12. ResuscitationAssessmentHeated roomsTheatre Bedside Critical Care 2012 13. Adult Burn Resuscitation Formulae(first 24 h)Formula Crystalloid Colloid OtherEvans (1952)1 ml/kg/%burn(N/S) 1 ml/kg/%burn 2000ml D5WBrooke (1953) 1.5ml/kg/%burn(LR)0.5 ml/kg/%burn2000ml D5WParkland (1968)4 ml/kg/%burn(LR) Modified Brooke (71)2 ml/kg/%burn(LR) Hypertonic saline1250 mEq Na/L Titrate to UOModified hypertonic2180 mEq Na/L Titrate to UO(first 8 h) then LRDextran3LR (titrate to UO) 2 ml/kg/h0.5 ml/kg/h(first 8 h) thenFFP1Monafo (1970) 2Warden (1992) 3Demling (1985)Bedside Critical Care 2012 14. FORMULAE Formulas should be regarded as a resuscitationguideline Lactated Ringers (Hartmans) solution most closelyresembles normal body fluids, note NaCl ->hyperchloraemia The Parkland formula - renamed the Consensusformula - because it is the most widely usedguideline 4 mL/kg/% TBSA in first 8 hrs rest over the next 16 hrsBedside Critical Care 2012 15. RESUSCITATIONHypovolaemic State: 0-48 hoursRapid fluid shiftsMetabolic acidosisIntense inflammatory response Protein lossCapillary permeabilityOliguria 3rd spacingHaemoconcentrationFluid loss deep in wounds Hyponatraemiacirculating blood Hyperkalaemia volumeBedside Critical Care 2012 16. Consequences of fluid overload Airway oedema Compartment syndromesBedside Critical Care 2012 17. Dulhunty et al Burns 2008;34:1090-7Bedside Critical Care 2012 18. ESCHAROTOMIES Bedside Critical Care 2012 19. ESCHAROTOMIES How not to do it! Bedside Critical Care 2012 20. THE THREE MOST IMPORTANT ISSUESIN BURNS CARE 1. Debridement and get early coverage 2. Debridement and get early coverage 3. Debridement and get early coverage Bedside Critical Care 2012 21. Coverage Xenograft (Pig skin) Allograft (cadarver skin) Biosynthetics and Synthetics (biobrane,integra) Cultured epithelial autograft Bedside Critical Care 2012 22. Intensive Care Complications Ventilator associated pneumonia TACO/TRALI/ARDS CRBSI Pancreatitis Acalculous cholecystitis Ischaemic enterocolitis Gastritis Cardiomyopathy Bedside Critical Care 2012 23. OTHER EARLY MANAGEMENT TIPS1. Head position to reduce oedema2. Ears: avoid pressure/chondritis3. Graft tracheostomy site and central line sites firstBedside Critical Care 2012 24. Nose: avoid notching from NG tubeBedside Critical Care 2012 25. Eyes: avoid corneal ulcerationBedside Critical Care 2012 26. EARLY ENTERAL FEEDING Repeated theatre trips dont requirecessation of feeds. Do not stop feeds.... unless: a) prone position b) airway manipulation Bedside Critical Care 2012 27. RBWH FEEDING PROTOCOL 10-20% FTB/DPT: 125 - 145kJ/kg and 1.2 - 1.5g/kg protein >20% FTB/DPT: 145 - 160kJ/kg and 20% energy as protein Bedside Critical Care 2012 28. Principles of Burn Management:Secondary surveyThe ultimate distracting injuryBedside Critical Care 2012 29. The ultimate distracting injury Bedside Critical Care 2012 30. RBWH PEARLS1. Nebulised heparin for inhalation injury and to ??prevent VAP2. ETT wiring3. Feeding throughout4. 1st area grafted is over trachea Bedside Critical Care 2012 31. Thank youThank you Bedside Critical Care 2012