Heartland Hospital Medicine Conference

Heartland Hospital Medicine Conference is a conference for #Hospitalist and directed by @romilchadha & @JoeUKHM from @UKHospitalists

[Brent Bagley @brentbagley]

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

[Brent Bagley @brentbagley]

Presented with @GrahamCarlos at @HHMConf this AM - always fun to teach others about intricacies of care for the burn patient!

Reviving this #tweetorial with all of our burn #pearls (we couldn’t fit them all in one hour!!)

[Brent Bagley @brentbagley]

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

[Brent Bagley @brentbagley]

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

[Brent Bagley @brentbagley]

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

[Brent Bagley @brentbagley]

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

[Brent Bagley @brentbagley]

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

[Brent Bagley @brentbagley]

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

[Brent Bagley @brentbagley]

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

[Brent Bagley @brentbagley]

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

[Brent Bagley @brentbagley]

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

[Brent Bagley @brentbagley]

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

[Brent Bagley @brentbagley]

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

[Brent Bagley @brentbagley]

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

[Brent Bagley @brentbagley]

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

[Brent Bagley @brentbagley]

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

[Brent Bagley @brentbagley]

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

[Brent Bagley @brentbagley]

To celebrate my first publication in @AnnalsATS, a 🧵 on critical care of the burn patient! (1/16)

🧯🔥🔥🔥🫁

https://t.co/bJexBBdEec

[Heartland Hospital Medicine Conference @HHMConf]

#TWDFNR @SocietyHospMed @JHospMedicine

No need to routinely correct elevated INR and thrombocytopenia prior to Paracentesis in patients with Cirrhosis

https://t.co/xgDiVAOQfp

[Heartland Hospital Medicine Conference @HHMConf]

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

[Heartland Hospital Medicine Conference @HHMConf]

NPO after midnight #TWDFNR

@JHospMedicine @SocietyHospMed

[Journal of Hospital Medicine @JHospMedicine]

Rethinking "NPO after midnight" with our latest #TWDFNR https://t.co/hf6xLrQ7rD #VisualAbstract

[Heartland Hospital Medicine Conference @HHMConf]

Think of palliative care, goals of care and shared decision making

https://t.co/k5mv0jxrpn