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CASE 2
ANGGOTA KELOMPOK 9
Tutor Ketua Sekretaris Penulis Anggota : dr.Deni : Pamella Arteliana (405090164) : Ronald Krisbianto Gani (405090223) : Fendia Riska (405080125) : Malik Djamalludin (405080053) Yunita Widyaningsih (405080004) Meida Astriani (405080062) Silvina Isditya (405080088) Thomas Khosasih (405080111) Selvia Shienyanlin Surya (405090098) Thedi Darma Wijaya (405090120) Priskila Christy (405090252) Monica Sylviana Mayasari (405090259)
MIND MAPPING
32yo Burn Injury at UE & LE & Face & Nostril Burnt TBSA : 63%, suspect inhalation injury Severe Burn injury PE & Lab Tachycardia Tachypnea Fever Leukocytosis Bullae with pus High creatinine + SIRS + Second Degree Burn Injury + Sepsis + Assess for Acute Renal Failure
LEARNING OBJECTIVES
Thermal Burn Sepsis Syndromes
THERMAL BURNS
THERMAL BURNS
Injuries to the skin resulting from contact with heat, electrical current, radiation, or chemical agents Less than 44oC well tolerated Above 60oC denaturation of protein
EPIDEMIOLOGY
American Burn Association
500.000 burn injuries, 40.000 admissions 4.000 deaths Caused by : Fire (46%), scalds (32%), hot objects (8%), electricity (4%), chemical agents (3%) 38% >10% TBSA, 10% >30% TBSA Age 19-44 Location : UE (41%), LE (26%), Head & Neck (17%) <5% full thickness
Rosens Emergency Medicine 7th Ed
BURN ZONES
Burns consist of three geographic zones
Zone of coagulation: center of burn; greatest heat transfer Zone of stasis: pronounced inflammation and vascular injury; cell survival tenuous Zone of hyperemia: tissue injury minimal; expected recovery
PATHOPHYSIOLOGY
Clotting inflammatory cells recruitment (B2integrins, CD11b, CD18) cells marginate to vessel walls (ICAM-1) release of mediators and cytokines (cytotoxic reactive oxygen and nitrogen species) lipid peroxidation accumulation of leukocytes, RBC, platelet microthrombi reduce local perfusion
PATHOPHYSIOLOGY
Damage to the normal epidermal barrier bacterial invasion & external fluid loss; damaged tissues often become edematous, further enhancing volume loss. Heat loss can be significant because thermoregulation of the damaged dermis is absent, particularly in wounds that are exposed.
Surface
Sensation
Painful Painful Painful
Time to Healing
Days 14-21 days Weeks, or may progress to 3rd degree and require graft Requires excision Requires excision
Dry, leathery
Insensate Insensate
Disposition
Outpatient
Admission
DIAGNOSIS
Anamnesis
History of trauma / exposure to the heat source (flame, hot water, hot oil, chemicals, electricity, radiation) History trapped in a confined space History of exposure to a blast History of falls from a certain height after exposure to heat sources
MANAGEMENT
MANAGEMENT AT ED
Airway Management
Upper airway compromised fiberoptic laryngoscopy + endotracheal intubation Cricothyrotomy : needle/surgical
MANAGEMENT AT ED
General Measures for Moderate to Severe Burns
MANAGEMENT AT ED
Recognizing Inhalation Injury
Based on clinical findings :
facial burns singed nasal vibrissae carbonaceous sputum history of injury within a closed space
MANAGEMENT AT ED
Recognizing Inhalation Injury
Diagnosis : direct visualization
Fiberoptic laryngoscopy & Bronchoscopy Findings : presence of soot, charring, mucosal inflammation, edema/necrosis
MANAGEMENT AT ED
Management of Inhalation Injury
Indications for Endotracheal Intubation and Mechanical Ventilation in Burns Patients Upper airway obstruction Inability to handle secretion Hypoxemia despite 100% O2 Patient obtundation Muscle fatigue suggested by a low/high RR Hypoventilation (a PCO2 >50mmHg & pH < 7.2
The goals of mechanical ventilation : O2 saturation > 92% Recommended Initial Ventilator Settings Tidal Volume Respiratory Rate Plateau Pressures 6-8 mL/kg 8-12 in adults ; 12-45 in children < 35cm H2O
1:1-1:3
40-100 L/min 8cm H2O
MANAGEMENT AT ED
Management of Inhalation Injury
Alveolar lavage : to remove thick secretions & improve pulmonary toilette Aerosolized N-acetylcysteine +/- aerosolized heparin : to break down thick mucous secretions Bronchodilators : patients with wheezing
MANAGEMENT AT ED
Circulation and Fluid Resuscitation
Small burns : oral fluids Large burns : IV fluid resuscitation Parkland :
1st 24 hours : LR 4ml/kg/% burn within 1st 8hr Next 24 hours : Colloids in amount of 20-60% of plasma volume; glucose in water added 0.5-1.0 ml/kg/hr (adult) & 1 ml/kg/hr (children)
Care of the burn wound requires : oral/IV analgesic agents May need : tetanus toxoid booster with tetanus immune globulin
Large burns + ice water (1o-8oC) more necrosis Large burns + tap water (12o-18oC) least necrosis & fastest healing
Close method :
Occlusive dressing to enhance re-epitalization, angiogenesis & reduce pain for superficial 2nd degree burns with little exudate
Escharotomy : Indication
Doppler signals in the extremity Pulse oximetry < 90% +/- Doppler signals peak airway pressure/difficulty + ventilation in a mechanically ventilated burn
PAIN MANAGEMENT
Non pharmacologic
Cooling, tap water 10o-25oC Moist occlusive dressing
Pharmacologic
Morphine Sulfate (0,05-0,1mg/kg) titrated Acetaminophen (1g adults, 15mg/kg child) /4-6h Ibuprofen (400-800mg adults, 10mg/kg child) / 6-8h Fentanyl 0,5-1mg/kg Lidocaine Anxyolytics : benzodiazepin (Lorazepam) Others : gabapentin, stimulants, B-Blockers, antidepressants
Rosens Emergency Medicine 7th Ed
NUTRITION
enteral liquid foods RS / commercial formula with viscosity of 1 calorie / mL. duration of enteral feeding in the bottle should not be> 4 hours. For adults given 45 mL / h, in children <3 years with heavy burns 5 mL / hr and children> 3 years of 10-20 mL / hour. Enteral nutrition administered via nasogastric tube (for baby & children & for adults 8F 8-14 F). Droplet velocity using an infusion pump (cyclic). Monitor patients continuously., Especially GI tolerance.
Micronutrient composition
Carbohydrates 60-65% of total calories / does not exceed 4-5 mg / kg / min. Protein severe burns : 23-25% of total calories with calorie ratio: nitrogen = 80:1 / 2.5 to 4 g protein / kg. Post-traumatic fat 5-15% of total calories. Omega 3 is recommended in patients with burns because the omega 3 will compete & inhibition formation of PGE1 & PGE2 as. Linoleic.
Micronutrient supplementation
Micronutrients required as coenzyme and cofactor for the physiological reactions in the cell, macronutrient and energy metabolism. Vitamin for protein synthesis, wound healing, enhance immune function and antioxidant. In patients with burns in a state of severe pain and hipermetabolisme increased vitamin needs.
Recommended supplementation increased 500-1000 times recommended daily allowance (RDA) for vitamins and water soluble vitamin E, a safe dose for fat soluble vitamins and vitamin B6 to 10 times the RDA
Minerals play an important also for wound healing, immune function, antioxidant, etc.. Zinc to protein metabolism. Selenium-dependent glutathione peroxidase protect cells from damage by hydrogen peroxide.
10 mg
10 mg 200 mg 100 mg 5 mg 20 mg 2 mg 20 ug 2000 mg
COMPLICATION
Risk factors for severe systemic complications and mortality include all of the following:
Burns of > 40% of BSA Age > 60 yr or < 2 yr Presence of simultaneous major trauma or smoke inhalation The most common systemic complications are hypovolemia and infection.
SYSTEMIC COMPLICATION
Hypovolemia Infection. Most common : streptococci & staphylococci during the first few days and gram-negative bacteria after 5 to 7 days; however, flora are almost always mixed.
SYSTEMIC COMPLICATION
Metabolic abnormalities (hypoalbuminemia), Dilutional electrolyte deficiencies (hypomagnesemia, hypophosphatemia, and hypokalemia), Metabolic acidosis , Rhabdomyolysis or hemolysis -> acute tubular necrosis and renal failure. Hypothermia Ileus is common after extensive burns.
BURN SHOCK
LOCAL COMPLICATION
Eschar Scarring and contractures result from spontaneous healing of deep burns
SEPSIS SYNDROMES
DEFINITIONS
Activated Inflammatory cascade cause the bodyd defenses and regulatory system become overwhelmed leading to disruption of hemeostasis Systemic Inflammatory Response Syndrome (SIRS) 2 or more : tachycardia, tachypnea, hyperthermia or hypothermia, high or low WBC count, bandemia.
Rosens Emergency Medicine 7th Ed
DEFINITIONS
Sepsis : SIRS + infection Severe Sepsis : Sepsis + Organ Dysfunction Septic Shock : Severe Sepsis + hypotension which is not responsive to fluid challange Approach : PIRO (predisposition, infection source, response of host, organ dysfuntion) Bacteremia is not obligatory in diagnosis of sepsis
Rosens Emergency Medicine 7th Ed
PREDISPOSING FACTORS
Diabetes mellitus Cirrhosis Leukopenia, especially that associated with cancer or treatment with cytotoxic drugs; Invasive devices,ex : ETT, cathethers, drainage tubes, and other foreign materials; Prior treatment with antibiotics or corticosteroids.
EPIDEMIOLOGY
In United States :
10th most common cause of death 571.000 cases of severe sepsis Mortality rate 20-50% Incidence
PATHOPHYSIOLOGY
Infection host response neutrophil and macrophage mobilization to injury site release cytokines inflammatory cascade synthesis is not well regulated sepsis Ongoing toxin persistent inflammatory response mediator activation cellular hypoxia, tissue injury, shock, Multi-Organ Failure, death
Rosens Emergency Medicine 7th Ed
PATHOPHYSIOLOGY
Mediators of Sepsis
Proinflammatory : IL-1, IL8, TNF Anti-inflammatory IL-10, IL-6 TGF B, IL-1ra Growth promoting
Arachidonat acid pathway peripheral dilation, vasocontriction, leukocyte and platelet aggregation PG fever
Rosens Emergency Medicine 7th Ed
PATHOPHYSIOLOGY
Vasopressin release in stress condition, cause vasoconstriction, osmoregulation, maintenance of normovolemia NO Regulating vascular tone, platelet adhesion, insulin secretion, neurotransmission, tissue injurt, inflammation and cytotoxicity
PATHOGENESIS
SIRS
Sepsis
Severe Sepsis
SIRS
Sepsis
Severe Sepsis
Sepsis with 1 sign of organ failure Cardiovascular (refractory hypotension) Renal Respiratory Hepatic Hematologic CNS Unexplained metabolic acidosis
Shock
Bone et al. Chest. 1992;101:1644; Wheeler and Bernard. N Engl J Med. 1999;340:207.
DIFFERENTIAL DIAGNOSIS
MANAGEMENT
Principles
AB therapy Maintenance of adequate tissue perfusion
MANAGEMENT
Respiratory Support
Airway protection, intubation, mechanical ventilatory support if needed
Cardiovascular support
Initial therapy 2L of isotonic crystalloid Normal Saline/ LR. Maintain MAP >65mmHg, but 75mmHg in patient ith history of severe hypertensive patient
MANAGEMENT
Drugs : Vasopresin, Norepinephrine, Dopamine, Phenylephrine, Epinephrine. Inotropic agents : Dobutamine, Bicarbonate, AB
Novel Therapies
Activated Protein C Steroid Therapy
REFERENCES
Marx JA, Hockberger RS, Walls RM, Adams JG, editors. Rosens Emergency Medicine Concepts and Clinical Practice. 7th Ed. Philadelpia : Mosby Elsevier, 2010 Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, editors. Fitzpatricks Dermatology in General Medicine. 7th Ed. New York : McGraw-Hill, 2008