SCCM Resource Library-What Every Intensivist Should Know About the Care of Burn Patients in the ICU

Video Transcription

Good morning, everyone. Welcome to the session, What Every Intensivist Should Know About the Care of Burned Patients in the ICU. My name is Jong Lee.  I'm a burn surgeon and surgical intensivist at the University of Texas Medical Branch in Galveston.  It is my pleasure to be part of the 50th Clinical Care Congress Session on Burned Care. Most intensivists don't take care of burned patients on a regular basis unless you routinely  cover burned ICU. But if there is a mass disaster, you may have to care for burned patients in your ICU. Certainly, we all know how to manage burned patients in the initial period.  As an intensivist, we are experts in resuscitation and AOA management. But what if burned patient is staying in your ICU for more than 24 hours?  Now you have to manage the nitty-gritty of burned care for the foreseeable future. We have three outstanding speakers this morning covering three very relevant topics in burned  care, inhalation injury, nutrition, and care. We will have everyone present first, then have a question and answer session at the end.  You can enter your questions in the discussion chat box. Our first presentation, Management of Inhalation Injuries, including AOA Management and Ventilator  Considerations, will be presented by Dr. Parinlay Angpokta. When you see a patient with inhalation injury, initial management may not be different than other AOA management.  Then comes what to do next, what medications to use, what ventilator mode to use.  Dr. Angpokta is a professor of anesthesiology and the director of the Translational Intensive Care Unit at the University of Texas Medical Branch in Galveston.  Our second presentation, Nutritional Support for Burned Patients Just Feed a Lot, will be presented by Ms. Ashley DePriest.  Burned patients are one of the most hypermetabolic of all critically ill patients and require nutritional support. Does that mean feed a lot?  Is nutritional management different in burned patients compared to other ICU patients? Ms. DePriest is a clinical nutrition manager at Wellstar Kenstone Hospital in Marietta,  Georgia. She's also the current president of the Southeast Chapter of SCCM. Our third presentation, What About Burn Wounds, will be presented by Ms. Sarah Taylor.  After we stabilize burned patients, we have to manage the burned wounds. We certainly have to prevent infection.  Are burned wounds different than other wounds in the ICU, such as pressure ulcers? When do we debride? What do we use for the wounds?  Ms. Taylor is a clinical nurse specialist and has been practicing burn care for 13 years in the burn unit at Michigan Medicine, University of Michigan in Ann Arbor.  Thank you and enjoy the session. Hello, my name is Ashley DePriest. I am a clinical dietician and clinical nutrition manager at Wellstar Kenstone in Marietta, Georgia.  I am so honored today to talk to you guys a little bit about burn nutrition and whether it's just about feeding a lot. So no disclosures for now.  So when I was first brought this topic, I thought, gosh, that really does simplify it a lot. But there are certainly things that we need to consider when thinking about feeding our  burn ICU patients more than just the amount and whether or not it's about feeding excessive amounts.  Three things I want to talk about today that we should be considering when feeding our critically ill burn patients. The first is route. So where are we feeding?  The next thing is timing. When do we feed? And finally, how much should we really be feeding? So first, I want to talk about route.  And I don't think it's going to be a surprise to anyone that we, of course, recommend that we should feed the gut. If the gut works, use it, right?  However, I think the things that maybe aren't as well known about feeding the gut are the benefits to feeding the gut.  When we use our GI tract to provide nutrition, this does a lot of beneficial things, not only for all critically ill patients, but specifically for burn patients.  We see an extreme modulation of the stress response. We see a reduction in catabolic hormone secretions. We see an increase in the immunoglobulin production when we use the gut.  And what's very important for burn patients is an improved insulin production. So many of our burn patients tend to have a lot of hyperglycemia associated with their injury.  And when we use the gut, that allows the body to help produce insulin more naturally and improve that glycemic control.  So a couple of other things that we have seen in the literature associated with enteral  nutrition is fewer infections when it's compared to perennial nutrition use, as well as improved mortality when compared to perennial nutrition.  However, I did put asterisks there because I don't want anyone to be afraid to use perennial nutrition when they need it.  If your patient is not tolerating, it is very important to get calories and protein to that burn patient.  So we've come a long way with perennial nutrition care, and I think our pendulum is certainly swinging in a different direction now that perennial nutrition is not as dangerous as  we used to think it was, or as it may have used to have been. So I certainly don't want anyone to feel afraid to use perennial nutrition when you need it.  Now, I know I can certainly hear some folks out there screaming, but Ashley, these patients are sick. These are very, very sick patients, especially big burn patients.  They do not tolerate enteral nutrition. You probably see a lot of patients who have elevated gastric residual volumes, lots of diarrhea, vomiting, nausea, all of those things.  And I'm here to tell you that we do have something to help maybe prevent that, and that's going to be the timing.  Timing of enteral nutrition is absolutely important, but especially for our burn patients. So let's take a look at a timeline of a typical burn patient.  So when injury occurs, we obviously know we see a lot of capillary losses, right? We lose a lot of volume because we don't have that skin there to help hold in our fluids.  So what that often requires is very, very large volume resuscitation. So patients, burn patients, and especially critically ill burn patients will be getting lots of volume infused.  And as we all know, that typically will result in extreme edema. And that edema occurs in the gut as well, not just in the extremities.  And so when the gut is swollen and the villi are swollen, that reduces the ability of the gut to absorb those nutrients. And that often results in many feeding intolerances.  So what the data tells us, though, is if we can initiate enteral feeds at an optimal time, that can help mitigate some of that edema as well as mitigate some of the inflammatory  response and overall improve our feeding tolerance. So FCCM and ASPEN guidelines recommend trying to get this feeding started within four to six hours of injury.  And the European guidelines say within 12 hours of injury. What this is shown to do is help achieve nitrogen balance sooner for these patients, again,  reduce those catecholamine responses and plasma glucose levels while improving our insulin levels to help improve the glycemic response with these severely injured patients.  So once again, feeding early can help attenuate some of that, some of those intolerances that we see with many of our burn patients.  Trying to get within four to six hours of injury or at 12 hours of injury, depending on who you want to follow, what guidelines you're looking at, is really optimal and should  be a benchmark for your ICU. Now, I think it's important to point out here as well that this is not four to six hours with from admission.  This is actually four to six hours from the actual injury occurring. So it's another kind of tough point to think about and really think about how quickly we  can get that nutrition started. But again, the data shows that this really has a lot of improvements in tolerance as well as other benefits to feeding these burn patients.  So with that being said though, how much should we actually be feeding and what is important? And again, back to the title of this article, should we just be feeding a lot?  Well, I say think again. There are certainly some consequences to underfeeding as well as overfeeding.  And I think it's also important to note that many of our progressions in care for our burn patients, things like use of beta blockers, things like earlier excisions of skin and  on those types of interventions and surgical interventions are really helping to improve the hypercatabolic state of these burn patients.  So they may not be as hypercatabolic as they used to be and for as long as they used to be. However, that doesn't mean that burn patients don't need a lot of nutrition.  But it is important to understand and be able to recognize the signs of overfeeding as well as underfeeding.  So I've listed a few here, but I think the most important ones to think about when we're  looking at our burn patients are going to be some of those electrolyte imbalances, immunosuppression.  So if you're seeing a lot of nosocomial infections happening, a lot of poor wound healing, alterations  in hydration status, or failure to wean from mechanical ventilation, those can all be signs of overfeeding.  Now, on the other hand, there are certainly consequences to underfeeding as well. So again, underfeeding can result in a decrease in respiratory muscle strength.  So remember, our diaphragm is a muscle, so that can result in a decrease in our ventilatory drive and failure to wean from mechanical ventilation.  We also see impaired organ function.  Again, one of the biggest, the biggest organ in our body is our skin, and it's so important for burn patients to ensure that our skin is working the way it's supposed to and that  it's able to heal the way it's supposed to. And underfeeding can prevent that from happening.  Again, you can see an increase in the nosocomial infection rates, as well as low transport protein levels.  So, you know, burn patients certainly are highly, in a high inflammation state and often have infections.  So we need to make sure that we're using transport proteins or assessing transport proteins appropriately and in the context of inflammation.  However, if not much inflammation is occurring and we're seeing low transport protein levels, it could be an indication that we're not feeding enough adequately.  And that can result in, you know, medications, antibiotics, things like that, not being able to get to the right places in the body.  So again, underfeeding certainly has a lot of consequences as well. Now, thinking about how much to feed, we have a lot of challenges with our burn patients  in estimating our energy needs. So energy needs for our burn patients are certainly highly variable.  Like I mentioned, things like beta blockers can have an effect on the overall resting energy estimates. So that changes throughout the patient's stay as well.  We also have a lot of predictive equations that we've used in the past, but unfortunately most of those are inaccurate.  Some of the older equations have been shown to overestimate calories and some of the newer equations or a weight-based equation may underestimate the calories.  And then we always talk about indirect calorimetry as being the gold standard. However, I know that's not always available to many institutions, and especially in the  time of COVID now, we may not be moving those machines and using those machines for patients  in order to help reduce cross-contamination and reduce that risk. So indirect calorimetry, while it is the gold standard and is probably the best, most accurate  method of estimating calories, it's not always the most feasible. The other thing about indirect calorimetry is that the specific criteria that the patient  needs to meet in order to utilize a machine is very hard to meet. So there's lots of settings and functions that have to be met before you're able to  actually use the indirect calorimetry machine, and especially in a lot of the older machines. So again, not always the most practical part.  So thinking again about just feeding a lot, I want to add a few little caveats here. So yes, we need to choose an estimation method, but I would recommend choosing one and sticking  with it. Some are very accurate, but I would say pick one, and the one that I always usually recommend  is a weight-based approach, but choose one estimation method and stick with it. And that way you will be using the same one throughout your care of all your patients.  You can start to find and see trends of how it may be working for your patients. We certainly need to aim for 1.5 to 2 grams of protein per kilogram of body weight.  Getting to goal, so again, starting early, but getting to goal within 72 hours of that injury is also important.  And when we say goal, we're typically targeting at least 80% of those estimated needs. And then again, routinely monitoring the response to the dosing and adjusting it as indicated.  Now, this is where I pause for a second and give a big shout out and say, you know, advocating  for having a dietician in your burn ICU is certainly very, very beneficial for your patients. And I would say going so far as to advocate for them to be able to attend rounds every  day so that they can start to learn and see the response to the doses that they're providing.  They can understand and hear discussions about whether wounds are healing, whether skin grafts  are taking, whether they're weaning from the mechanical ventilation or not, or what barriers they're having to progressing care, and see how that may be affected by the news.  It's very, very important to have a dietician participating in that multi-professional rounding every day.  So I think the next question I probably hear a lot of you guys saying is, is this even attainable? Can we even do this? Can we feed patients within four to six hours?  Is anybody doing this? And luckily there was a pretty recent prospective analysis looking at about, I think it was  14 ICUs, burn ICUs throughout the country, throughout the world actually, Canada, Australia, the United States.  And they looked at some of these feeding practices to see where institutions were in these benchmarks.  As far as early feeding goes, unfortunately that was probably one of the most difficult, as anyone can imagine, one of the most difficult to attain.  So less than one out of every five patients received enteral nutrition within four to six hours.  The best site that achieved that was able to get 70% of their patients started within four to six hours. Protein was also another very difficult thing to accomplish and get to goal.  Only 19.2% of recorded patient days received 1.5 to 2 grams. And I believe the average length of stay was about 38 to 40 days.  So best site achieved 39.8% of days and worst site was 7.9% of days. So protein is another very hard thing to achieve. And energy requirements.  So about a third of the patients did receive 80% of their needs within 72 hours. But I think the good news here is that the best site achieved this in at least 80% of  their patients. So this seems to be one of the easier benchmarks to accomplish for your burn ICU. A few other considerations to think about.  Of course, micronutrient supplementation is common throughout burn ICUs. Vitamin C, zinc, selenium, for sure it makes sense.  Those are needed for wound healing and skin creation, collagen formation. And glutamine as well has been recommended by the European guidelines.  But in terms of how we get to, how we bust those barriers, how we get to feeding adequately,  I think there's a couple of strategies that I've seen many burn ICUs starting to implement. One of those being volume-based feeding.  So we know that many, many ICUs and many burn patients tend to go back and forth to the OR quite a bit and the two feeds get stopped very often.  So utilizing a volume-based feeding approach absolutely helped improve the delivery of that nutrition.  And the other thing that's kind of avant-garde or new, I guess, if you will, is feeding through surgery.  So many burn ICUs, and I think there's a few in Europe that have been doing this for many, many years, but many burn ICUs are starting to realize that patients don't have a whole  lot of gut involvement. And especially if they're getting these feeds started early and the patients are tolerating,  there's maybe no reason to stop two feeds for surgery when we're doing things like grafting. So consider feeding through the OR for some of your patients, and that can help deliver  adequate, more adequate nutrition. So again, to wrap all this up, for burn nutrition, it's not just about feeding a lot, but here  is my list of justs when considering feeding for your burn ICU patients. First of all, just feed the gut and feed early. This should absolutely be a benchmark for your ICU.  We should be monitoring this and adjusting as necessary. Indirect calorimetry weekly, if that's available or feasible.  If not, I recommend starting somewhere and monitoring and adjusting as necessary. My recommendation and what I've done in the past process is 25 to 30 for a TBSA of less  than 20%, 30, 35 to 40 for greater than 20%. And again, making sure you know the signs of over and under feeding and are able to  make those adjustments when they're needed for the patient. So those are my justs when feeding burn ICU patients. Not just feeding a lot, but feeding appropriately.  Thank you guys so much for having me. And I would be happy to answer any questions anyone has. Please feel free to reach out. Thank you.  Hello, my name is Sarah Taylor and I'm a clinical nurse specialist at Michigan Medicine. I want to thank the Society of Critical Care Medicine Congress Planning Committee for  inviting me to speak today. Today I'm going to be talking to you about burn wound care. I have nothing to disclose.  Our objectives today are to outline our current trends in burn wound care, to identify strategies  to prevent burn wound care infections, and to highlight the care of unique burn wounds. Before we start talking about specifics, I'd like to talk about the zones of thermal injury.  You can see from the picture here that depending on the depth of the burn, the superficial partial burn is on your left and the full thickness burn is on your right.  Depending on the thickness, the damage to the tissue is affected a bit differently. It's also good to note that initially the zones of injury is difficult to assess.  Depending on which zones are impacted, this could determine your need for wound care as well as your need for grafting. So it is important to take this into account.  Ultimately, this will determine your functional and cosmetic outcome as well. If we quickly review the depth of burn injury, you can see those listed here from superficial  all the way to full thickness burn. A full thickness burn will require surgical debridement, whereas a superficial partial  thickness burn may require a biologic dressing or perhaps a silver impregnated dressing in order to heal.  So as we talk through these different burn wounds, we'll provide you a variety of options to care for these.  The ultimate goal of all wound care is to prevent infection and to promote healing of the burn wound. Each of these categories below will be discussed briefly.  We'll talk about wound cleansing and debridement. We'll talk about different topicals. We'll talk about biologic and biosynthetic dressings, as well as definitive surgical  wound care. And again, depending on the severity of your burn wound, each of these will be determined by that. Initial wound cleansing can be done with mild soap and water.  There are some newer studies that talk about the use of a dilute chlorhexidine gluconate  for wound cleansing that have shown to reduce bacterial infections as well as improve outcomes.  If you are using a shower hydrotherapy, it is recommended to use a stretcher and no longer use submersion, as that's actually been shown to increase infection and bacterial load in  wounds. Depending on the frequency of the wound, sometimes it's desired to do a daily dressing or perhaps twice daily, depending on your bacterial load.  Also things to consider are hair removal and management. We know that hair can harbor bacteria and increase wound infection in those areas.  So the recommendation is to clip that hair surrounding the wound and again to monitor that in those areas. The picture there depicts a shower hydrotherapy tub.  There are many topical agents and dressings to care for your burn wound.  Again, depending on the wound depth, the anatomic location, the frequency of desired visualization  and the presence of microorganisms all really depict how and which topical agent or dressing will be chosen. So we'll kind of talk about each one of those a little bit.  If you are going to use bacterial counts to dictate your wound care or to define your wound care, quantitative cultures are an option.  The evidence is there's still not really a gold standard or universally accepted method of monitoring burn wound infections, but this is definitely a method that's out there and  talked about in the literature. We know that quantitative biopsies are more sensitive than swabs and we know that more  than one quantitative microbiological sample is actually better than just one in singular. If you do get these cultures and there are bacterial loads greater than 10 to the 5th,  bacterial counts per gram, this could predict a worse outcome. So again, if you are using quantitative cultures to guide your therapy, this would be an option for you.  So based on those results and again based on where the wound is and what type of bacteria you may have, there are a variety of topical antimicrobials.  I have a few of them listed here and this is by no means an extensive and exhaustive list, but kind of more of your more common ones.  Silvadene, silver sulfidizing cream is kind of the common go-to for burn care. It's initial dressing, it's easy to take on and take off, and it allows for good visualization  of the wound. If you had more of a post-op dressing or a post-graft dressing, more superficial dressing, you could use something like a Xeroform.  Or if you were looking for a solution instead of a cream, there are things like Dakin's solution, sulfamylon solution as well.  So again, depending on what your actual bacteria are in the wound and what your goal is, there are some topical antimicrobial options.  If you're looking for a more long-term dressing or a longer wear dressing, there are silver impregnated dressings.  These have an absorptive layer, some do not have an absorptive layer. This has a continuous release of silver ions, so again can be left in place for 5-14 days  depending on the product. Silver dressings are good against gram-negative and gram-positive bacteria, many antibiotic-resistant bacteria as well as yeast and mold.  So this is a really great option for some of your burn wounds. Some of these dressings do require re-wetting with water, so that's something to keep in mind, whereas some do not.  So these are pretty low maintenance, good dressings to send patients home with, return to clinic for follow-up, really eliminate your need for daily wound care, and it does  have easier range of motion for these patients as well. So this is a really great option. If you're worried about fungus in the wound, there are different antifungals that can be  added to either the creams or the powders, different solutions, so you can mix these in.  Again, topically, mixed in with those antibacterial agents, so this is also a good option, particularly if you know which fungus is growing.  If you have small areas that do require a debridement or small areas of full-thickness injury, there are enzymatic agents that are available.  Again these are used to debride smaller areas of necrotic tissue, usually nothing bigger than a quarter sized.  The thing to note about these agents is there's no antibacterial or antimicrobial properties, so if you are worried about infections in these areas, usually it's good practice to  rotate with an antimicrobial agent as well.  Some other agents that are used and worth discussing for burn wound care, there is medical grade honey that is available.  It is meant for use in superficial and partial thickness wounds only. There have been a number of animal trials that may suggest accelerated wound healing  with the medical grade honey. Again, this is medical grade honey, not the honey out of your kitchen cupboard. There's also been some trials with the povidine iodine.  Those are a bit controversial because of the cytotoxic effects and some believe that it may actually delay the epithelialization, but other products worth noting as you may  come across those in your practice. As we move away from topical creams, there are a couple of biologic dressing options.  Biologic dressing offers a temporary covering either from human or animal tissue. You have a couple options here.  Allograft or sometimes called homograft is the graft of skin transplanted from another human living or dead.  Usually this is a temporary covering, again, not meant to be permanent, but to cover the wound to help with pain as well as moisture management in these patients and fluid loss.  Adenograft, also called heterograft, is usually pigskin, and again, this can also be used as a temporary covering for partial thickness injuries. These are a couple options.  There are a couple biosynthetic dressings. These are based on wound coverage from a biologic or synthetic materials.  Epidermal replacements are commercially manufactured, cultural epidermal autografts from autologous  keratinocytes via a skin biopsy and morine fibroblasts delivered on a silicone or gauze layer.  This is another good option for a partial thickness wound or a wound that's been debrided where you have minimal donor site availability.  Another option for partial or some of your full thickness wounds is a negative pressure wound therapy.  You can see from the picture how this really increases blood flow, can improve granulation tissue, and sometimes this is used postoperatively as well.  Negative pressure wound therapy is a great option for some of these wounds. Ultimately, if your patient does have a deep or a full thickness burn, definitive surgical  wound closure is ultimately the goal of wound care. These patients require an autograft or a skin graft taken from their own body somewhere,  either split thickness, a sheet graft, or a mesh graft. Sometimes depending on the area involved, we can do a full thickness graft.  The cultured epidermal autograft that we talked about earlier taken from a small biopsy and  then grown on a gauze, that's another option as well as autologous cell harvesting device,  which is a newer device that's available that can help supplement the wider mesh autografts to help fill in and improve epithelialization. Also of note are donor sites.  I think donor sites are one of the trickier things in the burn wound world. There's still not a perfect donor site dressing.  Again, donor site is basically a partial thickness burn wound, and so all of your dressings that  you would use for partial thickness injuries can also be used for donor site, again, without really the perfect donor site yet to be out there.  The last thing that I'd like to talk about are just some other considerations that aren't necessarily burn wounds.  They're different types of burn wounds, but kind of get lumped into burn wounds that often are a little bit tricky and have lots of questions that come up.  The first thing that I want to talk about are chemical burns. The really important thing about chemical burns, first and foremost, keep yourself safe.  You always want to check the material safety data sheet for any sort of chemical information on what to do with each specific chemical, but in general, you want to make sure that  the clothing of the patient is removed. If there's any loose powder, you want to brush that off first and then really irrigate.  This is liters and liters and liters of fluid, so again, depending on where you might see this patient, you want to keep yourself safe as well.  You want to, again, take precautions for a splash injury. You want to always check the patient's eyes.  And hydrofluoric acid is what you would neutralize the fluoride iodine and prevent systemic toxicity with calcium gluconate gel.  So that is the one thing, if you have a hydrofluoric acid burn, that you would neutralize the agent.  Unfortunately, you don't neutralize agents as this actually causes an exothermic reaction and causes another burn injury. So that's why I like to talk about chemical burns.  The next burn that we'll briefly talk about are electrical burns. So again, just real brief, the current of electricity is going to flow through the path of least resistance.  The skin is your most resistant organ to the electrical injury, so it's going to usually flow down those bone paths.  Once that resistance is breached, the current then flows through the underlying tissue. So you may not see a lot of external burns on these patients, but usually an entrance  and exit wound. And so here's an example of an exit wound. So again, you want to just be mindful of that as you look at these burn wounds.  The other thing that gets lumped into burn wounds is frostbite. And again, as we're coming into that season here in the Midwest, we think about frostbite.  And so there really isn't a consensus on blister management, and so this is a really important thing to consider.  We do know that the non-hemorrhagic blisters may be debrided, but if there are hemorrhagic blisters, we really shouldn't be debriding those, as that can cause more damage.  There is a consensus about topical aloe. It can be used to prevent further pain and is a good option for these patients.  But these definitely should be consulted with a burn center or a professional for management of these burn wounds. The last thing that we'll briefly talk about are thermal blisters.  And so again, I think that this often comes up in our emergency department and even in our ICUs about should we leave the blisters intact or should we not?  Again, leaving them intact is less painful, but depending on the location of the blister, if it's over an area of function or mobility, those blisters should be unroofed.  And if the blister is greater than a centimeter, we really should unroof those blisters so that the antimicrobial dressing or ointment can penetrate those burn wounds.  Have my references listed here.  Thank you.

Video Summary

In this video, three speakers discuss various aspects of caring for burned patients in the ICU. Dr. Jong Lee introduces the session and highlights the importance of burn care for intensivists, particularly in the event of a mass disaster. He emphasizes the need for intensive care management beyond the initial resuscitation phase. The first speaker, Dr. Parinlai Angpokta, focuses on the management of inhalation injuries and the considerations for ventilator support. Ms. Ashley DePriest discusses nutritional support for burned patients and dispels the notion that it is simply about feeding a lot. She emphasizes the importance of feeding the gut and the benefits it provides for burns patients. Ms. Sarah Taylor provides an overview of burn wound care, discussing topics such as wound cleansing, topical agents, biologic dressings, and surgical wound closure. She also touches on special considerations for chemical burns, electrical burns, frostbite, and thermal blisters. Overall, the session covers important aspects of burn care for intensivists beyond the initial resuscitation phase.

Asset Subtitle

Trauma, GI and Nutrition, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Learning Objectives

Discuss the management of severe inhalation injuries, including initial considerations, airway management, and ventilator management
Describe practical approaches for feeding burn patients in the ICU, including timing, route, and amount
Compare optimal practical approaches to providing sedation and analgesia in burn patients
Recognize the unique wound management needs of burn patients in the ICU, including multidrug-resistant infection

Nutritional Support for Burn Patients: Just Feed a Lot? Ashley D. DePriest What About Burn Wounds? Sarah L. Taylor

Meta Tag

Content Type Presentation

Knowledge Area Trauma

Knowledge Area GI and Nutrition

Knowledge Level Advanced

Membership Level Select

Tag Burns

Tag Inhalation Injury

Tag Nutrition

Year 2021

Keywords

burn care

ICU

intensivists

inhalation injuries

nutritional support

burn wound care

wound cleansing

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