Term 4 Week 12 (w/c 19/11/12)
Good morning, Welcome to this weeks #gasclass.
This week we start with a general question.
What complications may arise from the cannulation of central veins?
Thank you for contributing yesterday, lots of potential complications noted.
As a follow up to yesterday – Which site do you routinely use?
You have been called to the Emergency Department to see a 35 year old man who has been brought in by ambulance following a a contained explosion.
As you walk to the ED what are your intial thoughts?
You discover that the man was cutting the top off a metal drum with an angle grinder on a remote farm. As the drum was pierced by the cutter the drum exploded and the whole room was burst into flames. He has significant burns to his head and neck, and arms and legs with evidence of early swelling of the lips.
The accident occurred approximately 1 hour ago.
On arrival his HR is 130 BP 90/40 CRT 4s Temp 35.2
What is your management plan? What else would you like to know?
Thank you for all your thoughts yesterday. You undertake a rapid ABCDE assessment, he now has obvious swelling of his lips and face. He is restless on the trolley and groaning. His RR is 35 SpO2 on 15L is 92% Air entry appears equal in both lung fields. He remains tachycardic at 130 BP 85/50 CRT is 4s after 2L of Hartmanns solution. via a cannula in the left ACF. He has extensive partial and full thickness burns which approximate to 52% the majority being on his head, neck, arms and legs, these are some burns on his anterior abdominal wall.
He has a pelvic pain and an open femoral fracture.
You are also told that at the scene he was screaming out in pain.
Excellent thoughts yesterday. You decide to sedate, intubate and ventilate the patient and arrange for a CT – There are multiple lung contusions, and it confirms the fractured pelvis. There is no other obvious abdominal injury. Despite fluid resuscitation his BP remains at 90/50 with HR 120.
Once his initial surgery is completed, how do you manage these patients on the ICU?
Ask the Expert
This weeks case has looked at major injuries in combination with significant burns. The patient has been involved in an explosion in a confined space. When considering burn injuries, it is important where possible to elicit an accurate account of exactly what happened where and when. This injury has occurred indoors and therefore there is risk of inhalational injury and the explosion may lead you to suspect that there is injury to lungs, bowels, ears.
Burns to the head & neck and upper airways causes considerable swelling and this leads to airway compromise, pre-emptive intubation and ventilation to secure and protect the airway should be performed. An uncut ET tube should be used as the odema can be considerable and a cut tube soon disappears into the oral cavity.
Fluid resuscitation – In this case the fluid resuscitation is made difficult because of the pelvic and femoral injury. Effective fluid resuscitation requires reliable IV access. In the short term this is via large bore cannulae but in a major burn central venous access will be required. The preferred routes are internal jugular or subclavian as these have a lower risk of infection.
Many formuale have been used for predicting fluid resuscitation relating to burns.
This is 4mls/kg/%TBSA burns to be given in the first 24 hours from onset of the burn. with half to be given within the first 8 hours.
Further information on Anaestheisa and Intensive Care for Major burns can be found in CEACCP 12 (3) 2012
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