MORBIDITY AND MORTALITY REVIEW14/2/2013

• Mrs M / 72y.o /malay• Underlying DM/HPT and IHD under KK f/up• Pt’s 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

• 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 son’s 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

• 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

• 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

• Deep partial thickness 17.5• Superficial partial thickness 25.5• Total area 43% TBSA

ASSESSMENTAlleged flame burn injury with 43% partial and full thickness burn injury over both LL, perineum and ant chest

• 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

• 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

• 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 control3. Underlying Dm, HPT

– classified as ASA II– Anaest plan: GA with IPPV

18/1/13

• Medical review– Premorbidly well– D’scan 15 13– Medical plan

• QID d’scan• Add s/c actrapid 6u tds• Add s/c insulatard 10u ON• Add captopril 12.5mg tds

• 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

• At 11.45pm, noted pt become drowsy• D’scan 1.8 given D50% 50ml + RTF peptamen 250ml rpt d’scan 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– D’scan Hly then 4Hly

…cont

• 3.00 am– Pt developed desaturation. Spo2 90% under HFOM, BP

156/91, HR 120– Given T digoxin 0.5mg stat– D’scan 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

• Urine output 400ml post IV lasix 20mg• Lung transmitted sound, crepts MZ• RR 24

• Plan– Reduced IVD 1pint D5%– Another 10mg IV lasix

• 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

• 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

• ABG– pH 7.31 pCO2 42 PO2 99 HCO3 21 BE -2 SPO2 98%

• ECG sinus tachycardia• TWCC ; 16

• Impression1. Alleged flame burn injury with 43% partial and full

thickness burn injury 2. Acute resp distress ? Secondary to aspiration / post

op atelectasis3. Geriatric with multiple comorbid – DM/HPT/AF

• 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

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

• 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

• 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

• 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

• Pronounced death at 3.55pm

Investigations • Full blood count

• BUSE/CREAT

17/1/13 21/1/13 21/1/13

hb 13.6 11.3 11.7

plat 212 151 98

twcc 21.4 5.6 1

19/1/13 20/1/13 21/1/13 21/1/13

urea 5.7 4.6 3.6 3.7

sodium 127 135 131 135

potassium 4.7 4.2 3.8 3.8

chloride 99 106 99 104

creatinine 51 36 29 46

Investigations • Full blood count

• BUSE/CREAT

17/1/13 21/1/13 21/1/13

hb 13.6 11.3 11.7

plat 212 151 98

twcc 21.4 5.6 1

19/1/13 20/1/13 21/1/13 21/1/13

urea 5.7 4.6 3.6 3.7

sodium 127 135 131 135

potassium 4.7 4.2 3.8 3.8

chloride 99 106 99 104

creatinine 51 36 29 46

• Phospate : 0.78• Magnesium : 0.43• Calcium 1.70• RBS : 2.6

• PT/PTTK/INR20/1/13 21/1/13 21/1/13

PT 14.1 14 >60

INR 1.06 1.05 >4.44

PTTK 35.4 46.6 >120

• 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 21/1/13

A/G 0.6 0.5

ALB 19 12

ALP 68 53

ALT 16 13

GLO 31 23

TB 7 10

TP 50 35

DISCUSSION

• 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 pt’s hand represents ~1% of pt’s BSA

Burn assessment

Classification of burn

Lund & Browder charts

Wallace rule of 9

• Parkland’s formula– Total fluid requirement in the first 24H

= 4 x pt’s weight (kg) x % TBSA – Infuse the first half in the first 8h– Infuse the rest in the next 16H

Start time = time of burn injuryFluid of choice = hartmann’s solution

Fluid regime

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

• Next 24H• Total volume = ½ of the first day• Colloids (o.5ml/kg/%) and 5% glucose or

isotonic glucose saline to make up the rest

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 thrombosis5. Curling’s 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. Sepsis5. Hemolysis with

anemia 6. hypothermia

• 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

• 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

Age and general condition

Site of the burn

Extent of the burn

Depth of the burn

Assoc respiratory injury

Prognosis of burn

1

2

3

4

5

Thank you

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 pt’s cond and

monitoring