Quemadura de vía aérea / Airway burn

La mayoría de las muertes tempranas por accidentes con fuego son provocadas por la inhalación de gases más que por las lesiones causadas por llamas, debido principalmente al compromiso ventilatorio que esto produce. Por lo anterior debe existir un alto grado de sospecha de compromiso de vía aérea en aquellos pacientes que presenten quemaduras faciales, en espacios cerrados, vibrisas chamuscadas, compromiso respiratorio progresivo, esputo carbonáceo o que se encuentren en estado de inconciencia. Sin embargo, la presencia de estos hallazgos no es patognomónica de daño en el árbol bronquial ni su ausencia lo descarta. El principal método de diagnóstico es la fibrobroncoscopía, que permite observar directamente las lesiones y además lavar y remover restos que puedan encontrarse en la vía aérea, pero lamentablemente no se encuentra disponible en todos los servicios de urgencia.

Most of the early deaths from accidents with are fire mainly caused by compromise of the ventilation due to gas inhalation rather thand by injuries caused by flames. Therefore there must be a high degree of suspicion of air compromise for patients presenting facial burns indoors, burnt hair of the nasal cavity, progressive respiratory compromise, carbonaceous sputum or unconsciousness. However, neither is the presence of these findings pathognomonic of damage to the bronchial tree nor does their discharge it. The main method is the fibrobroncoscopy diagnosis, which allows direct observation of the injuries and also the washing and removal of debris that can be found in the airways. Unfortunately, this is method is not available in all amergency services.

Treinamento muscular respiratório em lesão inalatória: relato de caso / Respiratory muscle training in inhalation injury: case report

Introdução: A lesão inalatória é hoje a principal causa de morte nos pacientes queimados. O tempo prolongado de ventilação mecânica leva a fraqueza muscular respiratória. Objetivo: Analisar um protocolo de treinamento muscular respiratório na lesão inalatória. Relato do Caso: Paciente HF, 76 anos, vítima de queimadura após incêndio ocorrido no seu domicílio. Encaminhada ao Hospital Santa Casa de Misericórdia de Limeira, inconsciente, intubada, com queimadura de segundo grau profunda, em face, região anterior do pescoço, ombro, antebraço e mão direita, perfazendo 6% de superfície corporal queimada e lesão inalatória. Evoluiu com piora do quadro respiratório, foi traqueostomizada e, em decorrência do tempo de ventilação mecânica, a paciente apresentou fraqueza muscular respiratória, iniciando treinamento muscular por meio de protocolo composto por aumento progressivo do tempo de respiração espontânea, alternado com o suporte ventilatório. O treinamento seguiu por sete dias, com melhora da força da musculatura respiratória, seguido por decanulação da traqueostomia e retorno da função respiratória. Após 36 dias de internação, a paciente recebeu alta hospitalar. Conclusão: O protocolo proposto mostrou-se eficaz, pois conseguiu obter melhora da força muscular respiratória, possibilitando retorno da paciente à respiração espontânea mais precocemente, diminuindo assim o risco de maiores complicações respiratórias associada à ventilação mecânica.

Introduction: Inhalation injury is the leading cause of death in burn patients. The prolonged mechanical ventilation leads to respiratory muscle weakness. Objective: To analyze a protocol of respiratory muscle training in inhalation injury. Case Report: Patient HF, 76 years, a victim of burn after fire at his home. Referred to the Hospital Santa Casa de Limeira, unconscious, intubated, with second-degree burn deep in the face, anterior neck, shoulder, forearm and right hand, making up 6% body surface burn and inhalation injury. Evolved with worsening of respiratory symptoms was due to tracheotomy and mechanical ventilation time the patient developed respiratory muscle weakness, starting with the muscle training protocol consisting of progressively increasing the time of spontaneous breathing, alternating with ventilatory support. The training followed by seven days with improvement in respiratory muscle strength, followed by decannulation of tracheostomy and return of respiratory function, and after 36 days of hospitalization he was discharged. Conclusion: The proposed protocol was effective because it has achieved an improvement in respiratory muscle strength, returning the patient to spontaneous breathing earlier, thus reducing the risk of major respiratory complications associated with mechanical ventilation.

Clinico-pathological profile and outcome of inhalational burns

To determine clinico-pathological profile and outcome of inhalational burns in a specialized burns treatment unit. Case-series. The Department of Plastic Surgery and Burns Centre Unit, Combined Military Hospital, Kharian Cantonment in March 2005. Patients of inhalational burns were included and evacuated within 30 hours of accident to the specialized burns centre after immediate resuscitation. Total Body Surface Area [TBSA] involved in burns was calculated. Complete blood count and renal profile along with serum albumin and total proteins was obtained. Portable chest radiographs and bronchoscopic examination was conducted. Escarotomies were carried and wounds were covered with split thickess skin grafts. Ventilatory support was used as needed. Comparison of the clinico-pathological profile of surviving and fatal cases was done for significance using t-test. There were 19 patients of inhalational burns, 8 [42%] of whom expired. The mean percentage of TBSA in 11 surviving patients was 50 +/- 10.87 and 70 +/- 15.46 in fatal cases. The mean haemoglobin [Hb] on admission was 15.8 +/- 1.6 g/dL and after fluid resuscitation it became 11.4 +/- 1.5 g/dL. The mean Total Leucocyte Count [TLC] in surviving patients was 9.6 +/- 6.1x10[9]/L and 1.5 +/- 2.3x10[9]/L in fatal cases [p=0.001]. The mean platelet count of surviving patients was 205 +/- 63x10[12]/L while in fatal cases was 58 +/- 48x10[12]/L [p=0.05]. The serum urea levels in surviving patients was 4.3 +/- 2 mmol/L while in fatal cases was 8.6 +/- 0.9 mmol/L [p=0.05]. The serum creatinine levels were 98.2 +/- 16.5 micro mol/L in the survivor group and 249.5 +/- 76 micro mol/L in the mortality group [p=0.05]. The serum total protein in surviving patients was 63 +/- 8 g/dL while in mortality cases it was 57 +/- 7 g/L. Serum albumin in the survivor group was 36.7 +/- 5 g/L and 35 +/- 4 g/L in fatal cases. Significant in Hb, protein and albumin levels. All the expired patients had acute respiratory distress syndrome while acute renal failure with multi-organ failure co-existed in 6 patients. Inhalational burns injury cases multi-system injury with high mortality. Body area involvement, total leucocyte count, platelet count, serum area and serum creatinine are important indicators of survival

Injuria inhalatoria en pacientes quemados: revisión / Inhalation injury in burned patient: a review

Every year almost three thousand people get burned in Chile. In this group, about 40 percent of the critical burned patients also suffer inhalation injury. This number is expected to grow bigger among the adult population in the next few years. Inhalation injury significantly increases mortality in burned patients. The prevalence, pathophysiology, clinical characteristics, treatment, and prognosis of this pathology have not been incorporated in the undergraduate curses of Chilean medical schools. Therefore, this subject is pooly known by most of our physicians. Because this disease will be included in the explicit warranties health plan of the public health care system in Chile, we decide to write this review about this pathological condition.

Cada año casi tres mil personas sufren quemaduras en Chile. En la población adulta se estima que este número se incrementará en los próximos años. En este grupo, cerca del 40 por ciento de las quemaduras graves se asocian a injuria inhalatoria. la injuria inhalatoria aumenta significativamente la mortalidad en los pacientes quemados. la prevalencia, fisiopatologia, cuadro clínico, manejo y pronóstico de esta patología no han sido incorporados en los estudios de pregrado de las escuelas de medicina y son temas desconocidos para la mayoría de los médicos. En el contexto de la próxima incorporación de este tipo de dolencias en el plan de garantías explícitas en la salud chilena hemos realizado una actualización del tema.

Traumatismos torácicos en el niño / Thoracic injuries in child

El trauma torácico en el niño es un motivo de consulta frecuente en la práctica médica, presentándose cada vez mayor número de casos, debido fundamentalmente al incremento de los accidentes automovilísticos. En este artículo se revisan los principios básicos de la fisiología, patología, diagnóstico y tratamiento de los traumatismos torácicos en el niño, los cuales difieren significativamente con los del adulto. Se describe el enfrentamiento que actualmente se preconiza frente a los principales lesiones torácicas del niño incluyendo: lesión de pared torácica, tórax volante, contusión pulmonar, asfixia traumática, enfisema subcutáneo, quemaduras por inhalación, neumotórax, hemotórax, lesión del árbol traqueobronquial, lesión del esófago, lesión del conducto torácico, lesión del diafragma, contusión cardíaca y el traumatismo torácico en el niño recién nacido

Principios generales del tratamiento del enfermo quemado / General principles of burn patient treatment

Aunque actualmente el tratamiento del paciente quemado supone una sere de medidas y actuaciones terapeuticas muy especilizadas, es habitual que sea el medico general o de asistencia primaria quien tiene el primer contacto con el paciente. En ese primer momento, el medico debe tomar decisiones que influiran de manera basica en la posterior evolucion del herido. Mas aun, de la actitud del primer medico que atienda al enfermo depende la propia supervivencia del mismo y, en el mejor de los casos, el estado general con que llegue a un centro especializado. Por todo lo anterior, es facil comprender lo fundamental que es el que todo medico sea capaz de: 1.- Adoptar las medidas de atencion inmediata, de las que dependera la supervivencia del paciente. 2.- Realizar una correcta valoracion de la extension y profundidad de las lesiones. 3.- Estabilizar al paciente quemado.4.- Conocer aquellas quemaduras especiales (electricas y quimicas) que presentan caracteristicas diferenciadas. 5.- Tener claros los criterios para el traslado de aquellos paciente cuyas condiciones exijan su tratamiento en un centro especializado