Problem based learning 3-2

5-5

Brief history

46-year-old man Hypertension without regular control Suffer from gas explosion on 2011/12/16 morning.
Sent to Inhalation injury and 50% TBSA burn was noted. Be intubated and transferred to this hospital for further evaluation and treatment.

Blast injury

Notification of scene

CLASSIFICATION OF BLAST INJURY

Physical Examination BH:172 cm BW:95.6 kg T:37.7 P:125 R:12 BP:116/72 mmHg Pain:0 HEENT: Burned and Intubated. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements intact. No icterus, no inflamed mucosa. NECK: Supple, no jugular venous distention. No nodules. No tenderness. CARDIOVASCULAR: S1 and S2, regular. LUNGS: Clear bilaterally. ABDOMEN: Nontender, nondistended, positive bowel sounds. EXTREMITIES: Severe burned. Swelling. SKIN: Burn injury over the whole body. PSYCHOLOGICAL: N/A

TBSA 50%
Head (face) Neck Arm Back Thigh

Inhalation injury Compartment syndrome Wound care

Inhalation injury

Common signs of significant smoke inhalation injury and the potential need for intubation include:
Persistent cough, stridor, or wheezing Hoarseness Deep facial or circumferential neck burns Nares with inflammation or singed hair Carbonaceous sputum or burnt matter in the mouth or nose Blistering or edema of the oropharynx Depressed mental status, including evidence of drug or alcohol use Respiratory distress Hypoxia or hypercapnia

Diagnostic tests and monitoring

Arterial blood gas (ABG) Chest x-ray If obtainable, in addition to repeat ABGs, can provide evidence of declining pulmonary function

2011-12-16

50 40 30 20 10 0 12/16 08:40 12/16 23:00 12/17 04:30 12/17 17:50 12/19 04:50

180 160 140 120 100 80 60 40 20 0

pH pCO2 HCO3 BE pO2

2011/12/16 08:40
pH pCO2 pO2

2011/12/16 23:00 7.38 43.7 132.9

2011/12/17 04:30 7.42 43.7 126.7

2011/12/17 17:50 7.46 42.6 170.2

12/19 04:50 7.42 47.4 158

7.31 39 93

HCO3
BE

22.1
4.3

34.8
0.1

27.8
3.3

29.8
5.7

30
4.9

Treatments
Supplemental oxygen and airway protection Patients with severe burns often require tracheal intubation. Bronchodilators can be useful when bronchospasm is present.

Avoid overhydration and possible exacerbation of pulmonary edema. Low tidal volume ventilation to reduces the incidence of ventilator-associated lung injury (permissive hypercapnia)

Vital sign monitoring

Laboratory studies and monitoring

25 20 15 10 5 0 12/16 12/17
1216 BUN Cre Na K 19 0.86 134 4.4

250 200 150 100 50 0 12/18

1217 18 0.69 131 4.5

BUN Cre K Ca Mg Albumin Na CK

12/19
1218 21 0.72 131 4

12/20
1219 1220 16 0.65 129 4.2

CK
Ca Mg Albumin

233
1.77 0.71 2.8

95
1.86 1.95 0.65 1.91 0.67 2.7 1.89

150 130 110 90 70 50 30 10 -10

400 350 300 250 200 150 100 50 0

WBC Hb Hct PLT

9 /1 12
1217

1)

2)

/1

/1

6(

6(

12

12

/1

12

12

/1

12/16(1)

12/16(2)

12
1218

/2

1219

1220

WBC Hb Hct PLT

38.05 15.8 45.7 340

16.39 17.9 50 289

8.89 16.4 48.9 208

4.19 12.5 37.4 142

7.39 16.5 34.4 173

7.67 16.2 36.5 208

Acute compartment syndrome

Decompressive fasiotomy
circumferential full thickness burns distal ischemia

Wound management

Cleansing and debridement

Remove loose, devitalized, necrotic tissue Brushing, scraping, curetting, cutting gently cleansed with skin disinfectants, soap and water

Topical antimicrobial agents

Silver sulfadiazine, conventional antibiotics, chlohexidine, povidone iodine, mafenide

Dressings
Absorb drainage Protection and isolation from the environment Decrease wound pain

Thanks for your attention