En respuesta a «Mascarilla laríngea para intubación Fastrach® en la lesión medular cervical postraumática» / In reply to «Fastrach(TM) intubating laryngeal mask for traumatic cervical spinal cord injury»

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Procedural sedation and analgesia during enzymatic debridement of burn patients.

Procedural sedation and analgesia (PSA) is a widely used strategy in various fields to carry out numerous diagnostic and therapeutic procedures. However, there is limited information on its efficacy and safety during enzymatic debridement of burn patients with Nexobrid®. The aim of our study was to describe the U-type PSA procedure in a series of patients requiring enzymatic debridement. We carried out a retrospective, descriptive study involving 28 patients requiring enzymatic debridement of a limb, trunk or multiple locations, who had been admitted to the Burn Unit of the University Hospital Complex of A Coruña (Spain). Of these, 17 patients (not requiring invasive mechanical ventilation [IMV]) received intravenous PSA and two received local/regional anesthesia. Among those patients who received PSA, the most frequently used sedative during the application and removal of Nexobrid® was ketamine following premedication with midazolam (median Ramsay sedation score = 3; range = 2-4). The most common type of analgesics prescribed for the debridement procedure was opioids. Three patients required rescue analgesia because of the intensity of their pain (Visual Analogue Scale [VAS] ≥ 4). The patients did not experience any of the complications analyzed. In our case series, U-type PSA proved to be a satisfactory and safe support strategy for enzymatic debridement of burn patients not requiring IMV due to another cause.

L'analgésie-sédation (AS) est largement utilisée au cours d'actes diagnostiques et thérapeutiques. Cependant, nous ne disposons que de peu de données concernant son efficacité et son innocuité et son efficacité durant le débridement enzymatique par Nexobrid® chez les brûlés. Nous décrivons ici une série rétrospective de 28 patients hospitalisés dans le CTB de La Corogne (Espagne) ayant bénéficié d'un débridement enzymatique du tronc, des membres ou de localisations multiples sous analgo-analgésie séquentielle avec rétrocontrôle. Parmi ces patients, 17 n'étaient pas ventilés et ont reçu une AS intraveineuse, 2 ont bénéficié d'anesthésie locale ou locorégionale. L'agent hypnotique le plus utilisé lors de la mise en place et du retrait de Nexobrid® était la kétamine (après prémédication par midazolam). Le score de sédation (Ramsay) médian était de 3 (interquartiles 2 et 4). Les opiacés étaient les analgésiques les plus fréquents. Trois patients ont eu besoin d'analgésie supplémentaire, indiquée par une EVA ≥ 4. Aucune complication n'a été retrouvée. Dans cette série, l'analgoanalgésie séquentielle avec rétrocontrôle apparaît comme un moyen efficace et sûr d'assurer l'analgésie pendant un débridement enzymatique chez des brûlés en ventilation spontanée.

Initial evaluation and management of the critical burn patient / Evaluación inicial y manejo del paciente quemado crítico

The major improvement in burn therapy is likely to focus on the early management of hemodynamic and respiratory failures in combination with an aggressive and early surgical excision and skin grafting for full-thickness burns. Immediate burn care by first care providers is important and can vastly alter outcomes, and it can significantly limit burn progression and depth. The goal of prehospital care should be to cease the burning process as well as prevent future complications and secondary injuries for burn shock. Identifying burn patients appropriate for immediate or subacute transfer is an important step in reducing morbidity and mortality. Delays in transport to Burn Unit should be minimized. The emergency management follows the principles of the Advanced Trauma Life Support Guidelines for assessment and stabilization of airway, breathing, circulation, disability, exposure and environment control. All patients with suspected inhalation injury must be removed from the enclosure as soon as possible, and immediately administer high-flow oxygen. Any patient with stridor, shortness of breath, facial burns, singed nasal hairs, cough, soot in the oral cavity, and history of being in a fire in an enclosed space should be strongly considered for early intubation. Fibroscopy may also be useful if airway damage is suspected and to assess known lung damage. Secondary evaluation following admission to the Burn Unit of a burned patient suffering a severe thermal injury includes continuation of respiratory support and management and treatment of inhalation injury, fluid resuscitation and cardiovascular stabilization, pain control and management of burn wound (AU)

Los principales avances en el tratamiento de la quemadura se centran en el manejo precoz de la disfunción hemodinámica y respiratoria junto con la excisión quirúrgica agresiva y precoz y el injerto de piel en quemaduras de espesor total. La atención inmediata a la quemadura puede cambiar el pronóstico, limitando significativamente su progresión y profundidad. El objetivo de la asistencia prehospitalaria es detener el proceso de combustión así como prevenir posteriores complicaciones y daños secundarios al shock por quemadura. Identificar los pacientes quemados subsidiarios de traslado inmediato es importante en términos de morbilidad y mortalidad. La demora en el traslado a una Unidad de Quemados de referencia debe ser minimizada. El manejo emergente debe ser el mismo que para cualquier otro paciente politraumatizado, con evaluación y estabilización de la vía aérea, la respiración, la circulación, la discapacidad y el control ambiental. Todos los pacientes con sospecha de inhalación deben ser trasladados del recinto tan pronto como sea posible y administrar inmediatamente oxígeno a alto flujo. Ante un paciente con estridor, dificultad para respirar, quemaduras faciales, vibrisas quemadas, tos, hollín en la cavidad oral e historia de inhalación de humo en un lugar cerrado debe ser considerada la indicación de intubación precoz. La fibroscopia puede ser útil si se sospecha daño de la vía aérea y para evaluar el daño pulmonar conocido. La valoración secundaria tras el ingreso en la Unidad de un paciente que ha sufrido una lesión térmica grave incluye la continuación del soporte respiratorio y el manejo y tratamiento del daño por inhalación, la reanimación con líquidos y la estabilización cardiovascular, el control del dolor y el manejo de la herida (AU)

Initial evaluation and management of the critical burn patient.

The major improvement in burn therapy is likely to focus on the early management of hemodynamic and respiratory failures in combination with an aggressive and early surgical excision and skin grafting for full-thickness burns. Immediate burn care by first care providers is important and can vastly alter outcomes, and it can significantly limit burn progression and depth. The goal of prehospital care should be to cease the burning process as well as prevent future complications and secondary injuries for burn shock. Identifying burn patients appropriate for immediate or subacute transfer is an important step in reducing morbidity and mortality. Delays in transport to Burn Unit should be minimized. The emergency management follows the principles of the Advanced Trauma Life Support Guidelines for assessment and stabilization of airway, breathing, circulation, disability, exposure and environment control. All patients with suspected inhalation injury must be removed from the enclosure as soon as possible, and immediately administer high-flow oxygen. Any patient with stridor, shortness of breath, facial burns, singed nasal hairs, cough, soot in the oral cavity, and history of being in a fire in an enclosed space should be strongly considered for early intubation. Fibroscopy may also be useful if airway damage is suspected and to assess known lung damage. Secondary evaluation following admission to the Burn Unit of a burned patient suffering a severe thermal injury includes continuation of respiratory support and management and treatment of inhalation injury, fluid resuscitation and cardiovascular stabilization, pain control and management of burn wound.

Alteraciones transitorias del ECG y de la motilidad del ventrículo izquierdo durante la hemorragia subaracnoidea / Transitory ECG alterations and left ventricular motility during subarachnoid hemorrhage

Presentamos el caso de una paciente con hemorragia subaracnoidea espontánea, secundaria a rotura de un aneurisma de la arteria cerebral media derecha, que presentó alteraciones electrocardiográficas sugestivas de isquemia, acompañadas además de anomalías segmentarias de la contractilidad ventricular izquierda, que se observaron en el estudio ecocardiográfico. La monitorización eléctrica, hemodinámica y ecocardiográfica puso de manifiesto que ambas alteraciones fueron transitorias, y se recuperaron espontáneamente y sin ocasionar en ningún momento arritmias, elevación de enzimas cardíacas por encima del rango normal ni inestabilidad hemodinámica.La paciente fue tratada de su proceso cerebral y su pronóstico vino determinado por dicha lesión (AU)