BLASTS AND BLASTS AND BURNS: BURNS:

Don’t Feel The Don’t Feel The Heat!Heat!

Susan Marie Baro, DO, FACOSSusan Marie Baro, DO, FACOS

Associate Trauma and Surgical Critical CareAssociate Trauma and Surgical Critical Care

Associate Director Surgical Critical CareAssociate Director Surgical Critical Care

Physician Director Blood Conservation ProgramPhysician Director Blood Conservation Program

OBJECTIVESOBJECTIVES

• Understand the injuries that result Understand the injuries that result from explosions and review current from explosions and review current management and treatment of Blast management and treatment of Blast InjuriesInjuries

• Review Burn Injury Classifications and Review Burn Injury Classifications and Standard TreatmentsStandard Treatments

• Calculate % TBSA in BurnsCalculate % TBSA in Burns

• Calculate IV Fluid Requirements in Calculate IV Fluid Requirements in BurnsBurns

AMERICAN BURN AMERICAN BURN ASSOCIATIONASSOCIATION

Burn Injury Severity Grading Burn Injury Severity Grading SystemSystem• Minor BurnMinor Burn

– 15% TBSA (Total Body Surface Area) or 15% TBSA (Total Body Surface Area) or less in adultsless in adults

– 10% TBSA or less in children and the 10% TBSA or less in children and the elderlyelderly

– 2% TBSA or less full thickness burn in 2% TBSA or less full thickness burn in children or adults without cosmetic or children or adults without cosmetic or functional risk to eyes, ears, face, functional risk to eyes, ears, face, hands, feet or perineumhands, feet or perineum

AMERICAN BURN AMERICAN BURN ASSOCIATIONASSOCIATION

Burn Injury Severity Grading Burn Injury Severity Grading SystemSystem• Moderate BurnModerate Burn

– 15 – 25% TBSA in adults with less than 10% 15 – 25% TBSA in adults with less than 10% full thickness burnfull thickness burn

– 10 – 20% TBSA partial thickness burn in 10 – 20% TBSA partial thickness burn in children < 10 and adults > 40 years of age children < 10 and adults > 40 years of age with less than 10% full thickness burnwith less than 10% full thickness burn

– 10% TBSA or less full thickness burn in 10% TBSA or less full thickness burn in children or adults without cosmetic or children or adults without cosmetic or functional risk to eyes, ears, face, hands, functional risk to eyes, ears, face, hands, feet, or perineumfeet, or perineum

AMERICAN BURN AMERICAN BURN ASSOCIATIONASSOCIATION

Burn Injury Severity Grading Burn Injury Severity Grading SystemSystem• Major BurnMajor Burn

– 25% TBSA or greater25% TBSA or greater– 20% TBSA in children <10 and adults > 20% TBSA in children <10 and adults >

40 years of age40 years of age– 10% TBSA or greater full thickness burn10% TBSA or greater full thickness burn– All burns involving eyes, ears, face, All burns involving eyes, ears, face,

hands, feet, or perineum that are likely to hands, feet, or perineum that are likely to result in cosmetic or functional result in cosmetic or functional impairmentimpairment

AMERICAN BURN AMERICAN BURN ASSOCIATIONASSOCIATION

Burn Injury Severity Grading Burn Injury Severity Grading SystemSystem• Major Burn (cont.)Major Burn (cont.)

– All high voltage electrical burnsAll high voltage electrical burns– All burn injury complicated b y major All burn injury complicated b y major

trauma or inhalation injurytrauma or inhalation injury– All poor risk patients with burn injuryAll poor risk patients with burn injury

CLASSIFICATION OF BURNSCLASSIFICATION OF BURNS

• ThermalThermal

• Cold ExposureCold Exposure

• ChemicalChemical

• Electrical CurrentElectrical Current

• InhalationInhalation

• RadiationRadiation

CLASSIFICATION BASED ON CLASSIFICATION BASED ON DEPTH OF TISSUE INJURYDEPTH OF TISSUE INJURY

• 11stst Degree – Superficial or Epidermal Degree – Superficial or Epidermal

• 22ndnd Degree – Partial Thickness Degree – Partial Thickness

• 33rdrd Degree – Full Thickness Degree – Full Thickness

• 44thth Degree – burns extending Degree – burns extending beneath the subcutaneous tissues beneath the subcutaneous tissues involving the fascia, muscle, and /or involving the fascia, muscle, and /or the bonethe bone

SUPERFICIAL BURNSUPERFICIAL BURN

• Epidermal layer (ex, sunburn)Epidermal layer (ex, sunburn)

• No BlistersNo Blisters

• Red, painful, and dryRed, painful, and dry

• Epidermal layer peels awayEpidermal layer peels away

• Blanches with pressureBlanches with pressure

• Subsides over 2 – 3 days and heals Subsides over 2 – 3 days and heals within 6 days without scarringwithin 6 days without scarring

PARTIAL THICKNESS: PARTIAL THICKNESS: SUPERFICIALSUPERFICIAL

• Between the epidermis and the dermisBetween the epidermis and the dermis

• Forms blisters within 24 hoursForms blisters within 24 hours

• Painful, red, weepingPainful, red, weeping

• Blanches with pressureBlanches with pressure

• Pigment changes can occurPigment changes can occur

• Usually heals in 7 – 21 daysUsually heals in 7 – 21 days

• Scarring unusualScarring unusual

PARTIAL THICKNESS:PARTIAL THICKNESS:DEEPDEEP

• Extends deep into the dermisExtends deep into the dermis

• Damages hair follicles and glandular Damages hair follicles and glandular tissuetissue

• Painful to pressure onlyPainful to pressure only

• Almost always blistersAlmost always blisters

• Wet, waxy, or dryWet, waxy, or dry

• Variable mottled coloration (Patchy Variable mottled coloration (Patchy cheezy white to red)cheezy white to red)

PARTIAL THICKNESS:PARTIAL THICKNESS:DEEP (cont).DEEP (cont).

• Does not blanchDoes not blanch

• Heals in 3 – 9 weeks if no grafting Heals in 3 – 9 weeks if no grafting requiredrequired

• Causes hypertrophic scarringCauses hypertrophic scarring

• If involves the joint, expect dysfunction If involves the joint, expect dysfunction even with aggressive physical therapyeven with aggressive physical therapy

• Hard to differentiate from Full Thickness Hard to differentiate from Full Thickness burnburn

FULL THICKNESSFULL THICKNESS

• Extends through and destroys all Extends through and destroys all layers of the dermis and often injures layers of the dermis and often injures underlying subcutaneous tissueunderlying subcutaneous tissue

• Burn eschar and denature dermis Burn eschar and denature dermis usually intactusually intact

• Eschar compromises viability of limb Eschar compromises viability of limb and torso if circumferentialand torso if circumferential

• Anesthetic or hypoestheticAnesthetic or hypoesthetic

FULL THICKNESS (cont.)FULL THICKNESS (cont.)

• Skin waxy white to leathery gray to Skin waxy white to leathery gray to charred and blackcharred and black

• Dry and inelasticDry and inelastic

• Does not blanchDoes not blanch

• No vesicles or blistersNo vesicles or blisters

FULL THICKNESS (cont.)FULL THICKNESS (cont.)

• Eschar usually separates from the Eschar usually separates from the underlying tissue and reveals an underlying tissue and reveals an unhealed bed of granulation tissueunhealed bed of granulation tissue

• Without surgery – they heal by Without surgery – they heal by wound contracture with wound contracture with epithelialization around the edgesepithelialization around the edges

• Scarring is severe with contracturesScarring is severe with contractures

FOURTH DEGREEFOURTH DEGREE

• DeepDeep

• Potentially life threateningPotentially life threatening

• Extend through the skin to Extend through the skin to underlying structuresunderlying structures

TOTAL BODY SURFACE TOTAL BODY SURFACE AREAAREA

• Size is usually underestimatedSize is usually underestimated– Results in under resuscitationResults in under resuscitation

• Lund-BrowderLund-Browder– Most accurate for both children and Most accurate for both children and

adultsadults– Takes into account the relative % of body Takes into account the relative % of body

surface area affected by growth surface area affected by growth •Kids have larger heads and smaller Kids have larger heads and smaller

extremitiesextremities

TOTAL BODY SURFACE TOTAL BODY SURFACE AREA (cont).AREA (cont).

• Rule of Nines (adults)Rule of Nines (adults)– Each leg represents 18% TBSAEach leg represents 18% TBSA– Each arm represent 9% TBSAEach arm represent 9% TBSA– Anterior and Posterior Trunk each Anterior and Posterior Trunk each

represent 18% TBSArepresent 18% TBSA– Head represents 9 % TBSAHead represents 9 % TBSA

TOTAL BODY SURFACE TOTAL BODY SURFACE AREA (cont).AREA (cont).

• Palm MethodPalm Method– Used when the burn is irregular and/or Used when the burn is irregular and/or

patchypatchy– Utilizes the surface area of the patients Utilizes the surface area of the patients

palmpalm– Palm, excluding extended fingers = 0.5% Palm, excluding extended fingers = 0.5%

patients TBSA patients TBSA – Palm, extending fingers = 1% of patients Palm, extending fingers = 1% of patients

TBSATBSA

INITIAL MANAGEMENTINITIAL MANAGEMENT• Essentially ATLSEssentially ATLS

• Special attention to respiratory distress Special attention to respiratory distress and smoke inhalationand smoke inhalation

• Remove clothing promptlyRemove clothing promptly

• Consider early transfer to Burn CenterConsider early transfer to Burn Center

• History is importantHistory is important– Materials, chemicals, open vs closed space, Materials, chemicals, open vs closed space,

explosion or blast involvement, associated explosion or blast involvement, associated traumatrauma

AIRWAYAIRWAY

• Inhalation injury remains a leading Inhalation injury remains a leading cause of death in the adult burn cause of death in the adult burn victimvictim

• Present in 2/3’s of patient with burns Present in 2/3’s of patient with burns > 70% TBSA> 70% TBSA

• Supplemental oxygen, maintain Supplemental oxygen, maintain airwayairway

• Upper airway edema occurs rapidlyUpper airway edema occurs rapidly

AIRWAY (cont.)AIRWAY (cont.)

• RSI with Succinylcholine acceptable in RSI with Succinylcholine acceptable in the first 72 hours but no later the first 72 hours but no later secondary to the risk of severe secondary to the risk of severe hyperkalemiahyperkalemia

• Significant % develop ARDSSignificant % develop ARDS

SIGNS OF SIGNIFICANT SIGNS OF SIGNIFICANT SMOKE INHALATION INJURYSMOKE INHALATION INJURY

• Persistent cough, stridor, or wheezingPersistent cough, stridor, or wheezing

• HoarsenessHoarseness

• Deep facial or circumferential neck Deep facial or circumferential neck burnsburns

• Nares with inflammation or singed hairNares with inflammation or singed hair

• Carbonaceous sputum or burnt matter Carbonaceous sputum or burnt matter in the nose or mouthin the nose or mouth

• Blistering or edema of the oropharynxBlistering or edema of the oropharynx

SIGNS OF SIGNIFICANT SIGNS OF SIGNIFICANT SMOKE INHALATION INJURY SMOKE INHALATION INJURY

(cont.)(cont.)• Depressed mental statusDepressed mental status

• Respiratory distressRespiratory distress

• Hypoxia or HypercapniaHypoxia or Hypercapnia

• Elevated Carbon Monoxide and/or Elevated Carbon Monoxide and/or Cyanide levelsCyanide levels

• Inhalation injury from hot gasses Inhalation injury from hot gasses usually occurs above the vocal cordsusually occurs above the vocal cords

CARBON MONOXIDE AND CARBON MONOXIDE AND CYANIDECYANIDE

• Check Carboxyhemaglobin level in all Check Carboxyhemaglobin level in all patients with moderate to severe burnspatients with moderate to severe burns

• Standard Pulse-Ox not reliableStandard Pulse-Ox not reliable

• Treatment with high flow oxygen alone Treatment with high flow oxygen alone effectively removes COeffectively removes CO

• Hyperbaric Oxygen Treatment if increased Hyperbaric Oxygen Treatment if increased CO or if treatment for Cyanide poisoning CO or if treatment for Cyanide poisoning places patient at risk for hypoxemiaplaces patient at risk for hypoxemia

CARBON MONOXIDE AND CARBON MONOXIDE AND CYANIDE (cont.)CYANIDE (cont.)

• Check Methemaglobin if Cyanide Check Methemaglobin if Cyanide poisoning suspectedpoisoning suspected

• Consider Cyanide toxicity in severe Consider Cyanide toxicity in severe burn patients with unexplained lactic burn patients with unexplained lactic acidosis and declining EtCOacidosis and declining EtCO22

• Treatment: Hydroxocobalamin Treatment: Hydroxocobalamin

TREATMENTTREATMENT

• Supplemental Oxygen and Airway Supplemental Oxygen and Airway ProtectionProtection

• Bronchodilators when bronchospasm Bronchodilators when bronchospasm present present

• Avoid CorticosteroidsAvoid Corticosteroids

• Fluid resuscitation with aggressive Fluid resuscitation with aggressive monitoringmonitoring

TREATMENT (cont.)TREATMENT (cont.)

• Vent Settings: low tidal volumes to Vent Settings: low tidal volumes to minimize airway pressures and to reduce minimize airway pressures and to reduce incidents of Ventilator Associated Acute incidents of Ventilator Associated Acute Lung Injury (ALI)Lung Injury (ALI)

• Inhaled Nitric Oxide – may increase Inhaled Nitric Oxide – may increase hypoxic vasoconstrictionhypoxic vasoconstriction

• Aerosolized Heparin and N-Acetylcysteine Aerosolized Heparin and N-Acetylcysteine (NAC) – may help to remove broncho-(NAC) – may help to remove broncho-pulmonary castspulmonary casts

FLUID RESUSCITATIONFLUID RESUSCITATION

• Burn Shock – occurs within 24 – 48 hoursBurn Shock – occurs within 24 – 48 hours

• Characterized by myocardial depression Characterized by myocardial depression and increased capillary permeabilityand increased capillary permeability

• Results in large fluid shifts and depletion Results in large fluid shifts and depletion of intravascular volumeof intravascular volume

• Rapid, aggressive fluid resuscitation Rapid, aggressive fluid resuscitation helps to reconstitute the intravascular helps to reconstitute the intravascular volume and maintain end organ perfusionvolume and maintain end organ perfusion

FLUID RESUSCITATION FLUID RESUSCITATION (cont.)(cont.)

• A-lineA-line

• Foley for accurate urine outputsFoley for accurate urine outputs

• Over-resuscitation leads to ARDS, Over-resuscitation leads to ARDS, pneumonia, MSOF, and compartment pneumonia, MSOF, and compartment syndromes (including abdomen, limb, syndromes (including abdomen, limb, and orbit)and orbit)

• Any patient with > 15% TBSA, Any patient with > 15% TBSA, nonsuperficial burns (2nonsuperficial burns (2ndnd/3/3rdrd Degree) Degree) should receive formal fluid resuscitationshould receive formal fluid resuscitation

FLUIDSFLUIDS

• IV Crystalloid – typically Ringer’s LactateIV Crystalloid – typically Ringer’s Lactate– helps to reduce incidence of hyperchloremic helps to reduce incidence of hyperchloremic

acidosis associated with large volumes of acidosis associated with large volumes of isotonic saline (NS)isotonic saline (NS)

– Colloid and Hypertonic Saline for initial Colloid and Hypertonic Saline for initial resuscitation not found to show any resuscitation not found to show any improvement in outcomes, are more improvement in outcomes, are more expensive, and possibly increase renal expensive, and possibly increase renal failure and deathfailure and death

FLUIDS (cont.)FLUIDS (cont.)• Following initial resuscitation IV fluids need Following initial resuscitation IV fluids need

to meet baseline fluid needs and maintain to meet baseline fluid needs and maintain Urine outputsUrine outputs

• IF UO < 0.5 ml/kg/hr – bolus with 500 to IF UO < 0.5 ml/kg/hr – bolus with 500 to 1000 ml fluid and increase rate by 20 – 30%1000 ml fluid and increase rate by 20 – 30%

• If adequate resuscitation and patient If adequate resuscitation and patient stabilizes, change to D5 ½ NS with 20 mEq stabilizes, change to D5 ½ NS with 20 mEq KCl per liter at maintenance to keep UO > KCl per liter at maintenance to keep UO > 0.5 ml/kg/hr0.5 ml/kg/hr

ESTIMATING INITIAL FLUID ESTIMATING INITIAL FLUID REQUIREMENTSREQUIREMENTS

• Parkland Formula – utilized in initial 24 Parkland Formula – utilized in initial 24 hrshrs

• Includes partial and full thickness burnsIncludes partial and full thickness burns

• 4 ml/kg for each % of TBSA burned 4 ml/kg for each % of TBSA burned over 15% TBSAover 15% TBSA

• ½ volume given in 1½ volume given in 1stst 8 hours and the 8 hours and the remaining volume given over the next remaining volume given over the next 16 hours16 hours

ESTIMATING INITIAL FLUID ESTIMATING INITIAL FLUID REQUIREMENTS (cont.)REQUIREMENTS (cont.)

• Modified Brooke FormulaModified Brooke Formula

• Given over initial 24 hoursGiven over initial 24 hours

• 2 ml/kg for each % TBSA2 ml/kg for each % TBSA

• Likely reduces the overall volumeLikely reduces the overall volume

BLOOD TRASFUSIONBLOOD TRASFUSION

• Avoid if possibleAvoid if possible

• Associated with increased mortalityAssociated with increased mortality

• Only if Hemoglobin < 8 gm/dL unless Only if Hemoglobin < 8 gm/dL unless patient with acute coronary patient with acute coronary syndrome syndrome

• If at risk for ACS – transfuse to 10 If at risk for ACS – transfuse to 10 gm/dLgm/dL

IMMEDIATE BURN CAREIMMEDIATE BURN CARE• Remove clothingRemove clothing

• Cool burned area immediately using cool Cool burned area immediately using cool water or saline soaked gauzewater or saline soaked gauze– can minimize the zone of injury in small burnscan minimize the zone of injury in small burns

• Monitor cor body temp to prevent Monitor cor body temp to prevent hypothermia, especially if >10% TBSAhypothermia, especially if >10% TBSA

• Avoid temps below 35Avoid temps below 35oo C/95 C/95oo F F

• Aggressive Pain control with Morphine and Aggressive Pain control with Morphine and Benzo’s for anxietyBenzo’s for anxiety

CHEMOPROPHYLAXISCHEMOPROPHYLAXIS• Extensive burns cause immunosuppression Extensive burns cause immunosuppression

on basis of altered neutrophil activity, T on basis of altered neutrophil activity, T lymphocyte dysfunction, and imbalance in lymphocyte dysfunction, and imbalance in production of cytokinesproduction of cytokines– Bacterial colonization of the burn eschar site can Bacterial colonization of the burn eschar site can

resultresult

• Burns destroy physical barrier to tissue Burns destroy physical barrier to tissue invasioninvasion– Permits spread of bacteria to the dermis and Permits spread of bacteria to the dermis and

through the lymphatics along the fibrous septaethrough the lymphatics along the fibrous septae

CHEMOPROPHYLAXIS (cont.)CHEMOPROPHYLAXIS (cont.)

• Once invasion occurs – organisms Once invasion occurs – organisms can invade the blood vessels can invade the blood vessels producing secondary bacteremiaproducing secondary bacteremia

• Topical antibiotics are given to all Topical antibiotics are given to all patients with nonsuperficial burnspatients with nonsuperficial burns

TETANUSTETANUS

• Update for any burns deeper than Update for any burns deeper than superficialsuperficial

• Tetanus Immune Globulin – if patient Tetanus Immune Globulin – if patient did not receive complete set of did not receive complete set of primary immunizationsprimary immunizations

ANTIBIOTICSANTIBIOTICS• Apply topically to all nonsuperficial burnsApply topically to all nonsuperficial burns

• If transferring to Burn Center – hold on If transferring to Burn Center – hold on topical coverage and cover with clean, dry, topical coverage and cover with clean, dry, dressingsdressings

• No Prophylactic IV antibioticsNo Prophylactic IV antibiotics

• Silver Sulfadiazine (SSD)Silver Sulfadiazine (SSD)– avoid near eyes and mouth, sulfonamide hypersensitivity, avoid near eyes and mouth, sulfonamide hypersensitivity,

pregnant women, newborns, and nursing motherspregnant women, newborns, and nursing mothers

• Bacitracin as an alternativeBacitracin as an alternative

WOUNDWOUND

• Wash with mild soap and waterWash with mild soap and water

• Remove debrisRemove debris

• Avoid local anestheticsAvoid local anesthetics

• Never aspirate intact blistersNever aspirate intact blisters

• Burn wound debridement and excision Burn wound debridement and excision and coverage is performed within the and coverage is performed within the first 6 – 24 hours after local injuryfirst 6 – 24 hours after local injury

DRESSINGSDRESSINGS• If transferring – clean, dry sheetIf transferring – clean, dry sheet

• Non-adherent mesh gauze after cleaning Non-adherent mesh gauze after cleaning with antibiotics ointmentwith antibiotics ointment

• Avoid tape on skinAvoid tape on skin

• Tubular gauze or light circumferential Tubular gauze or light circumferential wrapswraps

• Deep wounds – biologic or biosynthetic Deep wounds – biologic or biosynthetic dressings or bismuth impregnated dressings or bismuth impregnated petroleum gauzepetroleum gauze

ESCHAROTOMYESCHAROTOMY

• Occurs with deep dermal and full Occurs with deep dermal and full thickness burns which are circumferentialthickness burns which are circumferential

• Dermis can becomes stiff and unyielding – Dermis can becomes stiff and unyielding – referred to as an escharreferred to as an eschar

• Usually does not occur until 3 – 4 hours Usually does not occur until 3 – 4 hours following initiation of fluid resuscitationfollowing initiation of fluid resuscitation

• Utilize scalpel or electrocautery Utilize scalpel or electrocautery (preferred)(preferred)

ESCHAROTOMY (cont.)ESCHAROTOMY (cont.)

• Extend through the eschar to the fatty Extend through the eschar to the fatty tissue beneath – no furthertissue beneath – no further

• Leaves fascia intactLeaves fascia intact

• If no improvement, may have If no improvement, may have developed compartment syndrome developed compartment syndrome which could require fasciotomy, but which could require fasciotomy, but this is a different entitythis is a different entity

• If signs of ischemia or respiratory If signs of ischemia or respiratory distress occur – need to perform prior distress occur – need to perform prior to transferto transfer

ESCHAROTOMY (cont.)ESCHAROTOMY (cont.)

• Neck and Chest – can lead to Neck and Chest – can lead to respiratory compromiserespiratory compromise

• Abdomen – leads to Abdominal Abdomen – leads to Abdominal compartment syndromecompartment syndrome

• Extremities – ischemia with Extremities – ischemia with decreased pulses, capillary refill, decreased pulses, capillary refill, pulse-ox (if Pulse-Ox > 90%, likely pulse-ox (if Pulse-Ox > 90%, likely does not need escharotomy)does not need escharotomy)

GIGI

• Shock from thermal burn injuries Shock from thermal burn injuries results in mesenteric results in mesenteric vasoconstriction predisposing to vasoconstriction predisposing to gastric distention, ulceration gastric distention, ulceration (Cushing’s Ulcer) and aspiration(Cushing’s Ulcer) and aspiration

• NGT if > 20% TBSANGT if > 20% TBSA

• Stress ulcer prophylaxisStress ulcer prophylaxis

NUTRITIONNUTRITION• Early feeding: within 24 – 48 hoursEarly feeding: within 24 – 48 hours

• Meet basic patient energy needs to Meet basic patient energy needs to attenuate the catabolic response to burnsattenuate the catabolic response to burns

• HypermetabolicHypermetabolic

• Enteral preferredEnteral preferred

• Indication for Nutritional Support – failure Indication for Nutritional Support – failure to maintain LBM (Lean Body Mass) and to maintain LBM (Lean Body Mass) and body weight (dry body weight on day 5 body weight (dry body weight on day 5 post burn)post burn)

HARRIS BENEDICT HARRIS BENEDICT EQUATIONEQUATION

• Estimates basal energy expenditureEstimates basal energy expenditure

• For burn patients the BEE is multiplied For burn patients the BEE is multiplied by an arbitrary activity or stress factor by an arbitrary activity or stress factor of 1.2 to 2.0 (usually 1.2 to 1.5)of 1.2 to 2.0 (usually 1.2 to 1.5)

• Useful for initial estimate of energy Useful for initial estimate of energy demanddemand

• Usually overestimates caloric Usually overestimates caloric requirementsrequirements

HARRIS BENEDICT HARRIS BENEDICT EQUATIONEQUATION

• FemalesFemales– BEE (Kcal/day) = 655 + (9.6) x Kg + BEE (Kcal/day) = 655 + (9.6) x Kg +

(1.85) x Ht in cm – (4.68) x Age(1.85) x Ht in cm – (4.68) x Age– Then multiply by 1.2 to 2.0Then multiply by 1.2 to 2.0

• MalesMales– BEE (Kcal/day) = 66.5 + (13.8) x Kg + BEE (Kcal/day) = 66.5 + (13.8) x Kg +

(5) x Ht in cm – (6.76) x age(5) x Ht in cm – (6.76) x age– Then multiply by 1.2 to 2.0Then multiply by 1.2 to 2.0

CURRERI FORMULACURRERI FORMULA

• Takes into account TBSA and Body Takes into account TBSA and Body Weight prior to burnWeight prior to burn

• Estimates the energy required by Estimates the energy required by linear regression analysis based on linear regression analysis based on the number of calories required to the number of calories required to prevent weight lossprevent weight loss

• Still likely overfeedsStill likely overfeeds

CURRERI FORMULACURRERI FORMULA

• Age 16 – 59Age 16 – 59– Kcal/day = 25 kcal/Kg/day + 40 Kcal/day = 25 kcal/Kg/day + 40

Kcal/%TBSA burned/dayKcal/%TBSA burned/day

• Age > 60Age > 60– Kcal/day = 25 Kcal/Kg/day + 65 Kcal/day = 25 Kcal/Kg/day + 65

Kcal/%TBSA burned/dayKcal/%TBSA burned/day

GOLD STANDARDGOLD STANDARD

• Preferred method to estimate caloric Preferred method to estimate caloric requirements in burn patient is by requirements in burn patient is by Indirect Calorimetry (IDC)Indirect Calorimetry (IDC)

• Uses respiratory gas exchange to Uses respiratory gas exchange to estimate fuel consumptionestimate fuel consumption

• Results affected by oxygen therapy, Results affected by oxygen therapy, hemodynamic instability, fever, hemodynamic instability, fever, sepsis, ongoing proceduressepsis, ongoing procedures

NUTRITION IN CHILDRENNUTRITION IN CHILDREN

• RDA (RDI) – recommended daily RDA (RDI) – recommended daily allowance (recommended daily allowance (recommended daily intake)intake)

• RDI Kcal/day = 37 x KgRDI Kcal/day = 37 x Kg

• With a modifier based on ageWith a modifier based on age

NUTRITIONAL FORMULANUTRITIONAL FORMULA

• At least 50% calories as CarbohydratesAt least 50% calories as Carbohydrates

• 35% as Protein35% as Protein

• No more than 15% as FatNo more than 15% as Fat

• Supplement with micro and macro Supplement with micro and macro nutrientsnutrients

• Add Glutamine to standard formulas Add Glutamine to standard formulas (decreased Gran Negative Bacteremia)(decreased Gran Negative Bacteremia)

FORMULA (cont.)FORMULA (cont.)

• 1.5 to 2.0 grams protein/kg/day1.5 to 2.0 grams protein/kg/day

• 5 to 7 mg/kg/min of glucose/day 5 to 7 mg/kg/min of glucose/day representing ~ 50% of total caloriesrepresenting ~ 50% of total calories

• No more than 15% non-protein calories No more than 15% non-protein calories from fatsfrom fats

• Vitamin A,C, and DVitamin A,C, and D

• Trace Minerals (selenium, zinc, copper)Trace Minerals (selenium, zinc, copper)

• GlutamineGlutamine

THROMBOEBMOLIC THROMBOEBMOLIC PROPHYLAXISPROPHYLAXIS

• Burn patients are at an increased risk Burn patients are at an increased risk for thromboembolic complicationsfor thromboembolic complications

• Initial prophylaxis on arrival to ICUInitial prophylaxis on arrival to ICU– Enoxaparin 40 mg q dayEnoxaparin 40 mg q day– Enoxaparin 30 mg q day if < 40 Kg or with Enoxaparin 30 mg q day if < 40 Kg or with

creatinine clearance < 30 mL/mincreatinine clearance < 30 mL/min– Enoxaparin 40 mg q day if > 100 KgEnoxaparin 40 mg q day if > 100 Kg– Enoxaparin 30 mg bid with associated lower Enoxaparin 30 mg bid with associated lower

extremity or pelvic orthopedic injuries or burnextremity or pelvic orthopedic injuries or burn– Heparin 5000 mg q 8 if not a candidate for Heparin 5000 mg q 8 if not a candidate for

EnoxaparinEnoxaparin

SEPSISSEPSIS• > 20% TBSA Burns – increased risk for an > 20% TBSA Burns – increased risk for an

invasive burn wound infectioninvasive burn wound infection

• Referred to as “Burn Wound Sepsis”Referred to as “Burn Wound Sepsis”

• Often lead to MOF and deathOften lead to MOF and death

• 75% of the mortality following thermal 75% of the mortality following thermal injuries is related directly to infectioninjuries is related directly to infection

• Different criteria than non-burn patientsDifferent criteria than non-burn patients– Takes into account the changing metabolism Takes into account the changing metabolism

and altered inflammatory response in burnsand altered inflammatory response in burns

BACTERIAL BURN WOUND BACTERIAL BURN WOUND SEPSISSEPSIS

• Non-Invasive burn wound infectionNon-Invasive burn wound infection– > 10> 1055 bacteria per gram of tissue bacteria per gram of tissue

• Invasive burn wound infectionInvasive burn wound infection– Defined as the presence of Defined as the presence of

micororganisms in the adjacent micororganisms in the adjacent unburned tissueunburned tissue

FUNGAL BURN WOUND FUNGAL BURN WOUND INFECTIONINFECTION

• Non-Invasive fungal infectionNon-Invasive fungal infection– Defined as the recovery of mold or yeast by Defined as the recovery of mold or yeast by

culture of a specimen obtained from a burn culture of a specimen obtained from a burn wound or escharwound or eschar

• Invasive fungal infectionInvasive fungal infection– Need to identify hyphae or melanized yeast-Need to identify hyphae or melanized yeast-

like forms utilizing histopath/cytopath, or by like forms utilizing histopath/cytopath, or by direct microscopic exam of a needle aspirate direct microscopic exam of a needle aspirate or biopsy specimen, or by associated tissue or biopsy specimen, or by associated tissue damage or recovery of mold/yeast by culture damage or recovery of mold/yeast by culture of a specimen from a normally sterile siteof a specimen from a normally sterile site

ABA CRITERIA FOR ABA CRITERIA FOR DEFINITION OF SEPSIS & DEFINITION OF SEPSIS &

INFECTIONINFECTION• Most include three of the followingMost include three of the following– Temp > 102.2Temp > 102.2ooF/39F/39ooCC– Progressive tachycardiaProgressive tachycardia– Progressive tachypneaProgressive tachypnea– Refractory hypotensionRefractory hypotension– Leukocytosis or LeukopeniaLeukocytosis or Leukopenia– ThrombocytopeniaThrombocytopenia– Hyperglycemia (in the absence of DM)Hyperglycemia (in the absence of DM)– Inability to tolerate enteral feeds for > 24 hours Inability to tolerate enteral feeds for > 24 hours

(strict criteria for failure)(strict criteria for failure)

SEPSIS AND INFECTION SEPSIS AND INFECTION (cont.)(cont.)

• Requires infection be documented by Requires infection be documented by one of the followingone of the following– Confirmed on cultures (wound, blood, urine)Confirmed on cultures (wound, blood, urine)– Pathologic tissue source identified (> 10Pathologic tissue source identified (> 1055

bacteria on quantitative wound tissue bacteria on quantitative wound tissue biopsy or microbial invasion on surrounding biopsy or microbial invasion on surrounding tissue biopsytissue biopsy

– Documentation of clinical response to Documentation of clinical response to antimicrobial administrationantimicrobial administration

ORGANISMS IN BURNSORGANISMS IN BURNS• Immediately followingImmediately following

– Predominately Gram Positive bacteriaPredominately Gram Positive bacteria•Staph aureus, Pseudomonas aeruginosa, Serratia Staph aureus, Pseudomonas aeruginosa, Serratia

marcescens marcescens

• 2 – 4 days2 – 4 days– Gram Negative bacteriaGram Negative bacteria

• Within 1Within 1stst week week– Burns colonized with GP’s, GN’s, FungiBurns colonized with GP’s, GN’s, Fungi

• > 5 days> 5 days– Gram Negatives with abx resistant traitsGram Negatives with abx resistant traits

ORGANISMS IN BURNSORGANISMS IN BURNS• Most Common OverallMost Common Overall

– MSSA, MRSA, and PseudomonasMSSA, MRSA, and Pseudomonas

• Most Predominate Gram PositivesMost Predominate Gram Positives– Staph aureus and enterococcusStaph aureus and enterococcus

• Most Predominate Gram NegativesMost Predominate Gram Negatives– Pseudomonas and E coliPseudomonas and E coli

• Candida is the most common fungal Candida is the most common fungal infection (4infection (4thth most common cause most common cause overall)overall)

• HSV-1 – most common viral organismHSV-1 – most common viral organism

BLAST INJURIES - PHYSICSBLAST INJURIES - PHYSICS

• Explosive detonations differ from collisions Explosive detonations differ from collisions or impactsor impacts

• High-order explosive detonations cause a High-order explosive detonations cause a near instantaneous transformation of the near instantaneous transformation of the explosive material into a highly pressurized explosive material into a highly pressurized gasgas• Releases energy at supersonic speedsReleases energy at supersonic speeds• Transient shock waves travel in excess of the Transient shock waves travel in excess of the

speed of soundspeed of sound

• Results in formation of a blast wave that Results in formation of a blast wave that travels out from the epicenter of the blasttravels out from the epicenter of the blast

PHYSICS (cont.)PHYSICS (cont.)

• Simply put - an explosion is caused by the Simply put - an explosion is caused by the rapid chemical conversion of a solid or liquid rapid chemical conversion of a solid or liquid into a gas with resultant energy releaseinto a gas with resultant energy release

• An idealized free-field spherical blast creates An idealized free-field spherical blast creates a temporal pressure transient (Friedlander a temporal pressure transient (Friedlander Function) that has a leading overpressure Function) that has a leading overpressure phase followed by an under pressure phase phase followed by an under pressure phase all occurring within millisecondsall occurring within milliseconds• Rarely the common clinical explosion scenarioRarely the common clinical explosion scenario

PHYSICS (cont.)PHYSICS (cont.)

• Explosives do not always combust Explosives do not always combust instantaneously and multiple shock instantaneously and multiple shock waves can occurwaves can occur• This is very frequent with improvised This is very frequent with improvised

explosive devices (IED’s)explosive devices (IED’s)

• In addition, the blast wave is affected by In addition, the blast wave is affected by reflection from nearby surfaces, reflection from nearby surfaces, potentially causing a merger of the potentially causing a merger of the initial pressure wave and the reflected initial pressure wave and the reflected wave or waveswave or waves

TYPES OF INJURIESTYPES OF INJURIES

• Primary Blast InjuryPrimary Blast Injury

• Secondary Blast InjurySecondary Blast Injury

• Tertiary Blast InjuryTertiary Blast Injury

• Quaternary Blast InjuryQuaternary Blast Injury

• Electromagnetic PerturbationsElectromagnetic Perturbations

• Miscellaneous Effects from the Miscellaneous Effects from the explosionexplosion

TYPES OF INJURIESTYPES OF INJURIES

• Primary Blast InjuryPrimary Blast Injury

• Secondary Blast InjurySecondary Blast Injury

• Tertiary Blast InjuryTertiary Blast Injury

• Quaternary Blast InjuryQuaternary Blast Injury

• Electromagnetic PerturbationsElectromagnetic Perturbations

• Miscellaneous Effects from the Miscellaneous Effects from the explosionexplosion

PRIMARY BLAST INJURY (PBI)PRIMARY BLAST INJURY (PBI)

• Caused by the direct effect of the blast Caused by the direct effect of the blast overpressure on organsoverpressure on organs

• Characterized by anatomical and Characterized by anatomical and physiological changes from the force physiological changes from the force generated by the blast wave impacting the generated by the blast wave impacting the body’s surfacebody’s surface

• Affect primarily gas-containing structures Affect primarily gas-containing structures (lungs, GI tract, middle ear)(lungs, GI tract, middle ear)

• Consequence of extreme pressure Consequence of extreme pressure differentials developed at the body surfacesdifferentials developed at the body surfaces

• Leading edge of a blast wave is call the Leading edge of a blast wave is call the “Blast Front”“Blast Front”

SECONDARY BLAST INJURYSECONDARY BLAST INJURY• Results from shrapnel, objects or materials Results from shrapnel, objects or materials

hurled at the victimhurled at the victim• Secondary missiles created by container Secondary missiles created by container

fragments or nearby shattered objects have fragments or nearby shattered objects have the longest rangethe longest range

• Like sound waves, blast waves do not move Like sound waves, blast waves do not move mass, however, an additional “dynamic mass, however, an additional “dynamic pressure” is created by the net motion of air pressure” is created by the net motion of air molecules responding to blast-inducted molecules responding to blast-inducted differentials in static pressuredifferentials in static pressure

• Individuals far from the scene can be injuredIndividuals far from the scene can be injured• Penetrating neck and torso trauma is Penetrating neck and torso trauma is

common with this forcecommon with this force

TERTIARY BLAST INJURYTERTIARY BLAST INJURY• Occurs when the victims are flung Occurs when the victims are flung

through the air and strike other objectsthrough the air and strike other objects• A blast causing peak static A blast causing peak static

overpressures of 5 psi (strong enough to overpressures of 5 psi (strong enough to rupture ½ of exposed TM’s) can rupture ½ of exposed TM’s) can generate a “blast wind” of up to 145 generate a “blast wind” of up to 145 mphmph• this can propel objects and people a this can propel objects and people a

considerable distanceconsiderable distance

• The wind from a blast significant enough The wind from a blast significant enough to cause Pulmonary PBI may exceed 831 to cause Pulmonary PBI may exceed 831 mphmph

QUATERNARY BLAST INJURYQUATERNARY BLAST INJURY

• Characterized by burns produced Characterized by burns produced from the thermal effects of the from the thermal effects of the detonation itselfdetonation itself

• Adds difficulty to the resuscitation – Adds difficulty to the resuscitation – requiring additional fluids not likely requiring additional fluids not likely beneficial with PBI to the lungsbeneficial with PBI to the lungs

ELECTROMAGNETIC ELECTROMAGNETIC PERTURBANCESPERTURBANCES

• These occur with some types of These occur with some types of explosions, in particular, those explosions, in particular, those generated by IED’s that have generated by IED’s that have metallic casingsmetallic casings

• These events result in the generation These events result in the generation of small and brief radio-frequency of small and brief radio-frequency pulses for which the physiologic pulses for which the physiologic impact is unclearimpact is unclear

MISCELLANEOUS EFFECTSMISCELLANEOUS EFFECTS

• Inhalations of dust, smoke, carbon Inhalations of dust, smoke, carbon monoxide and other chemicalsmonoxide and other chemicals

• Burns from hot gasses or other firesBurns from hot gasses or other fires

• Crushing injuries from collapsed Crushing injuries from collapsed buildingsbuildings

• Accidental injuries not related to the Accidental injuries not related to the explosion itself but to the rescue explosion itself but to the rescue efforts still count as casualtiesefforts still count as casualties

PRIMARY BLAST INJURIES: PRIMARY BLAST INJURIES: LUNGLUNG

• Clinical diagnosisClinical diagnosis• Usually manifests as pulmonary Usually manifests as pulmonary

contusionscontusions• Worse on the side of approach of open-air Worse on the side of approach of open-air

blastsblasts• B/l and diffuse in confined space blastsB/l and diffuse in confined space blasts

• Characterized as respiratory difficulty Characterized as respiratory difficulty and hypoxia without evidence of obvious and hypoxia without evidence of obvious external trauma or injury to the chestexternal trauma or injury to the chest

PBI LUNG (cont.)PBI LUNG (cont.)

• May be complicated by pneumothoraces and May be complicated by pneumothoraces and air emboli, as well as suffocation from massive air emboli, as well as suffocation from massive hemoptysishemoptysis

• Can see pleural and subpleural petechiae and Can see pleural and subpleural petechiae and ecchymosis in parallel bands corresponding to ecchymosis in parallel bands corresponding to intercostal spacesintercostal spaces

• May be associated with multiple other injuriesMay be associated with multiple other injuries

• Presents with a variety of symptoms: dyspnea, Presents with a variety of symptoms: dyspnea, chest pain, cough, hemoptysischest pain, cough, hemoptysis

PBI LUNG PHYSICAL EXAMPBI LUNG PHYSICAL EXAM

• May reveal tachypnea, hypoxia, cyanosis May reveal tachypnea, hypoxia, cyanosis and decreased breath soundsand decreased breath sounds

• Can have sub-pleural multifocal Can have sub-pleural multifocal hemorrhages near the cheat wall, hemorrhages near the cheat wall, diaphragm, and mediastinumdiaphragm, and mediastinum

• Hemo-pneumothoraces, traumatic Hemo-pneumothoraces, traumatic emphysema, alveolovenous fistulas from emphysema, alveolovenous fistulas from stress-induced tears of the air tissue stress-induced tears of the air tissue interfaceinterface• Can lead to Broncho-Pleural fistulas (BPF) or Can lead to Broncho-Pleural fistulas (BPF) or

Arterial Air Fistulas (AAE)Arterial Air Fistulas (AAE)• Occurs following low vascular pressure after Occurs following low vascular pressure after

hemorrhage or high airway pressure during PPVhemorrhage or high airway pressure during PPV

ARTERIAL AIR EMBOLISM ARTERIAL AIR EMBOLISM (AAE)(AAE)

• AAE – most common cause of rapid death AAE – most common cause of rapid death solely caused by PBI in immediate survivors solely caused by PBI in immediate survivors

• Occurs at first moment of PPVOccurs at first moment of PPV

• Pulmonary barotrauma, not from PBI, can lead Pulmonary barotrauma, not from PBI, can lead to venous air embolito venous air emboli

• Long bone fractures lead to venous fat emboli Long bone fractures lead to venous fat emboli

• Both have same clinical picture as AAE: Both have same clinical picture as AAE: sudden hypoxemia and mental status changessudden hypoxemia and mental status changes

ARTERIAL AIR EMBOLUS ARTERIAL AIR EMBOLUS (AAE)(AAE)

• Visualization of air in the retinal vessels, Visualization of air in the retinal vessels, mottling of nondependent areas of skin, or mottling of nondependent areas of skin, or demarcated tongue blanching are demarcated tongue blanching are insensitive but rather specific indicators insensitive but rather specific indicators for systemic AAEfor systemic AAE

• No specific findings to detect MI and No specific findings to detect MI and Coronary AAE other than profound shock Coronary AAE other than profound shock and bradycardia with no other sources and bradycardia with no other sources identifiedidentified

LUNG PBI TREATMENTLUNG PBI TREATMENT

• CXR, CT, ABG, etc…can assist in CXR, CT, ABG, etc…can assist in diagnosis but should not delay diagnosis but should not delay treatmenttreatment

• Tx: high flow oxygen, airway Tx: high flow oxygen, airway management, chest tubes if needed, management, chest tubes if needed, mechanical vent if needed, permissive mechanical vent if needed, permissive hypercapnia (provided no additional hypercapnia (provided no additional TBI), and judicious utilization of fluidsTBI), and judicious utilization of fluids

PULM E & MPULM E & M

• Lung PBI acts like severe pulmonary Lung PBI acts like severe pulmonary contusions with impaired oxygen contusions with impaired oxygen diffusiondiffusion• Give highest FiO2 possibleGive highest FiO2 possible• If problems soley with oxygenation and If problems soley with oxygenation and

not ventilation – try NRB or CPAPnot ventilation – try NRB or CPAP• No CPAP if suspect facial trauma/skull fx’sNo CPAP if suspect facial trauma/skull fx’s

• Spontaneous respirations desired for Spontaneous respirations desired for PBI lung to lessen likelihood of AAE, PBI lung to lessen likelihood of AAE, but may require PPVbut may require PPV

PULM E & M (cont.)PULM E & M (cont.)• Poorly compliant blast-injured lungs need to Poorly compliant blast-injured lungs need to

be ventilated with techniques similar to those be ventilated with techniques similar to those used with severe contusions or ARDSused with severe contusions or ARDS• Pressure controlled ventilation with permissive Pressure controlled ventilation with permissive

hypercapnia to facilitate adequate oxygen hypercapnia to facilitate adequate oxygen exchange but keep transalveolar pressure less exchange but keep transalveolar pressure less than 35 cm Hthan 35 cm H22OO

• Initial PEEP of 10 cm HInitial PEEP of 10 cm H22OO

• Refractory hypoxemia or with associated bTBIRefractory hypoxemia or with associated bTBI• Need to be managed with inverse I:E ratios, Need to be managed with inverse I:E ratios,

independent lung ventilation, high-frequency jet independent lung ventilation, high-frequency jet vent, and nitric oxide inhalation, even ECMO if vent, and nitric oxide inhalation, even ECMO if neededneeded

PULM E & M (cont.)PULM E & M (cont.)

• ABGABG• Check PaOCheck PaO22/FiO/FiO22 ration ration

•Blast injury patients with initial ratio’s of > 200 Blast injury patients with initial ratio’s of > 200 mm Hg do not require mechanical vent for mm Hg do not require mechanical vent for respiratory failurerespiratory failure

•Moderately impaired: PFR 60 – 200 mm Hg – Moderately impaired: PFR 60 – 200 mm Hg – generally require vent assistance for at least generally require vent assistance for at least one day with PEEP > 5 cm Hone day with PEEP > 5 cm H22OO

•PFR < 60 mm Hg (often have b/l pneumo’s, PFR < 60 mm Hg (often have b/l pneumo’s, bronchopleural fistulas) – usually require PEEP bronchopleural fistulas) – usually require PEEP > 10 cm H> 10 cm H22O and unconventional vent O and unconventional vent strategiesstrategies

BLAST INDUCED TBI (bTBI)BLAST INDUCED TBI (bTBI)

• Most common cause of deathMost common cause of death• SAH and SDH – most common SAH and SDH – most common

findings in fatalitiesfindings in fatalities• ““Signature Wound” of the Signature Wound” of the

Afghanistan and Iraq warsAfghanistan and Iraq wars• Vulnerable target, but the primary Vulnerable target, but the primary

transduction pathway of blast energy transduction pathway of blast energy to the brain is not well understoodto the brain is not well understood

PRIMARY bTBIPRIMARY bTBI

• 3 ways transduction can occur3 ways transduction can occur• Through direct transcranial propagationThrough direct transcranial propagation• Via the vascular systemVia the vascular system• From the CSF in the spinal cord to the From the CSF in the spinal cord to the

Foramen MagnumForamen Magnum

(4(4thth Controversial mechanism – possible Controversial mechanism – possible transmission via peripheral vasculature)transmission via peripheral vasculature)

bTBI: EFFECTS OF EXPOSURE bTBI: EFFECTS OF EXPOSURE ON NEUROLOGIC FUNCTIONON NEUROLOGIC FUNCTION

• Spectrum of injury severities ranging Spectrum of injury severities ranging from mild effects to fatal injuriesfrom mild effects to fatal injuries

• Edema, contusions, DAI, hematoma, Edema, contusions, DAI, hematoma, hemorrhagehemorrhage

• Brain swelling occurs much soon Brain swelling occurs much soon after blasts (within hours) than after blasts (within hours) than routine traumaroutine trauma• Mortality decreased substantially with Mortality decreased substantially with

early decompressive craniectomiesearly decompressive craniectomies

bTBI: EFFECTS OF EXPOSURE bTBI: EFFECTS OF EXPOSURE (cont.)(cont.)

• Persistent traumatic focal cerebral Persistent traumatic focal cerebral vasospasmvasospasm• Worse outcomes notedWorse outcomes noted• Also noted as a common and potentially Also noted as a common and potentially

underappreciated sequellae of cTBIunderappreciated sequellae of cTBI

bTBIbTBI

• Milder end of the spectrum – “shell shock” Milder end of the spectrum – “shell shock” or “blast concussion”or “blast concussion”

• Symptoms include: physical (somatic), Symptoms include: physical (somatic), behavioral, psychological, and cognitive behavioral, psychological, and cognitive deficitsdeficits

• Symptoms often referred to as Post Symptoms often referred to as Post Concussive Syndrome or PCSConcussive Syndrome or PCS

• Includes retrograde amnesia, compromised Includes retrograde amnesia, compromised executive function, headaches, confusion, executive function, headaches, confusion, amnesia, difficulty concentrating, mood amnesia, difficulty concentrating, mood disturbances, alterations in sleep patterns, disturbances, alterations in sleep patterns, and anxietyand anxiety

cTBI and bTBIcTBI and bTBI

• Similar symptoms as far as cognitive Similar symptoms as far as cognitive impairmentimpairment

• Disturbances in pain, balance, equilibrium, Disturbances in pain, balance, equilibrium, motor functioning, vision, depression or motor functioning, vision, depression or communicative abilitiescommunicative abilities

• Frequently both occur at the same time Frequently both occur at the same time secondary to eventsecondary to event

• Can add penetrating trauma to the mix as wellCan add penetrating trauma to the mix as well• bTBI – increased risk for hearing loss and bTBI – increased risk for hearing loss and

tinnitus as well as PTSDtinnitus as well as PTSD

PE FOR bTBIPE FOR bTBI

• Subtle dysfunction to profound Subtle dysfunction to profound unresponsivenessunresponsiveness

• Causes of Altered Mental Status/SeizuresCauses of Altered Mental Status/Seizures• Hypoxemia from acute lung injuryHypoxemia from acute lung injury• Shock from tension pneumo, hemorrhage or Shock from tension pneumo, hemorrhage or

AAE induced MIAAE induced MI• Conventional blunt or penetrating head injuryConventional blunt or penetrating head injury• Cerebral AAECerebral AAE

• Brain lesions resulting in focal deficits will Brain lesions resulting in focal deficits will most likely be related to severe most likely be related to severe intracerebral hemorrhage or AAE induced intracerebral hemorrhage or AAE induced strokestroke

DIAGNOSITC APPROACH TO DIAGNOSITC APPROACH TO bTBIbTBI

• Significant correlation between tympanic Significant correlation between tympanic membrane perforation and LOCmembrane perforation and LOC

• Also good correlation between occulo-Also good correlation between occulo-motor dysfunction and bTBImotor dysfunction and bTBI

• Biochemical markers being developedBiochemical markers being developed• CT, MRI, DTI for diagnosisCT, MRI, DTI for diagnosis• DTI – Diffusion Tensor Imaging – detects DTI – Diffusion Tensor Imaging – detects

white matter damage by measuring white matter damage by measuring diffusion of water in parallel tractsdiffusion of water in parallel tracts

CLINICAL CONSIDERATIONS IN CLINICAL CONSIDERATIONS IN bTBIbTBI

• More injuries with higher severity of injury More injuries with higher severity of injury noted in closed vs open blast settingsnoted in closed vs open blast settings

• Up to 36% can have delayed finding on CT Up to 36% can have delayed finding on CT scans 48 hours laterscans 48 hours later

• 30 – 44% have abdominal injuries as well30 – 44% have abdominal injuries as well• Up to 50% have lung related PBIUp to 50% have lung related PBI

• Best practice guidelines difficult to follow with lung and Best practice guidelines difficult to follow with lung and brain injuries – contradictorybrain injuries – contradictory

• Rec’s: Inhaled Nitric Oxide to overcome severe Rec’s: Inhaled Nitric Oxide to overcome severe hypoxemia and raise O2 saturation to at least 95% in hypoxemia and raise O2 saturation to at least 95% in brain injury patient while also ameliorating the brain injury patient while also ameliorating the inflammatory effects in the lunginflammatory effects in the lung

• Polytrauma likelyPolytrauma likely