Heartland Hospital Medicine Conference

This was fun! Thanks for having us, @HHMConf!

Presented with @GrahamCarlos at @HHMConf this AM - always fun to teach others about intricacies of care for the burn patient! Reviving this #tweetorial with all of our burn #pearls (we couldn’t fit them all in one hour!!)

The End! Endless thanks to @GrahamCarlos @DeliriumKhan @EskenaziHealth amongst other #twitterphobes for their mentorship, edits, and support. This was a fun project and I learned a TON!

PALLIATIVE CARE - Pain with dressing changes most common issue - Pre-treatment with opiates helpful - Hypnosis, #VR being explored as adjuncts - Better pain control ➡️ more participation in PT ➡️ earlier discharge/recovery (15/16)

APPROACH TO EXTUBATION - Similar to other pts, with some extras - 🚫 cuff leak ➡️ steroids before tube out - Extubation failure related to ⬇️ pulm toileting - Cough peak flow may have a role when added to #RSBI (14/16)

#ECMO - 🔥 injury ➡️ SIRS ➡️ 🫁 injury - ⬆️ risk of #ARDS - Conventional #ARDS management also helpful here - Early #ECMO improves mortality in severe #ARDS, but rarely required (13/16)

NUTRITION - 🔥patients have ⬆️ nutrition reqs - Monitor pre-alb, CRP, LFTs, vit D 2x/week - Start high protein tube feeds ASAP (first 6h ideal) - Indirect calorimetry is most accurate in vented pts - Watch for refeeding, ⬆️ insulin resistance (12/16)

OPHTHO IN BURN @DGlaucomflecken - Corneal burns are subtle - Early ophtho consult is 🔑 - 👁 irrigation often needed to maintain pH - ⬆️grade burns may need tenonplasty - ⬆️IOP, ⬆️orbital compartment syndrome (tx canthotomy) - Watch for foreign bodies (#slitlamp) (11/16)

FLUID RESUSCITATION - Formal fluid resuscitation protects skin - #ParklandFormula = 2-4mL IVF x TBSA x weight in kg, delivered in 24h - Huge amounts of IVF often required, usually crystalloid - Monitor UOP to tailor approach - Watch for coagulopathy, compartment syndrome (10/16)

CYANIDE TOXICITY - 🔥textiles/rubber ⬆️ CN - 🛑oxidative phosphorylation ➡️ refractory lactic acidosis - REMOVE CLOTHES - Hydroxocobalamin is safest tx - Inducing methemoglobinemia is alternate tx, but risky ⚠️⚠️ - Empiric tx for cardiac arrest, ⬇️GCS, ⬆️ lactate, ⬇️ BP (9/16)

CARBON MONOXIDE - Binds Hgb 200x stronger than O2 - Toxicity often mistaken for viral illness in winter months - Co-oximetry is most helpful - SpO2, PaO2 may be falsely normal - Elevated lactate should trigger tx with high flow O2 (8/16)

SMOKING RELATED BURNS - 🚬 + O2 = 🙅🏻 - Nasal cannulas contain polyvinyl chloride (🔥🔥🔥) - ⬆️ inhalation injury with ⬇️TBSA - @VeteransHealth requires thermal fuses in line with home oxygen tubing - #BauxScore misleading here (7/16)

BRONCHOALVEOLAR LAVAGE - Burn patients have increased incidence of pulmonary complications, including #VAP - Sputum cx misleading ➡️ colonization - Clinical signs of pneumonia are nonspecific and often present in burn patients - PCT falsely ⬆️ in burn (6/16)

BRONCHOSCOPY - Early bronch useful in assessing degree of inhalation injury, considered gold standard by most burn centers - Abbreviated Injury Scale (AIS) is most commonly used grading system - Inhalation injury has significant impact on mortality #BauxScore (5/16)

NEBULIZED MEDS - Nebulized heparin is mainstay of treatment for high grade inhalation injury (#HIHI2 study) - Beta agonists may have a role, but not as well defined (4/16)

AIRWAY MANAGEMENT 🩺 - Secure airway ASAP if needed - Subglottic injury is subtle and can progress rapidly 🏃🏻 ‼️ Voice changes, decreased LOC, carbonaceous sputum, high TBSA all warning signs of inhalation injury ‼️ - Securing endotracheal tube requires creativity 🔐🔐 (3/16)

INITIAL ASSESSMENT 🩻 - Follow #ATLS protocol - Assess degree of burn injury including depth and TBSA - Evaluate for inhalation injury (2/16)

To celebrate my first publication in @AnnalsATS, a 🧵 on critical care of the burn patient! (1/16) 🧯🔥🔥🔥🫁 atsjournals.org/doi/10.1513/An…

#TWDFNR @SocietyHospMed @JHospMedicine No need to routinely correct elevated INR and thrombocytopenia prior to Paracentesis in patients with Cirrhosis …mpublications.onlinelibrary.wiley.com/cms/asset/cd61…

Dr. Marijeta Pekez from @UKYMedicine and @UK_HealthCare presenting on Updates in Gastroenterology

NPO after midnight #TWDFNR @JHospMedicine @SocietyHospMed

Think of palliative care, goals of care and shared decision making aasldpubs.onlinelibrary.wiley.com/doi/10.1002/he…