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MORBIDITY AND MORTALITY REVIEW

MORBIDITY AND MORTALITY REVIEW. 14/2/2013. HISTORY. 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.

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MORBIDITY AND MORTALITY REVIEW

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  1. MORBIDITY AND MORTALITY REVIEW 14/2/2013

  2. HISTORY • 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

  3. 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

  4. Physical examination • 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

  5. 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

  6. Deep partial thickness 17.5 • Superficial partial thickness 25.5 • Total area 43% TBSA ASSESSMENT Alleged flame burn injury with 43% partial and full thickness burn injury over both LL, perineum and ant chest

  7. Investigations • 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

  8. CARE PLAN • 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

  9. 18/1/13 • Premed review • BP: 151/97, HR: 104, SPO2 100% • ECG showed Atrial fibrillation, CXR showed cardiomegaly • Pb list • Alleged flame injury with 43% partial and full thickness burn injury over both lower limbs, perineum and ant chest • AF, rate control • Underlying Dm, HPT • classified as ASA II • Anaest plan: GA with IPPV

  10. 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

  11. 20/1/13 • 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

  12. …cont • 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’scanHly then 4Hly

  13. 21/1/13 • 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

  14. Urine output 400ml post IV lasix 20mg • Lung transmitted sound, crepts MZ • RR 24 • Plan • Reduced IVD 1pint D5% • Another 10mg IV lasix

  15. 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

  16. Anaest referral • 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

  17. ABG • pH 7.31 pCO2 42 PO2 99 HCO3 21 BE -2 SPO2 98% • ECG sinus tachycardia • TWCC ; 16 • Impression • Alleged flame burn injury with 43% partial and full thickness burn injury • Acute resp distress ? Secondary to aspiration / post op atelectasis • Geriatric with multiple comorbid – DM/HPT/AF

  18. ICU admission • 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

  19. Problem list • 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 • Fluid overload possible of CCF • Underlying DM,HPT, IHD, AF

  20. 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

  21. 2pm • BP progressively severe hypotensive • BP: 74/39, HR 144 • Require step up inotropic support • Infnoradrenaline 40mls/h • Inf Dopamine 10mls/h • InfDobutamine 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

  22. 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

  23. Pronounced death at 3.55pm

  24. Investigations • Full blood count • BUSE/CREAT

  25. Investigations • Full blood count • BUSE/CREAT

  26. Phospate : 0.78 • Magnesium : 0.43 • Calcium 1.70 • RBS : 2.6 • PT/PTTK/INR

  27. 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

  28. DISCUSSION

  29. Burn assessment • 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

  30. Classification of burn

  31. Wallace rule of 9 Lund & Browder charts

  32. Fluid regime • 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 injury • Fluid of choice = hartmann’s solution

  33. 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

  34. 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

  35. Consequences of burns Short term consequences Long term consequences Early consequences Hypovolaemia (loss of protein, fluid and electrolytes) Metabolic derangements hyponatraemia followed by risk of hypernatraemia, hyperkalaemia followed by hypokalaemia) Sepsis Hemolysis with anemia hypothermia Renal failure (acute tubular necrosis d/t hypovolaemia , haemoglobinuria and myoglobinuria) Resp failure (smoke inhalation, airway obstruction, ARDS) Catabolism and nutritional depletion Venous thrombosis Curling’s ulcer and erosive gastritis Permanent disfigurement Prolonged hospitalization Psychological problem Impaired function

  36. 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

  37. Resp • Early compl : 0-24H – carbon monoxide poisoning and direct inhalational injury  airway obstruction and pulmedem • Delayed 2-5days: adult resp distress syndrome • Late: days to weeks – pneumonia, atelectasis and pulm emboli

  38. Prognosis of burn Age and general condition 1 Extent of the burn 2 Depth of the burn 3 Site of the burn 4 Assoc respiratory injury 5

  39. Thank you

  40. 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

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