Industrial Fire Competition: SimWars 2021 Round: Final Participants: Undergraduate Medical/Nursing Students. Teams of 5. Learning Objectives ● Identification of blast injury and burns as ‘major trauma’. ● Use of ABCDE/primary survey ● Appropriate management of burns involving the airway ● Appropriate analgesia and fluid resuscitation of a severely burned patient ● General principles for management of burns and carbon monoxide poisoning ● Teamwork and communication ● Appropriate and timely discussion with a burn referral centre for patient transfer Scenario Location: Emergency Department, Resus. Patient: Actor (Decreased GCS, moaning, painful) Condition: Industrial fire & Burns Adam Kearney, a 35-year-old man, is brought to the rural ED you are currently working in by ambulance, a victim of an industrial fire. Apparently, a colleague called emergency services when he found a fire in the building. The patient was attempting to put out the fire when he was thrown clear by a blast. Prehospital team extracted Mr Kearney from under some burning debris. The patient has sustained burns to his upper chest, back and circumferentially around left arm. Pre-alert 20 mins following initial injury. ETA 5 mins. Initial Observations: Vitals: BP 160/95, HR 130, RR 20, O2 Sat 82% RA, 36.9°C, ECG – sinus tachycardia Withdrawing from pain; incomprehensible sounds; opens eyes to voice; GCS: 9/15 (E3, V2, M4) Appearance: Semi-alert, in severe pain, with soot around mouth and nares; moaning Past Medical History: unknown Medications: unknown Allergies: unknown Results Examination • HEENT: Pupils 2 mm and reactive; singed hair around nares and mouth; no soot in mouth; no appreciable oedema of lips or tongue • Neck: supple; no appreciable stridor • Chest: clear to auscultation; second-degree burns of chest wall; very tender right chest wall • Heart: regular rhythm, tachycardia • Back: second-degree burns • Abdomen: normal • Extremities: second-degree burns circumferentially around left arm; pulses symmetric • Neuro: withdrawing from pain; incomprehensible sounds; opens eyes to voice • TBSA: 25%; estimated weight 90kg Investigations ECG: sinus tachycardia Portable CXR – male CXR with right sided rib fractures (subtle) ; no pneumothorax/haemothorax CT (as ordered) ● Brain: No acute intracranial abnormality. ● C-spine: No acute cervical fracture. ● Thorax: Right sided anterior rib fractures of 4th, 5th and 6th ribs; no flail segments. Underlying pulmonary contusion and bilateral atelectasis. No pneumothorax; no haemothorax; no cardiac tamponade. ● Abdomen & Pelvis: No acute intra-abdominal/pelvic pathology Ultrasound – FAST negative Progression With Appropriate Resuscitation Time 00:00 02:00 04:00 06:00 08:00 10:00 Condition V V V U(T) U (T) U(T) Pulse 130 125 115 108 90 94 BP 160/95 150/72 150/72 110/70 109/74 115/72 Sp02 82% RA 85% on O2 88% on O2 94% on O2 96% on O2 98% on O2 RR 20 20 18 16 16 16 Without Appropriate Resuscitation Time 00:00 02:00 04:00 06:00 08:00 10:00 Condition V V P P P U(T) Pulse 130 135 135 132 144 110 BP 160/95 130/60 90/45 88/40 88/42 98/54 Sp02 82% RA 80% RA 80% on RA 84% on O2 86% on O2 90% on O2 RR 20 22 22 26 22 18 Transition point 1: 2 minutes ● 100% O2 via NRB should be administered ● Anaesthetics should be called; potential for difficult airway (use phone and communicate with anaesthetist) ● Team should complete entire primary survey ● Cover burns following E assessment ● IV fluids + analgesia should be administered Critical actions ● Identify a critical trauma patient and begin assessment ● Consider airway issues and call for help early ● Identify potential for additional traumatic injuries ● Cling wrap burns Transition point 2: 4 minutes ● 100% O2 applied by confederate if not done ● IV fluids and analgesia will decrease the heart rate somewhat ○ Fluid replacement considerations (4ml/kg/%= 4x25x90 = 9000ml) ○ ½ in first 8 hours = 4500ml/8hrs ○ Adequate analgesia (e.g. IV morphine) ● FAST: negative ● Labs: ABG (if requested) ● ECG (if requested) ● If ICU/anaesthetics consulted, will attend and manage airway ● If ICU/anaesthetics not consulted, voice becomes muffled, drooling, stridor ○ confederate may prompt Critical actions ● Obtain blood work including carboxyhaemoglobin and lactate levels ● Appropriate fluid resuscitation ● Appropriate analgesia Transition point 3: 6 minutes ● If ICU/anaesthetics consulted, will attend and manage airway ● If ICU/anaesthetics not consulted, voice remains muffled, drooling, stridor ○ Consultant will speak with Team leader/communication doctor, will enquire RE: plan, and advise RE: next steps ● Imaging: CXR (if requested); CT arranged when requested by phone ● Transfer should be considered for burn centre ● If team tried to consult burns service, this team is not available at this hospital. If they want to transfer, the receiving centre can be called (use phone and communicate with burns surgeon) Critical actions ● Recognise that this major trauma patient requires a CT whole body/PAN due to low GCS and evidence of thoraco/abdominal trauma ● Recognise that burns >10% TBSA require specialist treatment in a burns unit Transition point 4: 8 minutes ● ICU/anaesthetics will attend and manage airway ● If CT not arranged/burns service not consulted, consultant will speak with Team leader/communication doctor and advise RE: next steps incl. CT + burns service referral ● If CT arranged, patient taken to CT scanner, results as above. Critical actions ● Administer tetanus, NO IV antibiotics ● Ensure burns are appropriately covered to reduce evaporative fluid losses Transition point 5: 10 minutes ● Endgame 1: If critical actions completed successfully, case ends as stabilised patient is transferred by ambulance to burns unit accompanied by ICU doctor ● Endgame 1: If critical actions not satisfactorily completed, case ends with EM consultant directing management as patient going into CT scanner. ECG Chest XR Source: Radiopedia. Case courtesy of Dr Henry Knipe, Radiopaedia.org, rID: 30699 Burns - Team Assessment Care Provided 50 Points Marks Marks Criteria Available Awarded Patient Assessment Consider - Attention to handover - Systemic approach to assessment/exam 15 - Recognition that a patient is a major trauma Initial Resuscitation Consider - Fluid Bolus/requirements - Supplemental Oxygen - Delivery of IM tetanus booster 15 - Catheterisation - Prompt ICU consultation - Pain management with appropriate analgesia Diagnosis Consider - Recognition of burns and TBSA % - Recognition of carbon monoxide poisoning 10 - Recognise rib fracture on XR / CT Report - Recognition of potential fluid losses. - Recognition of potential tetanus. Investigations Consider - Request for CT trauma series +/- CXR. - Bloods (FBC, U&E, ABG/Serum Lactate, amylase, CRP) 5 - Request for group and hold - Consideration of eFAST. Disposition - Need for transfer to specialist burns unit and definitive 5 care Burns - Team Assessment Non-Technical Skills 50 Points Marks Marks Criteria Available Awarded Team Work Consider - Demonstrating leadership. - Exchanging information. 20 - Regaining situational awareness if team loses focus - Delegating Roles/tasks - Supporting Team Task Management Consider - Planning & preparing - Prioritising 10 - Providing & maintaining standards - Identifying & utilising resources Situation Awareness Consider - Gathering information 10 - Recognising & understanding task fixation - Anticipating Decision Making Consider - Identifying options - Balancing risks & selecting options 10 - Re-evaluating
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