Burn & ARDS

Question 1

the stem

Answer 1

calculate the surface area of burn according to Wallace rule of nine for this burn ( attached image)

Question 2

how to manage this burn patient?

Answer 2

Initial assessments should focus on airway, breathing, and circulation.
1.Airway: Assess for signs of airway burns and inhalational injury, as these may lead to airway edema. Intubation should be considered if airway edema is present.
2.Breathing& ventilation: Adequate ventilation is crucial in burn management because tracheal or pulmonary burns can significantly impair gas exchange, leading to respiratory distress. Additionally, full thickness chest burns may restrict chest expansion, further complicating ventilation efforts.
3. circulation: insert 2 large bore cannulae and to start Fluid resuscitation using the Parkland formula: Volume of crystalloids (ml) = 2 x % TBSA x patient weight (kg), with half administered in the first 8 hours and the other half over the subsequent 16 hours.

Question 3

What is the Parkland formula for fluid resuscitation?

Answer 3

Volume of crystalloids (ml) = 2 x % TBSA x patient weight, administered over 24 hours.

Question 4

Why are colloids not given in burn treatment?

Answer 4

Increased capillary permeability during the first 24 hours causes colloids to pass to the extravascular space, leading to paradoxical fluid accumulation.

Question 5

What parameters assess the adequacy of fluid therapy?

Answer 5

1. peripheral warmth.

2.capillary refill time.

3.urine output.

4.central venous pressure.

5. core temperature.

6.hematocrit.

Question 6

What are the clinical features of superficial second degree burns?

Answer 6

intense pain,
white to red skin,
blisters,
involvement of the epidermis and papillary dermis,
spontaneous re-epithelialization in 7-14 days.

Question 7

What can cause pulmonary infiltrates on CXR rather than ARDS? how to investigate for each?

Answer 7

1.pneumonia: Through sputum culture, blood culture, and CT scan.

2.atelectasis: By observing rapid changes in size, shape, or localization of infiltrates on serial chest x-rays.

3.pleural effusion,: by us and ct.

4.cardiogenic pulmonary edema; By identifying cardiomegaly, septal thickening, and pleural effusion in congestive heart failure.

5.pulmonary embolism.

Question 8

What are the managements for the initial predisposing insult?

Answer 8

respiratory support: Strategies include 1.low tidal volume ventilation to protect the lungs from over distintion and release of inflammatory mefiators.
2.moderate PEEP to improve oxygenation and prevent lung injury.
3. prone positioning to enhance lung function,
4. high-frequency oscillation to prevent ventilator-induced lung injury.

b. pharmacological support:
1.Low-dose steroids have been shown to improve oxygenation and survival in ARDS patients, but should not be initiated within two weeks of onset due to increased infection risk.
2.Inhaled nitric oxide causes pulmonary vasodilation, which reduces pulmonary hypertension and enhances gaseous exchange, improving overall oxygenation in ARDS patients.

c. hemodynamic support: to provide conservative fluid management which reduces pressure in pulmonary microvasculature.

d. nutrition: Enteral nutrition should begin after 48-72 hours of mechanical ventilation, using a low carbohydrate, high fat formula.

Question 9

What is ARDS? what sre its signs? and what are its charactracstics?

Answer 9

A syndrome of acute respiratory failure and persistent inflammatory disease of the lungs.

signs are: Reduced lung compliance, hypoxaemia resistant to oxygen therapy, and non-cardiogenic pulmonary oedema.

charactracstics are :
1.Diffuse bilateral pulmonary infiltrates not explained by effusions, fluid overload, or lung collapse.
2.Pulmonary artery capillary wedge pressure (PACWP) of <18 mmHg, excludes a cardiac cause due to no atrial hypertension
3.PaO 2/FiO 2 ratio of <26.6 kPa (200 mmHg)

Question 10

What else can cause pulmonary infiltrates on CXR rather than ARDS and how to investigate for each?

Answer 10

Causes include pneumonia: Through sputum culture, blood culture, and CT scan.

atelectasis: By observing rapid changes in size, shape, or localization of infiltrates on serial chest x-rays.

cardiogenic pulmonary edema,: Presence of cardiomegaly, septal thickening, and pleural effusion is assessed, often in congestive heart failure.

pleural effusion:Using ultrasound and CT scan.

pulmonary embolism:-CT pulmonary angiography (CTPA) is utilized.

Question 11

What else can cause pulmonary infiltrates on CXR rather than ARDS and how to investigate for each?

Answer 11

Causes include pneumonia: Through sputum culture, blood culture, and CT scan.

atelectasis: By observing rapid changes in size, shape, or localization of infiltrates on serial chest x-rays.

cardiogenic pulmonary edema,: Presence of cardiomegaly, septal thickening, and pleural effusion is assessed, often in congestive heart failure.

pleural effusion:Using ultrasound and CT scan.

pulmonary embolism:-CT pulmonary angiography (CTPA) is utilized.

Question 12

What are management strategies for ARDS?

Answer 12

A. respiratory support: Strategies include

1. low tidal volume ventilation: protect lung from over distintion and release of inflammatory response.
2. moderate PEEP: It prevents lung injury and improves oxygenation while minimizing cardiovascular compromise.

3 . prone positioning: It can significantly improve oxygenation, with reported improvements of up to 65%.

4. high frequency oscillation: It includes low positive pressure and high respiratory rates to prevent ventilator-assisted lung injury.
5. ECMO : used for profound refractory hypoxemia, though its advantages in combination therapy are still under investigation.

B. pharmacological support:

1. low steroid dose :may improve oxygenation and survival, but should not be started after two weeks of ARDS onset due to infection risks.

2.inhaled nitric oxide and prostacyclin : Both treatments cause pulmonary vasodilation, reducing pulmonary hypertension and improving gas exchange.

3. antibiotics: They should be given in cases of infective causes after obtaining appropriate cultures.

C. haemodynamic management: conservative fluid management maintains a low central venous pressure, reducing pressure in the pulmonary microvasculature.

D. nutrition: enteral nutrition commencement after mechanical should be started after 48-72 hours of mechanical ventilation.ventilation