Full document - International Hospital Federation

More documents

Recommendations

Info

Innovation and clinical specialities: burns In children, maintenance requirements must be added to the resuscitation formula, and should be provide as a dextrose containing solution for infants due to the risk of hypoglycemia if they are not drinking. The addition of maintenance is less important in adults due to the large volumes and low risk of hypoglycemia. One formula that accounts for the maintenance requirements is the Shiners Burns Hospital SBH-Galveston Formula, which calls for initial resuscitation with 5000 mL/m 2 BSA burn/d + 2000 mL/m2 BSA/d of Lactated Ringers solution. 18 See http://www.halls.md/body-surface-area/bsa.htm to express BSA in M2. Again, the first half is administered within the first 8 hours post-burn, and the remaining is given over the next 16 hours. Another option to intravenous fluids, in cases of less severe burns or where intravenous solutions are at a premium, includes oral rehydration solution. The WHO describes a method for preparation of an electrolyte-balanced solution 62 . Although very time consuming, IV fluids may also be prepared on site at low cost. 63 It is important to remember that these are only guidelines, and the infusion volumes must be titrated on a regular basis. Urine output is the usual indicator of adequate resuscitation. Urine output in a child should be maintained at 1 mL/kg/h. In an adult, 0.5 mL/kg/h is sufficient (unless myoglobinuria is suspected in which case it should be over 2 mL/kg/h). It is essential to avoid over-aggressive resuscitation, which may lead to increased extravascular hydrostatic pressure and pulmonary edema. This is especially important in patients who have a cardiac history, as well as patients with a concomitant inhalation injury, because they will also have increased pulmonary vascular permeability. Administration of colloid or hypertonic solutions decreases the total amount of fluid requirements in the first 24 hours post-injury; however, no clear advantages in long-term outcomes over isotonic crystalloid resuscitations have been clinically documented. In general, crystalloid resuscitation with isotonic Lactated Ringers is the best option in the acute phase. 18 If a patient is having increased fluid requirements, it should raise suspicion of concomitant inhalation injury, a delay in resuscitation, or another associated injury. It must be reiterated that the most important thing is to begin resuscitation as soon as possible after the time of injury. Unfortunately, delays in adequate resuscitation are common and lead to increased fluid requirements because of additive perfusion-reperfusion injury, which lead to unnecessary loss of life. 18 Escharotomy With circumferential full thickness, or deep partial thickness burns, there must be a high index of suspicion for compartment syndrome. The decreased skin compliance does not accommodate the extreme edema from the inflammatory response. Swelling increases with fluid resuscitation and it is much better to release a limb with early escharotomies than to discover too late that compartment syndrome and myonecrosis have set in. The diagnosis of compartment syndrome in a burned patient is challenging. Pallor is difficult to determine because the eschar often is discolored, soot stained and can be pale and leathery or red and plastic-like to the touch. Most burn wounds are painful to the touch, unless an area of pure full thickness exists. Paresthesia and paralysis are late findings of compartment syndrome and are impossible to address in a patient that may be paralyzed or sedated. The absence of a pulse is similarly too late of a finding. Delayed escharotomies can lead to muscle necrosis and limb loss. Sufficient release can usually be noted as soon as the dermis is released, as the wound opens and subcutaneous tissue bulges out. Escharotomies may need to be done on any limb. (Figure 4) Escharotomy may be done with a scalpel or diathermy blade. While it is true that Figure 4: Escharotomy lines full thickness burns are usually insensate, it is not true that escharotomy can routinely be performed without some kind of pain control. Ketamine or fentanyl and versed are safe and effective. The incision should go through skin but not into fascia or muscle. The mid-medial and mid-lateral lines of each limb are incised. A small “T” where the incision meets normal skin will ease constriction at the end of the incision. Thoracic escharotomies are also occasionally required for improving chest-wall compliance and facilitate ventilation. This may require multiple incisions across the chest, both longitudinally and transversely to allow full chest expansion. Figure 4 shows possible thoracic escharotomy lines, but more lines may be required for very deep constricting burns. In electrical injury, the final extent of tissue injury can be difficult to predict. Frequent assessments and surgical debridements are required often in the face of progressive myonecrosis. With any high voltage electrical injury, the index of suspicion for a deep injury should be high. The skin wound is not a reliable indicator of the underlying damage. These injuries will require a fasciotomy, with release of all muscle compartments to minimize muscle damage. Patients should also be monitored for myoglobinuria which will require treatment with increasing urine output, alkalinization of the urine, and sometimes with very cautious use of diuretics. Untreated myoglobinuria can lead to deposition in the glomerular tubules and renal failure. Inhalation injury Inhalation injuries are associated with severe burns and poor outcomes. A retrospective review in Cape Town, South Africa found that inhalation injury was present in 63% of severe burn patients (>30% TBSA), which resulted in a mortality rate of 76%. 21 However, it is believed that inhalation injuries are more frequently seen in high income countries due to the high prevalence of house burns, where victims are confined to enclosed spaces. Alcohol and smoking account for over half the deaths in developing countries, so prolonged exposure to smoke may occur as a result of intoxication. The prevalence of inhalational injury in low to middle income countries is unknown, but suspected to be lower. The reason for differences in prevalence is unclear, whether due to Hospital and Healthcare Innovation Book 2009/2010 57
Innovation and clinical specialities: burns under diagnosis 20 or a true difference given that the vast majority of burns occur outdoors. Researchers have found prevalence rates of inhalational injury in South Africa of 2.2 % of pediatric burn patients 19 and 14.5% of adult burn patients. 21 Successful management of inhalation injuries relies on early suspicion and resuscitation, as well as minimizing post-injury complications such as bronchopneumonia and acute respiratory distress syndrome (ARDS). In the early resuscitation phase (< 36hrs), it is key to suspect inhalation injury, consider early intubation and empirically oxygenate these patients. Patients who have had prolonged exposure to smoke (ie. trapped indoors), loss of consciousness, flash burns with singed facial hair, carbonaceous sputum, hoarseness should all be closely observed for impending airway obstruction. Suspicion should also be high in patient with facial scald injuries, where airway compromise is often misdiagnosed. Scald burns can be associated with direct thermal injury to the upper airway from ingestion of hot liquids or steam inhalation. 19 Intubation with a large endotracheal tube (to enable suctioning) should be done in patients with stridor, increased work to breathing, respiratory distress, hypoxia, hypercapnea, deep burns to the face or edema/erythema of the oropharynx on laryngoscopic exam. Respiratory distress may not develop for several hours, and intubation should be performed in the case of transfer in high risk patients even in absence of stridor as obstruction may progress quickly as a result of airway inflammation from injury or edema from resuscitation. 22 Smoke inhalation injury is often associated with significant carbon monoxide exposure, resulting in carboxyhemoglobinemia. Carbon monoxide poisonings account for the majority of deaths, which occur at the scene or early in the pre-hospital phase. Asphyxia or anoxic brain injury develop quickly; as the oxygencarrying capacity of the blood is decreased. The clinical manifestations of carbon monoxide poisoning are non-specific and can include headache, malaise, confusion, dyspnea, seizures and loss of consciousness. The diagnosis of carbon monoxide poisoning may be hard to confirm, given its imprecise presentation, unavailable carboxyhemoglobin levels, and misleading O 2 saturation measurement. Conventional pulse oxymetry monitors are unable to distinguish O 2 saturation from CO saturation, and therefore the patient may have a falsely normal O 2 saturation reading. Patients may also appear pink/red and wellperfused, classically described as “cherry red”. PaO 2 should be confirmed by blood gas if possible. Clinical suspicion is the mainstay for diagnosis and treatment. Given poor outcomes associated with neurologic findings or loss of consciousness in the setting of carbon monoxide poisoning 23 , administration of high flow oxygen should be used liberally to reverse tissue hypoxia and to accelerate the displacement of carbon monoxide (as well as cyanide) from their binding sites. The half-life of carboxyhemoglobin can be decreased from 240 minutes to 75-80 minutes by using 100% FiO 2 instead of room air (21% FiO 2). 24 In the post-resuscitation phase (2-5 days) many competing factors can contribute to exacerbate pulmonary insufficiency. Direct thermal injury or exposure to bronchopulmonary toxins from smoke exposure can lead to airway edema, inflammatory changes and activation of systemic inflammatory response, as well as disruption of the muco-ciliary transport, increased capillary Table 1: Burn Wound Dressings [Modified from Sabiston 33 ] Antimicrobial Salves Silver sulfadiazine (Flamazine, Silvadene) Mafenide acetate (Sulfamylon) Bacitracin Neomycin Polymyxin B Nystatin (Mycostatin) Mupirocin (Bactroban) Broad-spectrum antimicrobial; painless and easy to use; does not penetrate eschar; deeply may leave black tattoos from silver ion; mild inhibition of epithelialization Broad-spectrum antimicrobial; penetrates eschar well; may cause pain in sensate skin; wide application causes metabolic acidosis, therefore only suitable for small areas; mild inhibition of epithelialization. Ease of application; painless; antimicrobial spectrum not as wide as above agents Ease of application; painless; antimicrobial spectrum not as wide Ease of application; painless; antimicrobial spectrum not as wide Effective in inhibiting most fungal growth; cannot be used in combination with mafenide acetate More effective staphylococcal coverage; does not inhibit epithelialization; expensive Antimicrobial Soaks 0.5% Silver nitrate Effective against all microorganisms; stains contacted areas; leaches sodium from wounds; may cause methemoglobinemia 5% Mafenide acetate Wide antibacterial coverage; no fungal coverage; painful on application to sensate wound; wide application associated with metabolic acidosis, and therefore generally used for small high-risk areas such as cartilage coverage in nose and ears. 0.025% Sodium hypochlorite (Dakin solution) Effective against almost all microbes, particularly gram-positive organisms; mildly inhibits epithelialization 0.25% Acetic acid Effective against most organisms, particularly gram-negative ones; mildly inhibits epithelialization Synthetic Coverings OpSite Biobrane Transcyte Integra Biologic Coverings Xenograft (pig skin) Allograft (homograft, cadaver skin) Provides a moisture barrier; inexpensive; decreased wound pain; use complicated by accumulation of transudate and exudate requiring removal; no antimicrobial properties Provides a wound barrier; associated with decreased pain; use complicated by accumulation of exudate risking invasive wound infection; no antimicrobial properties Provides a wound barrier; decreased pain; accelerated wound healing; use complicated by accumulation of exudate; no antimicrobial properties Provides complete wound closure and leaves a dermal equivalent; sporadic take rates; no antimicrobial properties. Allows for coverage with a very thin skin graft with no dermis. Very expensive product Completely closes the wound; provides some immunologic benefits; must be removed or allowed to slough Provides all the normal functions of skin; can leave a dermal equivalent; epithelium must be removed or allowed to slough 58 Hospital and Healthcare Innovation Book 2009/2010
Page 1:
International Hospital Federation I
Page 4 and 5:
Introduction Sterile Barrier System
Page 6 and 7:
Contents Healthcare transformation
Page 8 and 9: International Hospital Federation H
Page 11 and 12: Introduction Introduction ERIC DE R
Page 13: Innovation and strategy 14 Creativi
Page 16 and 17: Innovation and strategy: creativity
Page 18 and 19: Innovation and strategy: risk manag
Page 26 and 27: Innovation and stategy: Acceleratin
Page 28 and 29: Innovation and stategy: Acceleratin
Page 30 and 31: Innovation and policy: disease surv
Page 36 and 37: Innovation and clinical specialitie
Page 42 and 43: Innovation and strategy: infectious
Page 48 and 49: Innovation and policy: infectious d
Page 54 and 55: Innovation in clinical specialities
Page 82 and 83: Innovations and clinical specialiti
Page 90 and 91: Company Profile: Shimadzu Europa Gm
Page 108 and 109:
Innovation and clinical specialitie
Page 110 and 111:
Page 112 and 113:
Page 114 and 115:
Page 116:
Page 119 and 120:
Company Profile: Wipak Medical Wipa
Page 121 and 122:
Innovations in patient care: infect
Page 123 and 124:
Page 125 and 126:
Page 127 and 128:
Page 129 and 130:
Innovation in patient care: patient
Page 131 and 132:
Innovation in patient care: patient
Page 133 and 134:
IHF reference The International Hos
Page 135 and 136:
C M Y CM MY CY CMY K with support f
Page 137 and 138:
IHF reference IHF Governing Council
Page 139 and 140:
IHF reference IHF Consultants Audit
Page 141 and 142:
IHF reference JAPAN JAPAN HOSPITAL
Page 143 and 144:
IHF reference KENYA THE NAIROBI HOS
Page 145 and 146:
IHF Corporate Member Profiles GE He
Page 147:
How Can Health Organizations Get th
show all

Full document - International Hospital Federation

Create successful ePaper yourself

Delete template?

Save as template?