WEBVTT 00:00:07.880 --> 00:00:10.759 You're in the bay. Once you get over to the bed, 00:00:10.919 --> 00:00:13.560 we'll give you the story. Everything's going 00:00:13.560 --> 00:00:17.339 to happen super fast. Welcome to the emergency 00:00:17.339 --> 00:00:44.000 room. You are a critical care clinician and I 00:00:44.000 --> 00:00:48.020 want you Listening right now to really put yourself 00:00:48.020 --> 00:00:50.259 into this exact scenario you're stepping through 00:00:50.259 --> 00:00:52.820 those heavy double doors into the burn intensive 00:00:52.820 --> 00:00:56.079 care unit and You know the heat hits you first 00:00:56.079 --> 00:00:58.299 right because the rooms are kept absolutely sweltering 00:00:58.299 --> 00:01:00.420 the patients have yeah They've lost their ability 00:01:00.420 --> 00:01:02.619 to regulate their own temperature exactly But 00:01:02.619 --> 00:01:05.299 as you walk up to the bedside of a major burn 00:01:05.299 --> 00:01:08.000 patient You need to realize immediately that 00:01:08.000 --> 00:01:10.000 you aren't just looking at a wound. You know 00:01:10.000 --> 00:01:11.980 you aren't just there to apply dressings You're 00:01:11.980 --> 00:01:16.390 looking at absolute catastrophic multi -system 00:01:16.390 --> 00:01:18.950 failure. It's a complete paradigm shift from 00:01:18.950 --> 00:01:20.609 almost anything else you'll see in medicine. 00:01:21.010 --> 00:01:22.230 Yeah. And when you walk into that room, you have 00:01:22.230 --> 00:01:24.390 to stop looking at the skin as just a covering. 00:01:24.450 --> 00:01:27.390 Yeah. You have to treat the massive systemic 00:01:27.390 --> 00:01:29.890 physiologic shock wave that follows the thermal 00:01:29.890 --> 00:01:33.489 injury. Because time is tissue. And hesitation 00:01:33.489 --> 00:01:36.849 in the burn ICU is deadly. And that's exactly 00:01:36.849 --> 00:01:38.950 our mission for this deep dive. We're bringing 00:01:38.950 --> 00:01:42.129 you an elite bedside masterclass on major burn 00:01:42.129 --> 00:01:44.650 injuries. We're applying the 80 -20 rule, so 00:01:44.650 --> 00:01:47.209 we're stripping away the fluff and focusing strictly 00:01:47.209 --> 00:01:50.069 on the pathophysiology, the clinical assessments, 00:01:50.069 --> 00:01:53.469 and the critical actions that dictate survival. 00:01:53.650 --> 00:01:55.129 Right, the stuff that actually matters at the 00:01:55.129 --> 00:01:57.390 bedside. Exactly. This is the knowledge that 00:01:57.390 --> 00:02:00.150 will save a patient's life, prevent irreversible 00:02:00.150 --> 00:02:03.390 injury, and, whoa, give you that intensivist 00:02:03.390 --> 00:02:06.650 level intuition. You really need to know exactly 00:02:06.650 --> 00:02:09.030 what is happening down at the cellular level. 00:02:09.830 --> 00:02:12.110 If you understand the micro level collapse, you 00:02:12.110 --> 00:02:14.789 can anticipate the macro level disaster before 00:02:14.789 --> 00:02:17.009 the alarms ever even sound on your monitor. So 00:02:17.009 --> 00:02:19.289 let's build an analogy to kind of hold onto throughout 00:02:19.289 --> 00:02:22.729 this entire journey. Imagine a highly functioning 00:02:22.729 --> 00:02:25.569 fortified city. OK, I like that. A major burn 00:02:25.569 --> 00:02:28.069 is like that city simultaneously losing its outer 00:02:28.069 --> 00:02:30.449 defensive walls, its internal water supply, and 00:02:30.449 --> 00:02:32.830 its communication grid all at the exact same 00:02:32.830 --> 00:02:35.169 moment. Yeah, it's a total collapse of systemic 00:02:35.169 --> 00:02:38.750 boundaries. And that brings us to the most immediate 00:02:38.750 --> 00:02:41.009 threat when that patient rolls through the doors, 00:02:41.129 --> 00:02:43.750 the emergent phase, like the first 72 hours. 00:02:43.770 --> 00:02:46.509 Right. But here is where my logic hits a wall. 00:02:47.310 --> 00:02:49.610 If the wall of the city is what's damaged like, 00:02:49.800 --> 00:02:52.319 If it's a thermal injury to the exterior of the 00:02:52.319 --> 00:02:55.060 body, why is the most immediate life -threatening 00:02:55.060 --> 00:02:58.439 problem essentially severe dehydration and cardiovascular 00:02:58.439 --> 00:03:01.219 collapse? It's the perfect question, and it gets 00:03:01.219 --> 00:03:03.400 right to the core of what we call burn shock. 00:03:03.800 --> 00:03:06.039 If we're looking at the 80 -20 of the emergent 00:03:06.039 --> 00:03:08.000 phase, you have to understand that burn shock 00:03:08.000 --> 00:03:11.520 is a deadly hybrid combination of distributive 00:03:11.520 --> 00:03:14.460 and hypovolemic shock. OK, distributive and hypovolemic. 00:03:14.500 --> 00:03:16.479 Yeah. And it typically strikes patients with 00:03:16.479 --> 00:03:18.539 burns covering more than 20 % of their total 00:03:18.539 --> 00:03:21.400 body surface area, or TBSA. So we're talking 00:03:21.400 --> 00:03:23.860 about major thermal, chemical, or electrical 00:03:23.860 --> 00:03:26.300 burns. But what's the actual mechanism? Like, 00:03:26.300 --> 00:03:28.500 what is the trigger that turns a skin injury 00:03:28.500 --> 00:03:30.819 into cardiovascular collapse? So the trigger 00:03:30.819 --> 00:03:33.300 is the intense heat and tissue destruction, right? 00:03:33.479 --> 00:03:36.460 which initiates a localized inflammatory response. 00:03:37.039 --> 00:03:40.199 But in a major burn, that localized response 00:03:40.199 --> 00:03:43.240 goes entirely systemic. It goes everywhere. Exactly. 00:03:44.099 --> 00:03:47.240 Capillary permeability massively increases across 00:03:47.240 --> 00:03:49.719 the entire body. Think of your blood vessels. 00:03:50.139 --> 00:03:52.520 Normally they're like semi -permeable pipes keeping 00:03:52.520 --> 00:03:55.800 the fluid moving forward. Suddenly, the heat 00:03:55.800 --> 00:03:58.319 and chemical mediators turn those pipes into 00:03:58.319 --> 00:04:01.099 porous soaker hoses. they completely lose their 00:04:01.099 --> 00:04:03.240 seal. So all the fluid components of the blood 00:04:03.240 --> 00:04:05.520 just start leaking out of the vascular space 00:04:05.520 --> 00:04:08.340 and into the surrounding tissue, the interstitium. 00:04:08.520 --> 00:04:11.439 Yes, and it's not just water. The most critical 00:04:11.439 --> 00:04:14.080 element you're losing into the tissue is plasma 00:04:14.080 --> 00:04:16.939 protein, specifically albumin. Albumin, right. 00:04:17.060 --> 00:04:19.620 Albumin is a massive molecule. Under normal conditions, 00:04:19.800 --> 00:04:21.399 it stays inside the blood vessel and acts like 00:04:21.399 --> 00:04:24.600 a molecular sponge. It provides colloidal osmotic 00:04:24.600 --> 00:04:26.899 pressure, which is essentially the magnetic pull 00:04:26.899 --> 00:04:29.019 that keeps water inside the blood vessels. Oh, 00:04:29.019 --> 00:04:31.259 I see. So when the pipe becomes porous, this 00:04:31.259 --> 00:04:34.319 giant albumin sponge escapes into the surrounding 00:04:34.319 --> 00:04:38.240 tissue. And because water follows protein, the 00:04:38.240 --> 00:04:40.779 magnetic pull is now on the outside of the vessel. 00:04:40.939 --> 00:04:44.019 That's it. Exactly. The water gets dragged out 00:04:44.019 --> 00:04:47.300 of the vascular space into the tissues. We call 00:04:47.300 --> 00:04:50.639 this massive fluid shift third spacing. So the 00:04:50.639 --> 00:04:53.720 patient's intravascular tank is rapidly emptying 00:04:53.720 --> 00:04:56.379 while their physical body is just swelling with 00:04:56.379 --> 00:04:59.600 liters of tract fluid. If the fluid is leaving 00:04:59.600 --> 00:05:02.259 the blood vessels that rapidly, I mean, my instinct 00:05:02.259 --> 00:05:03.819 tells me the patient's blood pressure should 00:05:03.819 --> 00:05:05.360 immediately tank. Is that what I'm going to see 00:05:05.360 --> 00:05:07.459 on the monitor the second they roll in? You'd 00:05:07.459 --> 00:05:10.800 think so, but the human body has incredible compensatory 00:05:10.800 --> 00:05:13.079 mechanisms that will trick you if you aren't 00:05:13.079 --> 00:05:15.720 paying attention. Really? Yeah. The body senses 00:05:15.720 --> 00:05:19.449 this profound drop in blood volume. So it kicks 00:05:19.449 --> 00:05:21.910 into overdrive to compensate. The heart rate 00:05:21.910 --> 00:05:24.610 shoots up tachycardia to pump whatever volume 00:05:24.610 --> 00:05:26.490 is left. Okay, that makes sense. And the peripheral 00:05:26.490 --> 00:05:29.910 vessels clamp down aggressively. This vasoconstriction 00:05:29.910 --> 00:05:32.389 increases peripheral resistance, which can actually 00:05:32.389 --> 00:05:34.310 artificially hold the blood pressure up in the 00:05:34.310 --> 00:05:36.769 early stages. But it's a house of cards. A very 00:05:36.769 --> 00:05:39.930 fragile one. And to make matters worse, because 00:05:39.930 --> 00:05:42.250 you're leaking all this plasma and water, but 00:05:42.250 --> 00:05:44.490 you're keeping your large red blood cells inside 00:05:44.490 --> 00:05:47.209 the vessels, the blood becomes highly concentrated. 00:05:47.629 --> 00:05:50.250 The hematocrit skyrockets. It's like the heart 00:05:50.250 --> 00:05:52.930 is trying to pump thick sludge instead of water. 00:05:53.129 --> 00:05:55.740 Precisely. You have decreased blood volume combined 00:05:55.740 --> 00:05:58.500 with increased blood viscosity. The heart is 00:05:58.500 --> 00:06:01.540 working exponentially harder to push sludge through 00:06:01.540 --> 00:06:03.920 clamped down pipes. And then it just fails. Right. 00:06:04.019 --> 00:06:06.339 Eventually this compensation fails, leading to 00:06:06.339 --> 00:06:09.360 decompensation. True burn shock. The lack of 00:06:09.360 --> 00:06:12.480 perfusion starves the cells. Potassium, which 00:06:12.480 --> 00:06:14.740 normally lives happily inside the cell, shifts 00:06:14.740 --> 00:06:17.180 out of the hemolyzed destroyed cells and floods 00:06:17.180 --> 00:06:19.720 the bloodstream, causing severe hyperkalemia. 00:06:19.879 --> 00:06:22.519 And hyperkalemia is a massive cardiac threat. 00:06:23.040 --> 00:06:25.439 Absolutely. Meanwhile, sodium rapidly shifts 00:06:25.439 --> 00:06:28.100 into the interstitial space, causing hyponatremia. 00:06:28.660 --> 00:06:31.339 If you don't correct this empty, sludgy vascular 00:06:31.339 --> 00:06:34.300 space immediately, the kidneys die, multiple 00:06:34.300 --> 00:06:36.639 organs fail, and the patient dies. OK, so let's 00:06:36.639 --> 00:06:38.199 translate this to the bedside assessment. I'm 00:06:38.199 --> 00:06:40.139 looking at the patient. Early on, I'm seeing 00:06:40.139 --> 00:06:43.339 that compensatory tachycardia. What else? Surprisingly, 00:06:43.660 --> 00:06:47.379 you'll often see profound shivering. Shivering. 00:06:47.600 --> 00:06:49.339 Yeah, they've lost their skin barrier, so they're 00:06:49.339 --> 00:06:51.339 losing heat to the room rapidly, and they're 00:06:51.339 --> 00:06:54.939 just flooded with adrenaline from anxiety. And 00:06:54.939 --> 00:06:58.800 regarding pain, this is a massive clinical nuance. 00:06:59.579 --> 00:07:01.860 If they have partial thickness burns, you know, 00:07:01.980 --> 00:07:04.560 second degree, it's going to be excruciatingly 00:07:04.560 --> 00:07:06.779 painful because the nerve endings are raw and 00:07:06.779 --> 00:07:09.420 exposed. But if they have full thickness burns, 00:07:09.740 --> 00:07:11.959 third or fourth degree, they might look at you 00:07:11.959 --> 00:07:13.779 and say, it doesn't hurt at all. Wait, really? 00:07:14.000 --> 00:07:16.279 Because the fire actually incinerated the dermal 00:07:16.279 --> 00:07:19.500 nerve endings? Exactly. The worse the burn, the 00:07:19.500 --> 00:07:21.839 less it might hurt initially. It's a terrifying 00:07:21.839 --> 00:07:25.420 paradox. Now, as the hours pass, you'll see the 00:07:25.420 --> 00:07:27.879 classic clinical picture of the fluid shift emerge. 00:07:28.889 --> 00:07:31.410 massive, unbelievable edema. Right, a third spacing. 00:07:31.730 --> 00:07:34.990 Yes. The patient's face, their limbs, their torso 00:07:34.990 --> 00:07:38.149 will swell to the point of being totally unrecognizable. 00:07:38.269 --> 00:07:40.310 And what about their urine output? Because if 00:07:40.310 --> 00:07:41.829 the kidneys are being starved of blood, they 00:07:41.829 --> 00:07:44.029 must be shutting down production, right? Urine 00:07:44.029 --> 00:07:47.569 output is your absolute holy grail of monitoring 00:07:47.569 --> 00:07:52.089 in the burn ICU. You will see a high urine -specific 00:07:52.089 --> 00:07:54.470 gravity, meaning the urine is dark and highly 00:07:54.470 --> 00:07:57.410 concentrated, and a very low output, which is 00:07:57.410 --> 00:08:00.069 oliguria. The kidneys are just panicking. Right. 00:08:00.250 --> 00:08:02.209 They're desperately holding on to every single 00:08:02.209 --> 00:08:03.970 drop of water to try and keep the blood pressure 00:08:03.970 --> 00:08:06.410 up. So what are the late dangerous findings, 00:08:06.610 --> 00:08:08.550 like the things that tell me the patient is actively 00:08:08.550 --> 00:08:11.769 slipping away? Profound hypotension. Yeah. Meaning 00:08:11.769 --> 00:08:14.069 the compensatory vasoconstriction has completely 00:08:14.069 --> 00:08:17.810 failed and altered mental status. OK. But a major 00:08:17.810 --> 00:08:21.670 ICU pearl here. If a burn patient becomes confused, 00:08:22.029 --> 00:08:24.509 agitated, or restless, do not just assume it's 00:08:24.509 --> 00:08:27.250 shock or that they're simply in pain. You must 00:08:27.250 --> 00:08:30.050 think hypoxia first. The airway. Yes, we'll cover 00:08:30.050 --> 00:08:31.529 this deeply in a moment, but you have to rule 00:08:31.529 --> 00:08:34.230 out an airway threat. Got it. Since we know the 00:08:34.230 --> 00:08:36.110 blood is turning to sludge and the cells are 00:08:36.110 --> 00:08:38.730 rupturing, what numbers in the lab results are 00:08:38.730 --> 00:08:42.070 going to sound the alarm? So your high yield 00:08:42.070 --> 00:08:43.929 diagnostics for the emergent phase are going 00:08:43.929 --> 00:08:47.200 to show that elevated hematocrit Due to the hemoconcentration, 00:08:47.399 --> 00:08:49.860 you'll see hyperkalemia from the massive cellular 00:08:49.860 --> 00:08:52.259 destruction. Which puts the patient at immediate 00:08:52.259 --> 00:08:54.399 risk for lethal cardiac arrhythmia. Exactly. 00:08:54.500 --> 00:08:56.460 And you'll see hyponatremia because the sodium 00:08:56.460 --> 00:08:58.360 is washing out into the tissues. And we have 00:08:58.360 --> 00:09:00.159 to quantify the size of the brun to know how 00:09:00.159 --> 00:09:02.879 much fluid they need, right? This is where the 00:09:02.879 --> 00:09:05.019 Rule of Nines comes in to calculate the total 00:09:05.019 --> 00:09:08.019 body surface area, or TBSA. Right. The Rule of 00:09:08.019 --> 00:09:11.879 Nines is your rapid visual triage tool for adults. 00:09:12.500 --> 00:09:14.639 You basically visualize the body in sections. 00:09:15.000 --> 00:09:18.419 The entire head and neck is 9%. Each entire arm 00:09:18.419 --> 00:09:22.720 is 9%. Each entire leg is 18%. The anterior trunk 00:09:22.720 --> 00:09:25.240 is 18. The posterior trunk is 18. And the perineum 00:09:25.240 --> 00:09:28.379 is 1%. So if a patient has burns on their entire 00:09:28.379 --> 00:09:31.720 chest, abdomen, and both full arms, that's 18. 00:09:31.529 --> 00:09:34.090 for the trunk, plus nine, plus nine for the arms. 00:09:34.330 --> 00:09:38.269 So 36 % TVSA. Spot on. Now, for more exact calculations, 00:09:38.429 --> 00:09:40.870 especially in the ICU or for pediatric patients, 00:09:40.950 --> 00:09:42.970 because their head -to -body ratios are completely 00:09:42.970 --> 00:09:45.909 different, we use the Lundbrouter chart. It breaks 00:09:45.909 --> 00:09:47.990 down the percentages much more precisely based 00:09:47.990 --> 00:09:51.389 on age. OK, so I'm at the bedside. I've recognized 00:09:51.389 --> 00:09:54.330 the massive fluid leak, the impending shock. 00:09:54.549 --> 00:09:57.970 I've calculated the burn size. What is my literal 00:09:57.970 --> 00:10:00.740 first move to stop this crash? I have to rank 00:10:00.740 --> 00:10:02.500 my interventions. First, you ensure the burning 00:10:02.500 --> 00:10:05.419 process is stopped, remove hot clothing, chemicals, 00:10:05.519 --> 00:10:08.759 whatever it is, and you assess the airway. Next, 00:10:09.059 --> 00:10:12.759 you must establish two large bore IVs. How large 00:10:12.759 --> 00:10:15.399 are we talking? We are talking 14 or 16 gauge 00:10:15.399 --> 00:10:18.259 or a central line for any burn greater than 20 00:10:18.259 --> 00:10:22.179 % TBSA. And you must simultaneously insert a 00:10:22.179 --> 00:10:24.740 urinary catheter. Let me stop you there. Why 00:10:24.740 --> 00:10:27.279 is the fully catheter grouped in with life -saving 00:10:27.279 --> 00:10:29.240 IV access? It seems like something that could 00:10:29.480 --> 00:10:31.320 You know, wait a minute. It absolutely cannot 00:10:31.320 --> 00:10:33.399 wait. You cannot safely manage the aggressive 00:10:33.399 --> 00:10:35.539 fluid resuscitation required to save their life 00:10:35.539 --> 00:10:38.639 without a Foley to measure hourly exact urine 00:10:38.639 --> 00:10:40.860 output. Because that's the holy grail. Exactly. 00:10:41.019 --> 00:10:43.700 DRN output is the only real -time window you 00:10:43.700 --> 00:10:46.059 have into whether your fluids are actually perfusing 00:10:46.059 --> 00:10:48.899 the internal organs. Okay, so airway, large bore 00:10:48.899 --> 00:10:52.299 IVs, Foley. Then what? Then you calculate and 00:10:52.299 --> 00:10:54.240 slam them with the fluid resuscitation. Let's 00:10:54.240 --> 00:10:56.399 dive into the math of this fluid, because this 00:10:56.399 --> 00:10:58.559 is where a critical care nurse saves the kidneys 00:10:58.559 --> 00:11:03.539 and the heart. We use lactated ringers, YLR, 00:11:03.940 --> 00:11:06.559 instead of normal saline. Because, I mean, we 00:11:06.559 --> 00:11:09.019 use saline for almost everything else. Because 00:11:09.019 --> 00:11:11.419 of the sheer volume you're about to give. Lactated 00:11:11.419 --> 00:11:14.159 ringers is an isotonic crystalloid that most 00:11:14.159 --> 00:11:17.120 closely mimics human plasma. It contains small 00:11:17.120 --> 00:11:19.559 amounts of potassium, calcium, and lactate, which 00:11:19.559 --> 00:11:22.620 the liver converts to bicarbonate to buffer acidosis. 00:11:23.179 --> 00:11:25.679 If you give 10 or 15 liters of normal saline, 00:11:26.120 --> 00:11:29.039 you will cause a massive hyperchloremic metabolic 00:11:29.039 --> 00:11:31.480 acidosis, which will just further depress their 00:11:31.480 --> 00:11:34.149 already struggling heart. Wow, okay. So we use 00:11:34.149 --> 00:11:36.649 the American Burn Association or ABA formula. 00:11:36.769 --> 00:11:38.450 Break that down for us. The standard formula 00:11:38.450 --> 00:11:41.029 is 2 milliliters of lactate in ringers multiplied 00:11:41.029 --> 00:11:43.370 by the patient's weight in kilograms multiplied 00:11:43.370 --> 00:11:45.629 by the TBSA percentage. Let's do a hypothetical. 00:11:45.870 --> 00:11:48.870 A 100 kilogram patient with a 50 % total body 00:11:48.870 --> 00:11:51.529 surface area burn. Okay, so 2 milliliter times 00:11:51.529 --> 00:11:55.049 100 kilograms is 200 times 50 % TBSA gives you 00:11:55.049 --> 00:11:57.629 10 ,000 milliliters. 10 liters. That is their 00:11:57.629 --> 00:12:00.190 fluid requirement for the first 24 hours. 10 00:12:00.190 --> 00:12:02.559 liters. But I don't just set the pump to run 00:12:02.559 --> 00:12:04.919 evenly over 24 hours, right? No, absolutely not, 00:12:05.000 --> 00:12:07.440 because the capillary leak is most severe immediately 00:12:07.440 --> 00:12:10.519 after the injury. You must administer half of 00:12:10.519 --> 00:12:13.500 that massive total volume, five liters, in this 00:12:13.500 --> 00:12:15.639 case, in the first eight hours post -injury. 00:12:16.000 --> 00:12:17.639 The remaining five liters are given over the 00:12:17.639 --> 00:12:21.000 subsequent 16 hours. Here is a terrifying clinical 00:12:21.000 --> 00:12:22.820 pitfall that I really want to highlight, something 00:12:22.820 --> 00:12:25.740 that catches new nurses off guard. We have this 00:12:25.740 --> 00:12:28.059 patient, they might be in agony from second degree 00:12:28.059 --> 00:12:30.360 burns. We need to give them pain medication. 00:12:31.100 --> 00:12:34.519 The source material is adamant. Intravenous opioids 00:12:34.519 --> 00:12:37.820 only. Morphine, hydromorphone, fentanyl, push 00:12:37.820 --> 00:12:41.779 5E. Why is it a lethal trap to give an intramuscular 00:12:41.779 --> 00:12:44.519 or subcutaneous injection to a major burn patient 00:12:44.519 --> 00:12:47.139 right now? Connect this back to the pathophysiology 00:12:47.139 --> 00:12:49.159 we just discussed. The tissues are massively 00:12:49.159 --> 00:12:51.960 swollen, third space with fluid. The blood vessels 00:12:51.960 --> 00:12:54.340 are clamped down, so perfusion to the muscle 00:12:54.340 --> 00:12:57.039 and subcutaneous tissue is virtually non -existent. 00:12:57.159 --> 00:12:59.440 So if I inject morphine into their deltoid muscle? 00:12:59.620 --> 00:13:01.700 It just sits there. It pools in the adimidus 00:13:01.700 --> 00:13:03.860 tissue and is not absorbed into the bloodstream. 00:13:04.090 --> 00:13:06.809 Right. So the patient stays in excruciating pain. 00:13:07.870 --> 00:13:09.950 So an inexperienced clinician might look at the 00:13:09.950 --> 00:13:12.809 writhing patient and think, ah, the dose wasn't 00:13:12.809 --> 00:13:16.009 high enough and give another IM injection and 00:13:16.009 --> 00:13:18.509 maybe a third. And the patient still hurts. But 00:13:18.509 --> 00:13:20.509 what happens three days later when the capillaries 00:13:20.509 --> 00:13:23.409 heal? The fluid shifts back and blood flow returns 00:13:23.409 --> 00:13:25.789 to that muscle. The muscle is suddenly perfused 00:13:25.789 --> 00:13:29.370 and all three doses of that IM narcotic are absorbed 00:13:29.370 --> 00:13:31.730 into the systemic circulation simultaneously. 00:13:31.870 --> 00:13:34.629 The patient suffers a massive iatrogenic overdose. 00:13:34.789 --> 00:13:37.809 Exactly and goes into respiratory arrest. That 00:13:37.809 --> 00:13:40.929 depo effect is why in the emergent phase it is 00:13:40.929 --> 00:13:44.019 the IV route only. You need immediate guaranteed 00:13:44.019 --> 00:13:46.740 delivery into the vascular space. That is brilliant 00:13:46.740 --> 00:13:48.740 and terrifying. Let's talk about another trap. 00:13:49.059 --> 00:13:51.700 The urine output is low. The patient is oliguric. 00:13:51.899 --> 00:13:54.200 As clinicians, our reflex is often, oh, they 00:13:54.200 --> 00:13:56.340 aren't peeing. I should push a diuretic like 00:13:56.340 --> 00:13:59.120 furosemide to force the kidneys to work. Never. 00:13:59.740 --> 00:14:02.039 Giving a diuretic for low urine output in the 00:14:02.039 --> 00:14:04.360 emergent burn phase is like pouring gasoline 00:14:04.360 --> 00:14:07.149 on a fire. because their intravascular tank is 00:14:07.149 --> 00:14:10.750 completely empty. Exactly. Low urine output here 00:14:10.750 --> 00:14:13.470 is not a kidney problem, it is a perfusion problem. 00:14:14.070 --> 00:14:15.809 The kidneys are working perfectly by holding 00:14:15.809 --> 00:14:17.950 on to water because there is no volume in the 00:14:17.950 --> 00:14:20.250 pipes. Right. If you force them to diaries, you 00:14:20.250 --> 00:14:22.669 will completely empty the vascular space and 00:14:22.669 --> 00:14:25.070 the patient will code. They need more fluid, 00:14:25.470 --> 00:14:27.929 not a drug that wastes it. Is there ever an exception 00:14:27.929 --> 00:14:30.570 to that rule? The only exception is for severe 00:14:30.570 --> 00:14:33.850 electrical burns. In an electrical burn, massive 00:14:33.850 --> 00:14:35.789 amounts of muscle are destroyed under the skin, 00:14:36.169 --> 00:14:38.470 releasing a protein called myoglobin into the 00:14:38.470 --> 00:14:41.009 blood. And that's bad for the kidneys. Very bad. 00:14:41.549 --> 00:14:43.590 Myoglobin is a large molecule that will clog 00:14:43.590 --> 00:14:46.009 the renal tubules and cause acute kidney failure. 00:14:46.690 --> 00:14:49.190 In that specific scenario, we increase our IV 00:14:49.190 --> 00:14:51.730 fluids aggressively to target a much higher urine 00:14:51.730 --> 00:14:56.429 output, 75 to 100 mL per hour. And we might administer 00:14:56.429 --> 00:14:58.929 an osmotic diuretic like mannitol to flush that 00:14:58.929 --> 00:15:01.250 heavy sludge out of the kidneys. Speaking of 00:15:01.250 --> 00:15:03.610 electrical burns, let's talk about differential 00:15:03.610 --> 00:15:07.049 diagnosis and pattern recognition. If I'm assessing 00:15:07.049 --> 00:15:10.629 a patient and I see like a small charred entrance 00:15:10.629 --> 00:15:12.950 wound on their hand and an exit wound on their 00:15:12.950 --> 00:15:16.049 foot, but they're complaining of deep agonizing 00:15:16.049 --> 00:15:19.730 muscle pain and their urine looks like dark tea. 00:15:20.049 --> 00:15:22.919 You must immediately think electrical burn. We 00:15:22.919 --> 00:15:25.019 call this the iceberg effect. The visible skin 00:15:25.019 --> 00:15:27.740 damage looks incredibly minor, almost deceptively 00:15:27.740 --> 00:15:30.340 so, but electricity follows the path of least 00:15:30.340 --> 00:15:33.299 resistance, blood vessels and nerves, and generates 00:15:33.299 --> 00:15:35.779 massive heat when it hits bone. It literally 00:15:35.779 --> 00:15:38.250 boils the muscle from the inside out. Wow. So 00:15:38.250 --> 00:15:41.250 that dark T urine is the myoglobin from the boiled 00:15:41.250 --> 00:15:43.870 muscle. Yes. And you must assume two other things 00:15:43.870 --> 00:15:46.789 immediately. First, a cervical spine injury because 00:15:46.789 --> 00:15:48.809 the electrical shock often violently throws the 00:15:48.809 --> 00:15:51.269 patient. Second, you must put them on a cardiac 00:15:51.269 --> 00:15:53.110 monitor immediately because the electrical current 00:15:53.110 --> 00:15:55.029 disrupts the heart's conduction system. They're 00:15:55.029 --> 00:15:57.789 at high risk for VFib. Incredibly high risk for 00:15:57.789 --> 00:16:00.009 sudden ventricular fibrillation. Let's touch 00:16:00.009 --> 00:16:03.159 on bedside procedures. Tetanus toxoid is a standard 00:16:03.159 --> 00:16:05.740 injection because the skin's barrier to environmental 00:16:05.740 --> 00:16:09.120 bacteria is gone. But tell me about the physical 00:16:09.120 --> 00:16:11.500 mechanics of an escharotomy. What is actually 00:16:11.500 --> 00:16:14.120 happening there? So when you have a full thickness 00:16:14.120 --> 00:16:17.379 third degree burn, the burn tissue, the escharophyll, 00:16:17.480 --> 00:16:21.200 turns into stiff leathery armor. It loses all 00:16:21.200 --> 00:16:23.679 of its elasticity. Now imagine that leathery 00:16:23.679 --> 00:16:25.960 armor completely circling a patient's arm or 00:16:25.960 --> 00:16:28.820 leg, a circumferential burn. And the fluid is 00:16:28.820 --> 00:16:30.639 leaking into the tissue underneath that armor. 00:16:30.840 --> 00:16:33.220 Exactly. As the edema builds up in the muscle 00:16:33.220 --> 00:16:35.360 compartments underneath, the escher refuses to 00:16:35.360 --> 00:16:37.299 stretch. The pressure builds inward. It acts 00:16:37.299 --> 00:16:39.399 like a literal tourniquet, eventually clamping 00:16:39.399 --> 00:16:41.039 shut the arteries, supplying the hand or the 00:16:41.039 --> 00:16:43.580 foot. If you don't relieve that pressure, the 00:16:43.580 --> 00:16:45.620 limb will die. So what does the clinician do? 00:16:46.000 --> 00:16:48.320 An escherotomy. It's a bedside surgical procedure. 00:16:48.639 --> 00:16:51.740 The physician takes a scalpel and slices lengthwise 00:16:51.740 --> 00:16:53.700 completely through that leathery escher down 00:16:53.700 --> 00:16:56.080 to the subcutaneous fat. Just slices it open. 00:16:56.419 --> 00:16:59.000 Yeah. And you literally watch the tissue instantly 00:16:59.000 --> 00:17:01.639 spring open and separate by inches as the internal 00:17:01.639 --> 00:17:03.980 pressure is released and blood flow is restored 00:17:03.980 --> 00:17:06.460 to the distal limb. They also do this on the 00:17:06.460 --> 00:17:09.180 torso if a circumferential chest burn is acting 00:17:09.180 --> 00:17:11.420 like a straitjacket, physically preventing the 00:17:11.420 --> 00:17:14.099 patient's lungs from expanding. How are we monitoring 00:17:14.099 --> 00:17:16.440 their hemodynamics through all this? Our goal 00:17:16.440 --> 00:17:19.460 is a mean arterial pressure of MAP greater than 00:17:19.460 --> 00:17:22.460 65, but the source text notes we should rely 00:17:22.460 --> 00:17:25.279 on arterial lines and completely ignore manual 00:17:25.279 --> 00:17:28.039 blood pressure cuffs. Why? Think about the physical 00:17:28.039 --> 00:17:31.000 state of the patient's arm. It is massively swollen 00:17:31.000 --> 00:17:33.759 with liters of third space fluid, and the vessels 00:17:33.759 --> 00:17:36.369 underneath are intensely vasoconstricted. If 00:17:36.369 --> 00:17:38.430 you wrap a standard blood pressure cuff around 00:17:38.430 --> 00:17:40.950 inches of edema and squeeze... It's just squishing 00:17:40.950 --> 00:17:43.210 water. Right. The pressure reading the machine 00:17:43.210 --> 00:17:46.369 gives you will be completely falsely low or invalid. 00:17:46.710 --> 00:17:48.849 You cannot titrate life -saving fluids based 00:17:48.849 --> 00:17:52.430 on a lie. You need the direct, continuous, invasive 00:17:52.430 --> 00:17:55.130 measurement of an arterial line sitting directly 00:17:55.130 --> 00:17:57.950 inside the radial or femoral artery. Okay, deterioration. 00:17:57.970 --> 00:17:59.789 I'm at the bedside. The patient is getting worse, 00:17:59.809 --> 00:18:02.920 if what? The patient is getting worse. If their 00:18:02.920 --> 00:18:06.400 urine output plummets below that 0 .5 millimolar 00:18:06.400 --> 00:18:09.539 per kilogram per hour threshold, despite the 00:18:09.539 --> 00:18:11.859 formula fluids running, they are worsening if 00:18:11.859 --> 00:18:15.380 the MAP falls below 65. And critically, they're 00:18:15.380 --> 00:18:18.039 deteriorating if the hematocrit continues rising 00:18:18.039 --> 00:18:21.019 on sequential lab draws. Because a rising hematocrit 00:18:21.019 --> 00:18:23.140 means your IV fluids are just leaking out into 00:18:23.140 --> 00:18:25.920 the tissues as fast as you put them in. The capillary 00:18:25.920 --> 00:18:28.180 leak is uncorrected and the hemoconcentration 00:18:28.180 --> 00:18:30.740 is getting deadlier. Exactly. And how do I handle 00:18:30.740 --> 00:18:33.380 escalation? Like when am I just notifying the 00:18:33.380 --> 00:18:36.279 provider versus calling an immediate rapid response? 00:18:36.519 --> 00:18:38.900 You notify the provider if the urine output is 00:18:38.900 --> 00:18:41.059 trending down or the MAP is borderline so you 00:18:41.059 --> 00:18:43.559 can get orders to titrate the IV fluids up. You 00:18:43.559 --> 00:18:45.579 call a rapid response or immediately alert the 00:18:45.579 --> 00:18:47.559 trauma surgeon if you lose a Doppler pulse in 00:18:47.559 --> 00:18:50.140 an extremity or if the limb becomes cold and 00:18:50.140 --> 00:18:52.160 pale. Because that means they need an escharotomy 00:18:52.160 --> 00:18:54.279 right now. Yes, that is an absolute emergency. 00:18:54.539 --> 00:18:56.519 So synthesizing this into how an intensivist 00:18:56.519 --> 00:18:59.119 thinks, the core problem is the capillary leak. 00:18:59.599 --> 00:19:02.039 The failing physiology is severe intravascular 00:19:02.039 --> 00:19:04.900 depletion. The immediate threat to life is burn 00:19:04.900 --> 00:19:08.859 shock and acute kidney injury. The intervention 00:19:08.859 --> 00:19:11.839 is aggressive lactated ringers via the ABA formula. 00:19:12.660 --> 00:19:15.660 And the ultimate reassessment tool is hourly 00:19:15.660 --> 00:19:18.519 urine output. That is the exact mental model 00:19:18.519 --> 00:19:20.240 you need to bring to the bedside. So if I'm stepping 00:19:20.240 --> 00:19:22.319 away from the bed after surviving those first 00:19:22.319 --> 00:19:24.980 few hours, I'm burning these five core concepts 00:19:24.980 --> 00:19:28.839 into my brain. Number one, the pathology is a 00:19:28.839 --> 00:19:31.380 massive fluid shift causing hemoconcentration. 00:19:31.539 --> 00:19:34.619 Two, my bedside assessment is looking for oliguria 00:19:34.619 --> 00:19:37.940 and unbelievable edema. Three, the enemy I'm 00:19:37.940 --> 00:19:40.359 fighting is hypovolemic and distributive shock. 00:19:40.559 --> 00:19:43.700 Perfect. Four, my absolute priority action are 00:19:43.700 --> 00:19:46.440 getting those large bore IVs and that Foley catheter 00:19:46.440 --> 00:19:49.950 secured. And five, My weapon is the ABA fluid 00:19:49.950 --> 00:19:51.970 formula tailored strictly to what the kidneys 00:19:51.970 --> 00:19:54.190 are telling me. To put it in a single clinical 00:19:54.190 --> 00:19:57.089 picture, you are managing an incredibly edematous 00:19:57.089 --> 00:20:00.190 tachycardic patient requiring leaders of precise 00:20:00.190 --> 00:20:02.630 fluid administration just to maintain enough 00:20:02.630 --> 00:20:04.930 vascular volume to keep their organs alive. If 00:20:04.930 --> 00:20:07.670 you see low urine output and a high hematocrit 00:20:07.670 --> 00:20:09.990 in the first 24 hours you think under resuscitation 00:20:09.990 --> 00:20:12.509 and you advocate to titrate those IV fluids up 00:20:12.509 --> 00:20:14.490 immediately. Fluids will save their kidneys and 00:20:14.490 --> 00:20:16.559 their heart. But what if they can't breathe? 00:20:17.039 --> 00:20:19.380 The fortified city has its water back, but there 00:20:19.380 --> 00:20:22.559 is toxic smoke in the ventilation system. Which 00:20:22.559 --> 00:20:25.880 brings us to the hidden killer. Inhalation injury. 00:20:26.160 --> 00:20:28.319 Yeah, this is huge. And I have to say, it is 00:20:28.319 --> 00:20:30.319 absolutely terrifying to me that a patient might 00:20:30.319 --> 00:20:32.740 look totally fine on a pulse oximeter. They're, 00:20:32.740 --> 00:20:34.359 you know, sitting on the stretcher talking to 00:20:34.359 --> 00:20:37.119 you. And then an hour later, their airway completely 00:20:37.119 --> 00:20:40.160 swells shut and they code. Why is the pulse ox 00:20:40.160 --> 00:20:42.900 lying to us? This is one of the most vital concepts 00:20:42.900 --> 00:20:46.309 in critical care. Inhalation injury is the leading 00:20:46.309 --> 00:20:49.150 cause of death in burn patients and the standard 00:20:49.150 --> 00:20:51.910 pulse oximeter is lying to you because it was 00:20:51.910 --> 00:20:54.990 never designed to detect toxic gases. It's a 00:20:54.990 --> 00:20:57.130 fundamental limitation of the technology. Let's 00:20:57.130 --> 00:20:58.930 trace the path of physiology from the trigger. 00:20:59.269 --> 00:21:01.029 A patient is pulled from a burning building. 00:21:01.069 --> 00:21:03.309 The trigger is the inhalation of intense heat, 00:21:03.730 --> 00:21:06.569 smoke, or noxious chemicals almost always in 00:21:06.569 --> 00:21:09.410 an enclosed space. This creates three distinct 00:21:09.410 --> 00:21:12.430 zones of injury. First, above the glottis, the 00:21:12.430 --> 00:21:15.029 upper airway. This is a thermal injury. Just 00:21:15.029 --> 00:21:17.170 raw heat. Right, the direct heat scorches the 00:21:17.170 --> 00:21:19.789 vocal cords and the surrounding mucosa, triggering 00:21:19.789 --> 00:21:23.650 massive rapid edema. Second, below the glottis, 00:21:23.730 --> 00:21:26.690 the lower airway. The heat usually cools before 00:21:26.690 --> 00:21:28.809 it reaches the lungs, but the toxic chemical 00:21:28.809 --> 00:21:31.529 particles in the smoke cause a severe chemical 00:21:31.529 --> 00:21:35.140 immunitis. And the third zone is systemic. Yes, 00:21:35.680 --> 00:21:37.960 exposure to toxic gases, specifically carbon 00:21:37.960 --> 00:21:41.700 monoxide or CO. This is where the deception happens. 00:21:42.019 --> 00:21:44.059 Walk us through the biochemistry of carbon monoxide 00:21:44.059 --> 00:21:46.900 because this explains the lying pulse ox. Carbon 00:21:46.900 --> 00:21:50.039 monoxide binds to the exact same spot on the 00:21:50.039 --> 00:21:53.019 hemoglobin molecule that oxygen does. But carbon 00:21:53.019 --> 00:21:56.049 monoxide has about 200 times the affinity for 00:21:56.049 --> 00:21:58.450 hemoglobin than oxygen. It's like a bully taking 00:21:58.450 --> 00:22:00.430 the seat on the bus, and it refuses to get up. 00:22:00.609 --> 00:22:03.130 Exactly. It hijacks the red blood cell. So the 00:22:03.130 --> 00:22:05.190 oxygen literally cannot get on the transport. 00:22:05.349 --> 00:22:07.289 The patient is suffocating at the cellular level. 00:22:07.730 --> 00:22:10.250 But a standard spio -2 monitor on the patient's 00:22:10.250 --> 00:22:13.390 finger just shines a red and infrared light through 00:22:13.390 --> 00:22:15.349 the tissue to see if something is bound to the 00:22:15.349 --> 00:22:16.950 hemoglobin. So it can't tell the difference? 00:22:17.170 --> 00:22:19.470 No. It cannot distinguish between oxyhemoglobin, 00:22:19.529 --> 00:22:21.930 which gives life, and carboxyhemoglobin, which 00:22:21.930 --> 00:22:25.500 causes death. So the monitor reads 99 % or 100 00:22:25.500 --> 00:22:28.319 % saturation. The nurse thinks the patient is 00:22:28.319 --> 00:22:30.039 oxygenating beautifully, but their brain and 00:22:30.039 --> 00:22:32.039 heart are actually starving for oxygen. It is 00:22:32.039 --> 00:22:34.539 chilling, and it happens all the time. The body's 00:22:34.539 --> 00:22:36.880 compensation for this cellular suffocation is 00:22:36.880 --> 00:22:39.039 dechipnia. The patient starts breathing faster 00:22:39.039 --> 00:22:41.420 and faster to try and pull in more oxygen. Which 00:22:41.420 --> 00:22:43.579 doesn't work. No, because the decompensation 00:22:43.579 --> 00:22:46.859 is inevitable. Complete airway obstruction from 00:22:46.859 --> 00:22:50.319 the heat edema and profound tissue hypoxia from 00:22:50.319 --> 00:22:53.400 the carbon monoxide. all despite that perfect 00:22:53.400 --> 00:22:56.839 PO2 reading and even a normal PO2 on a standard 00:22:56.839 --> 00:23:00.319 arterial blood gas. Because the PO2 just measures 00:23:00.319 --> 00:23:02.599 the oxygen dissolved in the plasma, not what 00:23:02.599 --> 00:23:04.799 is actually bound to the hemoglobin and delivered 00:23:04.799 --> 00:23:07.119 to the tissues? Yep. Okay, so how do we catch 00:23:07.119 --> 00:23:08.920 this during our assessment? What are the early 00:23:08.920 --> 00:23:11.799 clues? You must act like a detective. Was this 00:23:11.799 --> 00:23:13.640 an enclosed space fire? Look at their face. Do 00:23:13.640 --> 00:23:15.940 they have singed eyebrows or nasal hair? Are 00:23:15.940 --> 00:23:18.859 their oral or nasal membranes darkened or blistered? 00:23:18.880 --> 00:23:20.799 Are they coughing? And what are the classic findings 00:23:20.799 --> 00:23:23.519 that confirm it? Carbonaceous sputum. If they 00:23:23.519 --> 00:23:26.720 are coughing up sooty, black, or gray spit, they 00:23:26.720 --> 00:23:29.650 have inhaled smoke deep into their lungs. And 00:23:29.650 --> 00:23:32.589 the other classic finding is agitation. I cannot 00:23:32.589 --> 00:23:34.789 stress this enough to new ICU nurses. No, this 00:23:34.789 --> 00:23:37.130 is important. If a burn patient is restless, 00:23:37.569 --> 00:23:39.849 anxious, picking at their lines, or combative, 00:23:40.309 --> 00:23:42.190 do not assume they're just in pain or scared. 00:23:42.490 --> 00:23:45.049 Agitation equals hypoxia until proven otherwise. 00:23:45.369 --> 00:23:48.269 Always. The brain is starving for oxygen, and 00:23:48.269 --> 00:23:50.829 it manifests as severe anxiety and combativeness. 00:23:51.069 --> 00:23:53.650 What are the late dangerous findings, the red 00:23:53.650 --> 00:23:56.150 flags that mean the airway is actively shutting 00:23:56.150 --> 00:23:59.000 down? Extreme hoarseness. If you're talking to 00:23:59.000 --> 00:24:01.319 the patient and their voice starts getting raspy 00:24:01.319 --> 00:24:04.119 or whispery, the vocal cords are swelling shut, 00:24:04.559 --> 00:24:06.500 difficulty swallowing, and the most terrifying 00:24:06.500 --> 00:24:09.240 sound in the burn unit, stridor. That high -pitched 00:24:09.240 --> 00:24:11.500 sound? Right, that harsh, crowing sound when 00:24:11.500 --> 00:24:14.259 they inhale. That means the airway is a millimeter 00:24:14.259 --> 00:24:16.500 away from complete occlusion. Oh, and you might 00:24:16.500 --> 00:24:18.519 hear old textbooks talk about cherry red skin 00:24:18.519 --> 00:24:20.700 for carbon monoxide poisoning. Right, I've heard 00:24:20.700 --> 00:24:24.279 that. Erase it from your mind. It is an exceptionally 00:24:24.279 --> 00:24:27.559 late autopsy -level sign. It's very rare in living 00:24:27.559 --> 00:24:30.019 patients. Do not wait to see cherry red skin 00:24:30.019 --> 00:24:33.039 before you treat for CO poisoning. So, for diagnostics, 00:24:33.140 --> 00:24:35.460 if we throw out the standard pulse ox, what do 00:24:35.460 --> 00:24:37.759 we actually use to detect the carbon monoxide? 00:24:38.039 --> 00:24:40.339 High -yield diagnostics require a direct blood 00:24:40.339 --> 00:24:44.019 draw for a carboxyhemoglobin level. At the bedside, 00:24:44.240 --> 00:24:47.079 pre -hospital teams and some ICUs use a pulse 00:24:47.079 --> 00:24:50.180 co -oximeter, an SBCO device. It uses multiple 00:24:50.180 --> 00:24:52.059 wavelengths of light to specifically identify 00:24:52.059 --> 00:24:54.160 the carbon monoxide molecule. And for the lower 00:24:54.160 --> 00:24:56.750 airway? For diagnosing the severity of the lower 00:24:56.750 --> 00:24:59.210 airway chemical burn, the gold standard is a 00:24:59.210 --> 00:25:01.849 fiber optic bronchoscopy, where a camera is driven 00:25:01.849 --> 00:25:04.650 down into the lungs. So my assessment has recognized 00:25:04.650 --> 00:25:06.910 the enclosed space fire and the singed facial 00:25:06.910 --> 00:25:09.769 hair. My nursing diagnoses are ineffective airway 00:25:09.769 --> 00:25:12.289 clearance and impaired gas exchange. My plan 00:25:12.289 --> 00:25:14.430 is to maintain a patent airway and flush out 00:25:14.430 --> 00:25:17.490 the carbon monoxide. What is my very first immediate 00:25:17.490 --> 00:25:21.349 nursing action? First priority, apply 100 % humidified 00:25:21.349 --> 00:25:24.049 oxygen via a non -rebreather mask at 15 liters 00:25:24.049 --> 00:25:27.059 per minute. Oxygen is the ultimate literal antidote 00:25:27.059 --> 00:25:28.940 for carbon monoxide poisoning. How does that 00:25:28.940 --> 00:25:32.460 work? By flooding the alveoli with 100 % oxygen, 00:25:33.079 --> 00:25:35.759 you create a massive concentration gradient that 00:25:35.759 --> 00:25:38.319 physically forces the carbon monoxide off the 00:25:38.319 --> 00:25:41.200 hemoglobin, dramatically reducing its half -life 00:25:41.200 --> 00:25:44.220 in the body. And my next priority? You anticipate 00:25:44.220 --> 00:25:47.380 immediate prophylactic endotracheal intubation. 00:25:47.740 --> 00:25:50.559 We're talking within the first one to two hours 00:25:50.559 --> 00:25:54.220 for patients with severe facial burns or respiratory 00:25:54.220 --> 00:25:57.660 distress. Prophylactic, meaning we intubate them 00:25:57.660 --> 00:25:59.480 even if they're still breathing on their own 00:25:59.480 --> 00:26:02.220 and protecting their airway. Why? Because of 00:26:02.220 --> 00:26:05.099 the edema trajectory. That heat injury above 00:26:05.099 --> 00:26:07.519 the glottis is going to swell relentlessly over 00:26:07.519 --> 00:26:09.920 the next several hours. If you wait until the 00:26:09.920 --> 00:26:12.279 patient is in severe stridor to decide they need 00:26:12.279 --> 00:26:15.039 a tube. It's too late. Way too late. The vocal 00:26:15.039 --> 00:26:17.420 cords will be completely obliterated by swelling. 00:26:17.940 --> 00:26:19.500 The physician won't be able to see the opening. 00:26:19.680 --> 00:26:21.380 The tube won't pass. The patient will arrest 00:26:21.380 --> 00:26:23.579 and you'll be forced into a bloody desperate 00:26:23.579 --> 00:26:26.359 emergency cricothyrotomy through the neck. You 00:26:26.359 --> 00:26:28.920 intubate early while the anatomy is still recognizable 00:26:28.920 --> 00:26:31.480 to secure the passage before the door swells 00:26:31.480 --> 00:26:33.500 shut. Okay then, I elevate the head of the bed 00:26:33.500 --> 00:26:35.740 to high foulers to use gravity to help reduce 00:26:35.740 --> 00:26:39.160 facial and airway edema, and I send my ABGs and 00:26:39.160 --> 00:26:42.220 carboxyhemoglobin levels. What other medications 00:26:42.220 --> 00:26:44.799 might we be pushing here? The respiratory therapists 00:26:44.799 --> 00:26:47.859 are crucial here. They may administer aerosolized 00:26:47.859 --> 00:26:51.720 heparin and anacetylcysteine or mucomist. What 00:26:51.720 --> 00:26:53.980 do those do? Well, the chemical pneumonitis causes 00:26:53.980 --> 00:26:56.680 the lung lining to slough off, creating thick, 00:26:56.940 --> 00:26:59.519 bloody, fibrin casts that can physically flood 00:26:59.519 --> 00:27:02.539 the airways. The heparin and mucomist help break 00:27:02.539 --> 00:27:04.720 down those casts so they can be suctioned out. 00:27:05.180 --> 00:27:07.619 We also use bronchodilators like albuterol to 00:27:07.619 --> 00:27:10.339 treat the reactive bronchospasm. Let's loop back 00:27:10.339 --> 00:27:12.880 to hemodynamics and fluids for a second. We're 00:27:12.880 --> 00:27:15.079 pumping this patient full of lactated ringers 00:27:15.079 --> 00:27:18.059 for their burn shock, but they also have damaged 00:27:18.059 --> 00:27:20.680 weeping lungs. That sounds like a catastrophic 00:27:20.680 --> 00:27:23.740 intersection. It's a razor -thin tightrope. You 00:27:23.740 --> 00:27:25.940 have to resuscitate them to save the kidneys 00:27:25.940 --> 00:27:28.500 and reverse the burn shock. But if you give even 00:27:28.500 --> 00:27:30.680 a little bit too much fluid, it'll third space 00:27:30.680 --> 00:27:33.440 directly into those damaged lungs, causing profound 00:27:33.440 --> 00:27:35.839 pulmonary edema and worsening the respiratory 00:27:35.839 --> 00:27:38.420 failure. You're balancing kidney survival against 00:27:38.420 --> 00:27:41.720 lung survival hour by hour. What is the most 00:27:41.720 --> 00:27:44.200 dangerous complication for patients who survive 00:27:44.200 --> 00:27:47.619 the initial smoke inhalation? Pneumonia. The 00:27:47.619 --> 00:27:50.099 cause is that sloughing of dead respiratory tissue 00:27:50.099 --> 00:27:52.839 and the loss of the mucociliary escalator. The 00:27:52.839 --> 00:27:54.720 little hairs that sweep bacteria out of our lungs 00:27:54.720 --> 00:27:56.519 are burned away. And the finding? The finding 00:27:56.519 --> 00:27:59.799 is worsening oxygenation, new fever, and purulent 00:27:59.799 --> 00:28:02.339 secretions. The action is aggressive pulmonary 00:28:02.339 --> 00:28:05.099 hygiene, frequent suctioning, turning, and precise 00:28:05.099 --> 00:28:07.579 mechanical ventilation. Pneumonia is the leading 00:28:07.579 --> 00:28:09.640 cause of death for inhalation injuries in the 00:28:09.640 --> 00:28:12.690 ICU. Deterioration. The patient is getting worse 00:28:12.690 --> 00:28:15.109 if... If their restlessness and anxiety increase, 00:28:15.430 --> 00:28:17.269 if that hoarseness starts turning into stridor, 00:28:17.829 --> 00:28:20.509 or if their respirations become shallow and rapid, 00:28:21.049 --> 00:28:23.650 signaling respiratory muscle fatigue. Escalation 00:28:23.650 --> 00:28:27.549 is incredibly clear here. Stridor, or rapidly 00:28:27.549 --> 00:28:30.490 worsening hoarseness, requires an immediate rapid 00:28:30.490 --> 00:28:34.480 response and a stat intubation. You do not wait 00:28:34.480 --> 00:28:36.339 for the provider to finish their rounds. You 00:28:36.339 --> 00:28:38.940 call for the airway team immediately. Exactly. 00:28:39.119 --> 00:28:41.519 So pattern recognition. If I see an enclosed 00:28:41.519 --> 00:28:44.779 spacefire, plus confusion, plus a perfectly normal 00:28:44.779 --> 00:28:47.819 SpO2, I am thinking carbon monoxide poisoning. 00:28:47.920 --> 00:28:50.700 And you avoid the deadly traps, assuming combative 00:28:50.700 --> 00:28:53.680 patients are just in pain, and trusting a 99 00:28:53.680 --> 00:28:56.799 % SpO2 reading from a house fire victim. Thinking 00:28:56.799 --> 00:28:58.900 like an intensivist for the airway, the core 00:28:58.900 --> 00:29:01.539 problem is airway heat exposure. The failing 00:29:01.539 --> 00:29:04.319 physiology is progressive glottic edema. The 00:29:04.319 --> 00:29:06.799 ultimate threat is complete airway occlusion. 00:29:06.839 --> 00:29:09.380 Right. The necessary intervention is prophylactic 00:29:09.380 --> 00:29:11.940 early intubation. And the reassessment is continuous 00:29:11.940 --> 00:29:14.839 capnography, watching the end -tidal CO2, and 00:29:14.839 --> 00:29:17.299 drawing ABGs to ensure we're actually ventilating 00:29:17.299 --> 00:29:19.400 and oxygenating the patient. That is how you 00:29:19.400 --> 00:29:21.640 protect the airway in the brain. If I'm locking 00:29:21.640 --> 00:29:24.440 in my five takeaways for inhalation injury, one, 00:29:24.880 --> 00:29:27.420 the pathology is massive heat swelling and carbon 00:29:27.420 --> 00:29:30.880 monoxide hijacking the blood. Two, my assessment 00:29:30.880 --> 00:29:33.480 is looking for soot, hoarseness, and unexplained 00:29:33.480 --> 00:29:37.359 agitation. Three, the complication I'm terrified 00:29:37.359 --> 00:29:41.619 of is a total airway obstruction. Four, my absolute 00:29:41.619 --> 00:29:44.759 priority action is throwing on that 100 % non 00:29:44.759 --> 00:29:48.289 -rebreather mask. And five, The definitive treatment 00:29:48.289 --> 00:29:50.650 is getting the endotracheal tube secured before 00:29:50.650 --> 00:29:53.190 the swelling peaks. Your clinical picture is 00:29:53.190 --> 00:29:56.170 this. A soot -covered patient with singed facial 00:29:56.170 --> 00:29:58.769 hair who is becoming increasingly restless and 00:29:58.769 --> 00:30:01.410 tech -chipnaic despite a monitor showing a perfect 00:30:01.410 --> 00:30:04.069 oxygen saturation. If you see increasing hoarseness 00:30:04.069 --> 00:30:06.289 in Strider, think impending airway loss and do 00:30:06.289 --> 00:30:09.230 call for STAT intubation. Okay. So we've aggressively 00:30:09.230 --> 00:30:11.049 resuscitated them with fluids, we saved their 00:30:11.049 --> 00:30:12.910 kidneys, we caught the carbon monoxide, and we've 00:30:12.910 --> 00:30:15.299 secured their airway with a breathing tube. They 00:30:15.299 --> 00:30:18.019 survive the first 72 hours. The fluid is finally 00:30:18.019 --> 00:30:19.819 starting to shift back into the blood vessels. 00:30:20.279 --> 00:30:22.119 We're in the clear, right? Not even close. You've 00:30:22.119 --> 00:30:24.640 just survived the initial siege. Which brings 00:30:24.640 --> 00:30:27.940 us to the next massive challenge. The acute phase. 00:30:28.740 --> 00:30:31.880 Sepsis, healing, and hypermetabolism. If the 00:30:31.880 --> 00:30:34.240 city analogy holds, the walls are still destroyed, 00:30:34.579 --> 00:30:36.339 but now the scavengers are trying to get in and 00:30:36.339 --> 00:30:39.299 the city is starving. Why is sepsis the leading 00:30:39.299 --> 00:30:41.700 cause of death in this phase, and how does the 00:30:41.700 --> 00:30:44.319 body's own drive to heal become a double -edged 00:30:44.319 --> 00:30:47.140 sword? So the 80 -20 of the acute phase is this. 00:30:47.390 --> 00:30:50.789 It begins when the capillary leak seals and the 00:30:50.789 --> 00:30:53.150 fluid starts to mobilize back into the vascular 00:30:53.150 --> 00:30:55.450 space. You'll see this clinically as a massive 00:30:55.450 --> 00:30:58.269 diuresis. Their urine output will suddenly jump. 00:30:58.450 --> 00:31:00.910 Like they start peeing out all that fluid. Yes. 00:31:01.150 --> 00:31:03.250 This phase lasts for weeks or months until the 00:31:03.250 --> 00:31:05.069 burn wounds are completely closed by healing 00:31:05.069 --> 00:31:07.809 or surgical grafting. And the absolute must -know 00:31:07.809 --> 00:31:10.849 facts are that infection and sepsis are now your 00:31:10.849 --> 00:31:13.269 greatest enemies. Right. The massive hypermetabolic 00:31:13.269 --> 00:31:16.309 drive demands immense early aggressive nutrition. 00:31:16.430 --> 00:31:19.009 Surgical excision and grafting are the definitive 00:31:19.009 --> 00:31:21.490 treatments. And as the nurse, you have to fight 00:31:21.490 --> 00:31:24.289 against highly preventable devastating complications 00:31:24.289 --> 00:31:27.049 like curlings, ulcers, and joint contractures. 00:31:27.369 --> 00:31:30.150 Let's check the pathophysiology here. The trigger 00:31:30.150 --> 00:31:33.690 is the prolonged massive loss of the skin barrier 00:31:33.690 --> 00:31:36.589 combined with profound systemic immune depression 00:31:36.589 --> 00:31:39.769 from the trauma. What is the physiologic change 00:31:39.769 --> 00:31:41.970 happening in the body? Because the physical barrier 00:31:41.970 --> 00:31:44.829 is gone, the burn wound inevitably becomes colonized 00:31:44.829 --> 00:31:47.470 by flora. And we aren't just talking about normal 00:31:47.470 --> 00:31:50.990 skin bacteria. Hospitals breed vicious multi 00:31:50.990 --> 00:31:53.829 -drug resistant gram negative bacteria like Pseudomonas 00:31:53.829 --> 00:31:56.549 aeruginosa, which thrives in moist burn tissue. 00:31:56.549 --> 00:31:59.750 Oh, nasty. Very. At the same time, the body is 00:31:59.750 --> 00:32:02.509 mounting a monumental stress response. It releases 00:32:02.509 --> 00:32:05.710 massive sustained levels of catecholamines epinephrine 00:32:05.710 --> 00:32:08.109 and norepinephrine and cortisol. And what does 00:32:08.109 --> 00:32:10.529 that chemical cocktail do to the patient's metabolism? 00:32:10.710 --> 00:32:12.990 It drives their resting metabolic expenditure 00:32:12.990 --> 00:32:15.589 through the roof, increasing it by 50 to 100 00:32:15.589 --> 00:32:18.369 percent above normal. Their core body temperature 00:32:18.369 --> 00:32:20.809 resets higher, constantly running a baseline 00:32:20.809 --> 00:32:23.230 fever. They're burning through calories at an 00:32:23.230 --> 00:32:26.099 astronomical rate just to exist. The body's compensation 00:32:26.099 --> 00:32:29.500 for this is massive gluconeogenesis, right? The 00:32:29.500 --> 00:32:33.140 liver is cranking out tons of glucose for energy 00:32:33.140 --> 00:32:36.200 and it starts cannibalizing the body's own protein. 00:32:36.500 --> 00:32:38.960 It's literally breaking down skeletal muscle 00:32:38.960 --> 00:32:41.720 to fuel the wound healing process. Yes. It will 00:32:41.720 --> 00:32:43.299 melt away in front of your eyes if you don't 00:32:43.299 --> 00:32:45.720 intervene. And the decompensation occurs when 00:32:45.720 --> 00:32:48.799 that localized wound colonization breaches the 00:32:48.799 --> 00:32:50.859 weakened immune defenses, and goes systemic. 00:32:50.980 --> 00:32:53.240 Gram -negative bacteremia. Which leads to sepsis, 00:32:53.319 --> 00:32:55.839 which rapidly plummets in deceptive shock, causing 00:32:55.839 --> 00:32:59.380 massive vasodilation. And finally, multiple organ 00:32:59.380 --> 00:33:02.220 dysfunction syndrome, or MODS. Let's talk about 00:33:02.220 --> 00:33:04.670 bedside assessment. Early on, I'm looking at 00:33:04.670 --> 00:33:06.430 the wound beds every time I change a dressing. 00:33:06.890 --> 00:33:08.990 I might see localized inflammation, induration, 00:33:09.210 --> 00:33:12.230 or redness at the margins. What are the classic 00:33:12.230 --> 00:33:15.369 systemic findings in this hypermetabolic acute 00:33:15.369 --> 00:33:17.869 phase? You'll see transient hyperglycemia. Their 00:33:17.869 --> 00:33:19.869 blood sugars will be high, often requiring an 00:33:19.869 --> 00:33:22.029 insulin drip. Not because they're diabetic, but 00:33:22.029 --> 00:33:24.470 purely because of the stress response and gluconeogenesis. 00:33:24.690 --> 00:33:26.950 You'll see high white blood cell counts. And 00:33:26.950 --> 00:33:29.660 you'll see that massive caloric demand. If they 00:33:29.660 --> 00:33:31.799 are underfed, you'll see profound weight loss 00:33:31.799 --> 00:33:34.579 and delayed wound healing because the body simply 00:33:34.579 --> 00:33:37.279 lacks the building blocks to create new tissue. 00:33:37.759 --> 00:33:40.500 What are the late, dangerous findings that scream, 00:33:40.720 --> 00:33:43.279 this patient is crossing the line from colonized 00:33:43.279 --> 00:33:45.940 to septic? This is a critical nuance for ICU 00:33:45.940 --> 00:33:50.200 nurses. Yes, a spiking high fever can mean sepsis. 00:33:50.599 --> 00:33:53.960 But hypothermia... A sudden unexpected drop in 00:33:53.960 --> 00:33:56.579 core body temperature is an exceptionally grave 00:33:56.579 --> 00:33:59.079 sign of late sepsis and complete immune exhaustion. 00:33:59.339 --> 00:34:01.920 Wow, so their body just stops. Their body literally 00:34:01.920 --> 00:34:04.019 gives up the fight. You'll also see their blood 00:34:04.019 --> 00:34:06.460 pressure dropping, requiring vasopressors, their 00:34:06.460 --> 00:34:08.300 urine output plummeting again as the kidneys 00:34:08.300 --> 00:34:11.159 take another hit, and new onset altered mentation. 00:34:11.440 --> 00:34:13.519 In older adults, sudden unexplained delirium 00:34:13.519 --> 00:34:15.940 is often the very first sign of a systemic infection. 00:34:16.219 --> 00:34:18.519 Diagnostics for the acute phase. We're watching 00:34:18.519 --> 00:34:21.780 the WBCs creep over 15 ,000 or 20 ,000. We're 00:34:21.780 --> 00:34:23.840 taking routine wound cultures, watching for that 00:34:23.840 --> 00:34:26.219 pseudomonas or even fungal infections like Candida 00:34:26.219 --> 00:34:29.360 taking over, daily blood glucose checks, and 00:34:29.360 --> 00:34:31.739 tracking albumin and prealbumin levels. Yes, 00:34:31.800 --> 00:34:34.199 prealbumin is highly sensitive. It gives you 00:34:34.199 --> 00:34:36.760 a real -time window into their nutritional status 00:34:36.760 --> 00:34:38.880 and whether your feeding regimen is actually 00:34:38.880 --> 00:34:42.059 working. My ADPIE framework here. Assessment 00:34:42.059 --> 00:34:44.739 means meticulously monitoring wound beds for 00:34:44.739 --> 00:34:47.250 purulence. tracking the core temperature and 00:34:47.250 --> 00:34:50.530 watching systemic perfusion. My nursing diagnoses 00:34:50.530 --> 00:34:53.369 are risk for infection and imbalanced nutrition, 00:34:53.969 --> 00:34:56.909 less than body requirements. My plan is to prevent 00:34:56.909 --> 00:34:59.570 sepsis and initiate enteral feeds immediately. 00:34:59.820 --> 00:35:02.019 And your implementation starts with the first 00:35:02.019 --> 00:35:04.619 priority nursing action, strict infection control. 00:35:04.719 --> 00:35:06.619 Right. You're not protecting yourself from the 00:35:06.619 --> 00:35:09.099 patient, you're protecting the immunosuppressed 00:35:09.099 --> 00:35:11.019 patient from the environment. That means strict 00:35:11.019 --> 00:35:14.000 use of disposable hats, masks, gowns, and gloves 00:35:14.000 --> 00:35:16.699 whenever those wounds are exposed. My next T 00:35:16.699 --> 00:35:19.820 priority is pain management. The source material 00:35:19.820 --> 00:35:21.639 makes a very specific distinction here that I 00:35:21.639 --> 00:35:24.789 want to explore. Background pain versus treatment 00:35:24.789 --> 00:35:27.590 -induced pain. It's a vital distinction. Background 00:35:27.590 --> 00:35:29.909 pain is the continuous, throbbing, relentless 00:35:29.909 --> 00:35:32.590 pain of the injury itself. This is managed by 00:35:32.590 --> 00:35:35.590 a steady baseline of 5E opioids, perhaps a PCA 00:35:35.590 --> 00:35:37.909 pump, and adjuvant medications like Gabentin 00:35:37.909 --> 00:35:40.730 for nerve pain. And the other kind. Treatment 00:35:40.730 --> 00:35:44.389 -induced pain is the agonizing, acute spike in 00:35:44.389 --> 00:35:46.989 pain caused by you, the nurse, doing dressing 00:35:46.989 --> 00:35:49.650 changes, scrubbing the wounds, and doing physical 00:35:49.650 --> 00:35:52.780 therapy. So the action is I must administer pain 00:35:52.780 --> 00:35:56.300 medications and often anxiolytics like lorazepam 00:35:56.300 --> 00:35:59.000 well before I begin that agonizing wound care. 00:35:59.679 --> 00:36:01.340 Absolutely. If you wait until you're pulling 00:36:01.340 --> 00:36:03.880 off bandages to give the medication, you have 00:36:03.880 --> 00:36:06.800 failed the patient. You pre -medicate, wait for 00:36:06.800 --> 00:36:09.579 peak effect, and then proceed. Then your next 00:36:09.579 --> 00:36:11.800 priority is assisting with early physical therapy 00:36:11.800 --> 00:36:14.750 and massive nutritional support. Let's talk medications. 00:36:15.030 --> 00:36:17.570 We're using topical antimicrobials like silver, 00:36:17.789 --> 00:36:20.210 sulfateazine cream directly on the burns, but 00:36:20.210 --> 00:36:21.969 there's a safety alert there. You must check 00:36:21.969 --> 00:36:24.710 for a sulfa allergy before applying it and monitor 00:36:24.710 --> 00:36:26.789 their white blood cell count as it can cause 00:36:26.789 --> 00:36:29.869 a transient leukopenia. We also give GI medications. 00:36:30.449 --> 00:36:33.670 Proton pump inhibitors like SMPrazol or H2 blockers. 00:36:33.829 --> 00:36:35.750 Why are we so worried about the stomach in a 00:36:35.750 --> 00:36:39.110 burn patient? To prevent a curling's ulcer. During 00:36:39.110 --> 00:36:41.570 that intense stress response, the body shunts 00:36:41.570 --> 00:36:43.710 blood away from the gastrointestinal tract to 00:36:43.710 --> 00:36:46.269 protect the brain and heart. Ah. This is ischemia, 00:36:46.429 --> 00:36:49.090 combined with excess acid production, rapidly 00:36:49.090 --> 00:36:52.429 leads to nucosal erosion and massive GI bleeding. 00:36:53.230 --> 00:36:56.070 The PPIs neutralize the acid. But the tech says 00:36:56.070 --> 00:36:58.730 early enteral feeding -like, putting a tube down 00:36:58.730 --> 00:37:01.130 into their stomach or jejunum and pumping in 00:37:01.130 --> 00:37:03.429 high protein formula within hours of the injury 00:37:03.429 --> 00:37:06.250 is also protective against ulcers. It's arguably 00:37:06.250 --> 00:37:08.639 more protective than the drugs. Feeding the gut 00:37:08.639 --> 00:37:10.719 maintains blood flow to the intestinal lining. 00:37:11.219 --> 00:37:13.059 More importantly, it prevents the intestinal 00:37:13.059 --> 00:37:16.039 villi from atrophy. If the gut starves, the barrier 00:37:16.039 --> 00:37:18.260 breaks down and the bacteria living in the gut 00:37:18.260 --> 00:37:20.599 can translocate directly into the bloodstream, 00:37:21.059 --> 00:37:23.710 causing sepsis from the inside out. Wow. Yeah, 00:37:23.809 --> 00:37:25.530 enteral feeding isn't just for calories. It's 00:37:25.530 --> 00:37:27.730 a vital infection control measure. We also give 00:37:27.730 --> 00:37:30.849 insulin coverage for the hyperglycemia and inoxaparin 00:37:30.849 --> 00:37:34.050 for VTE prophylaxis because these patients are 00:37:34.050 --> 00:37:36.650 bedbound, immobilized, and highly inflamed, which 00:37:36.650 --> 00:37:39.329 is a perfect storm for blood clots. Let's talk 00:37:39.329 --> 00:37:41.349 about the surgical procedures. The burn team 00:37:41.349 --> 00:37:43.590 takes the patient to the OR for excision and 00:37:43.590 --> 00:37:46.150 grafting. What physically happens? The surgeon 00:37:46.150 --> 00:37:48.909 takes a specialized tool. and physically slices 00:37:48.909 --> 00:37:52.070 away the dead necrotic escher layer by layer 00:37:52.070 --> 00:37:55.670 until they reach healthy bleeding fascia. You 00:37:55.670 --> 00:37:57.570 have to remove the dead tissue because it's just 00:37:57.570 --> 00:38:00.469 a breeding ground for bacteria. Then they cover 00:38:00.469 --> 00:38:03.150 that massive raw area with a graft. There are 00:38:03.150 --> 00:38:05.710 several types of grafts and the terminology can 00:38:05.710 --> 00:38:08.530 get confusing. Break them down. An autograft 00:38:08.530 --> 00:38:11.929 is the holy grail. It's the patient's own skin, 00:38:12.369 --> 00:38:14.829 usually shaved from an unburned donor site on 00:38:14.829 --> 00:38:18.170 the thigh or back using a dermatome. It's permanent 00:38:18.170 --> 00:38:20.690 and the body will not reject it. But it's usually 00:38:20.690 --> 00:38:23.170 small pieces, right? Right, because donor skin 00:38:23.170 --> 00:38:25.550 is often limited. They run the autograph through 00:38:25.550 --> 00:38:28.230 a mesher, which cuts tiny slits in it so it can 00:38:28.230 --> 00:38:30.769 stretch like a chain link fence to cover a larger 00:38:30.769 --> 00:38:33.670 area. But what if the burn is 80 % of their body 00:38:33.670 --> 00:38:35.929 and they simply don't have enough unburned skin 00:38:35.929 --> 00:38:38.309 to use as a donor site? Then we use an allograft, 00:38:38.590 --> 00:38:41.679 which is cadaver skin. It is temporary. The patient's 00:38:41.679 --> 00:38:43.480 immune system will eventually reject it after 00:38:43.480 --> 00:38:46.420 a few minutes, but it acts as an incredible biological 00:38:46.420 --> 00:38:49.260 dressing to stop fluid loss, reduce pain, and 00:38:49.260 --> 00:38:52.219 buy time. We also use CEA cultured epidermal 00:38:52.219 --> 00:38:55.320 autographs. We take a tiny biopsy of the patient's 00:38:55.320 --> 00:38:58.079 unburned skin, send it to a lab, and over three 00:38:58.079 --> 00:39:00.980 weeks, they grow massive fragile sheets of the 00:39:00.980 --> 00:39:04.550 patient's own epidermis. Finally, there's Integra, 00:39:04.849 --> 00:39:07.429 which is an artificial dual -layered dermal matrix 00:39:07.429 --> 00:39:10.309 used to build a foundation for massive reconstructive 00:39:10.309 --> 00:39:13.130 burns. Let's check in on hemodynamics during 00:39:13.130 --> 00:39:15.809 the acute phase. We were pumping them full of 00:39:15.809 --> 00:39:18.570 fluid earlier. Are we still worried about dehydration? 00:39:18.849 --> 00:39:21.769 No, the threat has entirely flipped. We are now 00:39:21.769 --> 00:39:24.329 watching closely for fluid overload. Remember 00:39:24.329 --> 00:39:26.949 those 10 liters of fluid we pumped into the interstitial 00:39:26.949 --> 00:39:29.630 space? The capillaries have now healed and regained 00:39:29.630 --> 00:39:32.050 their seal. So all that trapped fluid begins 00:39:32.050 --> 00:39:34.570 shifting back into the vascular space to be filtered 00:39:34.570 --> 00:39:37.050 by the kidneys. So their blood volume suddenly 00:39:37.050 --> 00:39:39.849 expands massively. Exactly. In a young, healthy 00:39:39.849 --> 00:39:41.900 patient, they just pee out liters of urine. But 00:39:41.900 --> 00:39:43.780 in older adults or patients with a history of 00:39:43.780 --> 00:39:46.280 heart failure, this massive rapid return of fluid 00:39:46.280 --> 00:39:48.619 can overwhelm the heart, causing congestive heart 00:39:48.619 --> 00:39:50.980 failure and flash pulmonary edema. You have to 00:39:50.980 --> 00:39:53.260 watch their lung sounds and oxygenation closely 00:39:53.260 --> 00:39:55.900 during this diuresis phase. And electrolytes. 00:39:55.980 --> 00:39:58.360 What's the trend? We often see hyponatremia. 00:39:58.440 --> 00:40:00.860 They're losing sodium through excessive GI suction, 00:40:01.519 --> 00:40:04.780 massive wound drainage, or dilutional hyponatremia 00:40:04.780 --> 00:40:06.559 if they're drinking too much free water without 00:40:06.559 --> 00:40:09.969 electrolytes. We also see hypokalemia because 00:40:09.969 --> 00:40:12.550 the potassium shifts back into the cells and 00:40:12.550 --> 00:40:15.409 is lost through the massive diuresis. Complications. 00:40:15.789 --> 00:40:18.010 We discussed the curling's ulcer and sepsis, 00:40:18.309 --> 00:40:20.510 but let's talk about contractures because this 00:40:20.510 --> 00:40:23.769 is where bedside nursing care literally dictates 00:40:23.769 --> 00:40:26.659 the patient's future quality of life. As burns 00:40:26.659 --> 00:40:29.860 heal and as skin grafts take, the new scar tissue 00:40:29.860 --> 00:40:32.820 inherently shrinks and tightens. Now physiologically, 00:40:33.380 --> 00:40:35.619 our flexor muscles, the ones that pull our limbs 00:40:35.619 --> 00:40:38.619 inward, are much stronger than our extensor muscles. 00:40:39.159 --> 00:40:41.519 If a burn patient is left in bed to lie in a 00:40:41.519 --> 00:40:43.380 comfortable field position. Which is exactly 00:40:43.380 --> 00:40:44.719 what they want to do because they're in pain 00:40:44.719 --> 00:40:47.860 and cold. Exactly. If you let them do that, their 00:40:47.860 --> 00:40:50.309 joints will freeze in flexion. The scar tissue 00:40:50.309 --> 00:40:52.449 will literally fuse their chin to their chest. 00:40:52.530 --> 00:40:54.929 It'll lock their arms in a bent position. They 00:40:54.929 --> 00:40:56.909 will become functionally disabled, requiring 00:40:56.909 --> 00:40:58.989 massive corrective surgeries down the road. So 00:40:58.989 --> 00:41:01.170 the nursing action is active range of motion, 00:41:01.550 --> 00:41:04.250 pushing through the pain and proper rigid splinting. 00:41:05.010 --> 00:41:08.250 The text emphasizes NO pillows for ear or neck 00:41:08.250 --> 00:41:11.670 burns. Why? Because a pillow naturally flexes 00:41:11.670 --> 00:41:14.250 the neck forward, encouraging a devastating neck 00:41:14.250 --> 00:41:17.090 contracture. Also, the pressure of the head resting 00:41:17.090 --> 00:41:19.449 on a pillow can completely destroy the exposed, 00:41:19.630 --> 00:41:21.909 fragile cartilage of a burned ear, causing it 00:41:21.909 --> 00:41:24.489 to necros and fall off. Oh wow, so what do you 00:41:24.489 --> 00:41:26.989 do instead? Instead of a pillow, you place a 00:41:26.989 --> 00:41:29.349 rolled towel under their shoulders to hyperextend 00:41:29.349 --> 00:41:32.030 the neck backwards. You must stretch their tissue, 00:41:32.230 --> 00:41:34.829 even when they're begging you to stop. It's brutal, 00:41:35.190 --> 00:41:36.809 but it's the only way to save their mobility. 00:41:37.599 --> 00:41:39.900 Deterioration. The patient is getting worse if... 00:41:39.900 --> 00:41:41.960 If the blood pressure drops again, requiring 00:41:41.960 --> 00:41:44.340 vasopressors, if the urine output falls, and 00:41:44.340 --> 00:41:46.739 if the temperature spikes or plummets, I will 00:41:46.739 --> 00:41:49.519 say it again, hypothermia in this phase is a 00:41:49.519 --> 00:41:52.900 grave sign of late sepsis. Escalation. Notify 00:41:52.900 --> 00:41:55.440 the provider immediately for new foul -smelling 00:41:55.440 --> 00:41:57.920 or purulent wound drainage or sudden delirium 00:41:57.920 --> 00:42:00.199 in an older adult. You call a rapid response 00:42:00.199 --> 00:42:02.840 if the hemodynamics indicate septic shock. Let's 00:42:02.840 --> 00:42:04.940 do some differential pattern recognition. If 00:42:04.940 --> 00:42:08.610 you see tachycardia... hyperglycemia, and a completely 00:42:08.610 --> 00:42:12.130 normal blood pressure. Think normal hypermetabolic 00:42:12.130 --> 00:42:14.670 state. The body is just running incredibly hot 00:42:14.670 --> 00:42:16.570 to fuel the healing process. Continue feeding 00:42:16.570 --> 00:42:19.690 them and managing pain. But if you see tachycardia, 00:42:19.929 --> 00:42:22.289 a dropping blood pressure, and a dropping urine 00:42:22.289 --> 00:42:25.530 output, think sepsis and septic shock. Exactly. 00:42:25.949 --> 00:42:28.849 Draw pan cultures, start broad -spectrum antibiotics, 00:42:29.469 --> 00:42:31.849 and prepare for pressors. I see you pearls and 00:42:31.849 --> 00:42:34.610 exam traps for this phase. Trap. Letting a burn 00:42:34.610 --> 00:42:36.730 patient heal in a flexed position because it's 00:42:36.730 --> 00:42:39.070 comfortable, they must be stretched. Or Pearl. 00:42:39.829 --> 00:42:41.550 Enteral nutrition isn't just for calories, it 00:42:41.550 --> 00:42:43.610 protects the gut barrier from breaking down. 00:42:43.969 --> 00:42:45.869 Thinking like an intensivist for the acute phase. 00:42:46.550 --> 00:42:49.289 The core problem is the massive open wound. The 00:42:49.289 --> 00:42:51.449 failing physiology is severe immunosuppression 00:42:51.449 --> 00:42:53.889 and hypermetabolism. The lethal threat is gram 00:42:53.889 --> 00:42:56.309 -negative sepsis. The intervention is early surgical 00:42:56.309 --> 00:42:59.590 excision, strict PPE, targeted antibiotics, and 00:42:59.590 --> 00:43:02.099 massive caloric support. The reassessment is 00:43:02.099 --> 00:43:04.639 watching hemodynamics, pre -obumin, and white 00:43:04.639 --> 00:43:07.300 blood cell trends. If I'm locking in my five 00:43:07.300 --> 00:43:10.880 takeaways for the acute phase, one, the pathology 00:43:10.880 --> 00:43:13.380 is a hypermetabolic engine and an immunosuppressed 00:43:13.380 --> 00:43:15.559 system acting as a magnet for gram -negative 00:43:15.559 --> 00:43:18.880 bacteria. Two, my assessment is hyper -focused 00:43:18.880 --> 00:43:20.900 on rune pyrroleins, temperature instability, 00:43:21.079 --> 00:43:24.780 and dropping urine output. Perfect. Three, the 00:43:24.780 --> 00:43:27.340 complication I'm terrified of is sepsis progressing 00:43:27.340 --> 00:43:30.019 to multiple organ dysfunction syndrome. Four, 00:43:30.619 --> 00:43:33.039 my priority actions are early enteral feeding, 00:43:33.679 --> 00:43:36.420 strict infection control, and aggressive, proactive 00:43:36.420 --> 00:43:39.500 pain management. And five, the definitive treatment 00:43:39.500 --> 00:43:41.920 is getting them to the O .R. for excision and 00:43:41.920 --> 00:43:44.760 autografting. Your clinical picture is a diareasing 00:43:44.760 --> 00:43:47.300 patient with healing but exquisitely painful 00:43:47.300 --> 00:43:50.840 grass, requiring massive continuous caloric intake 00:43:50.840 --> 00:43:53.360 and meticulous infection control to stave off 00:43:53.360 --> 00:43:56.199 systemic sepsis. If you see hypothermia dropping 00:43:56.199 --> 00:43:58.380 urine output and mild confusion in the acute 00:43:58.380 --> 00:44:01.119 phase, you think gram -negative sepsis, and you 00:44:01.119 --> 00:44:03.460 aggressively escalate for pancultures and pressor 00:44:03.460 --> 00:44:05.679 support. And that eventually brings us out of 00:44:05.679 --> 00:44:08.039 the acute phase and into rehabilitation, which 00:44:08.039 --> 00:44:10.000 brings up a profound concept touched on in the 00:44:10.000 --> 00:44:12.639 source text. Toast traumatic growth. Yes. We 00:44:12.639 --> 00:44:14.780 spend all our time as clinicians in the ICU, 00:44:15.139 --> 00:44:17.559 hyper -focused on managing fluids, titrating 00:44:17.559 --> 00:44:20.059 electrolytes, supporting hemodynamics, and protecting 00:44:20.059 --> 00:44:23.380 grafts. But the most challenging, enduring scar 00:44:23.380 --> 00:44:26.400 to heal is psychological. A major burn injury 00:44:26.400 --> 00:44:29.579 is arguably one of the most physically and psychologically 00:44:29.579 --> 00:44:32.179 devastating traumas a human being can survive. 00:44:32.199 --> 00:44:35.639 There is survivor's guilt, profound fear of disfigurement, 00:44:35.960 --> 00:44:38.380 the absolute agony of physical rehabilitation, 00:44:38.699 --> 00:44:40.920 and the loss of independence. But the research 00:44:40.920 --> 00:44:43.219 on post -traumatic growth shows that this immense 00:44:43.219 --> 00:44:46.159 distress and trauma can act as a catalyst. Many 00:44:46.159 --> 00:44:48.519 survivors after navigating the darkness remark 00:44:48.519 --> 00:44:50.840 on a completely renewed appreciation for life, 00:44:51.260 --> 00:44:53.659 shifting priorities, and a deeper sense of personal 00:44:53.659 --> 00:44:55.760 strength. We talked at the very beginning of 00:44:55.760 --> 00:44:57.599 this deep dive about the skin being the literal 00:44:57.599 --> 00:44:59.960 boundary between the self and the world. The 00:44:59.960 --> 00:45:02.119 wall of the city. Right. When that boundary is 00:45:02.119 --> 00:45:04.880 violently destroyed and then painstakingly surgically 00:45:04.880 --> 00:45:07.300 rebuilt over months, the patient must fundamentally 00:45:07.300 --> 00:45:09.400 rebuild their psychological identity as well. 00:45:09.800 --> 00:45:11.760 The person they were before the fire is gone. 00:45:12.239 --> 00:45:14.440 They have to forge who they will be after. And 00:45:14.440 --> 00:45:18.139 that is the ultimate true job of the ICU nurse 00:45:18.139 --> 00:45:21.280 and the interdisciplinary burn team. You aren't 00:45:21.280 --> 00:45:23.340 just adjusting pumps to keep the organs alive. 00:45:23.559 --> 00:45:26.179 You are managing the pain, building trust, and 00:45:26.179 --> 00:45:28.280 protecting the person inside until they are strong 00:45:28.280 --> 00:45:31.099 enough to face the world again. It is an incredibly 00:45:31.099 --> 00:45:33.480 heavy responsibility, but it's one of the most 00:45:33.480 --> 00:45:35.659 phenomenal and rewarding things you can do in 00:45:35.659 --> 00:45:38.239 medicine. Thank you for joining us on this intense 00:45:38.239 --> 00:45:41.139 deep dive into the burn ICU. Keep questioning 00:45:41.139 --> 00:45:43.539 the monitor, keep connecting the cellular dots, 00:45:43.920 --> 00:45:45.239 and always stay curious.