Thanks to Vijay and the ICU team for presenting a great case of a 68M w/ diabetic neuropathy who presented with thermal burns to the legs c/b by likely septic shock.
- Superficial skin conditions (e.g. cellulitis) rarely lead to hemodynamic comprise. The presence of systemic illness should prompt consideration for a deeper space process (e.g necrotizing fasciitis).
- For patients with burns:
- Calculate the affected BSA and assess depth of skin involvement
- Use the Parkland Formula for fluid repletion
- Contact surgery early
- Consider transfer to a burn center
- On initial assessment, four categories of shock (distributive, hypovolemic, cardiogenic and obstructive) can be sorted by SVR (cold skin –> high SVR; warm skin –> low SVR) and JVP.
Assessing the extent of skin involvement (body surface area and depth) is the an important initial step
- Use the rule of 9’s to estimate BSA involved
- 9%: head + neck, upper extremity
- 18%: lower extremity, torso, back
- Estimate the depth of involvement
- Consult surgery early
- Early debridement (< 1 week) reduces risk of super-infection
- Early consideration of escharotomy reduces risk of compartment syndrome from the edema that naturally follows a burn injury.
- Use the Parkland formula to calculate fluid requirements
- Consider transfer to a burn center. Some criteria include (full list on UpTodate):
- Full thickness burn on BSA > 10%
- Involvement of the face, hands, feet, genitals or joints
- Third degree burns
On the initial assessment, gauging the SVR (warm skin –> low SVR; cool –> high SVR) and the JVP provide strong clues to etiology of shock.