16. Critial care and Surgery cases learnign points

Question 1

What are the different types of burns

Answer 1

Scalds- wet heat burns

Thermal- dry heat butns

Electrical burns- caused by electricity

Chemical burns- caused by substances

Radiation burn- caused by sunburn/sunbeds

Question 2

What is the Jackson Burn Model

Answer 2

Well known explanation of how burns effect the body;

Zone of coagulative necrosis- the zone where the heat is transferred to leading to cellular death

Zone of stasis- Inflammation and impaired vascularity leads to ischemia. Tissue may be viable

Zone of hyperaemia- Inflammatory mediators are released leading to inflammation and hyperaemia

Question 3

What is classes as a significant burn injury.

Why is this important?

Answer 3

20-25%,

This causes alterations in the function o almost every organ system in the body due to neural stimulation and inflammatory repsonses

Question 4

How is circulation affected by burns?

Answer 4

Fluid is loss by weeping areas

Red cells destroyed by heamolysis

Vascular permeability is increased along with vasodilation leading to hypovolaemic shock

Question 5

How are the kidneys affected by burns

Answer 5

Renal perfusion is reduced

The release of heamobglobin (heamolysis) and myoglobin (rhabdomyolysis) leads to acute renal failure

Question 6

How does a burn affect metabolic rate

Answer 6

Cortisol, glucagon and various catecholamines (e.g. epinephirine) are released

Insulin and growth hormone are released (suppression of anabolic hormones)

This causes a hypermetabolic state due to the bodys attempt to try and make free amino acids

Question 7

How is the immune system affected by burns?

Answer 7

It is suppressed due to the release of cortisol

Question 8

What are the common problematic agents involved in burns infections

Answer 8

Pseudomonas and MRSA

Fungal infections in the later stages

Question 9

How is the respiratory system affected by burns

Answer 9

Leads to ARDS- lung damage due to inflammatory mediators causing increased vascular permeability

Question 10

How do burns affect the GI system

Answer 10

May develops stress uclers and so are given PPI’s prophylactically

Question 11

What should be assessed for in a burns history to try and illicit any hidden causes of injury

Answer 11

Time of injury and circumstances (broken bones)
First aid received (water, analgesia)
Immunisation history (especially tetanus)
PMH (esp diabetes)
DH (including allergies)

Question 12

Describe what is involved in the treatment of burns

Answer 12

Stop burn from happening
Cool wound (water temp 15 degrees for 20 mins)
(too cold leads to vasoconstriction)
Wrap burn in clingfilm, place in plastic bag
Analgesia

Question 13

What is the next stage of burn management when someone arrives at hospital?

Answer 13

A
B
C- apply pressure to bleeding wounds, fluid resus, take blood (U&E’s, carboxyhaemoglobin)
D
E- check back, strip clothes, prevent hypothermia

Question 14

What other management options should be considered?

Answer 14

X-ray (chest, pelvis, cervical spine)
Pain relief (IV morphine titrated)
Tetanus immunisation
Antibiotic- contested topic since wound is sterile

Question 15

What is involved in the secondary survey?

Answer 15

Allergies
Mediactions
Past medical history
Last meal
Evironemnt/events surrounding injury

Question 16

What are the two most important determinants of a burn?

Answer 16

Depth of tissue affected

Total body surface area affected

Question 17

What is the next stage of burn management when someone arrives at hospital?

Answer 17

A
B
C- apply pressure to bleeding wounds, fluid resus, take blood (U&E’s, carboxyhaemoglobin)
D
E- check back, strip clothes, prevent hypothermia

Question 18

What other management options should be considered?

Answer 18

X-ray (chest, pelvis, cervical spine)
Pain relief (IV morphine titrated)
Tetanus immunisation
Antibiotic- contested topic since wound is sterile

Question 19

What is involved in the secondary survey?

Answer 19

Allergies
Mediactions
Past medical history
Last meal
Evironemnt/events surrounding injury

Question 20

What are the two most important determinants of a burn?

Answer 20

Depth of tissue affected

Total body surface area affected

Question 21

How do you classify the depth of a tissue burn?

Answer 21

Superficial-
Partial thickness/deep dermal
Full thickness

Question 22

How should fluid resuscitation be calculated for Burns victims?

Answer 22

Using hospital policy or Parkland’s formula:

4ml x %BSA x Weight= fluid given per 24 hours

1/2 given in first 8 hours
1/2 given in next 16 hours

(this does not apply to kids)

Question 23

What changes are made to fluid resus in the paediatric population

Answer 23

intraosseous line if IV access cant be achieved
make sure childrens version of lund-brower chart is used
Children receive normal saline and 5% dextrose to avoid hypoglycaemia
Take capillary glucose every 4-6 hours
Children’s prescribing fluid varies by weight

Question 24

What methods are used to assess fluid resuscitation?

Answer 24

Catheter (aim for 0.5ml/kg/hr of urine
Central venous line (CVP-8-10)
Blood pressure 
HR (probably tachycardic anyway)
ABG- low pH or raised lactate= inadequate perfusion

Question 25

What is a very useful resource for assessing TBSA?

Answer 25

Lund-browner chart

Question 26

How should fluid resuscitation be calculated for Burns victims?

Answer 26

Using hospital policy or Parkland’s formula:

4ml x %BSA x Weight= fluid given per 24 hours

1/2 given in first 8 hours
1/2 given in next 16 hours

Question 27

What is the management of inhalation injuries?

Answer 27

Very hard to detect and prove so if slight suspicion TREAT!

Humdiified oxygen at 15 litres per minute via a non breathing mask

Monitor sats continuously

Get senior help and anaesthetist

Need greater quantities of fluid resus

Question 28

What methods are used to assess fluid resuscitation?

Answer 28

Catheter (aim for 0.5ml/kg/hr of urine
Central venous line (CVP-8-10)
Blood pressure 
HR (probably tachycardic anyway)
ABG- low pH or raised lactate= inadequate perfusion

Question 29

What types of burns require immediate surgery?

Answer 29

Burns to eyelids, circumferential burns

Escharotemy/fasciotmey/debridement to avoid complications such as limb ischaemia

Question 30

What are the two most common inhalation injuries?

Answer 30

Carbon monoxide poisoning

Cyanide poisoning- loss of coniousness, neurotoxicity, convulsions

Very hard to detect and prove so treat ASAP!

Question 31

What is the management of inhalation injuries?

Answer 31

Very hard to detect and prove so if slight suspicion TREAT!

Humdiified oxygen at 15 litres per minute via a non breathing mask

Monitor sats continuously

Get senior help and anaesthetist

Need greater quantities of fluid resus

Question 32

What is the main treatment for burn victims?

Answer 32

Surgery to excise non-viable tissue and close wound sites with autografts

Question 33

What types of burns require immediate surgery?

Answer 33

Burns to eyelids, circumfrential burns

Escharotemy/fasciotmey/debridement to avoid complications such as limb ischeamia

Question 34

How do you treat a chemical burn?

Answer 34

Irrigation with water (until it brings the pH level down)