CRITICAL CARE QUIZ;REAL LIFE SCENARIOS: CASE 10: SEVERE BURNS & INHALATION INJURY: A pediatric flame burns victim age 9 years weight 28 kg was brought to Burn Centre islamabad PIMS hospital. He has 70% TBSA mixed 2nd & 3rd degree burns involving front & back of chest,portion of neck and abdomen, both arms and legs. He was coughing carbonaceous sputum and initial ABGs showed pH 7.09 pO2 44mmHg pCO2 78mmHg HCO 18mmol, he was elective intubated and shifted to Burn-ICU on mechanical ventilator. Central line was passed,Arterial line,NGT,Foley also inserted. According to consensus fluid protocol for pediatric burn victims, we started him Inj.R/L 3000ml in 8 hours followed by 3000ml in next 16 hrs. After 18 hours of resusitation patient still had poor gas exchange and shock. spO 100% pulse 140, MAP 54, corrected CVP 15mmHg temperature 38C, cold clammy skin, poor capillary refill. O/P 0.6ml/kg/hr. Chest Mode VC-ACMV ;Vt 200ml; Rate 25, I:E 1:3, fiO 0.8, PEEP 8, mVe 5.4L/min, Pplat 45 cm H2O, PF ratio 172, A-a 463mmHg, CXR bilateral fluffy infiltrates, ECG sinus tachy with occasional APCs. Hb 8.2g/dl; TLC 43000/ul; PLT 670,000/ul, HCT 46%, Na 151; K 4.2; Urea 86mg/dl, Creatinine 2.8mg/dl. BSR 342mg/dl, ALT 67U/L, PT 18s, aPTT 38s, ScVO 74%, His medicines are, Inj.R/L as described before, Inj.Fentanyl@12ug/hr, Inj.Midazolam@3mg/hr, Inj.Norepinephrine@6ug/kg/min, Inj.Dopamine@10ug/kg/min, Inj.Meropenem 0.5g OD, Inj.Amikacin 250mg BD, Inj.Ranitidine 25mg BD, Inj.Hydrocortisone 25mg QID, Inj.Insulin R on sliding scale. Ipratropium nebs QID. Which of the following interventions might improve his final outcome alongwith gas exchange? A) Chest physiotherapy every 4 h combined with aerosolized N-acetylcysteine alternating with aerosolized heparin. B) Therapeutic bronchoscopy & frequent suctioning with BAL. C) Urgent bedside escharotomy of chest with bronchial hygiene therapy. D) Switch to Veno-venous ECMO (extracorporeal membrane oxygenation). E) Hyperbaric Oxygen Therapy with hydroxycobalamin & sodium thiosulphate.
Posted on: Sun, 10 Aug 2014 01:39:51 +0000
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