Major burns in adults: a practice review.

There are approximately 180 000 deaths per year from thermal burn injury worldwide. Most burn injuries can be treated in local hospitals but 6.5% require specialist burn care. The initial ED assessment, resuscitation and critical care of the severely burned patient present significant challenges and require a multidisciplinary approach. The management of these patients in the resuscitation room impacts on the effectiveness of continuing care in the intensive care unit. The scope of the present practice review is the immediate management of the adult patient with severe burns, including inhalation injury and burn shock. The article uses an illustrative case to highlight recent developments including advanced airway management and the contemporary approach to assessment of fluid requirements and the type and volume of fluid resuscitation. There is discussion on new options for pain relief in the ED and the principles governing the early stages of burn intensive care. It does not discuss minor injuries, mass casualty events, chemical or radiation injuries, exfoliative or necrotising conditions or frost bite.

Clinical review: the critical care management of the burn patient.

Between 4 and 22% of burn patients presenting to the emergency department are admitted to critical care. Burn injury is characterised by a hypermetabolic response with physiologic, catabolic and immune effects. Burn care has seen renewed interest in colloid resuscitation, a change in transfusion practice and the development of anti-catabolic therapies. A literature search was conducted with priority given to review articles, meta-analyses and well-designed large trials; paediatric studies were included where adult studies were lacking with the aim to review the advances in adult intensive care burn management and place them in the general context of day-to-day practical burn management.

Critical care in emergency department: massive haemorrhage in trauma.

Inadequate resuscitation of major haemorrhage is an important cause of avoidable death in severely injured patients. Early recognition of blood loss, control of bleeding and restoration of circulating volume are critical to the management of trauma shock, and transfusion of blood components is a key intervention. Vital signs may be inadequate to determine the need for transfusion, and resuscitation regimens targeting vital signs may be harmful in the context of uncontrolled bleeding. This article addresses current concepts in haemostatic resuscitation. Recent guidelines on the diagnosis and treatment of coagulopathy in major trauma, and the role of component and adjuvant therapies, are considered. Finally, the potential role of thromboelastography and rotational thromboelastometry are discussed.

Metformin-associated lactic acidosis.

A 58-year-old female with known type 2 diabetes mellitus continued to take her usual medications, including metformin, an ACE inhibitor and a non-steroidal anti-inflammatory drug, while suffering from diarrhoea and vomiting. On presentation to the emergency department, she was found to have a profound lactic acidosis, cardiovascular instability and acute kidney injury. Despite a pH of 6.6, lactate of 14 mmol/L and a brief asystolic cardiac arrest, supportive treatment and the use of renal replacement therapy resulted in rapid improvement in her acid-base abnormalities and haemodynamic parameters. Metformin-associated lactic acidosis is a rare but life-threatening complication of diabetes management. Patient education and awareness amongst clinicians are paramount in the prevention and treatment of this condition.

Early massive transfusion in trauma patients: Canadian single-centre retrospective cohort study.

PURPOSE: To determine associations between red blood cell (RBC) transfusion and early and late clinical outcomes in massively transfused adult trauma patients. METHODS: A retrospective cohort study (1992-2001) including 260 patients receiving >or=10 RBC units or=48 hr, the maximum SOFA score was associated with RBC units transfused before 48 hr (linear regression beta coefficient 0.075, P < 0.0001), lower nadir hemoglobin before 48 hr (0.034, P = 0.03), age (0.032, P = 0.015), and admission SOFA (0.59, P < 0.0001). The RBC units transfused by 48 hr were not associated with either hospital mortality (n = 35) among patients surviving >or=48 hr (independent predictors, age [logistic regression odds ratio (OR) 1.06, 95% confidence interval 1.03-1.10], ISS [OR 1.07, 1.02-1.13], and maximum SOFA score [OR 1.56, 1.27-1.93]) or 48-hr mortality (n = 117) (independent predictors, admission SOFA [1.65, 1.45-1.88] and later year of hospital admission [OR 1.15, 1.02-1.29]). CONCLUSIONS: Hospital mortality is high among massively transfused trauma patients. Among early survivors, 48-hr RBC transfusion volume is associated with increased organ dysfunction, but not hospital mortality. Also, it is not associated with 48-hr mortality. Future research should continue to explore methods to improve hemostasis and minimize the need for RBC transfusion.

Validation of a classification system for causes of death in critical care: an assessment of inter-rater reliability.

OBJECTIVE: Trials in critical care have previously used unvalidated systems to classify cause of death. We aimed to provide initial validation of a method to classify cause of death in intensive care unit patients. DESIGN, SETTING AND PARTICIPANTS: One hundred case scenarios of patients who died in an ICU were presented online to raters, who were asked to select a proximate and an underlying cause of death for each, using the ICU Deaths Classification and Reason (ICU-DECLARE) system. We evaluated two methods of categorising proximate cause of death (designated Lists A and B) and one method of categorising underlying cause of death. Raters were ICU specialists and research coordinators from Australia, New Zealand and the United Kingdom. MAIN OUTCOME MEASURES: Inter-rater reliability, as measured by the Fleiss multirater kappa, and the median proportion of raters choosing the most likely diagnosis (defined as the most popular classification choice in each case). RESULTS: Across all raters and cases, for proximate cause of death List A, kappa was 0.54 (95% CI, 0.49-0.60), and for proximate cause of death List B, kappa was 0.58 (95% CI, 0.53-0.63). For the underlying cause of death, kappa was 0.48 (95% CI, 0.44-0.53). The median proportion of raters choosing the most likely diagnosis for proximate cause of death, List A, was 77.5% (interquartile range [IQR], 60.0%-93.8%), and the median proportion choosing the most likely diagnosis for proximate cause of death, List B, was 82.5% (IQR, 60.0%-92.5%). The median proportion choosing the most likely diagnosis for underlying cause was 65.0% (IQR, 50.0%-81.3%). Kappa and median agreement were similar between countries. ICU specialists showed higher kappa and median agreement than research coordinators. CONCLUSIONS: The ICU-DECLARE system allowed ICU doctors to classify the proximate cause of death of patients who died in the ICU with substantial reliability.