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Advanced Principles 2 > Anesthesia for Burn injuries > Flashcards

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
Q

The resuscitative phase of burns involves

A

-initial treatment of the burn patient should involve- airway, breathing, circulation, and coexisting trauma

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26
Q

Closed space thermal injury equates to

A

airway injury**

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27
Q

Open space “accidental injury (campfire), motor vehicle crash equates to

A

multiple co-existing injuries

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28
Q

Electrical injury may lead to occult

A 
severe fracture
hematoma
visceral injury
skeletal
cardiac injury
neurologic injury
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29
Q

Diagnosis of airway injury in the burn patient is made by

A

history & physical exam (DVL or fiberoptic bronchoscopy)

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30
Q

Airway management in the burn patient includes aggressively ruling out

A

upper airway injury in patients at risk (closed space injury, unconsciousness)

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31
Q

Signs & symptoms of airway complications include

A

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)***

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32
Q

Inhalation injury refers to

A

damage to the respiratory tract or lung tissue from heat, smoke, or chemical irritants carried into the airway during inspiration

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33
Q

Upper airway inhalational injury presents as

A

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

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34
Q

Lower airway inhalational injury presents as

A

pulmonary edema/ARDS develops 1-5 days post-burn

pneumonia and pulmonary embolism >5 days post burn

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35
Q

Smoke inhalation occurs in conjunction with

A

face/neck burns and closed space fires

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36
Q

______ occurs after smoke/toxic fume inhalation

A

chemical pneumonitis similar to gastric aspiration

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37
Q

Smoke inhalation may present as

A

honeymoon period 1st 48 hours with clear CXR
decreased PaO2 on room air is 1st sign
increased sputum with rales/wheeze

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38
Q

In regards to hypoxia in the burn patient with inhalational injury, the first 36 hours equates to

A

high risk of pulmonary edema

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39
Q

Hypoxia in the burn patient with inhalational injury will see the following in days 2-5

A

expect atelectasis, bronchopneumonia, airway edema maximum secondary to sloughing of airway mucosa, thick secretions, distal airway obstruction

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40
Q

Hypoxia in the burn patient with inhalational injury will see the following after >5 days post-burn

A

nosocomial pneumonia, respiratory failure, ARDS

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41
Q

Circumferential burns of chest & upper abdomen may cause

A

restricted chest wall motion as eschar contracts & hardens

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42
Q

If inhalation injury or facial burns occur

A

intubate & secure the airway early!

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43
Q

Airway management in the burn patient includes

A

patent airway= maximum FiO2 via facemask

44
Q

The following should be performed in patients with suspected inhalational airway injury

A

serial larygoscopic/bronchoscopic exams, CXR, ABGs, and PFTs

45
Q

An ETT is indicated in airway management in the burn patient if the following occur

A 
massive burn
stridor
respiratory distress
hypoxia/hypercarbia
altered level of consciousness
prophylactic intubation if deterioration likely
46
Q

Intubation technique for the airway management in the burn patient depends on

A

patient factors
extent of airway damage
age
co-existing disease

47
Q

The safest approach for airway management in the burn patient is

A

fiberoptic intubation under adequate topical anesthesia is safest approach

48
Q

For the pediatric patient with suspected inhalational or burn injury,

A

there is a low threshold for intubation due to small diameter airways

49
Q

Treatment of hypoxia in burn patient with inhalational injury includes

A 
PEEP
airway humidification
bronchial suctioning/lavage
bronchodilators
antibiotics
chest physiotherapy
50
Q

Restriction of respiratory excursion may necessitate

A

escharotomy

51
Q

Smoke inhalation and ______ are usually found together

A

CO poisoning

52
Q

Carbon monoxide has 200 times the affinity

A

for hemoglobin as O2

53
Q

CO shifts hemoglobin dissociation curve

A

LEFT***** impairing O2 unloading to the tissue

54
Q

CO interferes with

A

mitochondrial function
uncouples oxidative phosphorylation
reduces ATP production
resulting in metabolic acidosis*****

55
Q

CO may act as a

A

myocardial toxin & prevent survival of cardiac arrest

56
Q

With carbon monoxide toxicity, the following signs & symptoms may appear

A

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
Q

Management of patients with suspected carbon monoxide toxicity includes

A

high FiO2 on all burn patients until CO toxicity is ruled out

58
Q

COHbg >60% is

A

incompatible with life

DEATH

59
Q

Hyperbaric chamber is recommended for patients with carbon monoxide if

A

COHgb is >30% & patient is hemodynamically & neurologically stabilized

60
Q

Carbon monoxide levels of <15-20% may appear as

A

headache, dizziness, confusion

61
Q

Carbon monoxide levels of 20-40% may appear as

A

nausea, vomiting, disorientation & visual impairment

62
Q

Carbon monoxide levels of 40-60% may appear as

A

agitation, combative, hallucinations, coma & shock

63
Q

Cyanide is produced as

A

synthetic materials burn

-victims inhale & absorb it through mucous membranes

64
Q

______ results with elevated lactate levels as a result of cyanide toxicity

A

metabolic acidosis

65
Q

Cyanide toxicity may present as

A

altered LOC with agitation, confusion or coma

CV depression/arrhythmia risk

66
Q

Blood cyanic levels of _____ confirm diagnosis

A

> 0.2 mg/L

1.0 mL/L is lethal

67
Q

The treatment of choice for cyanide poisoning is

A

oxygen

68
Q

Cyanide has a half-life of

A

60 minutes

69
Q

Other treatments for cyanide toxicity include

A

hydroxycobalamine (Vitamin B12), amyl nitrate, sodium nitrate, thiosulfate

70
Q

Release of inflammatory mediators locally at the burned tissue and systemically contribute to

A

edema associated with burn injury

71
Q

Increase in microvascular permeability lead to

A

fluid leak loss of proteins

72
Q

Additional systemic effects of burns include

A

increased intravascular hydrostatic pressure/decreased interstitial hydrostatic pressure
interstitial osmotic pressure increases

73
Q

__________ can perpetuate this mediator-induced systemic inflammatory response that may lead to multiple organ failure

A

surgery & infections

74
Q

Overall systemic results of burn injuries include

A 
immune suppression 
activation of the hypothalamo-adrenal axis and the renin-angiotensin/aldosterone system
hypermetabolism 
protein catabolism
sepsis
multi system organ failure
75
Q

In regards to cardiovascular stresses with burn injury, after 24-48 hours, the body has a

A

hyperdynamic state (high output CHF)- increased BP, HR, CO 2x normal

76
Q

In regards to cardiovascular stressors, _______ lasts for the first 24 hours

A

severe decrease in cardiac output

77
Q

Circulating tumor necrosis factor leads to

A

myocardial depression

78
Q

Increased microvascular permeability leads to

A

hypovolemia

79
Q

Cardiovascular stressors related to burn injuries include

A

diminished response to catecholamines
increased microvascular permeability–> hypovolemia
intense vasoconstriction compensation
decreased tissue O2 supply and coronary blood flow
hemolysis of erythrocytes

80
Q

Increased metabolic rate is proportional to

A

TBSA burned (can double in 50% TBSA)

81
Q

________ reflects increased metabolic state

A

increased core body temp

82
Q

Loss of skin leads to

A

loss of vasoactivity, piloerection, insulation functions

83
Q

Daily evaporative loss of burn patients is

A

4000 mL/m2

84
Q

________ is increased in burn patients as a result of increased metabolism

A

caloric consumption

85
Q

End organ complications related to GI include

A

ileus, ulceration, cholecystitis

86
Q

End organ complications related to the renal system include

A

decreased GFR, RBF, loss of Ca, K, Mg with retention of Na, H2O

87
Q

End organ complications related to blood & coagulation include

A

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
Q

End organ complications related to endocrine include

A

increased corticotropin, ADH, renin, angiotensin, aldosterone, increased glucagon, insulin resistance, hyperglycemia (at risk nonketotic hyperosmolar coma esp. TPN).

89
Q

Loss of fluid from vascular compartment occurs in

A

1st 24 hours–> replaced with 2-4 mL/kg for each 1% TBSA burned

90
Q

Fluids should be titrated to

A

urine output of 0.5-1.0 mL/kg/hr.

91
Q

Over aggressive fluids can worsen

A

airway edema, increase chest wall restriction and contribute to abdominal compartment syndrome

92
Q

Fluid type in the first 24 hours should be

A

crystalloid only

93
Q

> 24 hour fluid administration can consider

A

colloids at 0.3-0.5 mL/kg/% burn with 5% dextrose in water

94
Q

Describe the Parkland formula

A

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
Q

Describe the modified Brooke formula

A

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
Q

Goals of fluid resuscitation include

A 
urine output= 0.5-1.0 mL/kg/hr
HR= 80-140 (consider age)
MAP= adults >60 mmHg
Base deficit= <2
normal Hct
97
Q

If perfusion/urine output is inadequate despite >6 mL/kg/% TBSA burn & the patient has normal or high CVP

A

consider low dose dopamine 5 mcg/kg/min

consider other vasopressors

98
Q

Major areas of concern related to repeat surgeries for burn patients includes

A

maintain Hct: multiple transfusions
coagulopathy
temperature
fluids & electrolytes
hypermetabolic state= increase O2, ventilation, nutrition
increased risk for GI ileus- aspiration/hyperalimentation

99
Q

Describe blood loss per excision of skin

A

200-400 mL of blood loss for each % area that is excised

conservation can be by epi or thrombin soaked sponges

100
Q

Challenges related to monitoring of the burn patient includes

A

burned tissue= limited access for ECG, SaO2, PNS, NIBP- consider a-line

101
Q

Blood loss for burn patients can be minimized by

A

topical/SQ epinephrine, only 15-20% TBSA q procedure, tourniquets

102
Q

Challenges for the burn patient include

A

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
Q

Preop evaluation of the burn patient includes

A 
airway
phase of resuscitation 
monitoring
intravascular access
equipment
104
Q

Anesthesia considerations for the high voltage electrical injury include

A

follows path of least resistance; bone most resistant
cardiac arrhythmias
respiratory arrest
seizure
fractures
muscle damage–> myoglobinurea–> renal failure

105
Q

Patients with burns require HIGH

A

opioid requirements

-ideal anesthetic choice is isoflurane+ large dose opioid

106
Q

Serial debridements may require

A

ketamine in incremental doses

regional anesthesia

107
Q

Describe the use of muscle relaxants for burn patients

A

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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