Critical Care of the Burn Patient.

Care of the critically ill burned patient must integrate a multidisciplinary care team composed of burn care specialists. As resuscitative mortality decreases more patients are surviving to experience multisystem organ failure relating to complications of their injuries. Clinicians must be aware of physiologic changes following burn injury and the implicated impacts on management strategy. Promoting wound closure and rehabilitation should be the backdrop for which management decisions are made.

Adjunct Use of Continuous Renal Replacement Therapy with Extracorporeal Membrane Oxygenation Achieves Negative Fluid Balance and Enhances Oxygenation Which Improves Survival in Critically Ill Patients without Kidney Failure.

INTRODUCTION: Fluid overload in extracorporeal membrane oxygenation (ECMO) patients has been associated with increased mortality. Patients receiving ECMO and continuous renal replacement therapy (CRRT) who achieve a negative fluid balance have improved survival. Limited data exist on the use of CRRT solely for fluid management in ECMO patients. METHODS: We performed a single-center retrospective review of 19 adult ECMO patients without significant renal dysfunction who received CRRT for fluid management. These patients were compared to a cohort of propensity-matched controls. RESULTS: After 72 h, the treatment group had a fluid balance of -3840 mL versus + 425 mL (p ≤ 0.05). This lower fluid balance correlated with survival to discharge (odds ratio 2.54, 95% confidence interval 1.10-5.87). Improvement in the ratio of arterial oxygen content to fraction of inspired oxygen was also significantly higher in the CRRT group (102.4 vs. 0.7, p ≤ 0.05). We did not observe any significant difference in renal outcomes. CONCLUSIONS: The use of CRRT for fluid management is effective and, when resulting in negative fluid balance, improves survival in adult ECMO patients without significant renal dysfunction.

Initial treatment strategies in new-onset atrial fibrillation in critically ill burn patients.

INTRODUCTION: Atrial fibrillation is associated with increased morbidity and mortality in critically ill patients. Few studies have specifically examined this arrhythmia in burn patients. Given the significant clinical implications of atrial fibrillation, understanding the optimal management strategy of this arrhythmia in burn patients is important. Consequently, the purpose of this study was to examine rate- and rhythm-control strategies in the management of new onset atrial fibrillation (NOAF) and assess their short term outcomes in critically ill burn patients. METHODS: We identified all patients admitted to our institution's burn intensive care unit between January 2007 and May 2018 who developed NOAF. Demographic information and burn injury characteristics were captured. Patients were grouped into two cohorts based on the initial pharmacologic treatment strategy: rate-(metoprolol or diltiazem) or rhythm-control (amiodarone). The primary outcome was conversion to sinus rhythm. Secondary outcomes included relapse or recurrence of atrial fibrillation, drug-related adverse events, and complications and mortality within 30 days of the NOAF episode. RESULTS: There were 68 patients that experienced NOAF, and the episodes occurred on median days 8 and 9 in the rate- and rhythm-control groups, respectively. The length of the episodes was not significantly different between the groups. Conversion to sinus rhythm occurred more often in the rhythm-control group (P = 0.04). There were no differences in the incidences of relapse and recurrence of atrial fibrillation, and the complications and mortality between the groups. Hypotension was the most common drug-related adverse event and occurred more frequently in the rate-control group, though this difference was not significant. CONCLUSIONS: Conversion to sinus rhythm occurred more often in the rhythm-control group. Outcomes were otherwise similar in terms of mortality, complications, and adverse events. Hypotension occurred less frequently in the rhythm-control group, and although this difference was not significant, episodes of hypotension can have important clinical implications. Given these factors, along with burn patients having unique injury characteristics and a hypermetabolic state that may contribute to the development of NOAF, when choosing between rate- and rhythm control strategies, rhythm-control with amiodarone may be a better choice for managing NOAF in burn patients.

Traumatic Pneumocephalus Without Skull Fracture From a High-Voltage Electrical Injury.

Pneumocephalus, the presence of intracranial air, most commonly occurs secondary to a traumatic injury. Patients with simple pneumocephalus often present with nonspecific symptoms or with headaches. These patients may have little to no clinically relevant physical examination findings and can be managed conservatively. Tension pneumocephalus can present more acutely as a neurosurgical emergency. On physical examination, patients can present with neurologic deficits or papilledema. Computed tomography is the imaging modality of choice to detect intracranial air. We present a novel case of a simple pneumocephalus in the setting of a high-voltage electrical injury without evidence of displaced skull fracture or dural violation. The identification of unanticipated air within the cranial vault should prompt emergency physicians to determine its etiology which can guide treatment and disposition.

Outcomes after the administration of hydroxocobalamin.

Background: Hydroxocobalamin is frequently administered to patients after injures sustained during structure fires or fires in enclosed spaces, prior to confirming inhalation injury with bronchoscopy. Hydroxocobalamin is generally considered safe. However, over the last several years, the safety of hydroxocobalamin has been called into question by case reports of crystalline nephropathy and interference with renal replacement therapies. Objectives: The aim of this project was to describe the population in which hydroxocobalamin was administered and assess clinical outcomes such as mortality and need for renal replacement therapy. We hypothesized that there is a relationship between the administration of hydroxocobalamin and the development of acute kidney injury (AKI). Methods: This was a retrospective chart review that was approved by our institution's research and regulatory compliance division as a performance improvement (PI) project (H-19-019nr). All patients admitted to the burn ICU at a large, government medical center between July 1, 2016 and April 30, 2019 were considered for inclusion. Patients were included if they received hydroxocobalamin after burn ICU admission. Patients who received hydroxocobalamin in the pre-ICU or pre-hospital setting were not included. Data were collected from the electronic medical record and included demographic information, number of hydroxocobalamin doses administered, burn size (%TBSA), presence and grade of inhalation injury, lactate levels during the first 72 hours of hospitalization, carboxyhemoglobin levels, duration of mechanical ventilation, and in-hospital mortality. Development of acute kidney injury (AKI) as per the AKIN criteria, as well as need for and duration of continuous renal replacement therapy (CRRT) were also collected. Results: Thirty five patients received at least 1 dose of hydroxocobalamin after ICU admission; 31 patients received 1 dose and 4 patients received 2 doses. Twenty nine (82.9%) patients who received hydroxocobalamin in the ICU were diagnosed with inhalation injury via bronchoscopy. The median fluid resuscitation requirement was 7.4 mL/kg/%TBSA (IQR 4.6, 12.7). Twenty two (63%) patients who received hydroxocobalamin developed an acute kidney injury (AKI) during the first 72 hours of admission, with the average time from burn to AKI being approximately 20 hours. Twenty one (60%) patients required CRRT at some point during their hospital stay, with 42.8% of patients being initiated on CRRT during the resuscitation period. On average, lactate clearance occurred in 34.6 hours; 11 (31.4%) patients did not clear lactate within 72 hours. One patient had a carboxyhemoglobin level greater than 10% on admission and 4 patients had a carboxyhemoglobin level greater than 3% on admission. The average time to carboxyhemoglobin level less than 3% was 3.4 ± 2.6 hours. The average duration of mechanical ventilation was 11 ± 7 days. Ten (28.9%) patients died during their hospital stay. Conclusions: Most patients who receive at least 1 dose of hydroxocobalamin after ICU admission developed AKI within the first 72 hours, with 42.8% of patients requiring CRRT during the initial resuscitation period. One-third of patients who received hydroxocobalamin after ICU admission died during their hospital stay. Further studies on the relationship between the administration of hydroxocobalamin and the development of AKI and in-hospital mortality are warranted.