EMERGENCY MEDICINE BLOCK

CASE 2

GROUP 09 Faculty of Medicine Tarumanagara University

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

Rosens Emergency Medicine 7th Ed

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

Rosens Emergency Medicine 7th Ed

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.

BURN DEPTH CLASSIFICATION

Appearance
1st Degree Superficial 2nd Degree Deep 2nd Degree Pink or Red Pink, clear blisters Pink, hemorrhagic blisters, red White, brown Dry Moist Moist

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

3rd Degree 4th Degree

Dry, leathery

Insensate Insensate

Brown, charred Dry

TOTAL BODY SURFACE AREA

TOTAL BODY SURFACE AREA

LUND-BROWDER CHART

Rosens Emergency Medicine 7th Ed

BURN SEVERITY CLASSIFICATION

Mild Children Adult Eldery All <5% TBSA <10% TBSA <5% TBSA <2% full thickness Moderate 5-10% TBSA 10-20% TBSA 5-10% TBSA 2-5% full thickness, high voltage, inhalation, circumferential, cormobid disease Severe >10% TBSA >20% TBSA >10% TBSA >5% full thickness, high voltage, significant burn to face, eyes, ears, genitalia, or joints, significant associated trauma Burn unit

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

Physical examination Primary Survey : ABC Secondary Survey

Embed also:
1. The degree and extent of burns 2. Causes burns 3. As well as the problems that exist at the time of the first inspection, the example problem: - inhalation injury - Eschar around chest - shock

Schwartz's Principles of Surgery

MANAGEMENT

MANAGEMENT PRIOR TO ED ARRIVAL

1st priority : stop the burning process & protect the patient from additional injury Priorities of care : ABC Burns : Covered with a clean dressing & Cooling
Topical antimicrobial agents shouldnt be used in the prehospital phase of care

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

O2 : to maintain an O2 saturation > 92% Severe burns :

IV access : 2 large-bore IV catheters Urethral catheter : to monitor urine output Cardiac, O2 saturation, BP monitoring

MANAGEMENT AT ED
Recognizing Inhalation Injury
Based on clinical findings :
facial burns singed nasal vibrissae carbonaceous sputum history of injury within a closed space

Signs : wheezing, crepitations, hypoxemia

MANAGEMENT AT ED
Recognizing Inhalation Injury
Diagnosis : direct visualization
Fiberoptic laryngoscopy & Bronchoscopy Findings : presence of soot, charring, mucosal inflammation, edema/necrosis

Diagnosis of injury to parenchyma of the lung : xenon ventilation scanning

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

I/E Ratio (inspiratory/exp)

Flow Rates PEEP (positive end exp pressure)

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)

MANAGEMENT : LOCAL WOUND CARE

All burns are considered contaminated :
Cleansing with soap & water Debris & necrotic tissue should be gently removed

Care of the burn wound requires : oral/IV analgesic agents May need : tetanus toxoid booster with tetanus immune globulin

MANAGEMENT : LOCAL WOUND CARE

Cooling of the Burn
Optimal cooling temperature : 10o-25oC
pain, progression of tissue necrosis & limit the requirement for skin grafting

Large burns + ice water (1o-8oC) more necrosis Large burns + tap water (12o-18oC) least necrosis & fastest healing

MANAGEMENT : LOCAL WOUND CARE

Burn Dressing
The purposes of a burn dressing :
To protect the wound Reduce pain & evaporative heat loss Absorb wound exudate

1st degree burns :

topical anesthetic, aloe vera, topical NSAIDs

MANAGEMENT : LOCAL WOUND CARE

Burn Dressing : 2nd Degree Burns
Open method :
Topical antimicrobials for contaminated large burns with large amounts of exudate

Close method :
Occlusive dressing to enhance re-epitalization, angiogenesis & reduce pain for superficial 2nd degree burns with little exudate

MANAGEMENT : LOCAL WOUND CARE

Burn Dressing : 3rd Degree Burns
Cover the wound with a petrolatum-type dressing transferred to a burn center

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.

for patients with severe burns

Vitamin larut lemak Beta karoten vitamin D Vitamin E vitamin K 10.000 IU 200 IU 400-1000 IU 1 mg Mikromineral Koper Mangan Selenium Seng 1,5-3 mg 3,5- 5 mg 100 ug 50 mg

Vitamin larut air Tiamin

Riboflavin Niacin Asam pantotenat Biotin Piridoksin Asam folat Vitamin B12 Vitamin C

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

Rosens Emergency Medicine 7th Ed

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

Rosens Emergency Medicine 7th Ed

PATHOGENESIS

Sepsis: Defining a Disease Continuum

Infection/ Trauma

SIRS

Sepsis

Severe Sepsis

A clinical response arising from a nonspecific insult, including 2 of the following:

Temperature 38oC or 36oC HR 90 beats/min Respirations 20/min WBC count 12,000/mm3 or 4,000/mm3 or >10% immature neutrophils

SIRS with a presumed or confirmed infectious process

SIRS = systemic inflammatory response syndrome. Bone et al. Chest. 1992;101:1644.

Sepsis: Defining a Disease Continuum

Infection/ Trauma

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

Rosens Emergency Medicine 7th Ed

MANAGEMENT
Principles
AB therapy Maintenance of adequate tissue perfusion

Rosens Emergency Medicine 7th Ed

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

Rosens Emergency Medicine 7th Ed

MANAGEMENT
Drugs : Vasopresin, Norepinephrine, Dopamine, Phenylephrine, Epinephrine. Inotropic agents : Dobutamine, Bicarbonate, AB

Novel Therapies
Activated Protein C Steroid Therapy

Rosens Emergency Medicine 7th Ed

Rosens Emergency Medicine 7th Ed

CONCLUSION & SUGGESTION

The patient is suffering from second degree thermal burn and severe sepsis Perform Primary and Secondary Survey as needed

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