Case presentation on burns

Assessment of the case by clinical pharmacist services

1. CASE PRESENTATION ON BURNS Done by A.J.Vishali

2. PATIENT DEMOGRAPHIC DETAILS: PATIENT NAME: Mary margarat AGE :59yrs SEX : female IP NO . : 1701015 DOA : 25-8-18 DOD :5-9-18( death ) WEIGHT :55kgs HEIGHT :154cms BMI: 23.2kg/m2 LBW :46.9kgs BSA :1.53m2 DEPARTMENT :GENERAL MEDICINE

3. SOAP ANALYSIS S-SUBJECTIVE O-OBJECTIVE A-ASSESSMENT P-PLANING

4. S-SUBJECTIVE EVIDENCE CHIEF COMPLAINTS : burn both foot until ankle and lower backache PAST MEDICAL HISTORY : handicapped since birth, RT upper & lower limb deformity with difficulty walking PAST MEDICATION HISTORY : nil SOCIAL HISTORY : nil PRELIMINARY DIAGNOSIS : BURN \ DM FINAL DIAGNOSIS: Accidental burns ,UTI with sepsis with renal impairement

5. O-OBJECTIVE EVIDENCE VITAL PARAMETERS : PR-82/min Bp-130/80mmhg Oedema of feet: yes RFT : Blood urea:52mg/dl Serum creatinine : 1.9 Bp: 130/80mmhg TLC-19600

6. A-ASSESSMENT From the subjective and objective evidence the patient is suffering from accidental burns, UTI, sepsis, AKI.

7. BURNS: DEFINITION: The term “burn” means more than the burning sensation associated with this injury. Burns are characterized by severe skin damage that causes the affected skin cells to die.

8. Pathophysiology At temperatures greater than 44 °C (111 °F), proteins begin losing their three-dimensional shape and start breaking down . This results in cell and tissue damage. Many of the direct health effects of a burn are secondary to disruption in the normal functioning of the skin. They include disruption of the skin's sensation, ability to prevent water loss through evaporation, and ability to control body temperature. Disruption of cell membranes causes cells to lose potassium to the spaces outside the cell and to take up water and sodium. In large burns (over 30% of the total body surface area), there is a significant inflammatory response. This results in increased leakage of fluid from the capillaries , and subsequent tissue edema . This causes overall blood volume loss, with the remaining blood suffering significant plasma loss, making the blood more concentrated. Poor blood flow to organs such as the kidneys and gastrointestinal tract may result in renal failure and stomach ulcers . Increased levels of catecholamines and cortisol can cause a hypermetabolic state that can last for years. This is associated with increased cardiac output , metabolism , a fast heart rate , and poor immune function .

9. PLANING: DAY 1 Every day follow up: 25-8-18 RFT: Blood urea:52mg/dl Serum creatinine : 1.9 Bp: 130/80mmhg TLC-19600

10. DAILY FOLLOWUP : 25-8-18 :accidental burns both legs untill ankel 4 am- Rx- 1.Ivf ns and rl -50ml 2.Inj cegava -1.14g-IV-BD 3.Inj pantop -40mg-IV-BD 4.Inj tramadol 1amp IV BD 5.Inj optineuron IM OD 6.Check GRBS

11. DI: MINOR: OPTINEURON <> PANTOP- supressing GI secretion, interferes GI absorption of optineuron 11am: H /o - pain both knee joints, swelling of feet, nausea, constipation- pedal edema. ? ckd . So avoid nsaids , aminoglycosides , ACEI , ARBI Rx- Inj metrogyl 100ml IV tid Inj cegava 1.05g IV BD Inj pan 40mg IV BD Inj tramadol 1amp IM BD Inj optineuron 1amp IV OD DI: minor : metrogyl <> tramadol - rarely prolongs QT interval

12. MECHANISM OF ACTION: 1.Inj cegava MOA :Cegava 1000 mg/500 mg Injection is a combination of two medicines: Cefoperazone and Sulbactam . Cefoperazone is an antibiotic. It works by preventing the formation of the bacterial protective covering which is essential for the survival of bacteria. Sulbactam is a beta- lactamase inhibitor which reduces resistance and enhances the activity of Cefoperazone against bacteria. ADRS: Diarrhea Altered liver function test Allergic reaction

13. 2.Inj pantop MOA :Pantop 40 Tablet is a proton pump inhibitor (PPI). It works by reducing the amount of acid in the stomach which helps in relief of acid related indigestion and heartburn ADRS : Vomiting Headache Stomach pain Nausea 3.Inj tramadol MOA :Tramadol Hydrochloride 50 mg Injection is an opioid analgesic (pain reliever) which works by blocking transmission of pain signals to the brain to lower pain perception. ADRS : Dizziness Sleepiness Vomiting

14. 4.Inj optineuron : MOA : Pyridoxine, A Vitamin B6 Supplement Is Required For The Proper Function Of Glucose, Fats, And Proteins In The Body. It Is Also Required For The Growth And Development Of The Brain, Nerves, Skin, And Many Other Parts Of The Body. ADRS : Long Term Administration Of Large Doses Is Associated With The Development Of Severe Peripheral Neuritis Resulting In Numbness And Pain, Usually In Hands And Feet. 5.Inj metrogyl MOA : Metrogyl 400 Tablet is an antibiotic. It kills the bacteria and other microorganisms that cause infections by damaging their DNA. ADRS : Headache Dryness in mouth Nausea

15. DAY 2: 26-8-18 : type 2 DM/ burns 9am Rx- CST+ tab zymoflam

16. 6.Tab zymoflam MOA :Bromelain Is A Mixture Of Enzymes That Digest Protein ( proteolytic ) That Are Found In Pineapples ( Ananas Comosus ). Trypsin Breaks Down Proteins Into Smaller Fragments Thereby Making It Available For Absorption Into The Blood Stream. Trypsin When Applied Directly To Wounds And Ulcers Removes Dead Tissue And Improves Healing. Rutoside Trihydrate Is Known To Interact With Other Drugs Like Amiloride ( HCl ), Ascorbic Acid, Ciprofloxacin, Docetaxel , Gemifloxacin , Hydrochlorothiazide, Lomefloxacin ( HCl ), Spironolactone , Triamterene . Always Consult Your Physician For The Change Of Dose Regimen Or An Alternative Drug Of Choice That May Strictly Be Required. ADRS :Nausea , Stomach Upset, Skin Rash, Acute Toxicity

17. DAY 3 11 am: 27-8-18 LFT:WNL PT WITH INR: 12.36 sec , 1.0 APTT: 34.19sec Bp: 110/80mmhg, PR:82/min CBP: Hb : 10.2% WBC: 15000 Platelet count: 2.84 L SERUM ELECTROLYTES: Sodium: 127 Potassium: 4.0 Chloride:106

18. 27-8-18: 9am Accidental burns,UTI with sepsis with renal impairment CAD-MOD LV DYSFUNCTION C/O-SWEATING Rx- CST + Inj fragnim 5000 OD Tab atchol 40mg High salt diet Advice all lab tests

19. 7.Inj fragnim : MOA: Fragmin 5000 IU Solution for Injection is an anticoagulant that prevents the formation of harmful blood clots. ADRS : Bleeding Injection site reaction 8.Tab atchol MOA :Atchol 40 Tablet is a lipid-lowering medication ( statin ). It works by blocking an enzyme (HMG- CoA - reductase ) that is required in the body to make cholesterol. It thus lowers "bad" cholesterol (LDL), triglycerides and raises "good" cholesterol (HDL). ADRS : Headache Stomach pain Constipation Feeling sick

20. 11am Rx- Cst+Tab ecoprine , k bind sachet DI: moderate: Ecosprine <> zymoflam - increase GI ulcer and bleeding Major: Ecosprin <> fragnim - increase the risk of bleeding Zymoflam <> fragnim - increase in bleeding complications 9.Tab ecosprine : MOA: Ecosprin 75 Tablet is a non-steroidal anti-inflammatory drug (NSAID) with anti-platelet action. It works by preventing platelets from sticking together which decreases the formation of harmful blood clots. This lowers the chance of heart attack or stroke. ADRS: Gastritis Bleeding disorder Low blood platelets Gastric erosion Gastric ulcer

21. DAY 4 28-8-18: Sodium: 127 Bp: 100/60mmhg, PR:74/min Sodium: 128 Potassium:4.6 Creatinine:1.6 Urea:52 Accidental burns both legs untill ankel , DM,UTI with sepsis,HYPONATREMIA (Na+ 127) , LV clot+, EF- 45%,stroke , antery thrombosis CST + Tab acitron Removed ecosprin , k bind, high salt diet

22. 10.Tab acitron : MOA :Acenocoumarol / Nicoumalone is an oral anticoagulant. It acts by preventing the formation of harmful blood clots. Although it does not dissolve the existing blood clots, it inhibits them from growing larger and causing serious problems. ADRS :Bleeding

23. DAY 5 29-8-18 : CAD with apical stent – on anticoagulant , DM, accidental burns , uti,sepsis c/o – pedal edema , decrease pyramidal movements CST + Tab dytor 10mg OD Tab ecosprin 75mg OD Inj pyeropenum 1g IV BD DI: Moderate: dytor <> cegava –dose adjustment needed Metrogyl <> dytor -increase blood levels of dytor Dytor <> pantop -sometimes causes hypomagnesemia

24. 11.Tab dytor MOA : Torasemide is a diuretic. It removes extra water and certain electrolytes from the body by increasing the amount of urine produced. In doing so, it causes potassium loss . ADRS : Dizziness, Weakness, Dehydration, Decreased potassium level in blood, Increased blood uric acid, Decreased magnesium level in blood, Increased thirst 12.Inj pyeropenum MOA : Meropenem exerts its bactericidal activity by inhibiting bacterial cell wall synthesis in Gram-positive and Gram-negative bacteria through binding to multiple penicillin-binding proteins (PBPs). ADRS :nausea , vomiting

25. DAY 6 30-8-18: GC-FAIR Sodium:136 Potassium: 2.3( dytor drug cause low potassium levels) Chloride: 105 Serum creatinine : 0.9 WBC: 18900cells/ cumm Bp:100/70mmhg,PR:78/min

26. 30-8-18: accidental burns /UTI/SEPSIS/ AKI recovering with DM with severe hypokalemia (k+= 2.3) ADR ,LV apical clot+ 9am CST + Inj kcl -2amp in 30ml ns IV Syp potklor 15 ml tid ADVICE INR AND PT LEVELS DI: Minor: kcl <> optineuron : decrease GI absorption of optineuron 12.Inj kcl MOA: Kcl Injection works by raising potassium levels in your blood. ADRS:i njection site reactions (pain, swelling, redness)

27. 4pm PT-36.24,INR-5.8 CST + inj augmentin 1.2g IV tid Withhold tab acitron 2mg OD 13.Inj augmentin : MOA :Augmentin 1.2gm Injection is a combination of two medicines: Amoxycillin and Clavulanic Acid. Amoxycillin is an antibiotic. It works by preventing the formation of the bacterial protective covering which is essential for the survival of bacteria. Clavulanic Acid is a beta- lactamase inhibitor which reduces resistance and enhances the activity of Amoxycillin against bacteria. ADRS: Vomiting Nausea Diarrhea

28. DAY 7: GC-POOR Bp: 110/70mmhg,PR:78/min 31-8-18: Accidental burns/ UTI /SEPSIS/ DM with severe hypokalemia correction Increase intake of coconut water and bananas. CAD with LV Clot with mod dysfunction CST + Tab atorvas Tab dolo650 Inj biopipe t2 Mgso3 -1amp Stop cegava DI: moderate : mgso4<> dytor - risk of dehyration and electrolyte abnormalities. Atorvas <> pantop -increase blood levels of atorvas Metrogyl <> atorvas -increase of nerve demage

29. 14.Tab atorvas MOA :Atorva 20 Tablet is a lipid-lowering medication ( statin ). It works by blocking an enzyme (HMG- CoA - reductase ) that is required in the body to make cholesterol. It thus lowers "bad" cholesterol (LDL), triglycerides and raises "good" cholesterol (HDL). ADRS : Headache Stomach pain Constipation 15.Tab dolo MOA :Dolo 650 mg Tablet is an analgesic (pain reliever) and anti-pyretic (fever reducer). It works by blocking the release of certain chemical messengers that cause pain and fever. ADRS :No common side effects seen

30. Pt is on kcl transfusion Inj piptaz Inj linezolid DUPLICATIONS: Cegava,metrogyl,augmentin - beta lactam antibiotics and inhibitors Ecosprine , zymoflam - NSAIDS

31. 16.Inj piptaz MOA : Piptaz 4.5gm Injection is a combination of two medicines: Piperacillin and Tazobactum . Piperacillin is an antibiotic. It works by preventing the formation of the bacterial protective covering which is essential for the survival of bacteria. Tazobactum is a beta- lactamase inhibitor which reduces resistance and enhances the activity of Piperacillin against bacteria. ADRS: Allergic reaction Nausea Diarrhea 17.Inj linezolid MOA :Lnz 600 Infusion is an antibiotic. It stops bacterial growth by preventing synthesis of essential proteins required by bacteria to carry out vital functions ADRS : Nausea Decreased blood cell count Diarrhea

32. DAY 8:GC-FAIR 1-9-18: TLC: 25000cells/ cumm GRBS:258mg/dl INR: 1.61 Bp: 130/80mmhg,PR:78/min 1-9-18: c/o- ADR(mgso3, ecosprine )caused bleeding pv –clot noted with lower abd pain (supra pubic region) , mod LV dysfunction with apical clot , accidental burns , sepsis ,UTI,AKI improved Inj vitk IM stat Inj tramadol IM stat Tab ecosprin Kcl Tab acetrone Inj frag Inj optineuron

33. Fresh orders : Inj piptaz -4.5g IV tid Inj linezolid - 600mg IV bd Tab dolo -650mg oral tid Inj fragnim -5000u s.c od Ivf with optineuron 1amp in 1 ns IV Tab zymoflam tid Inj pan 40mg IV od Tab atorvas od GRBS DI: Major: zymoflam <> fragnim - increase risk of bleeding Moderate:atorvas <>pan-increase bloodlevels & effects of atorvas Atorvas <> linezolid -increase risk of bleeding

34. DAY 9 2-9-18: Bp: 90/60mmhg Spo2:98% PR:106/min

35. 2-9-18: CAD with mod LV dysfunction with apical clot with DM with accidental burn with UTI with sepsis Rx CST + Inj H.mixtard Inj HAI Inj fragnim 5000u OD Syp ancool 2amp tid Inj tramadol 1amp IV ns@ 3000hr with 1amp optineuron Inj calcium Inj nahco3 100ml DI: Major: tramadol <> linezolid : increase risk of serotonin syndrome

36. Moderate: ancool <> tramado -prolong qt interval HAI<> linezolid : increase risk of hypoglycemia 18.Syp ancool MOA :Ancool Oral Suspension Sugar Free is a combination of four medicines: Aluminium hydroxide, milk of magnesia, simethicone and oxetacaine . Aluminium hydroxide is an inorganic salt that neutralises the excess acid in stomach. Milk of magnesia is a laxative that works by drawing water into the intestine through osmosis, making the stools soft and easier to pass. Simethicone is an antifoaming medicine which disintegrates gas bubbles and allows easy passage of gas. Oxetacaine is a local anesthetic that provides faster relief from pain due to ulcers or acidic injury in the stomach. ADRS : Diarrhea Constipation Allergic reaction

37. 19.Inj ca gluconate MOA : Calcium Gluconate provides essential nutrients. ADRS : Central nervous system depression, Coma, Ectopic mineralization 20.NAHCO3 MOA : Sodium Bicarbonate is an antacid and alkalizer . It works by neutralizing excess acid in stomach. ADRS : Constipation, Muscle twitching, Irritability Ancool <> tramadol - cause bardycardia

38. DAY10 3-9-18: GRBS: 240mg/dl Spo2: 91% 3-9-18: DM,Mod lv dysfunction, lv clot, decubitus ulcer, accidental burns ,UTI, s/p- CPR (hypotension) developed sudden episodes of bradycardia -cardiac arrest 9am Inj linezolid 600mg iv tid Inj piptaz 4.5g iv tid Inj pan 40mg iv od Inj fragnim 5000u sc od Inj optineuron 1amp iv od Tab zymoflam tid Tab dolo 650mg tid Tab atorvas 80mg od Syp ascoril

39. 20.Syp ascoril MOA : Ascoril C Syrup is a combination of two medicines: Chlorpheniramine Maleate and Codeine, which relieves dry cough. Chlorpheniramine Maleate is an antiallergic . It blocks the action of a chemical messenger (histamine) which may trigger cough due to allergy. Codeine is a cough suppressant. It suppresses cough by reducing the activity of cough center in the brain. ADRS : Nausea,Vomiting,Constipation

40. 11 am: post CPR status respiratory failure on mechanical ventillation , aspiration pneumonia ( ascoril <> linezolid ) Shock-septic, cardiac Patient may deteriorate further , possibility of cardiac arrest and death explained, grave prognosis Inj colistin Inj tegicycle Inj dalaci 600 iv tid Inj pan 40mg iv tid Inj ondem 4mg iv tid Inj imyen Inj fragnim Tab atchol Inj hydrocestin Inj optineuron Start [email protected] start [email protected]/hr

41. 21.Inj colistin MOA: Colistin 1 MIU Injection is an antibiotic. It kills bacteria by destroying the bacterial cell membrane. ADRS: Injection site reactions (pain, swelling, redness) Neurotoxicity Kidney damage 22.Inj tegicycle MOA: Tigi 50 mg Injection is an antibiotic. It stops bacterial growth by preventing synthesis of essential proteins required by bacteria to carry out vital functions. ADRS: Headache Vomiting Nausea

42. 23.Inj dalacin MOA : Dalacin C 600 mg Injection is an antibiotic. It works by preventing synthesis of essential proteins required by bacteria to carry out vital functions. Thus, it stops the bacteria from growing, and prevents the infection from spreading. ADRS : Vomiting Stomach pain Nausea Diarrhea

43. DAY 11 4-9-18 : GRBS:179mg/dl Hb : 8.1 Platelet: 4.79 TLC:31800 RFT: Urea: 70 Creatinine : 1.6 HR: 140/min,bp:110/60mmhg

44. 4-9-18 : 11am: mod lv dysfunction,apical clot, accidental burns, uti , aspiration pneumonia, sepsis- septic.cardiac,AKI with encephalopathy Rx-CST Shock on noradrenaline,dobutamin,vasopressin,adrenaline 2pm: CST+ Inj ceftrazidine 2g iv bd Inj imyen Inj HAI Inj optineuron Tab ivabrad 5mg bd

45. DAY 12: 5-9-18: TC: 26700 RFT: UREA: 115, CREATININE: 2.2 Hb : 7.3 PR:128/min, bp:80/60mmhg, RR:28/min

46. 5-9-18 : CST + Tab ivabrad 5mg bd Nebulization levolin Inj atropine o.6mg iv stat Inj adrenaline 1 mg iv repeated every 2to5mints Death declared at 6:30pm on 5-9-18

47. 24.Tab ivabrad MOA: Ivabrad 10 mg Tablet is a heart rate lowering medication. It works by reducing the heart rate which lowers the oxygen requirement of the heart. As a result, heart works more efficiently. ADR S: Slow heart rate Headache Luminous phenomena 25.Inj atropine MOA :Atropine Sulphate Injection is an anticholinergic medication. It works by blocking the activity of a chemical messenger (acetylcholine). This helps dry up secretions (saliva, sweat, etc.) from glands before surgery, increases a low heart rate and decreases intestinal contractions (spasms). It also works as an antidote in certain types of poisoning and reverses the side effects of certain muscle relaxing medicines. ADRS : Blurred vision Increased heart rate Dryness in mouth

48. 26.Inj adrenaline: MOA: Adrenaline /Epinephrine is an alpha- and beta-adrenergic agonist. It relaxes muscles in your lungs and relieves spasm, wheezing, and shortness of breath that occurs during a severe allergic reaction (anaphylaxis). ADRS: Headache Restlessness Tremor Palpitations

49. CPR NOTES: Patient had bradycardia followed by cardiac arrest , CPR was intiated immediately as per ACCS guidelines with 5 cycles of CPR given but not achieved. Death at 6:30 pm @ 5/9/18. Cause of death: Septic shock with MODS , burns –bilateral lower limbs

50. PATIENT COUNSELLING: Burn rehabilitation is an undeniably difficult and time consuming effort that, to attain the objective of optimal long-term function, must begin at the outset of burn care. Treatment goals and strategies vary, depending on the patient's injury, stage of treatment, age, and comorbidities . Goals range from minimizing loss of range of motion (ROM) in the critically ill patient to establishing a work-hardening program in recovered patients.

51. Goals of nutritional management To promote optimal wound healing and rapid recovery from burn injuries To minimise risk of complications, including infections during the treatment period To attain and maintain normal nutritional status To minimise metabolic disturbances during the treatment process Objectives of nutritional management Provide nutrition via enteral route within 6 - 18 hours post burn injury Maintain weight within 5 % - 10 % of pre-burn weight Prevent signs and symptoms of micronutrient deficiency Minimise hyperglycaemia Minimise hypertriglyceridaemia      Historically, about half of all burns were deemed preventable. Burn prevention programs have significantly decreased rates of serious burns. Preventive measures include: limiting hot water temperatures, smoke alarms, sprinkler systems, proper construction of buildings, and fire-resistant clothing. Experts recommend setting water heaters below 48.8 °C (119.8 °F). Other measures to prevent scalds include using a thermometer to measure bath water temperatures, and splash guards on stoves. While the effect of the regulation of fireworks is unclear, there is tentative evidence of benefit with recommendations including the limitation of the sale of fireworks to children.

52. PHARMACIST INTERVENTION: ADRS WHICH HAVE BEEN NOTICED IN CASE SHEET: 30/8/18: hypokalemia due to zymoflam <> dytor 1/9/18: zymoflam <> fragnim – increase risk of bleeding complications 2/9/18: ancool <> tramadol – bradycardia 3/9/18: ascoril <> linezolid –aspiration pneumonia 5/9/18: death

53. THANK YOU