VA ICU report 6.23.17: Burns and shock!


Case summary

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.

Top pearls.

  • 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:
  1. Calculate the affected BSA and assess depth of skin involvement
  2. Use the Parkland Formula for fluid repletion
  3. Contact surgery early
  4. 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.

Burns

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 Burns.png

Management

  1. 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.
  2. Use the Parkland formula to calculate fluid requirements
  3. 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

Shock

Determining the etiology of shock is critical for management.  This is often made easier when data from invasive monitoring is available (SvO2, CVP etc).

On the initial assessmentgauging the SVR (warm skin –> low SVR; cool –> high SVR) and the JVP provide strong clues to etiology of shock.

Shock INitial.png

Shock Approach.png

 

Evernote: https://www.evernote.com/l/AGK1Q3o8zU5PNow4gfikXrkRBLX8MWA7v8A

 


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