Anestesia y manejo peri-operatorio del paciente quemado / Anesthesia and perioperative handling of burned patients / Anestesia e manejo perioperatório do paciente queimado

Introducción: Los pacientes quemados son un reto para el anestesiólogo, el cirujano plástico y el médico general, quien es el primer implicado en su atención. El manejo especializado y cuidadoso de los pacientes mejora su morbi- lidad y disminuye su mortalidad. Objetivo: El articulo revisa los retos que enfrenta el anestesiólogo en el paciente con quemaduras como la dificultad para el monitoreo, la vía aérea difícil, las grandes pérdidas sanguíneas, el manejo del dolor y el trabajo en equipo. Se hace una actualización de la literatura y se presenta la experiencia de la Unidad de quemados del Hospital Simón Bolívar de Bogotá. Método: Se hizo una búsqueda bibliográfica no sistemática de la literatura actual en las bases de datos de Pubmed, Lilacs y Bireme y se consultaron las estadísticas del servicio de quemados del Hospital. Resultados: Se presentan los datos estadísticos de los últimos 20 años del servicio y se desarrolla el contenido de la revisión en varios apartes incluyendo fisiopatología, resucitación inicial, monitoreo, manejo intraoperatorio y manejo del dolor. Conclusión: El manejo anestésico y peri-operatorio del paciente quemado es un reto para el anestesiólogo, el cirujano y el médico tratante, requiriendo un conocimiento básico sobre la fisiopatología y el manejo inicial del paciente. Igualmente debemos tener las habilidades necesarias en el manejo de la vía aérea complicada y la hemorragia intra- operatoria. El manejo de estos pacientes en unidades especializadas mejora su mortalidad.

Introduction: Burned patients are a challenge for anesthe- siologists, plastic surgeon and general practitioner, who is the first involved in your care. The specialized and careful management of patients improves morbidity and mortality decreases. Objective: The article reviews the challenges facing the anesthesiologist in patients with burns as difficulty monitoring, difficult airway, large blood loss, pain management and teamwork. an update of the literature is made and the experience of the burn unit of Simon Bolivar Hospital in Bogota is presented. Method: It was a non-systematic literature search of current lite- rature in the databases PubMed, Lilacs and Bireme and service statistics burned Hospital was consulted. Results: The statistical data of the last 20 years of service are presented and the content of the review is carried out in several asides including pathophysiology, initial resus- citation, monitoring, intraoperative management and pain management. Conclusion: The anesthetic manage- ment and perioperative burn patient is a challenge for the anesthesiologist, surgeon and physician, requiring a basic understanding of the pathophysiology and initial mana- gement of the patient. We must also have the necessary skills in handling the difficult airway and intra-operative bleeding. The management of these patients in specia- lized units improves mortality.

Introdução: Os pacientes queimados são um grande desafio para o anestesista, o cirurgião plástico e o médico geral, primeiro em fazer o atendimento. O manejo especializado e cuidadoso dos pacientes melhora a morbilidade e diminui a mortalidade. Objetivo: O artigo faz uma revisão dos desafios que enfrenta o anestesista no atendimento do paciente com queimaduras, tais como a dificuldade para o controle, a difícil via aérea, as grandes perdas sanguíneas, alivio da dor e trabalho em equipe. Apresenta-se uma atualização na literatura a este respeito e se descreve a experiência da Unidade de Queimados do Hospital Simón Bolivar de Bogotá. Método: Realizou-se a busca bibliográfica da literatura atualizada nas seguintes bases de dados: Pubmed, Lilacs e Bireme, além disso foram consultadas as estadísticas do serviço de queimados do mencionado Hospital em Bogotá. Resultado: Apresentam-se dados estadísticos dos últimos vinte anos do serviço, como também a literatura incluindo fisiopatologia, ressuscitação inicial, monito-reio, manejo intraoperatório e alivio da dor. Conclusão: O manejo anestésico e perioperatório do paciente com queimaduras nas unidades especializadas é importante para diminuir mortalidade. A apresenta grandes desafios o manejo inicial do paciente para o anestesista, cirurgião e médico tratante, pois requer conhecimentos básicos da fisiopatologia e manejo inicial do paciente. Especial-mente cuidadoso deve ser o manejo da via aérea difícil e hemorragia intra operatória.

Dolor en el trauma térmico / Pain in thermal trauma

La máxima agresión física que puede sufrir un ser humano son las quemaduras. Actualmente, en Chile se hospitalizan alrededor de 9.000 personas al año por quemaduras, con una tasa de mortalidad que ha ido en disminución en los últimos 20 años, por lo tanto la cantidad de pacientes sobrevivientes va en aumento. La IASP (Internacional Association for Study of Pain) definió el dolor en quemados como: "un dolor agudo y grave, que se produce al sufrir una quemadura y luego continuo con exacerbaciones que declinan gradualmente". El dolor en el trauma térmico está siempre presente, es de intensidad severa y prolongada en el tiempo, con una alta prevalencia de dolor crónico. Se sabe que el aumento en la intensidad se debe a que las quemaduras dañan gran cantidad de nociceptores, produciéndose una amplificación de la respuesta al dolor. Los opioides son el principal pilar en el tratamiento farmacológico. Es fundamental el buen manejo del dolor, para evitar el dolor patológico que aumentará el dolor crónico y con ello el desmedro de la vida personal de nuestros pacientes. Desafortunadamente el subtratamiento es una realidad, produciendo directamente un retraso en la recuperación de sus quemaduras y en la inserción social y laboral.

Burns are the greatest physical aggression that a human being can experience. In Chile, approximately 9000 patients are hospitalized annually due to burns, with a mortality rate that has decreased progressively in the last 20 years, which means that the amount of survivors is increasing. The IASP (International Association for Study of Pain) has defined pain in the burn patient as "an acute and severe pain produced by a burn that later continues with exacerbations that gradually decline". Pain in thermal trauna is always present, of severe intensity and prolonged in time, with a high prevalence of chronic pain. It is Known that the increase in intensity of pain is due to the damage of a great number of nociceptors, that produces an amplification of the response to pain. Opioids are the mainstay of pharmacologic treatment. Appropriate management of pain is fundamental to avoid pathologic pain that will increase the chronic pain and deteriorate the quality of life of our patients. Unfortunately undertreatment is a reality, retarding the healing of the burn wound, and the social and workplace reintegration.

Análisis médico legal de las muertes ocurridas en el foco de un incendio: tragedia del Hospital Doutor Rafael Angel Calderón Guardia en julio del 2005 / Medical legal analysis of the deaths occurred in the focus of a fire: tragedy at Doctor Rafael Angel Calderón Guardia Hospital in July, 2005

El pasado 12 de julio del 2005, el Hospital Dr. Rafael Angel Calderón Guardia, uno de los principales centros médicos públicos de Costa Rica sufrió un incendio parcial en la parte más antigua de su estructura. El siniestro causó la muerte de 21 personas, 19 de ellas en el mismo sitio de la tragedia, pérdidas materiales por más de 20 millones de dólares y un menoscabo significativo al sistema hospitalario público costarricense. En el presente trabajo se analizan desde el punto de vista médico legal, este desastre y la totalidad de muertes ocurridas en focos de incendios en Costa Rica, en el período comprendido entre los años 2000 al 2005, y se establece un perfil demográfico de las víctimas, se comparan los hallazgos de las autopsias y los resultados de los exámenes complementarios solicitados. Esto con el fin de sugerir un manejo uniforme por parte del Médico Forense, frente a cadáveres recuperados de incendios, incluyendo cuerpos carbonizados y siniestros con gran número de víctimas mortales.

Last July 12th 2005, in the "Dr. Calderon Guardia" Hospital, located in San José, Costa Rica, a tragic fire happened in the oldest section of its structure. This hospital is one of the main public medical centers in our country. In the fire, 21 deaths were produced: 19 of them inside the building. Also, material losses were produced for more than 20 million dollars and a serious reduction in the public hospital system in Costa Rica. In this paper, we are doing a forensic analysis about this disaster and the totality of deaths that have happened in fire focus in Costa Rica in the period between years 2000 to the 2005, in order to establish a demographic profile of the victims to compare the findings of the autopsies and the results of complementary examinations. This, with the purpose of suggesting a uniform forensic pathological handling, of the bodies recovered from fire focuses, including carbonized bodies and fires with great number of mortal victims.

Emergency management of burns

1. Care of severe burns must be based on the correction of the alterations which result from the thermal trauma2. The severely burned patient should be saved from shock by adequate and prompt fluid therapy.3. A suitable formula is a great help to the physician in calculating fluid and electrolyte requirements. Certain safeguards must be observed to avoid overhydration4. The rule of nine is a good guide for determining the extent of area burned5. The burned wound can be satisfactorily treated either by dressing or exposure6. Local therapy should be secondary only to systemic therapy. Gentle cleaning of the wound under IV Demerol and analgesia may be done. Debridement under general anesthesia is contraindicated and may be done only after the patient has passed the state of shock7. ATS and Penicillin should be given prophylactically8. Restlessness in burns is usually not due to pain, but due to dehydration9. Pain should be relieved by Demerol or Morphine given intravenously10. Only deep burns need to be skin-grafted. After shock is controlled, nutrition is maintained and the areas debrided prior to elective skin grafting. (Summary)

Philippine experience with Sulfamylon in thermal trauma

The results of a pilot study of the use of Sulfamylon on 55 burn patients accumulated during a six month period are presented. Bacteriologic data, from the burn wound and blood, shows a changing pattern from the previous year. Findings in this study are essentially similar to experience of others from abroad. The evidence gathered here seems to show that there is nothing to prevent Sulfamylon from being an effective and useful adjunct in the treatment of burns in the Philippines. (Summary)