29/08 PACT Environmental hazards

PACT module
Enviromental hazards
Intensive Care Training Program
Radboud University Medical Centre Nijmegen
Brandwonden - EMSB
• Eerste opvang (buiten ziekenhuis)
•
•
•
Koelen door spoelen (10 min) met lauw stromend water
Bij chemische brandwonden 45 minuten
Koelingsdeken voor transport controversieel
-C-D-E
• A -B
• Infuus vanaf 15% (kinderen 10%) TVLO
inhalatie
•
CO/Cyanide
warme omgeving
4 ml/kg/%TVLO per 24 uur waarvan de helft in 1ste 8 uur
van af moment van verbranding
Wanneer naar
brandwonden centrum?
• > 10% TVLO (> 5% bij kinderen)
• > 5% 3 graads verbranding
• Bejaarden en kinderen
• In combinatie met ander trauma/inhalatie
• Verbranding functionele gebieden
• Electriciteit en chemische verbranding
de
Halfzittend
Beoordeling brandwond
• Uitgebreidheid
•
•
•
Regel van 9 ( bij kinderen relatief groter hoofd)
Lund en Browder Chart
Eerste graad telt niet mee
Lund en Browder
Verbranding
1 jaar
1-4 jaar
5-9 jaar
10-14 jaar
15 jaar
Hoofd
19
17
13
11
9
Hals
2
2
2
2
2
Romp voor
13
13
13
13
13
Romp achter
13
13
13
13
13
Rechter bil
2.5
2.5
2.5
2.5
2.5
Linker bil
2.5
2.5
2.5
2.5
2.5
Genitaliën
1
1
1
1
1
Rechter bovenarm
4
4
4
4
4
Linker bovenarm
4
4
4
4
4
Rechter onderarm
3
3
3
3
3
Linker onderarm
3
3
3
3
3
Rechter hand
2.5
2.5
2.5
2.5
2.5
Linker hand
2.5
2.5
2.5
2.5
2.5
Rechter bovenbeen
5.5
5.5
5.5
5.5
5.5
Linker bovenbeen
5.5
5.5
5.5
5.5
5.5
Rechter onderbeen
5
5
5
5
5
Linker onderbeen
5
5
5
5
5
Rechter voet
3.5
3.5
3.5
3.5
3.5
Linker voet
3.5
3.5
3.5
3.5
3.5
Beoordeling brandwond
• Diepte
•
•
•
•
•
Dynamisch proces
1ste graad - alleen epidermis (niet meetellen)
2de graad - dermis (glanzend, blaren, pijn, CR+)
3de graad - subcutis ( blaren kapot, CR-, geen pijn, dof)
4de graad - vaak verkoling
2de graad
3de graad
1ste graad
Burn shock
Initiële resuscitatie
• Vocht toediening is essentieel maar gebruik
geen rigide schema’s (“fluid creep”)
•
•
•
•
toename glottis oedeem en acute lung injury
ischemie bij circulaire verbrandingen
abdominaal- en extremiteit compartiment syndroom
verdiepen van de brandwond
UP 30 - 50 ml/uur
Inhalatie trauma
• Sterke toename morbiditeit en mortaliteit
• Indicatie overplaatsing centrum
• Bronchoscopie essentieel voor diagnose en
vaststellen uitgebreidheid
• Hittetrauma mondkeelholte, chemische
tracheobronchitis, CO/cyanide
Therapie
• Vroege intubatie
• Dagelijks bronchoscopie/lavage
Initiële resuscitatie
• Bij ernstig inhalatietrauma neemt
vochtbehoefte met 25% toe
• Vochtbehoefte neemt ook toe bij
electriciteitsverbranding
• Oedeemvorming na 24 - 48 uur stop
• Herstel hierna colloïd osmotische druk
• Na 48 uur verdampingsverlies
•
(25 + % TVLO) * lichaamsopp (m2) in ml/uur
Experimenteel
• Hoog gedoseerd vitamine
verbranding)
• Acetylcysteïne
C (< 2 uur na
Lichtenberg figuur
The explosion
3000 - 8000 m/s
Mechanisms
• Detonation resulting in shockwave
• Penetrating injury through bombfragments
or material at the site of explosion
• Wind of the explosion - blunt trauma
• Burn wound (flash/clothes), inhalation,
asphyxiation
85% of deadly injuries caused by shockwave
Explosion in closed space
• Higher mortality
• Higher ISS
• More damage through detonation
• More burn wounds
Detonation - blast wave
• Ear damage
➡ rupture tympanic membrane, dislocation and bleeding
middle ear
• Intestinal damage
➡ contusion, intramural hematoma, perforation 0.1 - 1.2%,
often delay between explosion and perforation, especially
in colon
Detonation -blast wave
• Lungs
➡ 4.8 - 8.4%
➡ contusion, pneumothorax, lung bleeding, air embolus
➡ bilateral and diffuse with explosion in closed space
• CNS
➡ air embolus, diffuse axonal damage
Detonation - blast wave
• Trias of bradycardia/hypotension/hypoxia
➡ (vagal) pulmonary “defensive” reflex through C fibres in
alveolar interstitium activated by acute pulmonary
congestion (duration 1 - 2 hours)
Madrid
• 243 victims
➡ 99 ruptured tympanic membranes
➡ 97 pulmonary trauma
➡ 89 bomb fragments
➡ 44 fractures
➡ 45 burn wounds
➡ 41 eye damage (rupture eye, retinitis)
➡ 12 abdominal damage
➡ 5 traumatic amputations
Tsokos M. Am J Respir Crit Care Med 2003;168:549-555
Tsokos M. Am J Respir Crit Care Med 2003;168:549-555
Tsokos M. Am J Respir Crit Care Med 2003;168:549-555
“Blast lung”
• Delay sometimes of 24 - 48 hours
• In closed space always < 6 hours
• Dyspnea, dry cough, hemorrhagic sputum
and hemoptoe
• Lung protective ventilation ± preventive
chest tube
Intensive Care
• Principes of ATLS + EGDT
• Damage control principles
• Standard intensive care treatment
• Intestinal perforation often after delay
• Unusual infections
➡ Candida, HIV, Hepatitis B
Inhalation trauma
• Especially in closed space
➡ Smoke
➡ Nitric oxides
➡ Phosgene
➡ Carbon monoxide
➡ Cyanide
➡ Heavy metals
Cyanide
• Cyanide often with CO after smoke
inhalation
• Hypotension, coma and persistent acidosis
despite adequate oxygenation
• Therapy with sodiumnitrite en thiosulfate
Sodiumnitrite
Hb
300 mg/iv
Met
Hb
Thiosulfate
C
12.5 gr/iv
TC
Met
Hb
C
Hydroxycobalamine
5 gr
To remember
• Intestinal damage often after delay
• Lung damage most frequent cause of death
in initial survivors
• Air embolus relatively frequent
• Remember toxic gasses
• Wounds often contaminated
Anthrax
• Bacillus anthracis
• Aerobic, gram-positive spore-forming rod
• Found in soil with infection most
commonly in herbivore mammals
• Human contact with contaminated animal
products
Clinical infection
• Cutaneous (most frequent)
• Gastrointestinal
• Inhalational (pulmonary)
• Injectional (drug use)
Anthrax - pathogenesis
• Presence of a capsule
• Production of 2 exotoxins (lethal factor inactivates MAPKK & edema factor increases intracellular cAMP)
• High microbial concentrations in infected
hosts
Cutaneous anthrax
• 95% of reported anthrax cases
• Subcutaneous introduction of spores
• Painless pruritic papule 3 - 5 days following
infection developing in characteristic black
eschar
• With appropriate antibiotics death
uncommon
Gastro-intestinal
anthrax
• Ingestion of poorly cooked meat
• Oral-pharyngeal (oral or esophageal ulcer
with lymphadenopathy, edema and sepsis)
or lower GI form (nausea, bloody diarrhea,
acute abdomen, ascites and sepsis)
• High mortality (may approach 100%)
Inhalational anthrax
• Inhalation of small spores < 5 μm
• Two-stage illness (modal incubation time of
10 days) with flu-like symptoms followed by
second fulminant stage with high fever,
dyspnea, cyanosis, shock and sometimes
hemorrhagic meningitis - very high
mortality
• Mediastinal adenopathy and hemorrhagic
pleural effusions
Injectional anthrax
• Mostly after subcutaneous heroin injection
• Tissue swelling and soft tissue infection 1 10 days after injection - no black eschar
• Surgical debridement and fasciotomy often
necessary
• Intermediate mortality
Diagnosis
• Gram stain and culture from blood and
different sites
• Real-time PCR
Treatment (CDC)
• Ciprofloxacin (2 dd 400 mg/iv) + Pen G (6
dd 4 × 106 U) + Clindamycin (3 dd 600 mg)
for severe disease (60 days)
• Ciprofloxacin alone for cutaneous form
• Anti-toxin therapies still experimental
• Pleural fluid drainage with inhalational form
Hicks CW. Intensive Care Med 2012;38:1092-1104