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Anesthesia for Burn injuries Flashcards

1
Q

Functions of the skin include

A 
barrier- body fluids & infection
temperature
elasticity 
appearance
sensory organ
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2
Q

Anatomy of the skin includes

A

the hair follicle and nerve fibers are in the dermis

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3
Q

Types of burn injuries include

A

thermal- flash, flame, & scaled
chemical
electrical
radiological

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4
Q

Regardless of the etiology, burns are classified according to

A

depth- extent of skin & tissue destruction- superficial, partial thickness, & full thickness
total body surface area involved- rule of nines

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5
Q

Describe the depth of superficial burns

A

1st degree

destruction of epidermis

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6
Q

Describe pain level of superficial burns

A

very painful

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7
Q

Describe appearance of superficial burns

A

red

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8
Q

Describe characteristics of superficial burns

A

dry, flaky

will heal spontaneously in 3-5 days

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9
Q

Describe depth of partial thickness burns.

A

2nd degree
superficial or deep
-epidermis up to deep dermal element

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10
Q

Describe pain level of partial thickness burns

A

very painful

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11
Q

Describe appearance of partial thickness burns.

A

bright cherry red, pink or pale ivory, usually with fluid filled blistering

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12
Q

Describe characteristics of partial thickness burns

A

hair follicle intact- may require skin graft

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13
Q

Describe depth of full thickness burns.

A

all of the epidermis, dermis, down into the subcutaneous tissue

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14
Q

Describe the pain level of full thickness burns

A

little or no pain- in a trauma situation a SNS response still may cause lots of pain due to psychological component

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15
Q

Describe the appearance of full thickness burns.

A

khaki brown, white, or charred/cherry red is pediatrics

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16
Q

Describe the characteristics of full thickness burns.

A

loss of hair follicles will require skin graft

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17
Q

Describe a fourth degree burn.

A

full thickness extending into muscle and bone

will require skin graft and possible amputation

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18
Q

Describe depth, appearance, causes, level of pain, healing time, and scarring for a first degree burn.

A 
Depth- epithelium
appearance- no blisters, dry pink
causes- sunburn, scald, flash flame 
level of pain- painful, tender, & sore
healing time- two to five days; peeling
scarring- no scarring; may have discoloration
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19
Q

Describe depth, appearance, causes, level of pain, healing time, and scarring for second degree burn.

A

depth- epithelium and top aspects of the dermis
appearance- moist, oozing blisters, moist, white to pink, to red
causes- scalds, flash burns, chemicals
level of pain: very painful
healing time: superficial- 5 to 21 days; deep 21-35 days
scarring: minimal to no scarring; may have discoloration

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20
Q

Describe depth, appearance, causes, level of pain, healing time, and scarring for third degree burn.

A

depth- epithelium & dermis
appearance- leathery, dry no elasticity; charred appearance
causes- contact with flame, hot surface, hot liquids, chemical, electric
level of pain: very little pain or no pain
healing time- small areas may take months to heal; large areas may need grafting
scarring- scarring present

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21
Q

Describe the rule of nines.

A

head= 9% TBSA
Upper extremities= 18% TBSA- each arm= 9%
trunk= 36%TBSA; front/back= 18% each
lower extremities= 36% TBSA; each leg= 18%
pediatric is exception

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22
Q

Burns that should be transferred to a burn center include

A

full thickness burns in any age group
partial thickness >10% TBSA
Burns of special areas
-at extreme of age
-burns of face, hands, feet, perineum, or major joints
-inhalation, chemical, & electrical burns
-those burns associated with co-existing disease

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23
Q

The National Burn Registry states the mortality of burns is as follows:

A

if the age of the patient plus the TBSA is >115 the mortality is greater than 80%

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24
Q

Mortality is increased with

A

associated injury- inhalation injury & other trauma

pre-morbid condition

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25
The resuscitative phase of burns involves
-initial treatment of the burn patient should involve- airway, breathing, circulation, and coexisting trauma
26
Closed space thermal injury equates to
airway injury****
27
Open space "accidental injury (campfire), motor vehicle crash equates to
multiple co-existing injuries
28
Electrical injury may lead to occult
``` severe fracture hematoma visceral injury skeletal cardiac injury neurologic injury ```
29
Diagnosis of airway injury in the burn patient is made by
history & physical exam (DVL or fiberoptic bronchoscopy)
30
Airway management in the burn patient includes aggressively ruling out
upper airway injury in patients at risk (closed space injury, unconsciousness)
31
Signs & symptoms of airway complications include
singed facial hair, facial burns, dysphonia/hoarseness, cough/carbonaceous sputum, soot in mouth/nose, swallowing impairment, oropharynx inflammation, CXR initially normal (until pulmonary edema or infiltration develops)***
32
Inhalation injury refers to
damage to the respiratory tract or lung tissue from heat, smoke, or chemical irritants carried into the airway during inspiration
33
Upper airway inhalational injury presents as
thermal damage to soft tissues of the respiratory tract and trachea can make intubation difficult thermal injury plus fluid resuscitation increases the risk for glottic edema
34
Lower airway inhalational injury presents as
pulmonary edema/ARDS develops 1-5 days post-burn | pneumonia and pulmonary embolism >5 days post burn
35
Smoke inhalation occurs in conjunction with
face/neck burns and closed space fires
36
______ occurs after smoke/toxic fume inhalation
chemical pneumonitis similar to gastric aspiration
37
Smoke inhalation may present as
honeymoon period 1st 48 hours with clear CXR decreased PaO2 on room air is 1st sign increased sputum with rales/wheeze
38
In regards to hypoxia in the burn patient with inhalational injury, the first 36 hours equates to
high risk of pulmonary edema
39
Hypoxia in the burn patient with inhalational injury will see the following in days 2-5
expect atelectasis, bronchopneumonia, airway edema maximum secondary to sloughing of airway mucosa, thick secretions, distal airway obstruction
40
Hypoxia in the burn patient with inhalational injury will see the following after >5 days post-burn
nosocomial pneumonia, respiratory failure, ARDS
41
Circumferential burns of chest & upper abdomen may cause
restricted chest wall motion as eschar contracts & hardens
42
If inhalation injury or facial burns occur
intubate & secure the airway early!
43
Airway management in the burn patient includes
patent airway= maximum FiO2 via facemask
44
The following should be performed in patients with suspected inhalational airway injury
serial larygoscopic/bronchoscopic exams, CXR, ABGs, and PFTs
45
An ETT is indicated in airway management in the burn patient if the following occur
``` massive burn stridor respiratory distress hypoxia/hypercarbia altered level of consciousness prophylactic intubation if deterioration likely ```
46
Intubation technique for the airway management in the burn patient depends on
patient factors extent of airway damage age co-existing disease
47
The safest approach for airway management in the burn patient is
fiberoptic intubation under adequate topical anesthesia is safest approach
48
For the pediatric patient with suspected inhalational or burn injury,
there is a low threshold for intubation due to small diameter airways
49
Treatment of hypoxia in burn patient with inhalational injury includes
``` PEEP airway humidification bronchial suctioning/lavage bronchodilators antibiotics chest physiotherapy ```
50
Restriction of respiratory excursion may necessitate
escharotomy
51
Smoke inhalation and ______ are usually found together
CO poisoning
52
Carbon monoxide has 200 times the affinity
for hemoglobin as O2
53
CO shifts hemoglobin dissociation curve
LEFT***** impairing O2 unloading to the tissue
54
CO interferes with
mitochondrial function uncouples oxidative phosphorylation reduces ATP production resulting in metabolic acidosis*****
55
CO may act as a
myocardial toxin & prevent survival of cardiac arrest
56
With carbon monoxide toxicity, the following signs & symptoms may appear
SaO2 may be normal respiratory effort may appear normal "Cherry-red" blood color may NOT be present if CO is <40% and/or the patient is cyanotic & hypoxic
57
Management of patients with suspected carbon monoxide toxicity includes
high FiO2 on all burn patients until CO toxicity is ruled out
58
COHbg >60% is
incompatible with life | DEATH
59
Hyperbaric chamber is recommended for patients with carbon monoxide if
COHgb is >30% & patient is hemodynamically & neurologically stabilized
60
Carbon monoxide levels of <15-20% may appear as
headache, dizziness, confusion
61
Carbon monoxide levels of 20-40% may appear as
nausea, vomiting, disorientation & visual impairment
62
Carbon monoxide levels of 40-60% may appear as
agitation, combative, hallucinations, coma & shock
63
Cyanide is produced as
synthetic materials burn | -victims inhale & absorb it through mucous membranes
64
______ results with elevated lactate levels as a result of cyanide toxicity
metabolic acidosis
65
Cyanide toxicity may present as
altered LOC with agitation, confusion or coma | CV depression/arrhythmia risk
66
Blood cyanic levels of _____ confirm diagnosis
>0.2 mg/L | 1.0 mL/L is lethal
67
The treatment of choice for cyanide poisoning is
oxygen
68
Cyanide has a half-life of
60 minutes
69
Other treatments for cyanide toxicity include
hydroxycobalamine (Vitamin B12), amyl nitrate, sodium nitrate, thiosulfate
70
Release of inflammatory mediators locally at the burned tissue and systemically contribute to
edema associated with burn injury
71
Increase in microvascular permeability lead to
fluid leak loss of proteins
72
Additional systemic effects of burns include
increased intravascular hydrostatic pressure/decreased interstitial hydrostatic pressure interstitial osmotic pressure increases
73
__________ can perpetuate this mediator-induced systemic inflammatory response that may lead to multiple organ failure
surgery & infections
74
Overall systemic results of burn injuries include
``` immune suppression activation of the hypothalamo-adrenal axis and the renin-angiotensin/aldosterone system hypermetabolism protein catabolism sepsis multi system organ failure ```
75
In regards to cardiovascular stresses with burn injury, after 24-48 hours, the body has a
hyperdynamic state (high output CHF)- increased BP, HR, CO 2x normal
76
In regards to cardiovascular stressors, _______ lasts for the first 24 hours
severe decrease in cardiac output
77
Circulating tumor necrosis factor leads to
myocardial depression
78
Increased microvascular permeability leads to
hypovolemia
79
Cardiovascular stressors related to burn injuries include
diminished response to catecholamines increased microvascular permeability--> hypovolemia intense vasoconstriction compensation decreased tissue O2 supply and coronary blood flow hemolysis of erythrocytes
80
Increased metabolic rate is proportional to
TBSA burned (can double in 50% TBSA)
81
________ reflects increased metabolic state
increased core body temp
82
Loss of skin leads to
loss of vasoactivity, piloerection, insulation functions
83
Daily evaporative loss of burn patients is
4000 mL/m2
84
________ is increased in burn patients as a result of increased metabolism
caloric consumption
85
End organ complications related to GI include
ileus, ulceration, cholecystitis
86
End organ complications related to the renal system include
decreased GFR, RBF, loss of Ca, K, Mg with retention of Na, H2O
87
End organ complications related to blood & coagulation include
increased viscosity-> increase in clotting factors including fibrinogen, V & VIII, fibrin split products at risk of DIC development, HCT usually decreases (RBCs decreased half-life)
88
End organ complications related to endocrine include
increased corticotropin, ADH, renin, angiotensin, aldosterone, increased glucagon, insulin resistance, hyperglycemia (at risk nonketotic hyperosmolar coma esp. TPN).
89
Loss of fluid from vascular compartment occurs in
1st 24 hours--> replaced with 2-4 mL/kg for each 1% TBSA burned
90
Fluids should be titrated to
urine output of 0.5-1.0 mL/kg/hr.
91
Over aggressive fluids can worsen
airway edema, increase chest wall restriction and contribute to abdominal compartment syndrome
92
Fluid type in the first 24 hours should be
crystalloid only
93
>24 hour fluid administration can consider
colloids at 0.3-0.5 mL/kg/% burn with 5% dextrose in water
94
Describe the Parkland formula
4.0 mL LR/kg/% burn/1st 24 hours with 50% admin in 1st 8 hr. 25% 2nd 8 hr. 25% 3rd 8 hr.
95
Describe the modified Brooke formula
2.0 mL LR/kg/% burn/1st 24 hours with 50% admin in 1st 8 hr. 25% 2nd 8 hr. 25% 3rd 8 hr.
96
Goals of fluid resuscitation include
``` urine output= 0.5-1.0 mL/kg/hr HR= 80-140 (consider age) MAP= adults >60 mmHg Base deficit= <2 normal Hct ```
97
If perfusion/urine output is inadequate despite >6 mL/kg/% TBSA burn & the patient has normal or high CVP
consider low dose dopamine 5 mcg/kg/min | consider other vasopressors
98
Major areas of concern related to repeat surgeries for burn patients includes
maintain Hct: multiple transfusions coagulopathy temperature fluids & electrolytes hypermetabolic state= increase O2, ventilation, nutrition increased risk for GI ileus- aspiration/hyperalimentation
99
Describe blood loss per excision of skin
200-400 mL of blood loss for each % area that is excised | conservation can be by epi or thrombin soaked sponges
100
Challenges related to monitoring of the burn patient includes
burned tissue= limited access for ECG, SaO2, PNS, NIBP- consider a-line
101
Blood loss for burn patients can be minimized by
topical/SQ epinephrine, only 15-20% TBSA q procedure, tourniquets
102
Challenges for the burn patient include
need large bore IV access- may consider alternative areas for placement compensate for evaporative/exposure heat loss- room temp 28-32 degrees C treat the complications of massive transfusion (coagulopathy & hypocalcemia
103
Preop evaluation of the burn patient includes
``` airway phase of resuscitation monitoring intravascular access equipment ```
104
Anesthesia considerations for the high voltage electrical injury include
follows path of least resistance; bone most resistant cardiac arrhythmias respiratory arrest seizure fractures muscle damage--> myoglobinurea--> renal failure
105
Patients with burns require HIGH
opioid requirements | -ideal anesthetic choice is isoflurane+ large dose opioid
106
Serial debridements may require
ketamine in incremental doses | regional anesthesia
107
Describe the use of muscle relaxants for burn patients
1st 24 hours- unaltered response to depolarizing & non-depolarizing muscle relaxants 24 hours to 1 year post burn avoid succinylcholine due to massive release of K+--> may be due to the proliferation of acetylcholine receptors along the entire muscle membrane -resistance to most NDMR if >30% TBSA burned

Advanced Principles 2 (42 decks)

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