by eeman abou bakr assistant lecturer of anaesthesia and intensive care by eeman abou bakr assistant...

By

Eeman Abou BakrAssistant lecturer of Anaesthesia

and Intensive Care

By

Eeman Abou BakrAssistant lecturer of Anaesthesia

and Intensive Care

You have been called to anesthesia and You have been called to anesthesia and emergency department to provide emergency department to provide anesthesia for reduction of a anesthesia for reduction of a colle’s colle’s fracture.fracture.

The patients is a The patients is a 68 years old68 years old, heavy , heavy smokersmoker and and drinkerdrinker who has been who has been involved in a involved in a firefire she has she has burnsburns to her to her face, chest and arms.face, chest and arms.

QuestionsQuestions What assessment of the patients would you

make? Discuss airway assessment, The significance of perform SaO2 and other

investigations you would perform (COHb). What are the indications for intubations. What fluid requirements will patients have ? What fluid would you give, when you give,

and why ? Discuss analgesia, are burns painful ? Would you give an anesthetic for the

fracture ? Where should the patient be looked after ?

What assessment of the What assessment of the patient would you make?patient would you make?

Step 1: Initial Step 1: Initial AssessmentAssessment

Assessment of the burn patient follows the Assessment of the burn patient follows the standard EMS assessment pattern:standard EMS assessment pattern:Airway: Airway: does the patient have a patent airway?does the patient have a patent airway?Breathing:Breathing: is the patient breathing adequately? is the patient breathing adequately?Circulation:Circulation: Is the patient’s circulatory and Is the patient’s circulatory and cardiac status stable?cardiac status stable?Neurological status: Neurological status: AVPUAVPU

Note: burns do NOT alter mentation—if the Note: burns do NOT alter mentation—if the patient is un-alert or disoriented, something else patient is un-alert or disoriented, something else is going on!is going on!Expose the patient, and treat for hypothermiaExpose the patient, and treat for hypothermia

Secondary SurveySecondary Survey

History: obtain burn specific historyHistory: obtain burn specific history How did the burn occur?How did the burn occur?

Did the patient’s clothing ignite?Did the patient’s clothing ignite?

Were accelerants involved?Were accelerants involved?

Was patient found in smoke-filled room?Was patient found in smoke-filled room?

Did the patient leap from a window, fall, or roll a vehicle?Did the patient leap from a window, fall, or roll a vehicle?

Are the purported circumstances of the injury consistent Are the purported circumstances of the injury consistent with the burn characteristics? Is abuse a possibility?with the burn characteristics? Is abuse a possibility?

Secondary Survey Secondary Survey (Cont’d.)(Cont’d.)

Head-to-toe: look carefully for injuries Head-to-toe: look carefully for injuries other than the actual burnother than the actual burn

Start detailed physical examination Start detailed physical examination

Establish an adequate IV access Establish an adequate IV access

Burn injuries are not considered immediate life threats, but they do often accompany traumatic injuries

that are life threats!

Burn injuries are not considered immediate life threats, but they do often accompany traumatic injuries

that are life threats!

Step 2: Determining Burn Step 2: Determining Burn SeveritySeverity

• Burn severity is determined primarily by assessing the extent of the burn as percentage of total body surface area, and its depth

• ‘Partial/full thickness’ and ‘1st/2nd/3rd degree’ are acceptable terminology

• First and second degree burns are partial thickness burns

• Third degree burns are full thickness burns

Determining Burn Severity Determining Burn Severity (Cont’d)(Cont’d)

First degree burns First degree burns ((epidermal burns) are red,

appear DRY, blanch when pressed upon,

and blister mildly. Second degree Second degree ((dermal) burns tend to

be red or yellowish, appear WET, usually

blister, and may or may not blanch Third degree (subcutaneous) burns

appear very DRY, may be yellow, gray or

black, do not blanch, and are ‘leathery’ to touch.

Patient is: Patient is: 68 yrs old. 68 yrs old.

Fire – burns to face, chest and arms.Fire – burns to face, chest and arms.

Colle’s fracture. Colle’s fracture.

Heavy smoker. Heavy smoker.

Drinker.Drinker.

First of all trauma patient !! First of all trauma patient !!

Discuss Airway Assessment

This patient at RISK of developing This patient at RISK of developing inhalational injury due toinhalational injury due toUnable to escape fire due toUnable to escape fire due to-Extremes of ageExtremes of age-Immobility due to other traumaImmobility due to other trauma-Reduction of level of consciousness: alcohol, Reduction of level of consciousness: alcohol, drugs, effects of smoke.drugs, effects of smoke.Lack of functional smoke detectorLack of functional smoke detectorChronic pulmonary disorders: asthma, COPD Chronic pulmonary disorders: asthma, COPD morbidity of smoke inhalation increased.morbidity of smoke inhalation increased.

Airway assessment Airway assessment (Cont’d)(Cont’d)

History

- Was the fire in an enclosed space.

- Duration of exposure.

-What type of material burned, e.g., paints,

chemicals.

- Level of consciousness on scene.

Airway assessment Airway assessment (Cont’d)(Cont’d)

Burns and smoke inhalation victims should

be treated as a “trauma” patient, with trauma

protocol being followed as routine. This

includes cervical immobilization until injury

is excluded.

Airway assessment Airway assessment (Cont’d)(Cont’d) Examination

- Stridor: indicates severe laryngeal edema and the possibility of

imminent airway obstruction

- Voice hoarseness—an excellent warning sign

- Tachypnea

- Use of accessory muscles

- Persistent cough

- Soot in oropharynx

- Singed nasal hair

Carbonaceous Carbonaceous particles particles staining a staining a patient’s face patient’s face after a burn after a burn in an enclosed in an enclosed space. This space. This suggests suggests there is there is inhalational inhalational injuryinjury

Airway assessment Airway assessment (Cont’d)(Cont’d)

Laryngoscopy detect edema to the

pharynx or larynx or vocal cords.

Bronchoscopy

Airway edema

Mucosal slouging

Charring or soot

Discuss the significance to perform SaO2 and other

investigations you would perform as(COHb).

Oxygen saturation(SaO2)Oxygen saturation(SaO2)

SaO2 is inaccurate in the presence SaO2 is inaccurate in the presence of significant carboxyhemoglobin of significant carboxyhemoglobin (COHb) or methemoglobinemia.(COHb) or methemoglobinemia.

Carbon Monoxide Carbon Monoxide PoisoningPoisoning

Asphyxiation and/or carbon Asphyxiation and/or carbon monoxide poisoningmonoxide poisoning causes most causes most fire scene fatalitiesfire scene fatalities

Inhaled carbon monoxideInhaled carbon monoxide bonds to bonds to hemoglobin in the blood, taking the hemoglobin in the blood, taking the place of oxygen with approximately place of oxygen with approximately 200 times greater affinity. 200 times greater affinity.

The pulse oximiterThe pulse oximiter, which measures , which measures bonded hemoglobin, will deliver a bonded hemoglobin, will deliver a normal reading, normal reading, even when the even when the patient patient is hypoxic, or deadis hypoxic, or dead

Carbon Monoxide Carbon Monoxide PoisoningPoisoning

Cherry-red lipsCherry-red lips, skin and nail beds occur , skin and nail beds occur in only 50% of patients with severe in only 50% of patients with severe carbon monoxide poisoning and are carbon monoxide poisoning and are not not a clinically reliable indicatora clinically reliable indicator

If sufficient carbon monoxide is inhaledIf sufficient carbon monoxide is inhaled, , tissue perfusion WILL cease, and the tissue perfusion WILL cease, and the patient WILL diepatient WILL die

CO2 removal is not affected, so ET CO2 removal is not affected, so ET capnography does remain an accurate capnography does remain an accurate indicator of ET placementindicator of ET placement

The only accurate assessmentThe only accurate assessment is blood is blood level carboxyhemoglobin, which must be level carboxyhemoglobin, which must be assessed at the hospitalassessed at the hospital

Signs of Signs of CarboxyhaemoglobinaemiaCarboxyhaemoglobinaemia

COHb COHb levels levels

SymptomsSymptoms

0-10% Minimal (normal level in heavy smokers)

10-20% Nausea, headache

20-30% Drowsiness, lethargy

30-40% Confusion, agitation

40 -50% Coma, respiratory depression

>50% Death COHb = Carboxyhaemoglobin

Investigations for major Investigations for major burnsburns

GeneralGeneral Full blood count, packed cell volume, Full blood count, packed cell volume,

urea and electrolyte concentration, urea and electrolyte concentration, clotting screen, liver enzymesclotting screen, liver enzymes

Blood group, and save or crossmatch Blood group, and save or crossmatch serumserum

12 lead electrocardiography12 lead electrocardiography Cardiac enzymesCardiac enzymes

Investigations for major Investigations for major burns burns

For inhalational injury:For inhalational injury: Arterial Blood Gases—mandatoryArterial Blood Gases—mandatory Chest x-ray—Frequently normal Chest x-ray—Frequently normal

initially but essential initially but essential nonetheless as baseline nonetheless as baseline assessment and to exclude assessment and to exclude trauma.trauma.

What are the indications of intubation?

Early intubation required to treat “4” causes of

respiratory dysfunction:

1. CO poisoning

2. Upper airway edema

3. Subglottic thermal and chemical burns

4. Chest wall restriction

What are the indications of intubation?

Early intubation required to treat “4” causes of

respiratory dysfunction:

1. CO poisoning

2. Upper airway edema

3. Subglottic thermal and chemical burns

4. Chest wall restriction

What fluid requirement will patient have ?

What fluid would you give when you give and why ?

Fluid ResuscitationFluid Resuscitation

Related to:Related to: extent of burn (rule of nines) extent of burn (rule of nines) body size (pre-injury weight estimate)body size (pre-injury weight estimate)

Delivered through large bore Delivered through large bore peripheral IVperipheral IV Attempt to avoid overlying burned Attempt to avoid overlying burned

skinskin Can use venous cut down or central Can use venous cut down or central

lineline

Fluid ResuscitationFluid Resuscitation

Goal:Goal: Maintain perfusion to vital Maintain perfusion to vital organsorgans

Fluid requirement calculations Fluid requirement calculations

for infusion rates for infusion rates are based on the are based on the

time from injurytime from injury, not from the time , not from the time

fluid resuscitation is initiated. fluid resuscitation is initiated.

Resuscitation Fluid Resuscitation Fluid Needs:Needs:

First 24 HoursFirst 24 Hours Parkland Formula:Parkland Formula: Adults:Adults: 2-4 ml RL x Kg body 2-4 ml RL x Kg body

weight x % burnweight x % burn First half of volume over first 8 First half of volume over first 8

hours, second half over following hours, second half over following 16 hours16 hours Hypovolemia, decreased COHypovolemia, decreased CO Increased capillary permeabilityIncreased capillary permeability Crystalloid fluid is keystone, colloid Crystalloid fluid is keystone, colloid

not usefulnot useful

Fluid resuscitationFluid resuscitation

Lactated Ringers - preferred Lactated Ringers - preferred solutionsolution

Contains Na+ - restoration of Na+ Contains Na+ - restoration of Na+ loss is essentialloss is essential

Free of glucose – high levels of Free of glucose – high levels of circulating stress hormones may circulating stress hormones may cause glucose intolerancecause glucose intolerance

Resuscitation Fluid Resuscitation Fluid Needs:Needs:

Second 24 HoursSecond 24 Hours Capillary permeability gradually returns to Capillary permeability gradually returns to normalnormal

30–50% burn: 0.3 mL/kg body weight 30–50% burn: 0.3 mL/kg body weight per % burnper % burn

50–70% burn: 0.4 mL/kg body weight 50–70% burn: 0.4 mL/kg body weight per % burnper % burn

>70% burn: 0.5 mL/kg body weight per >70% burn: 0.5 mL/kg body weight per % burn% burn

Usually check for BP, CVP and urinary Usually check for BP, CVP and urinary output.output.

Resuscitation endpoints Resuscitation endpoints

Fluid resuscitationFluid resuscitation

Over resuscitationOver resuscitation Results in:Results in:

Pulmonary edemaPulmonary edema 33rdrd spacing of tissues of chest— spacing of tissues of chest—escharotomiesescharotomies

Prolonged ventilationProlonged ventilation Source of morbidity—monitor Source of morbidity—monitor

U/O closelyU/O closely

Discuss analgesia, are Discuss analgesia, are burns painful ?burns painful ?

AnalgesiaAnalgesia

Pain management is indicated for most Pain management is indicated for most burns.burns.

First degree and superficial second degree First degree and superficial second degree burns are generally painful.burns are generally painful.

Full thickness burns are not painful due to Full thickness burns are not painful due to destruction of the dermis.destruction of the dermis.

AnalgesiaAnalgesia

Should be titrated intravenously only.Should be titrated intravenously only. Subcutaneous and intramuscular routes become Subcutaneous and intramuscular routes become

trapped in tissues by edema and can induce trapped in tissues by edema and can induce respiratory arrest as the edema resolves which respiratory arrest as the edema resolves which may kill the patient.may kill the patient.

Morphine is of choice for (background pain).Morphine is of choice for (background pain).

Morphine is the drug of choice for pain

Morphine is the drug of choice for pain

For extremely painful procedures in both For extremely painful procedures in both

emergency and acute phase, emergency and acute phase, FentanylFentanyl has a has a

major advantage.major advantage. It is shorter acting It is shorter acting (procedural pain).(procedural pain). It avoids It avoids over sedation over sedation following a following a

procedure.procedure. Other drugs as Other drugs as BenzodiazepinesBenzodiazepines may be may be

indicated to clam patients in anxiety induced indicated to clam patients in anxiety induced

hyperventilations.hyperventilations.

Would you give an anesthetic for the fracture ?

To answer this question we must know what is the pathophysiology of burn

injury

Fluid and Electrotype Shifts—Fluid and Electrotype Shifts—EmergentEmergentPhasePhase Generalized dehydrationGeneralized dehydration Reduced blood volume and Reduced blood volume and

hemoconcentrationhemoconcentration Decreased urine outputDecreased urine output Trauma causes release of potassium Trauma causes release of potassium

into extracellular fluid: hyperkalemiainto extracellular fluid: hyperkalemia Sodium traps in edema fluid and shifts Sodium traps in edema fluid and shifts

into cells as potassium is released: into cells as potassium is released: hyponatremiahyponatremia

Metabolic acidosisMetabolic acidosis

Fluid and Electrolyte Shifts—Fluid and Electrolyte Shifts—Acute PhaseAcute Phase Fluid reenters the vascular space from Fluid reenters the vascular space from

the interstitial spacethe interstitial space HemodilutionHemodilution Increased urinary outputIncreased urinary output Sodium is lost with diuresis and due to Sodium is lost with diuresis and due to

dilution as fluid enter vascular space: dilution as fluid enter vascular space: hyponatremiahyponatremia

Potassium shifts from extracellular Potassium shifts from extracellular fluid into cells: potential hypokalemiafluid into cells: potential hypokalemia

Metabolic acidosisMetabolic acidosis

Three variables estimate a high probability of Three variables estimate a high probability of

deathdeath Age > 60 Age > 60 Burn more than 40% TBSA Burn more than 40% TBSA Presence of inhalational injury Presence of inhalational injury

Other variables include:Other variables include: Presence of coexisting disease Presence of coexisting disease Delay in resuscitation Delay in resuscitation

Anesthetic management for this patient Anesthetic management for this patient Give anesthesia for patients as soon as Give anesthesia for patients as soon as

hemodynamics are stabilized.hemodynamics are stabilized. Regional anesthesia can be used effectively in small Regional anesthesia can be used effectively in small

burns or patients undergoing reconstructive burns or patients undergoing reconstructive

procedures.procedures. For upper extremity procedures brachial plexus For upper extremity procedures brachial plexus

block may be considered as primary anesthetic or block may be considered as primary anesthetic or

as an adjunct for postoperative pain control. as an adjunct for postoperative pain control. In this patient as there is injury to both the arms and In this patient as there is injury to both the arms and

chest regional anesthesia would be a difficult chest regional anesthesia would be a difficult

choice.choice.

Remember also:Remember also: Casts over burn must be avoided.Casts over burn must be avoided. Avoid prolonged immobilization of joints in Avoid prolonged immobilization of joints in

burn area.burn area. Therefore external and internal fixation Therefore external and internal fixation

techniques are of choice. techniques are of choice.

Operative management

Ketamine has many advantages for burn patients as

an induction and maintenance agent.

Induction dose 0.5-2 mg/Kg.

Ketamine preserves hemodynamics compared to

other IV anesthetics.

Airway reflexes remain more intact with small risk

of aspiration

Maintenance can be done by volatile agents opioid

nitrous oxide.

Operative management

Ketamine has many advantages for burn patients as

an induction and maintenance agent.

Induction dose 0.5-2 mg/Kg.

Ketamine preserves hemodynamics compared to

other IV anesthetics.

Airway reflexes remain more intact with small risk

of aspiration

Maintenance can be done by volatile agents opioid

nitrous oxide.

Muscle relaxantsMuscle relaxants Succinylcholine is contraindicated un Succinylcholine is contraindicated un

the first 24 hours (the first 24 hours (cardiac arrestcardiac arrest)) Burn patients require higher than Burn patients require higher than

normal doses of non depolarizing normal doses of non depolarizing muscle relaxants duet o altered muscle relaxants duet o altered protein binding and increase in protein binding and increase in extrajunctional acetyl choline extrajunctional acetyl choline receptors.receptors.

Note :Note : Consider alcoholic liver cirrhosisConsider alcoholic liver cirrhosis Consider COPD patientConsider COPD patient

Where would the patient be looked after ?

Where would the patient be looked after ?

This patient should be admitted to ICU Second and third degree ≥ 20% TBSA. Second and third degree burns that involve face,

hands, genitalia perineum and major joints. Full thickness burn ≥5% TBSA. Inhalational injury. Burn in patient with pre-existing medical conditions

alcoholic smoker.

This patient should be admitted to ICU Second and third degree ≥ 20% TBSA. Second and third degree burns that involve face,

hands, genitalia perineum and major joints. Full thickness burn ≥5% TBSA. Inhalational injury. Burn in patient with pre-existing medical conditions

alcoholic smoker.

what would you do if an anesthetized patient suddenly became hard to

ventilate?

Discuss your management in this critical situation

What are the signs of pneumothorax?How should a pneumothorax be treated?

what would you do if an anesthetized patient suddenly became hard to

ventilate?

Discuss your management in this critical situation

What are the signs of pneumothorax?How should a pneumothorax be treated?

Ventilation may be difficult because of a problem with one of three sites:

Anesthetic equipment (ventilator, anesthetic breathing system) Airway device (endotracheal tube, laryngeal mask, face mask) The patient.

Ventilation may be difficult because of a problem with one of three sites:

Anesthetic equipment (ventilator, anesthetic breathing system) Airway device (endotracheal tube, laryngeal mask, face mask) The patient.

ManagementManagement

The anesthetist should immediately The anesthetist should immediately look for obvious causes. look for obvious causes. Airway Airway pressure may be high immediately pressure may be high immediately after intubation, when neuromuscular after intubation, when neuromuscular blockade has decreased and if the blockade has decreased and if the airway is kinked.airway is kinked. If there is no obvious cause, the If there is no obvious cause, the anesthetist should have a systematic anesthetist should have a systematic approach approach to the diagnosis of high to the diagnosis of high airway pressureairway pressure

ManagementManagement Gas supplyGas supply Breathing circuitBreathing circuit: (hand ventilate the : (hand ventilate the

patient with a selfinflating resuscitation bag)patient with a selfinflating resuscitation bag) AirwayAirway: not kinked or obstructed(suction : not kinked or obstructed(suction

catheter)catheter) Lungs:Lungs: Look for bilateral chest expansion and Look for bilateral chest expansion and

listen to both sides of the chest. endobronchial listen to both sides of the chest. endobronchial intubation (withdraw the endotracheal tube 2cm intubation (withdraw the endotracheal tube 2cm and reassess) or pneumothorax (and reassess) or pneumothorax (check the heartcheck the heartrate rate and blood pressure, feel to see if the trachea is and blood pressure, feel to see if the trachea is central and percuss the chest). central and percuss the chest).

ManagementManagement

If wheezes are present, consider If wheezes are present, consider bronchospasm, aspiration or bronchospasm, aspiration or pulmonary oedemapulmonary oedema

The surgical procedure or the The surgical procedure or the position of the patient may also position of the patient may also make ventilation difficultmake ventilation difficult

Pneumothorax Pneumothorax A pneumothorax may occur for A pneumothorax may occur for

many reasons including :many reasons including : Insertion of intercostal nerve Insertion of intercostal nerve

blocks orblocks or Placing a central venous catheter. Placing a central venous catheter. It can happen spontaneously or It can happen spontaneously or

because of chest trauma or high because of chest trauma or high ventilation pressure during general ventilation pressure during general anesthesia.anesthesia.

Signs and SymptomsSigns and Symptoms

The awake patient The awake patient may complain of may complain of dyspnoea, chest pain, and be tachypnoeic dyspnoea, chest pain, and be tachypnoeic and hypoxic.and hypoxic.

In the anaesthetized patient, In the anaesthetized patient, it can be it can be very difficult to diagnose a pneumothorax.very difficult to diagnose a pneumothorax.

The patient may be The patient may be hypoxichypoxic and have and have raisedraised inspiratory airway pressuresinspiratory airway pressures. A . A large pneumothorax or a tension large pneumothorax or a tension pneumothorax will cause pneumothorax will cause hypotension, hypotension, tachycartachycardia and may cause death.dia and may cause death.

Signs and SymptomsSigns and Symptoms

On examination On examination the patient may the patient may have reduced or absent breath have reduced or absent breath sounds on one side, increased sounds on one side, increased resonance to percussion, tracheal resonance to percussion, tracheal deviation or subcutaneous deviation or subcutaneous emphysema.emphysema.

The anesthetist must always consider a The anesthetist must always consider a pneumothorax in their diagnosis, pneumothorax in their diagnosis,

especially if the patient is at increased especially if the patient is at increased riskrisk

(central venous catheter inserted, chest (central venous catheter inserted, chest trauma, asthma, high airway pressure). trauma, asthma, high airway pressure).

The anesthetist must always consider a The anesthetist must always consider a pneumothorax in their diagnosis, pneumothorax in their diagnosis,

especially if the patient is at increased especially if the patient is at increased riskrisk

(central venous catheter inserted, chest (central venous catheter inserted, chest trauma, asthma, high airway pressure). trauma, asthma, high airway pressure).

Signs and SymptomsSigns and Symptoms

A pneumothorax may be present with A pneumothorax may be present with signs and symptoms signs and symptoms similar to several similar to several other problems,other problems, including aspiration including aspiration of gastric contents, endobronchial of gastric contents, endobronchial intubation, a blocked endotracheal intubation, a blocked endotracheal tube and bronchospasm.tube and bronchospasm.

An erect chest x-ray An erect chest x-ray will help with will help with the diagnosis (a pneumothorax can the diagnosis (a pneumothorax can be very difficult to see on a supine be very difficult to see on a supine chest x-ray).chest x-ray).

Chest X-RayChest X-Ray

ManagementManagement

Always ensure that the patient is Always ensure that the patient is well oxygenated and ventilatingwell oxygenated and ventilating

Turn off the nitrous oxide and Turn off the nitrous oxide and give 100% oxygen (70% nitrous give 100% oxygen (70% nitrous oxide will rapidly increase the oxide will rapidly increase the size of a pneumothorax by 100% size of a pneumothorax by 100% in 10 minutes).in 10 minutes).

Check the blood pressure and Check the blood pressure and pulse rate.pulse rate.

ManagementManagement

If the blood pressure is low If the blood pressure is low and and there is no other cause for a low there is no other cause for a low blood pressure, treat the patient as blood pressure, treat the patient as if they have a tension if they have a tension pneumothorax. A tension pneumothorax. A tension pneumothorax can rapidly cause pneumothorax can rapidly cause death and must be treated as an death and must be treated as an emergency.emergency.

Inform the surgeon and call for Inform the surgeon and call for help.help.

ManagementManagement

Insert a large intravenous catheter into Insert a large intravenous catheter into the pleural space to aspirate the the pleural space to aspirate the

pneumothorax.pneumothorax. The intravenous catheter should be The intravenous catheter should be

placed in the second intercostal space placed in the second intercostal space above the rib in line with the middle of above the rib in line with the middle of the clavicle, to avoid damaging the the clavicle, to avoid damaging the intercostal nerves and blood vessels. intercostal nerves and blood vessels.

A chest tube must be inserted following A chest tube must be inserted following insertion of an intravenous catheter.insertion of an intravenous catheter.