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MORBIDITY AND MORTALITY REVIEW 14/2/2013

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Mrs M / 72y.o /malay Underlying DM/HPT and IHD under KK f/up Pts meds T gliclazide 80mg bd T metformin 1g bd T amlodipine 5mg od T metoprolol 100mg bd T digoxin 0.25mg od T lovastatin 20mg ON HISTORY

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Case referred from Hosp Setiu on 17/1/13 Pt alleged flame burn injury at 2 pm on the day of admission She went to her sons workshop when a fire sparked from the welding apparatus. She was caught on fire from the petrol Premorbidly ADL independent had on and off palpitation Denied chest pain, sob and failure sx NYHA I-II

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Alert, conscious, pink, afebrile GCS 15/15 BP: 205/108 140/98 (after T adalat 10mg stat) PR: 120 88bpm Spo2 100% Lungs clear, equal air entry CVS irregular rhythm PA: soft Physical examination

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Deep partial thickness burn injury at Rt lower limbs fr foot up to whole thigh Partial thickness burn injury at Lt LL from foot up to whole thigh involving perineum Mixed partial thickness burn at ant part of torso including both nipples Superficial partial thickness burn at left hand up to wrist Partial thickness burn at right hand

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Deep partial thickness 17.5 Superficial partial thickness 25.5 Total area 43% TBSA ASSESSMENT Alleged flame burn injury with 43% partial and full thickness burn injury over both LL, perineum and ant chest

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Ix from hosp setiu Twcc 16.7 / hb 6.9 / plat 267 BUSE: 3.4 / 128 / 3.1 / 96 PT/PTTK/INR: 13.9 / 21.2 / 0.95 ECG: atrial flutter Investigations

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IVD HM 500ml/H till 10pm then 355ml/h till 2pm cm Daily SSD dressing and CMC ointment Hourly circulation chart FM 5L/min Strict I/O chart High protein diet CARE PLAN

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Premed review BP: 151/97, HR: 104, SPO2 100% ECG showed Atrial fibrillation, CXR showed cardiomegaly Pb list 1.Alleged flame injury with 43% partial and full thickness burn injury over both lower limbs, perineum and ant chest 2.AF, rate control 3.Underlying Dm, HPT classified as ASA II Anaest plan: GA with IPPV 18/1/13

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Medical review Premorbidly well Dscan 15 13 Medical plan QID dscan Add s/c actrapid 6u tds Add s/c insulatard 10u ON Add captopril 12.5mg tds

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Operation done under GA Operation: WD, euro skin application and dressing Time of op: 12:56 14:57 Intraop: cardiac monitor showed Atrial fibrillation with HR 90-100. EBL 800ml fluid given 2.5L (4 pints crystalloid and 1 pint WB) Post op order: admit ward with FMO2 5L/min IVD 2 pints NS 2 pints HM 20/1/13

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At 11.45pm, noted pt become drowsy Dscan 1.8 given D50% 50ml + RTF peptamen 250ml rpt dscan 5.6 Otherwise, GCS full, but pt not taken orally well since post op Documented urine output 0.5ml/kg/h Plan Change IVD to 4 pint D5% Start RTF 250ml/4Hly Dscan Hly then 4Hly cont

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3.00 am Pt developed desaturation. Spo2 90% under HFOM, BP 156/91, HR 120 Given T digoxin 0.5mg stat Dscan 10.3 Lungs: crept up to bilat UZ ECG showed AF with HR 130bpm Plan IV lasix 20mg stat reduce IVD 2 pint D5% Withhold RTF 21/1/13

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Urine output 400ml post IV lasix 20mg Lung transmitted sound, crepts MZ RR 24 Plan Reduced IVD 1pint D5% Another 10mg IV lasix

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7am Pt become more tachypneoic SPO2 80-85% under HFOM On oral suction noted yellowish fluid RT aspirate >150ml undigested milk Clinically drowsy BP 123/56 HR 95 RR 25 SPO2 on manual bagging 85% Lungs: gen crepts Plan : refer anaest for airway protection

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Refer by plastic team for acute respiratory distress ? Secondary to aspiration / atelectasis Upon attended by anaest MO, SPO2 patient on manual bagging only 85% Clinically pt drowsy, open eyes spontaneously, not obey command, tachypneoic (RR 25) BP: 110/60. PR 100. afebrile lung: gen crepts Anaest referral

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ABG pH 7.31 pCO2 42 PO2 99 HCO3 21 BE -2 SPO2 98% ECG sinus tachycardia TWCC ; 16 Impression 1.Alleged flame burn injury with 43% partial and full thickness burn injury 2.Acute resp distress ? Secondary to aspiration / post op atelectasis 3.Geriatric with multiple comorbid DM/HPT/AF

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Pt on sedation mida/morphine Warm peripheries BP 144/66, HR 126 IX reviewed ECG: atrial fibrillation CXR: pneumonic patch Bedside ECHO: dilated all chambers, global hypokinesia ICU admission

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1.Alleged flame injury with 43% partial and full thickness burn injury over both lower limbs, perineum and ant chest D1 post WD, euro skin application and dressing 2.Fluid overload possible of CCF 3.Underlying DM,HPT, IHD, AF Problem list

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Plan Start IV cefepime 2g tds IV MGSO4 10mmol stat Mist KCL 15mls tds T digoxin 0.25mg od T lovastatin 20mg ON IVD HsD5% 80ml/h Sedate with mida/fentanyl Put on bilevel fio2 1, HPEEP 30, LPEEP 14, f 10, PS 10 Keep urine output >30mls/h

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2pm BP progressively severe hypotensive BP: 74/39, HR 144 Require step up inotropic support Inf noradrenaline 40mls/h Inf Dopamine 10mls/h Inf Dobutamine 5mls/h ABG : refractory hypoxia on high setting bilevel pH 7.25, pCO2 41.6, pO2 43.9, spo2 77.8, HCO3 15.4, BE -10, lactate 7.5

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3pm Still in refractory hypotensive and hypoxia Given multiple IV adrenaline boluses BP: 62/30, HR 110 Gasping, self sedated Pupils bilaterally dilated ASSESSMENT severe septicaemic shock with underlying poor cardiac reserve

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Pronounced death at 3.55pm

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Investigations Full blood count BUSE/CREAT 17/1/1321/1/13 hb13.611.311.7 plat21215198 twcc21.45.61 19/1/1320/1/1321/1/13 urea5.74.63.63.7 sodium127135131135 potassium4.74.23.8 chloride9910699104 creatinine51362946

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Investigations Full blood count BUSE/CREAT 17/1/1321/1/13 hb13.611.311.7 plat21215198 twcc21.45.61 19/1/1320/1/1321/1/13 urea5.74.63.63.7 sodium127135131135 potassium4.74.23.8 chloride9910699104 creatinine51362946

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Phospate : 0.78 Magnesium : 0.43 Calcium 1.70 RBS : 2.6 PT/PTTK/INR 20/1/1321/1/13 PT14.114>60 INR1.061.05>4.44 PTTK35.446.6>120

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LFT C&S Tissue C&S (17/1/13) : NG Urine C&S (21/1/13) : NG Blood C&S (21/1/13) : klebsiella pneumonia Multisensitivity. Resistant ONLY to ampicillin 21/1/13 A/G0.60.5 ALB1912 ALP6853 ALT1613 GLO3123 TB710 TP5035

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DISCUSSION

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The depth of burn is documented as partial or full thickness The extent of burns is assessed using Wallace Rule of 9 in adult Lund browder chart in children The palm of pts hand represents ~1% of pts BSA Burn assessment

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Classification of burn

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Lund & Browder charts Wallace rule of 9

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Parklands formula Total fluid requirement in the first 24H = 4 x pts weight (kg) x % TBSA Infuse the first half in the first 8h Infuse the rest in the next 16H Start time = time of burn injury Fluid of choice = hartmanns solution Fluid regime

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Adequate resuscitation is monitored by vital parameters and urine output 0.5 1ml/kg/h If urine output falls below 0.5ml/kg/h a bolus of 10ml/kg body weight can be given If urine output >2ml/kg/h the rate of infusion should be reduced

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Next 24H Total volume = of the first day Colloids (o.5ml/kg/%) and 5% glucose or isotonic glucose saline to make up the rest

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Consequences of burns 1.Renal failure (acute tubular necrosis d/t hypovolaemia, haemoglobinuria and myoglobinuria) 2.Resp failure (smoke inhalation, airway obstruction, ARDS) 3.Catabolism and nutritional depletion 4.Venous thrombosis 5.Curlings ulcer and erosive gastritis Short term consequences Early consequences 1.Permanent disfigurement 2.Prolonged hospitalization 3.Psychological problem 4.Impaired function Long term consequences 1.Hypovolaemia (loss of protein, fluid and electrolytes) 2.Metabolic derangements 3.hyponatraemia followed by risk of hypernatraemia, hyperkalaemia followed by hypokalaemia) 4.Sepsis 5.Hemolysis with anemia 6.hypothermia

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CVS: Acute phase: transient decrease in cardiac output d/t hypovolaemia, depressed myocardial function, increased blood viscosity and release of vasoactive substance causing poor organ and tissu perfusion Second phase (metabolic phase) :after 48H increased blood flow

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Resp Early compl : 0-24H carbon monoxide poisoning and direct inhalational injury airway obstruction and pulm edem Delayed 2-5days: adult resp distress syndrome Late: days to weeks pneumonia, atelectasis and pulm emboli

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Risk factors for the development of pneumonia in older adults with burn injury By Tam N. Pham et al. J burn care res. 2010 jan feb; 31(1) 105 110 Older adult with burns are at risk for worse outcomes because of factors related to age, comorbidities and response to treatment Pneumonia is the most common infection in hospitalizes burn patients and is frequently assoc with death

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Respiratory complications in burns: an evolving spectrum of injury Boots, Robert J et all, clinical pulmonary medicine: may 2009 vol 16 issue 3 pp 132-138 Respiratory complications associated with burn injury are responsible for significant morbidity and mortality and occur in up to 41% of patients admitted to hospital after thermal injury Inhalation injury can be due to a combination of thermal, chemical and systemic effects and is the most significant complication in the early phase post burn injury (first 48hours), predisposing the patient to the development of pulmonary edema, acute respiratory distress syndrome and pneumonia

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Age and general condition Site of the burn Extent of the burn Depth of the burn Assoc respiratory injury Prognosis of burn 11 22 33 44 55

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Thank you

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Points to learn Detail hx taking in burn case Facial and neck involvement Surrounding area: close vs open Clinical examination: Sx of burn smoke Sx of airway involvement: difficult articulation, change of voice, stridor Proper ASA classification Proper intraop management Invasive monitoring Fluid management Major burn : >10% in children, >15% in adult Major burn case admit icu ventilated for airway protection/post op Proper burn management inhalational, chem,etc Parkland formula is just a guide. Resuscitation must be based on pts cond and monitoring