CASE PRESENTATIONSCASE PRESENTATIONS

Rashid M.KhanRashid M.KhanReaderReader

Department of AnaesthesiologyDepartment of AnaesthesiologyJ.N.Medical CollegeJ.N.Medical College

AligarhAligarh

CASESCASES

Burns: Acute & Late stages includingBurns: Acute & Late stages including

Contractures. Contractures.

Temporomandibular Joint Ankylosis.Temporomandibular Joint Ankylosis.

QuestionsQuestions

AnswersAnswers

STRUCTURED APPROACHSTRUCTURED APPROACH Short Case Presentation with photographs.Short Case Presentation with photographs. Relevant Anatomy & Physiology.Relevant Anatomy & Physiology. Etiology.Etiology. Classification.Classification. Diagnosis, Treatment.Diagnosis, Treatment. Anaesthetic Management with special Anaesthetic Management with special

reference to airway management.reference to airway management.

CASE – ICASE – I

BurnsBurns

A 23 year-old female patient presented with severe A 23 year-old female patient presented with severe contractures of the face & neck following burns contractures of the face & neck following burns

sustained about 9 months back.sustained about 9 months back.

What is the normal structure of the skin?What is the normal structure of the skin?

What are the physiological functions of the skin?What are the physiological functions of the skin?

It is a sensory organ.It is a sensory organ.

It performs a major role in thermoregulation It performs a major role in thermoregulation for dissipation of metabolic heat.for dissipation of metabolic heat.

It acts as a barrier to protect the body It acts as a barrier to protect the body against microorganism in the environment against microorganism in the environment

WE SHALL DISCUSSWE SHALL DISCUSS BURNS BURNS

AS:AS:

•ACUTE BURNSACUTE BURNS

* CHRONIC BURNS WITH CONTRACTURES* CHRONIC BURNS WITH CONTRACTURES

How are burns classified?How are burns classified?

11st st degreedegree burns = involves upper layer of epidermis, skin is burns = involves upper layer of epidermis, skin is painful & red.painful & red.

22ndnd degree burns = Damage extends into the dermis, degree burns = Damage extends into the dermis, develops blisters, has red or whitish areas, very painful. develops blisters, has red or whitish areas, very painful. Regenerates into new skin.Regenerates into new skin.

33rdrd degree burns = Destruction of all layers of skin degree burns = Destruction of all layers of skin including nerve endings, painless. No regeneration.including nerve endings, painless. No regeneration.

44thth degree burns = Destruction of all skin layers, muscle & degree burns = Destruction of all skin layers, muscle & fascia, may even reach the bones.fascia, may even reach the bones.

How do you calculate the % of total body surface How do you calculate the % of total body surface burned?burned?

Rule-of-nine for 2Rule-of-nine for 2ndnd & 3 & 3rdrd degree burns degree burns Head & neck – 9%Head & neck – 9% Upper extremities – 9% each.Upper extremities – 9% each. Chest [anterior & posterior] – 9% each.Chest [anterior & posterior] – 9% each. Abdomen – 9%.Abdomen – 9%. Lower back – 9%.Lower back – 9%. Lower extremities – 18% each.Lower extremities – 18% each. Perineum – 1%.Perineum – 1%.

What is the modified Rule-of-Nine for children?What is the modified Rule-of-Nine for children?

NewbornNewborn 3 years3 years 6 years6 years

HeadHead 18%18% 15%15% 12%12%

TrunkTrunk 40%40% 40%40% 40%40%

ArmsArms 16%16% 16%16% 16%16%

LegsLegs 26%26% 29%29% 32%32%

What is the definition of a MAJOR BURN?What is the definition of a MAJOR BURN?

The American Burn Association defines Major The American Burn Association defines Major Burns as:Burns as:

Full thickness burns > 10% TBSA.Full thickness burns > 10% TBSA. Partial thickness burns more > 25% in adults or 20% Partial thickness burns more > 25% in adults or 20%

at extremes of age.at extremes of age. Burns involving face, hands, feet, or perineum.Burns involving face, hands, feet, or perineum. Inhalation, chemical, or electrical burns.Inhalation, chemical, or electrical burns. Burns in patients with serious pre-existing medical Burns in patients with serious pre-existing medical

disorders.disorders.

There are several causes which predispose a poorly There are several causes which predispose a poorly managed 3rd & 4th grade burnt patient to develop managed 3rd & 4th grade burnt patient to develop

post-burn fibrotic deformity. These include:post-burn fibrotic deformity. These include:– Persistent edema.Persistent edema.– Wound infection.Wound infection.– Poor post-burn positioning.Poor post-burn positioning.– Prolonged immobilization [lack of mobilization].Prolonged immobilization [lack of mobilization].– Delayed or inadequate skin coverage.Delayed or inadequate skin coverage.

If left unattended, why do patients with 3rd & 4th If left unattended, why do patients with 3rd & 4th grade burns develop Post-burn Fibrotic Deformity?grade burns develop Post-burn Fibrotic Deformity?

Why do these patients usually develop a flexion Why do these patients usually develop a flexion deformity?deformity?

The most common position of comfort that the The most common position of comfort that the patient assumes in the post-burn period is usually patient assumes in the post-burn period is usually

flexion (fetal posture)flexion (fetal posture)[exception: hyperextension of intercarpo-phalyngeal [exception: hyperextension of intercarpo-phalyngeal

joints]. joints]. If this habitus is not quickly corrected, irrevocable If this habitus is not quickly corrected, irrevocable

fibrosis develops even before full healing of the fibrosis develops even before full healing of the burned area. burned area.

What systems are affected by burns?What systems are affected by burns?

Nearly all systems are affected by burns.Nearly all systems are affected by burns.

Cardiovascular system.Cardiovascular system. Respiratory system.Respiratory system. Hepatic, Renal, and endocrine functions.Hepatic, Renal, and endocrine functions. G.I. System.G.I. System. Haempoiesis, coagulation, and immunologic Haempoiesis, coagulation, and immunologic

responses.responses.

How is the CVS affected?How is the CVS affected?

ACUTE PHASE:[0 – 48Hrs]ACUTE PHASE:[0 – 48Hrs]Organ & tissue perfusion decreases due to Organ & tissue perfusion decreases due to 11. hypovolemia, . hypovolemia, 22. depressed myocardial function, . depressed myocardial function, 33. increased blood . increased blood viscosity, & viscosity, & 44. release of vasoactive substances.. release of vasoactive substances.

METABOLOIC PHASE: [48 Hrs onwards]METABOLOIC PHASE: [48 Hrs onwards] Increased blood flow to organs & tissues.Increased blood flow to organs & tissues.

NOTENOTE: Geriatric patients may have a delayed or non-: Geriatric patients may have a delayed or non-existing metabolic phase.existing metabolic phase.Hypertension of unknown cause may develop.Hypertension of unknown cause may develop.

How is the respiratory system affected?How is the respiratory system affected?

THREE DISTNCT PHASESTHREE DISTNCT PHASES

1. Phase of early complications1. Phase of early complications [0 – 24 hrs]: Includes CO [0 – 24 hrs]: Includes CO poisoning, direct inhalation injury leading to airway poisoning, direct inhalation injury leading to airway obstruction & pulmonary edema.obstruction & pulmonary edema.

2. Phase of delayed injury2. Phase of delayed injury: [2 – 5 days]: ARDS.: [2 – 5 days]: ARDS.

3. Phase of late complications3. Phase of late complications [>5 days]: Includes [>5 days]: Includes pneumonia, atelectasis, pulmonary emboli.pneumonia, atelectasis, pulmonary emboli.

What is inhalation injury?What is inhalation injury?

Causes:Causes: Hot gases, toxic substance, reactive smoke particles in Hot gases, toxic substance, reactive smoke particles in

tracheobronchial tree.tracheobronchial tree.Results in :Results in :

Wheezing, bronchospasm, corrosion, and airway edema.Wheezing, bronchospasm, corrosion, and airway edema.

Implications of inhalational injury:Implications of inhalational injury: Presence of carbonaceous sputum, perioral soot, burns to Presence of carbonaceous sputum, perioral soot, burns to

face & neck, stridor, dyspnea,or wheezing are indications face & neck, stridor, dyspnea,or wheezing are indications for a low threshold for for a low threshold for elective intubationelective intubation..

What are the features of CO poisoning?What are the features of CO poisoning?CausesCauses

Incomplete combustion associated with fires, exhaust from internal Incomplete combustion associated with fires, exhaust from internal combustion engines, cooking stoves, and charcoal stoves.combustion engines, cooking stoves, and charcoal stoves.

Results inResults inCOHb [CO affinity is 200 that of OCOHb [CO affinity is 200 that of O22] that leads to ] that leads to 11.tissue hypoxia, .tissue hypoxia, 22. shift in O-Hb dissociation curve, . shift in O-Hb dissociation curve, 33. direct CVS depression, . direct CVS depression, 44. . cytochrome enzyme inhibition, cytochrome enzyme inhibition, 55. overestimation of SaO2.. overestimation of SaO2.

TreatmentTreatment1.1. Initiate 100% OInitiate 100% O22 therapy at atmospheric pressure [decreases half life therapy at atmospheric pressure [decreases half life

of COHb].of COHb].2.2. If COHb > 20%, comatose patient pregnancy, myocardial ischemia, If COHb > 20%, comatose patient pregnancy, myocardial ischemia,

neonate, persistent symptoms after 4 hrs of 100% Oneonate, persistent symptoms after 4 hrs of 100% O22 therapy at therapy at atmospheric, or lactic acidosis = Hyperbaric Oatmospheric, or lactic acidosis = Hyperbaric O22

How do burns affect the GI System?How do burns affect the GI System?

Adynamic ileus at any time after injury.Adynamic ileus at any time after injury.

Curling’s ulcer leading to GI bleeding.Curling’s ulcer leading to GI bleeding.

Small & large intestine may develop acute Small & large intestine may develop acute necrotizing enterocolitis with abdominal distension, necrotizing enterocolitis with abdominal distension, hypotension, and bloody diarrhea.hypotension, and bloody diarrhea.

During 2During 2ndnd & 3 & 3rdrd week – acalculous cholecystitis is week – acalculous cholecystitis is commoncommon

How is renal system affected? How is renal system affected?

ATN & ARFATN & ARF CausesCauses

Hemoglobinuria secondary to hemolysis.Hemoglobinuria secondary to hemolysis.Myoglobinuria secondary to muscle necrosis.Myoglobinuria secondary to muscle necrosis.

Incidence & mortalityIncidence & mortality ATN & ARF = 0.5% - 38%, Mortality = 77 – 100%.ATN & ARF = 0.5% - 38%, Mortality = 77 – 100%.

OnsetOnsetImmediately: RBF & GFR is decreased. This activates RAA Immediately: RBF & GFR is decreased. This activates RAA system. Release of ADH leading to retention of Na & H2O and loss system. Release of ADH leading to retention of Na & H2O and loss of K, Ca, & Mgof K, Ca, & Mg

TreatmentTreatment1.1. Vigorous fluid resuscitation [Formulae guided].Vigorous fluid resuscitation [Formulae guided].2.2. Maintain urine output , if needed with mannitol.Maintain urine output , if needed with mannitol.3.3. Administer bicarbonates to alkalinize urine to reduce pigment Administer bicarbonates to alkalinize urine to reduce pigment

associated renal failure.associated renal failure.

How is hepatic system altered?How is hepatic system altered?

DECREASED HEPATIC FUNCTIONDECREASED HEPATIC FUNCTION

CausesCauses1.1. Acute reduction of Cardiac Output.Acute reduction of Cardiac Output.2.2. Increased viscosity of blood.Increased viscosity of blood.3.3. Splanchnic vasoconstriction leading to hepatic hypoperfusion.Splanchnic vasoconstriction leading to hepatic hypoperfusion.

EffectEffectReduced Phase I metabolism [oxidative] Reduced Phase I metabolism [oxidative] Phase II reaction not effected [conjugative]Phase II reaction not effected [conjugative]

TreatmentTreatmentRestore CO, decrease blood viscosity.Restore CO, decrease blood viscosity.

Are drug responses altered in patients with burns?Are drug responses altered in patients with burns? 11stst 48 hrs = Decreased drug absorption [except IV route] leads to 48 hrs = Decreased drug absorption [except IV route] leads to

slow, erratic action.slow, erratic action. After 48 hrs = Plasma albumin concentration decreases leading to After 48 hrs = Plasma albumin concentration decreases leading to

increase free drug fractionincrease free drug fractionSPECIFIC DRUGSSPECIFIC DRUGS

DiazepamDiazepam – Effect prolonged. – Effect prolonged.OpioidsOpioids – Requirement increased. – Requirement increased.KetamineKetamine – May cause hypotension. – May cause hypotension.Thiopental, propofol Thiopental, propofol - May cause hypotension in the acute - May cause hypotension in the acute

hypovolemic stage.hypovolemic stage.Inhalational agentInhalational agent–Poorly tolerated in hypovolemics–Poorly tolerated in hypovolemics..Muscle relaxantsMuscle relaxants–Depolarizing: Sensitive/hyperkalemia–Depolarizing: Sensitive/hyperkalemia

Non-depolarizing: Resistant Non-depolarizing: Resistant

What is the cause of resistance to non-depolarizing What is the cause of resistance to non-depolarizing muscle relaxants?muscle relaxants?

Patients with more than 30% burn area may manifest Patients with more than 30% burn area may manifest resistance to non-depolarizing muscle relaxants. resistance to non-depolarizing muscle relaxants.

The cause is multi-factorial: The cause is multi-factorial: 1.1. Proliferation of extra-junctional receptors,Proliferation of extra-junctional receptors,2.2. Alterations in the number & affinity of junctional Alterations in the number & affinity of junctional

receptors, andreceptors, and3.3. Synthesis of α1 glycoproteins to which the muscle Synthesis of α1 glycoproteins to which the muscle

relaxants binds leaving little free fraction to act. relaxants binds leaving little free fraction to act.

This is usually seen after one week of burns, lasting up to This is usually seen after one week of burns, lasting up to 3-6 months. 3-6 months.

Is there any non-depolarizing muscle relaxant which is Is there any non-depolarizing muscle relaxant which is not affected by burns?not affected by burns?

Mivacurium is a muscle relaxant, degraded by plasma Mivacurium is a muscle relaxant, degraded by plasma cholinesterase, whose enzyme activity is decreased in cholinesterase, whose enzyme activity is decreased in burns. burns.

The decreased metabolism of mivacurium, resulting from The decreased metabolism of mivacurium, resulting from depressed plasma cholinesterase activity, probably depressed plasma cholinesterase activity, probably counteracts the receptor-mediated potential for resistance.counteracts the receptor-mediated potential for resistance.

Martyn et al have shown that a normal mivacurium dosage Martyn et al have shown that a normal mivacurium dosage (0.2 mg/kg) effects good relaxation conditions in burned (0.2 mg/kg) effects good relaxation conditions in burned patients, with an onset time similar to that in controls patients, with an onset time similar to that in controls

[Anesthesiology 2000; 92: 31-7][Anesthesiology 2000; 92: 31-7]

What is the endocrine response to a burn?What is the endocrine response to a burn?

MASSIVE RELEASE OF:MASSIVE RELEASE OF: Catecholamines.Catecholamines. Glucagon.Glucagon. ACTH.ACTH. ADH.ADH. RAA.RAA.1.1. Hyperglycemia Hyperglycemia [non-ketotic hyperosmolar coma][non-ketotic hyperosmolar coma]2.2. Adrenal necrosisAdrenal necrosis [should be suspected in hypotensive [should be suspected in hypotensive

patients unresponsive to volume infusion].patients unresponsive to volume infusion].

What are the hematologic complications of What are the hematologic complications of burns?burns?

ANEMIAANEMIA Early Anemia due to RBC damage, dilutional due to Early Anemia due to RBC damage, dilutional due to

fluid resuscitation.fluid resuscitation. Decreased erythropoiesis.Decreased erythropoiesis. Ongoing infection.Ongoing infection. Various degrees of coagulopathy.Various degrees of coagulopathy.

PLATELET FUNCTIONSPLATELET FUNCTIONS

Qualitatively & quantitatively depressedQualitatively & quantitatively depressed

What are the 3 Phases of burn management?What are the 3 Phases of burn management?

I- Resuscitative phaseI- Resuscitative phase

2. Stabilization phase.2. Stabilization phase.

3. Reconstructive phase.3. Reconstructive phase.

What are your priorities in the resuscitative phase?What are your priorities in the resuscitative phase?

A,B,C,D,E,F,G,HA,B,C,D,E,F,G,H

A-Airway management.A-Airway management. B-Breathing.B-Breathing. C-Circulation/CVS stabilization.C-Circulation/CVS stabilization. D-Drugs [Analgesics, Antibiotics, D-Drugs [Analgesics, Antibiotics, Vasoactive Vasoactive

drugs].drugs]. E-Escharectomy.E-Escharectomy. F-Fluid management.F-Fluid management. G-Gen. Supp. Care [Nutritional, G-Gen. Supp. Care [Nutritional,

Physiotherapy,Psychological support]Physiotherapy,Psychological support]

How will you manage the How will you manage the AAirway in the resuscitative irway in the resuscitative phase?phase?

Secure the airway early before airway edema progresses to Secure the airway early before airway edema progresses to obstruction [obstruction [11. difficulty in swallowing, . difficulty in swallowing, 22. stridor, and . stridor, and 3.3.use of accessory muscle].use of accessory muscle].

Administer humidified OAdminister humidified O22 by mask to all patients by mask to all patients immediately.immediately.

Why does airway edema occur in acute burn patients?Why does airway edema occur in acute burn patients?

Exposure of the epiglottis or larynx to either dry air Exposure of the epiglottis or larynx to either dry air at 300at 30000C or steam at 100C or steam at 10000C.C.

Chemical products of combustion such as ammonia, Chemical products of combustion such as ammonia,

nitrogen dioxide, sulfur dioxide, and chlorine nitrogen dioxide, sulfur dioxide, and chlorine dissolves in the upper airway & produce edema.dissolves in the upper airway & produce edema.

What are the indications for ETI in the resuscitative What are the indications for ETI in the resuscitative phase?phase?

Airway obstruction.Airway obstruction. Depressed level of consciousness.Depressed level of consciousness. Posterior pharyngeal wall swelling.Posterior pharyngeal wall swelling. Circumferential nasolabial burns [full Circumferential nasolabial burns [full

thickness]thickness] Hypoxia uncontrolled with mask & OHypoxia uncontrolled with mask & O22

What are the modes of securing the airway?What are the modes of securing the airway?

Nasal/oral intubation [FOI, Fastrach aided Nasal/oral intubation [FOI, Fastrach aided Anesth Analg 2002; 95: 1454-Anesth Analg 2002; 95: 1454-

88, Trachlight aided, Blind]., Trachlight aided, Blind].

LMA LMA [Anesthesiology 1997; 86:1011-2[Anesthesiology 1997; 86:1011-2]], Combitube , Combitube [J Clin Anesth 2003; 15: 463-6],[J Clin Anesth 2003; 15: 463-6],

Cobra PLA Cobra PLA [Can J Anesth 2005; 52: 340][Can J Anesth 2005; 52: 340] or any suitable supraglottic or any suitable supraglottic device till you can arrange alternative intubation device till you can arrange alternative intubation technique.technique.

Needle cricothyroidotomyNeedle cricothyroidotomy

Surgical cricothyroidotomy.Surgical cricothyroidotomy.

Tracheostomy ?Tracheostomy ?

What will be your ventilation strategy [What will be your ventilation strategy [BBreathing]reathing]

If carboxyhemoglobin [COHB] is < 20%, ventilate If carboxyhemoglobin [COHB] is < 20%, ventilate with titrated O2 to achieve SaO2 > 95%.with titrated O2 to achieve SaO2 > 95%.

If COHB is >20%, ventilate with 100% O2.If COHB is >20%, ventilate with 100% O2.

If COHB is >20% and is unresponsive to ventilation If COHB is >20% and is unresponsive to ventilation with 100% O2, consider hyperbaric oxygenation. with 100% O2, consider hyperbaric oxygenation.

How would you resuscitate the How would you resuscitate the CCirculation?irculation?

REASON FOR RESUSCITATIONREASON FOR RESUSCITATIONTo correct hypovolemia secondary to increased capillary To correct hypovolemia secondary to increased capillary permeability leading to fluid & protein loss in interstitial permeability leading to fluid & protein loss in interstitial

tissue.tissue.DIFFERENT FORMULA FOR FLUID DIFFERENT FORMULA FOR FLUID

RESUSCITATIONRESUSCITATION Parkland Formula.Parkland Formula. Brooke Formula.Brooke Formula. Evan’s FormulaEvan’s Formula Muir & Barclay Formula.Muir & Barclay Formula.

END POINT OF RESUSCITATIONEND POINT OF RESUSCITATION1.1. Hemodynamic stability.Hemodynamic stability.2.2. Urine output > 1 ml/lkg/hr.Urine output > 1 ml/lkg/hr.

Parkland formula for fluid administrationParkland formula for fluid administration

For the first 24 h is: Lactated Ringer 4 ml / kg / % For the first 24 h is: Lactated Ringer 4 ml / kg / % burn / 24h, of which 50% should be administered burn / 24h, of which 50% should be administered over the first 8 h. Remaining 50% over the next 16 hover the first 8 h. Remaining 50% over the next 16 h

Over the next 24 h, D5W should be administered at Over the next 24 h, D5W should be administered at the rate of 2ml / kg / % burn, plus plasma calculated the rate of 2ml / kg / % burn, plus plasma calculated as 0.3-0.5ml / kg / % burn.as 0.3-0.5ml / kg / % burn.

Brooke Formula for fluid resuscitationBrooke Formula for fluid resuscitation

For the first 24 h is: Lactated Ringer 2 ml / kg / % For the first 24 h is: Lactated Ringer 2 ml / kg / % burn / 24 h.burn / 24 h.

This is to be followed with D5W 1-2ml / kg / % This is to be followed with D5W 1-2ml / kg / %

burn, plus plasma calculated as 0.3-0.5ml / kg / % burn, plus plasma calculated as 0.3-0.5ml / kg / % burn over the second 24 h. burn over the second 24 h.

Role of colloid during resuscitation ?Role of colloid during resuscitation ?

In the In the United StatesUnited States, The American College of , The American College of Surgeons Committee on Trauma advocates Surgeons Committee on Trauma advocates only only crystalloidscrystalloids for resuscitation of all burn patient for resuscitation of all burn patient because of its simplicity, reduced cost, and nearly because of its simplicity, reduced cost, and nearly identical outcome with that wherein colloid regimes identical outcome with that wherein colloid regimes are used. are used.

In In EuropeEurope, some institutions use resuscitation , some institutions use resuscitation regimens which include a regimens which include a combination of combination of crystalloid and colloid.crystalloid and colloid. However, this simply adds However, this simply adds to the expense without demonstrable benefit. to the expense without demonstrable benefit.

End point of successful resuscitation.End point of successful resuscitation.

Hemodynamic stability: In a young patient HR of 100/min Hemodynamic stability: In a young patient HR of 100/min or lower and systolic blood pressure of 100mmHg or more.or lower and systolic blood pressure of 100mmHg or more.

-Correction of base deficit.-Correction of base deficit. -Mixed or central venous oxygen saturation exceeding 60%.-Mixed or central venous oxygen saturation exceeding 60%. -Urine output > 1 ml/kg/hr.-Urine output > 1 ml/kg/hr. Approximately 20% of the patients will be over-hydrated, Approximately 20% of the patients will be over-hydrated,

particularly with the Parkland Formula. If urine output particularly with the Parkland Formula. If urine output exceeds 2 ml/kg/h, then the rate of infusion should be exceeds 2 ml/kg/h, then the rate of infusion should be reduced in steps of 25%.reduced in steps of 25%.

Approximately 10% of the burned patients shall not respond Approximately 10% of the burned patients shall not respond to fluid therapy as outlined above. These are generally older to fluid therapy as outlined above. These are generally older patients, having underlying medical conditions, had a delay patients, having underlying medical conditions, had a delay in initiating resuscitation, and may be having concomitant in initiating resuscitation, and may be having concomitant inhalation injury. inhalation injury.

What is important in the preoperative history before What is important in the preoperative history before anaesthesia?anaesthesia?

Time of burn: For fluid replacement.Time of burn: For fluid replacement. Type of burn: [Thermal or electrical]Type of burn: [Thermal or electrical] Associated injuries.Associated injuries. Past & current medical conditions.Past & current medical conditions. Past & current medications.Past & current medications. Allergies.Allergies. Anaesthetic history.Anaesthetic history.

What should the anaesthesiologist look for on the What should the anaesthesiologist look for on the preoperative physical examination?preoperative physical examination?

Status of patient’s airway: Complete Airway Status of patient’s airway: Complete Airway Assessment.Assessment.

Excessive sputum & decreased breath sounds Excessive sputum & decreased breath sounds may suggest inhalation injuries.may suggest inhalation injuries.

CVS: HR, Rhythm, BP,Cardiac filling pressures CVS: HR, Rhythm, BP,Cardiac filling pressures [if available].[if available].

Urine output.Urine output. CNS: Level of consciousness & orientation.CNS: Level of consciousness & orientation.

What preoperative Lab tests are required before What preoperative Lab tests are required before induction of anaesthesia?induction of anaesthesia?

ABG for correcting acid-base & electrolyte ABG for correcting acid-base & electrolyte imbalance.imbalance.

Blood Chemistry.Blood Chemistry. Chest radiograph.Chest radiograph. COHb level estimation.COHb level estimation. Coagulation tests.Coagulation tests.

What monitors are needed to give a safe anaesthetic?What monitors are needed to give a safe anaesthetic?

Access for monitoring may be difficult.Access for monitoring may be difficult. Needle electrodes for EKG & PNS.Needle electrodes for EKG & PNS. NIBP cuff or arterial catheter for IBP/ABG.NIBP cuff or arterial catheter for IBP/ABG. ETCO2ETCO2 Temperature probe.Temperature probe. CVP: If large blood loss is anticipated.CVP: If large blood loss is anticipated. PA catheter, if severe myocardial dysfunction.PA catheter, if severe myocardial dysfunction.

What induction agents will you use in patients with What induction agents will you use in patients with acute burns?acute burns?

Ketamine.Ketamine.

Propofol/thiopentone–safePropofol/thiopentone–safe if adequately resuscitated. if adequately resuscitated.

Etomidate – If patient is still hemodynamically Etomidate – If patient is still hemodynamically unstable.unstable.

Role of narcotics, muscle relaxants & inhalational Role of narcotics, muscle relaxants & inhalational agents has already been discussed.agents has already been discussed.

What are the Surgical Objective During Reconstructive Stage?What are the Surgical Objective During Reconstructive Stage?

Severe anterior neck burn scar contracture issues in Severe anterior neck burn scar contracture issues in serious functional embarrassment.serious functional embarrassment.

Reconstruction is based on three principles:Reconstruction is based on three principles: 1. Releasing shrinked area.1. Releasing shrinked area.2. Restoring contour of the mento-collical angle, &2. Restoring contour of the mento-collical angle, &3. Preventing recurrence. 3. Preventing recurrence.

What are the problems of airway management for elective What are the problems of airway management for elective anaesthesia during the anaesthesia during the Reconstructive PhaseReconstructive Phase, like the , like the present present

casecase??

Difficulty in securing airway [ETI] especially in Difficulty in securing airway [ETI] especially in facial & neck contractures.facial & neck contractures.

Use of muscle relaxants [Dep/Non-dep].Use of muscle relaxants [Dep/Non-dep]. Patient positioning.Patient positioning. Securing IV lines.Securing IV lines. Applying monitoring devices.Applying monitoring devices.

What are the problems associated with facial/neck What are the problems associated with facial/neck contractures during airway management?contractures during airway management?

Reduced mouth opening.Reduced mouth opening. Restricted neck movement.Restricted neck movement. Stiff submandibular space [Anterior larynx]Stiff submandibular space [Anterior larynx] Scar & contracture in suprasternal area obviates the Scar & contracture in suprasternal area obviates the

use of lightwand assisted ETI / cricothyrotomy / use of lightwand assisted ETI / cricothyrotomy / emergency tracheostomy. emergency tracheostomy.

Larynx may be shifted from the midline.Larynx may be shifted from the midline. Ineffective cricoid pressure.Ineffective cricoid pressure. Applying OELM during difficult laryngoscopy Applying OELM during difficult laryngoscopy

/intubation is not possible./intubation is not possible. Applying BURP on the larynx may not be possible Applying BURP on the larynx may not be possible

What are the implications of a non-compliant What are the implications of a non-compliant submandibular space?submandibular space?

During laryngoscopy the tongue is During laryngoscopy the tongue is depressed into the submandibular space. A depressed into the submandibular space. A

non-compliant space will not accept the base non-compliant space will not accept the base of the tongue and patient will exhibit the of the tongue and patient will exhibit the appearance of an anterior/superior larynxappearance of an anterior/superior larynx..

What are the options available for airway What are the options available for airway management in the present case undergoing elective management in the present case undergoing elective

anaesthesia?anaesthesia? Awake FOI [nasal or oral] especially if mouth opening is < Awake FOI [nasal or oral] especially if mouth opening is <

2 fingers.2 fingers. Mouth opening >2 finger ILMA + ETI in awake patient.Mouth opening >2 finger ILMA + ETI in awake patient. Mouth opening >2 finger breadth – LMA in awake patient.Mouth opening >2 finger breadth – LMA in awake patient. Release of contracture partially under ketamine anaesthesia Release of contracture partially under ketamine anaesthesia

or L.A + hyaluronidase infiltration & then try to intubate by or L.A + hyaluronidase infiltration & then try to intubate by conventional laryngoscope conventional laryngoscope [Acta Chir Plast. 1997;39(2):56-9].[Acta Chir Plast. 1997;39(2):56-9]. . .

Successful Combitube placement has been described in Successful Combitube placement has been described in burned patients with limited mouth opening .burned patients with limited mouth opening .

REMEMBERREMEMBER= Release of contracture in the front of neck = Release of contracture in the front of neck does not guarantee a lax, pliable submandibular space. ETI does not guarantee a lax, pliable submandibular space. ETI may be still difficult.may be still difficult.

What about conventional rigid laryngoscopy & What about conventional rigid laryngoscopy & intubation?intubation?

In this patients with fixed flexion deformity In this patients with fixed flexion deformity of the head & neck [as in the present case], of the head & neck [as in the present case], it is not possible to align the 3 airway axes it is not possible to align the 3 airway axes and this would most likely lead to failed and this would most likely lead to failed laryngoscopy & intubation. laryngoscopy & intubation.

Non compliant submandibular space will not Non compliant submandibular space will not allow the tongue to be compressed by the allow the tongue to be compressed by the laryngoscope : Anterior larynx.laryngoscope : Anterior larynx.

Persisting with this technique may produce Persisting with this technique may produce trauma and subsequent edema leading to trauma and subsequent edema leading to failure of other methods [FOI].failure of other methods [FOI].

What about Trachlight Intubation, Blind Intubation, What about Trachlight Intubation, Blind Intubation, Retrograde Intubation and Surgical Tracheostomy?Retrograde Intubation and Surgical Tracheostomy?

Trachlight would fail in the presence of the neck scar.Trachlight would fail in the presence of the neck scar.

Experienced person may give a trial of awake blind Experienced person may give a trial of awake blind intubation techniques.intubation techniques.

Retrograde method is also not recommended due to loss of Retrograde method is also not recommended due to loss of landmarks over front of the neck.landmarks over front of the neck.

Surgical tracheostomy should be reserved as the last option. Surgical tracheostomy should be reserved as the last option. Its presence makes skin grafting difficult and it may run the Its presence makes skin grafting difficult and it may run the risk of infection.risk of infection.

How will you prepare this patient for awake How will you prepare this patient for awake intubation?intubation?

Premedicate with mild sedation + drying agent.Premedicate with mild sedation + drying agent.

Instill vasoconstrictor in the nose.Instill vasoconstrictor in the nose.

Topicalization of the airway using 4% xylocaine Topicalization of the airway using 4% xylocaine spray & 4% xylocaine gargle or “spray-as-you-spray & 4% xylocaine gargle or “spray-as-you-go” using 4% xylocaine through suction channel go” using 4% xylocaine through suction channel of the bronchoscope. of the bronchoscope.

How will you conduct GA in such patient if patient is How will you conduct GA in such patient if patient is not feasible or refuses awake intubation?not feasible or refuses awake intubation?

It is prudent to gradually induce the patient with inhalational agent in It is prudent to gradually induce the patient with inhalational agent in 100% O2, after adequate depth attempt gentle laryngoscopy to assess 100% O2, after adequate depth attempt gentle laryngoscopy to assess laryngeal view and then decide to intubate with or without muscle laryngeal view and then decide to intubate with or without muscle relaxants. Keep FO/ LMA/ Combitube ready as alternative devices.relaxants. Keep FO/ LMA/ Combitube ready as alternative devices.

Release of contracture partially under ketamine anaesthesia or L.A + Release of contracture partially under ketamine anaesthesia or L.A + hyaluronidase infiltration & then intubate.hyaluronidase infiltration & then intubate.

Vasilious et al have successfully induced patients with propofol and Vasilious et al have successfully induced patients with propofol and

fentanyl after preoxygenation. They ventilated the lungs manually fentanyl after preoxygenation. They ventilated the lungs manually with oxygen and halothane by a size 4 face mask. If regular with oxygen and halothane by a size 4 face mask. If regular laryngoscopy failed, they passed LMA. laryngoscopy failed, they passed LMA. Anesthesiology 86:1011-2, 1997Anesthesiology 86:1011-2, 1997

What are special features of electric burns?What are special features of electric burns?

Extent of injury is misleading resulting in under initial fluid Extent of injury is misleading resulting in under initial fluid resuscitation.resuscitation.

Myoglobinuria is common [ATN].Myoglobinuria is common [ATN]. Neurologic complications are more common such as Neurologic complications are more common such as

peripheral neuropathies or spinal cord deficits.peripheral neuropathies or spinal cord deficits. Cardiac arrhythmias, VF, or asystole may occur upto 48 hrs.Cardiac arrhythmias, VF, or asystole may occur upto 48 hrs. Apnea from tetanic contraction or cerebral medullary injury.Apnea from tetanic contraction or cerebral medullary injury. Cataract formation as a late sequele.Cataract formation as a late sequele.

END OF CASE – IIEND OF CASE – II

CASE – IICASE – II

Temporomandibular Temporomandibular Joint AnkylosisJoint Ankylosis

A 14-year-old female patient has come with A 14-year-old female patient has come with complaints of limited mouth opening [< I cm] and complaints of limited mouth opening [< I cm] and

poorly developed lower jaw. She had sustained lower poorly developed lower jaw. She had sustained lower jaw injury during fall from stairs when she was 4 jaw injury during fall from stairs when she was 4

years old.years old.

What is your working dignosis?What is your working dignosis?

Post Traumatic Temporo-mandibular Joint Post Traumatic Temporo-mandibular Joint DysfunctionDysfunction

What is the gross anatomy of TMJ?What is the gross anatomy of TMJ?

It is a diarthrodial synovial joint like most other joints with It is a diarthrodial synovial joint like most other joints with three important exceptions:three important exceptions:

Both TMJ’s function as a single unit i.e. craniomandibular Both TMJ’s function as a single unit i.e. craniomandibular articulation.articulation.

Articular surfaces are lined with fibrocartilage instead of Articular surfaces are lined with fibrocartilage instead of the usual hyaline cartilage.the usual hyaline cartilage.

Articular disc [ dense fibrous connective tissue – Articular disc [ dense fibrous connective tissue – biconcave] separates the joint into 2 spaces, each with a biconcave] separates the joint into 2 spaces, each with a different function.different function.

What is the physiological function of the TMJ?What is the physiological function of the TMJ?

ChewingChewing

SpeechSpeech

During maximum jaw opening what motions can be During maximum jaw opening what motions can be observed?observed?

2 separates motions can be observed in 2 distinct joint spaces:2 separates motions can be observed in 2 distinct joint spaces:

*Hinge like movement*Hinge like movement*Sliding movement*Sliding movement

What history would you like to elicit in addition to What history would you like to elicit in addition to what patient has already complained off?what patient has already complained off?

Classic TriadClassic Triad

H/O pain in the preauricular area.H/O pain in the preauricular area. Noises emanating from the region of TMJ.Noises emanating from the region of TMJ. Limited mandibular movementLimited mandibular movement

What physical examination would you conduct?What physical examination would you conduct?

Joint movement in all directions [Maximum Joint movement in all directions [Maximum opening opening -- inter-incisor = 4-5 cms, Lateral inter-incisor = 4-5 cms, Lateral jaw excursions jaw excursions –– 1cm] 1cm]

Pay attention to the face for any signs of Pay attention to the face for any signs of facial asymmetry.facial asymmetry.

Occlusion defects.Occlusion defects. Dentitions problems.Dentitions problems.

What other associated problems secondary to TMJA What other associated problems secondary to TMJA you will look for?you will look for?

Nutrition problems.Nutrition problems.

Oral hygiene leading to dental decay / Oral hygiene leading to dental decay / abscessabscess

What is the aetiopathogenesis in this case?What is the aetiopathogenesis in this case?

TraumaTrauma

Infection.Infection.

Rheumatoid arthritisRheumatoid arthritis

Congenital deformityCongenital deformity

What are the investigations needed to confirm the What are the investigations needed to confirm the diagnosis?diagnosis?

MRI : Investigation of choice.MRI : Investigation of choice. Conventional radiography [Transcranial view]Conventional radiography [Transcranial view] CAT scanning with mouth open & closed CAT scanning with mouth open & closed

position.position. Arthrography using contrast media into joint Arthrography using contrast media into joint

spaces.spaces. ESR, Autoantibodies, Uric acid level may uncover ESR, Autoantibodies, Uric acid level may uncover

inflammatory TMJ.inflammatory TMJ.

What surgical interventions are possible in cases of What surgical interventions are possible in cases of TMJ dysfunction?TMJ dysfunction?

TMJ Arthroscopy.TMJ Arthroscopy.

TMJ Arthrotomy.TMJ Arthrotomy.

TMJ ImplantsTMJ Implants

What specific surgical interventions are reserved for What specific surgical interventions are reserved for TMJA?TMJA?

Condylectomy.Condylectomy.

Gap arthroplasty.Gap arthroplasty.

Autogenous replacement of resected Autogenous replacement of resected condyle with 5-6condyle with 5-6thth rib graft rib graft

What airway assessment shall you perform?What airway assessment shall you perform?

BONESBONES

LEMONLEMON

Anesthetist's ConcernsAnesthetist's Concerns

This relatively rare problem becomes even more This relatively rare problem becomes even more difficult to manage in difficult to manage in childrenchildren because of their because of their

smaller mouth openingsmaller mouth opening with near total with near total trismustrismus, and , and the need for the need for general anaesthesiageneral anaesthesia before making any before making any

attempts to secure the airway.attempts to secure the airway.

What are your airway management options in this What are your airway management options in this case?case?

Nasotracheal intubation.Nasotracheal intubation.

PCT / tracheostomy.PCT / tracheostomy.

How will you achieve nasotracheal intubation in this How will you achieve nasotracheal intubation in this case?case?

Fiberoptic nasotracheal intubation[FOI].Fiberoptic nasotracheal intubation[FOI]. Seeing optic stylet system [SOS] aided.Seeing optic stylet system [SOS] aided. Flexible airway scope tool [FAST] aided.Flexible airway scope tool [FAST] aided. Trachlight aided.Trachlight aided. Retrograde NTIRetrograde NTI Blind NTIBlind NTI

What are your anaesthetic options for achieving What are your anaesthetic options for achieving NTI?NTI?

Awake, under topical / nerve block Awake, under topical / nerve block anaesthesia using mild sedation + drying anaesthesia using mild sedation + drying agent.agent.

Under inhalational anaesthesia Under inhalational anaesthesia ± L.A.± L.A...

Under inhalational Under inhalational ±± muscle relaxant. muscle relaxant.

What will be your anaesthetic technique in this What will be your anaesthetic technique in this patient?patient?

AWAKE FO/LW AINTUBATION, AFTER AWAKE FO/LW AINTUBATION, AFTER CONSENTCONSENT

Psychological preparation.Psychological preparation. Antisialogogue.Antisialogogue. Sedation.Sedation. LA-Topical & N. BlockLA-Topical & N. Block

Alternative Anaesthetic TechniqueAlternative Anaesthetic Technique

A technique for securing the airway that combines A technique for securing the airway that combines LA/GA: LA/GA:

local blocks for nerves of larynx,local blocks for nerves of larynx, topical anaesthesia of upper airways for topical anaesthesia of upper airways for

placement of these blocks,placement of these blocks, and minimal general anaesthesia and minimal general anaesthesia

[halothane/sevoflurane] for airway manoeuvres. [halothane/sevoflurane] for airway manoeuvres. Paediatr Anaesth. 2001; 11: 237-44. Paediatr Anaesth. 2001; 11: 237-44.

A simple and safe technique of intubation with A simple and safe technique of intubation with minimal discomfort to the patient using a minimal discomfort to the patient using a

nasopharyngeal airway, fibreoptic bronchoscope nasopharyngeal airway, fibreoptic bronchoscope and guide wire in a three-year-old is presented and guide wire in a three-year-old is presented

Paediatric Anaesthesia 1999; 3: 260Paediatric Anaesthesia 1999; 3: 260

In the absence of FiberscopeIn the absence of Fiberscope

Recently BJA published report of 2 cases of TMJ Recently BJA published report of 2 cases of TMJ Ankylosis where retrograde nasal intubation was Ankylosis where retrograde nasal intubation was

achieved using fluoroscopy-assisted nasal retrieval achieved using fluoroscopy-assisted nasal retrieval of the guide wire [50 cm guide wire from a 16 G of the guide wire [50 cm guide wire from a 16 G

central venous catheter] passed through a central venous catheter] passed through a cricothyroid puncture and up via nasal airways cricothyroid puncture and up via nasal airways

placed in both the nostrils.placed in both the nostrils.[ British Journal of Anaesthesia 2005 94:128-131][ British Journal of Anaesthesia 2005 94:128-131]

What are your options for tracheostomy?What are your options for tracheostomy?

Percutaneous dilatational tracheostomy.Percutaneous dilatational tracheostomy.

Surgical tracheostomy.Surgical tracheostomy.

If while trying NTI suddenly your patient goes into If while trying NTI suddenly your patient goes into CVCI situation, what will be your next step?CVCI situation, what will be your next step?

CRICOTHYROTOMYCRICOTHYROTOMY

• Needle cricothyrotomy.Needle cricothyrotomy.

• Percutaneous cricothyrotomy.Percutaneous cricothyrotomy.

• Surgical cricothyrotomy.Surgical cricothyrotomy.

What monitors you will apply to patient while What monitors you will apply to patient while attempting NTI?attempting NTI?

Pulse oximeter.Pulse oximeter. Cardioscope.Cardioscope. NIBP.NIBP. PNS.PNS. Capnograph ready.Capnograph ready.

What precautions you will take prior to extubation of What precautions you will take prior to extubation of this patient?this patient?

Extubate when the patient is fully awake.Extubate when the patient is fully awake. Wait for complete reversal of the residual Wait for complete reversal of the residual

NMB.NMB. Extubate over a ventilating stylet.Extubate over a ventilating stylet.

END OF CASE - IIEND OF CASE - II

Wish you all a grand success in Wish you all a grand success in the examthe exam