Case 8: Firefighter presents following burn injury and being trapped under beam

Question 1

What is your initial assessment?

Answer 1

• Perform rapid assessment of patient
  
  • Initial assessment - is patient stable, unstable, or facing impending hemodynamic compromise?
  • Primary survey - Assessment of stabilzation of the patient’s airway, ventilation, circulation, and neurologic function. A quick assessment of the undressed patient to identify additional injury
  • Secondary - Head to toe exam for additional injury, order radiographs, diagnositic procedures, lab tests.
  • Tertiary survey - Occurs within the first 24 hours to indentify clinically significant injuries missed in the initial eval (consider pre existing co moribities, medical record, results of lab and diagnostic testing)

Question 2

What is mechanism of cyanide toxicity?

Management?

Answer 2

Inhibits mitochondria cytochrome oxidase, thus blocking electron transport, oxidative metabolism and utilization of oxygen.

Lactic acidosis occurs as a result of anaerobic metabolism

Most affected cells are heart and CNS

Treat with sodium thiosulfate to convery cyanide to thiocyanate which is excreted renally.

Question 3

What is the parkland formula?

Answer 3

4 mL/kg x TBSA = fluid deficit

Widely accepted formula to guide fluid resuscitation following sigificant burn injury.

Formula calls for fluid replacement with lactated ringers

Using this formula as a guideline, would set the rate to deliver 50% in first 8 hours followed by 50% over 16 hours.

However formula is guideline, would take precautions to avoid excessive fluid administration.

Question 4

What are the different degress of burn injury?

Answer 4

1st degree - epidermis

2nd degree - epidermis + dermis

3rd degree - full thickness, w/ complete destruction of epidermis and dermis

4th degree - involvement of muscle fascia and bone.

Question 5

In adults what is defined as a major burn injury?

Answer 5

full thickness burn involving >10% TBSA or partial thickness involving >25% TBSA

Question 6

What are the concerns regarding smoke inhalational injury?

Answer 6

Upper airway inhalational injury is concerning since it can lead to glottic and periglottic edema formation, copious thick secretions, and subsequent airway obstruction.

Unfortunately aggressive fluid resuscitation can excerbate swelling and obstruction d/t third spacing.

Moreover in the event of lower airway injury, patient may experience bronchial obstruction, bronchopneumonia, and air trapping due to mucosal necrosis, edema formation, tissue sloughing, copious secretions, reduced surfactant, reduced mucociliary dysfunction.

Parenchymal lung injury usually presents day 1-5 as ARDS.

Question 7

Causes, contributing factors to post induction and intubation hypotension in the setting of blunt force thoracic trauma and fire injury

Answer 7

1. Anesthetic induced cardiovascular depression
2. Hemorrhagic Shock (occult bleeding)
3. Cardiogenic shock 2/2 burn injury induced myocardial depressent factors, myocardial toxicity 2/2 affects on mitochondrial dysfunction
4. CO poisoning - direct myocardial toxicity effects
5. Cyanide toxicity which leads to cardiovasculat depression
6. Hypovolemic shock
7. Vagal response to laryngoscopy
8. Tension PTX
9. Fat emobolism (leg splint)
10. Neurogenic shock
11. hypothermia
12. Allergic reaction
13. Transfusion induced reaction

Question 8

Would you administer bicarbonate in burn patient to treat acidosis?

Answer 8

I would not due to the generation of additonal CO2 that could worsen acidosis

Left ward shift of Oxygen hemoglobin curve which may already be compromised by CO and CN poisioning

Worsening of hypokalemia due movement of K+ from extracellular to intracellular compartment

However i recognize that significant acidosis may lead to dysrhymia, hypotension, myocardial depression and catecholamine release. Therefore if pH dropped below 7.1 I would consider bicarbonate administration

Question 9

What monitors would you require for this type of case?

Answer 9

Question 10

What cardiovascular changes you expect to occur following significant burn injury?

Answer 10

24-48 hours CO reduced d/t circulating myocardial depressants factors, hypovolemia, decreased coronary blood flow

Question 11

How long after major burn injury would you be concerned about administration of succinylcholine?

Answer 11

24 HOURS

Question 12

What is the pathophysiology of bone cement syndrome?

Answer 12

Question 13

Treatment of bone cement syndrome?

Answer 13

Largely supportive

100% O2, Fluid, pressor support to maintain hemodynamic stability