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Principles of Anesthesia II - Fall 2024 > Anesthesia Implications for Burns - Exam 1 > Flashcards

Anesthesia Implications for Burns - Exam 1 Flashcards

1
Q

What are the 5 types of burn injury/damage to skin or tissue?

A
  1. Heat
  2. Electrical
  3. Friction
  4. Chemical
  5. Radiation
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2
Q

Heat Burns

What 3 things are the depth of the thermal injury r/t?

A
  1. contact temperature (very cold/hot)
  2. Duration of contact
  3. Thickness of skin
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3
Q

Heat Burns

What are the “thin skin areas of the body”?

A
  1. joints
  2. hands
  3. face
  4. genitals
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4
Q

Heat Burns

The ____ ____ ____ determines the extent of the damage to the patient.
Except in what 2 special circumstances?

A
  1. depth of injury
  • trapped in a fire - toxic exposure
  • electrical burns
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5
Q

Heat Burns usually involve the ____ and ____.

A
  • epidermis & dermis
    can involve muscle/bone
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6
Q

What are the 4 most common examples of Heat Burns?

A
  • Flame
  • Hot liquid
  • Hot solid
  • Steam
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7
Q

5Ts of heat burn risks: LOL.

A
  1. Testoterone
  2. Tequila
  3. Tattoos
  4. Tooth:Tattoo Ratio
  5. Teeth
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8
Q

In electrical burns, ____ ____ is transformed to ____ as current passes through body tissues

A
  • electrical energy
  • heat
  • basically the body is turned into a conduction pathway
  • membrane potential disrupted
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9
Q

Electrical burns

What 3 things does the magnitude of the electrical burn depend on?

A
  1. pathway of current
  2. resistance to current flow
  3. strength and duration of current flow
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10
Q

Electrical Burns

Is DC or AC worse?

A
  • DC worse - stays into contact w/ source longer
  • most houses have AC
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11
Q

How do electrical burns often happen?

A
  • lightning
  • line men - high tension
  • POC: head/arm
  • POG: the feet/ground
  • travels through whole body
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12
Q

What cardiac dysrhythmia do electrical burn pts commonly present with?
Tx:

A
  • V-fib
  • quick defibrillation
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13
Q

Friction burns are a combo of ________ disruption & ____ generated by friction.
Ex:

A
  • mechanical disruption
  • heat
  • ex: rope around arms/legs
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14
Q

Chemical Burns

What 3 caustic reactions happen with chemical burns?

A
  1. pH alteration d/o compound
  2. widespread cellular disruption = electrolyte disruption
  3. direct toxic effect on metabolic process
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15
Q

What types of chemicals cause chemical burns?

A
  • liquids/powders
  • aerosol
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16
Q

Chemical Burns

What 2 things are the magnitude of chemical burns related to?

A
  1. Duration of exposure - decontamination
  2. Nature of the agent (acid/base)
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17
Q

Chemical Burns

aCids cause necrosis by:

A

Coagulation

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18
Q

Chemical Burns

Alkali cause necrosis by:

A

Liquefacation

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19
Q

________ causes damage w/ radiation burns.

A
  • ionization
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20
Q

Radiation burns

what 2 things does the magnitude depend on?

A
  1. dose and time of exposure
  2. type of particles
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21
Q

Radiation Burns

What are 4 common examples?

A
  1. sunburns
  2. therapeutic radiation
  3. diagnostic procedures (cataracts, neuropathy exposure risk)
  4. nuclear industry workers
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22
Q

How long does it take for burns to declare themselves?

A

24-72 hours
* may progress from 2nd degree - 3rd degree

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23
Q

Are burns usually uniform in depth?

Where is the most concentrated damage usually?

A
  • not uniform in depth (mix of superifcial and deep)
  • center of exposure = inreased concentrated damage
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24
Q

What degree of burns are included in the TBSA % calculation?

A
  • 2nd and 3rd degree
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25
Q

Classification of Burn Depth

Why do kids < 5 have deeper burns?

A
  • thinner skin (more adipose tissue)
  • leads to deeper burns
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26
Q

Classification of burn depth

Why do adults >55 have deeper burns?

A
  • less tissue there to disrupt the thermal effects
  • thinner skin - less adipose tissue
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27
Q

Classification of Burn Depth

Characteristics of Superficial (1st degree burn):

A
  • epidermis only
  • skin intact, red
  • dry skin, no blisters
  • painful & hypersensitive (extreme temps cause pain)
  • heal time: 3-6 days
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28
Q

Classifications of Burn Depth

Characteristics of Superficial Partial Thickness (2nd degree burn)

A
  • epidermis & part of dermis
  • mottled, red
  • blisters/weeping
  • very painful - exposed nerve endings
  • Heal time: 10-14 days
  • minimal scarring
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29
Q

Classifications of Burn Depth

Characteristics of Deep Partial Thickness (2nd degree burn)

A
  • extends deeply into dermis
  • decreased moisture (sweat glands destroyed)
  • pale color
  • absent/prolonged blanching
  • less painful - nerve endings damaged
  • Heal time: 21-28 days
  • requires skin grafting
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30
Q

Classifications of Burn Depth

Characteristics of Full Thickness (3rd degree) burns:

A
  • dermis is destroyed
  • translucent, dry, painless, charred
  • non-blanching (decreased perfusion)
  • requires grafting/amputation
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31
Q

Rule of 9s

Head (adult)

A

9%

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32
Q

Rule of 9s (adult)

Each arm

A

9%
* 4.5% anterior
* 4.5% posterior

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33
Q

Rule of 9s (adult)

Each leg

A

18%
* 9% anterior
* 9% posterior

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34
Q

Rule of 9s (adult)

Ant/Post Trunk

A

36%
* 18% Anterior
* 18% Posterior

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35
Q

Rule of 9s (adult)

Perineum

A

1%

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36
Q

Rule of 9s (infant)

Head/Neck:
Abdomen:
Each arm:
Each leg:
Back:
Buttocks:
Genital Area:

A
  • head/neck: 21%
  • Abdomen: 13%
  • Each arm: 10%
  • Each leg: 13.5%
  • Back: 13%
  • Buttocks: 5%
  • Genital Area: 1%

head % larger b/c disproportionate to body

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37
Q

Estimation of TBSA

How accurate is the Rule of 9s?

A
  • 60-70% accurate - various depths
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38
Q

Estimation of TBSA %

Palmer method -

A
  • useful for irregular areas
  • patients palm w/ fingers together
  • 1% per palm
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39
Q

Estimation of Burn TBSA%

Inaccuracies
larger burn SA:
women w/ large breasts:
obese:

A
  • larger burn SA: underestimated - longer to declare
  • large breasts: larger SA compared to other areas
  • Obese: underestimate torso, overestimate extremity
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40
Q

Pathophysiology of Burns

What are the 2 conflicting priorities happening?

A
  • shock & edema
  • d/o where they are in the burn process
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41
Q

Pathophys burns

early on: (hypovolemia)

A
  1. hypovolemic shock & decreased perfusion
  2. plasma loss from microvasculature into interstitium (increased permeability)
  3. relative hypovolemia
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42
Q

pathophys burns

Edematous state:

A
  • pt becomes edematous from loss of plasma into interstitium
  • fluid load & edematous/volume depletion intravascularly
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43
Q

Pathophys of burns

What is fluid loss a funtion of?

A
  • burn size
  • pt weight
  • type of burn
  • visible burn SA may not be directly r/t extent of burn (inhalation - Lung SA tennis court)
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44
Q

Pathophys of Burns

Patients w/ what TBSA develop burn shock and need IV resuscitation in ICU?

A

> 20% TBSA

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45
Q

Pathophys of burns

What does under resuscitation lead to?

A

decreased intravascular vol.
* decreased perfusion
* burn shock
* end organ failure (kidneys susceptible)

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46
Q

Pathophys of burns

What does over resuscitation lead to?

A
  • abdominal compartment syndrome (mesenteric edema, esp. crystalloid)
  • pulmonary edema
  • ARDS
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47
Q

What is the generic metabolic response in burns?

A

Auto-cannibalism - hypermetabolic

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48
Q

What 6 things does Autocannablism lead to?

A
  1. loss of fat
  2. loss of lean body mass (proteolysis)
  3. gluconeogenesis (lose glucose)
  4. lipolysis
  5. hypermetabolism
  6. insulin resistance
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49
Q

What 2 things make the intensity & duration of auto-cannabilism (hypermetabolic state) worse?

A
  • the magnitude of the injury
  • degree of pain
50
Q

Autocannabilsm

How long can cannibalism last?

What do we need to ensure in these pts?

A
  • metabolic rate doubles in 40% TBSA - can last for 3-6 months or longer
  • meeting nutritional needs
  • continue tube feeds, clear carb liquids 2hrs pre-op, TPN!
51
Q

Burn Metabolism

What happens w/ carbohydrate metabolism?

A
  • increases in cortisol, catecholamines, and glucagon
  • accelerated hepatic gluconeogenesis
  • peripheral insulin resistance
52
Q

Burn metabolism - carbs

What causes peripheral insulin resistance? What is it related to? How long can it last?

what can we do for them?

A
  • post-receptor defect hindering the uptake of insulin & impaired intracellular glucose transport
  • r/t extent of burn
  • can last 3 yrs (3-6mos common)
  • keep an eye on glucose levels & be mindful of carb status
53
Q

Burn Metabolism

What happens w/ lipid metabolism?

A
  • accelerated lipolysis
54
Q

Burn Metabolism

What causes accelerated lipolysis associated w/ burn injuries?

A
  • B2 and B2 adrenergic stimulation - increased cAMP
  • elevated glucagon, TNF, IL
  • elevated levels of FFA.. produce ATP
55
Q

Burn metabolism

What is the Tx for accelerated lipolysis?

A
  • daily dose of BB
  • they will struggle more w/ BP
  • MOA: decreases lipid oxidation & metabolic rate
56
Q

Burn Metabolism

What happens with protein metabolism?

A
  • accelerated proteolysis of skeletal muscle
  • provides substrate for hepatic gluconeogenesis
57
Q

Burn Metabolism

What is the degree of protein loss proportional to?

A
  • degree of stress
  • doubled in severe burns
58
Q

Burn Metabolism

What is the treatment for proteolysis/what can improve it?

What makes it worse?

A
  • encourage early PT
  • caution w/ positioning in OR
  • improved by cortisol (anti-inflammatory)
  • TNF, IL-1, IL-6 (inflammatory mediators - cytokines)
59
Q

Initial Stabilization of Burns

When should we intubate the patient?

A
  • prophylactically
  • airway soft tissues swell overtime & edema gets worse
60
Q

Initial Stabilization of Burns

When is fluid resuscitation most important?

A
  • early on
  • communicate w/ primary team to determine pt. specific goals
61
Q

Initial Stabilization of Burns

CV stabilization - what does the increased catecholamine surge lead to?

A
  • increased HR
  • increased metabolic demand & metabolism
  • problematic for elderly w/ comorbidities
62
Q

Secondary Priorities for Burn Pts

What are the pain control methods in initial and long-term management?

A
  • initial: IV
  • long-term: nerve blocks, SR options (methadone, oxycodone), NSAIDs, PCA, IV ketamine (procedural)
  • supplement w/ anxiolytics
63
Q

Secondary Priorties for Burn Pts

Why are burn pts @ increased risk of DVT?

A
  • fluid shifts
  • thromboprophylaxis important
64
Q

Secondary Priorities for Burn Pts

What are the concerns w/ wound closure and burn patients?

A
  • multiple OR trips
  • fluid/blood loss!
64
Q

Secondary Priorities of Burn Pts

What do we need to ensure for pts nutrition and hypermetabolic state?

A
  • ensure adequate nutrition
  • control hypermetabolic state w/ BB, early PT, glucose control
65
Q

Secondary Priorities of Burn Pts

How can we help prevent infections in burn injuries?

A
  • keep warm
  • keep hemostatic
  • maintain normal glucose
  • minimal indications for Abx early on
66
Q

Secondary Priorities for Burn Pts

What pts do we need to use caution in fluid resuscitation?

A
  • CHI - fluids/head injury can kill them
67
Q

Secondary Priorties for Burn Pts

What are the concerns w/ spinal injuries and burns?

A
  • they may need for fluids than just a burn pt
  • the spinal injury causes peripheral vasodilation = compounding factors
  • use vasopressors as well!
68
Q

What are the 2 possible PK/PD alterations in burn pts?

A
  1. May need less doses/drugs to avoid toxicity
  2. May need more dose/drugs b/c of the hypermetabolic state causing decreased efficacy
69
Q

Causes of Intravascular Vol Loss in Burns

  1. Impaired ________ ________.
  2. Increased ________ ________.
  3. Loss of intravascular ________ ________.

What else causes dilation of vessels in burns?

A
  1. impaired endothelial barrier
  2. increased capillary permeability
  3. loss of intravascular oncotic pressure

systemic inflammatory reactions - histamine, PG, cytokines

70
Q

Fluid Resuscitation

What is the Parkland Formula?

A

starts at time of injury
* 4 ml/kg/%TBSA (1st 24 hrs)
* 2mL/kg/%TBSA in 1st 8 hrs
* 2mL/kg/%TBSA in next 16 hrs

71
Q

Fluid Resuscitation - Parkland

What types of burn injury may need higher volumes?

A
  • inhalation
  • electrical
  • delayed initial resuscitation
72
Q

Fluid Resuscitation

What is the US Army ISR Rule of 10 (adult)?

A
  • 10mL/hr x TBSA
  • > 80kg = add 100mL/10kg over 80kg
73
Q

Fluid Resuscitation

What is the US Army ISR Rule of 10 (pedi)?

A
  • 3 x TBSA x kg = vol. for 1st 24 hrs
  • 1/2 total vol. over 8 hrs
74
Q

What are the 5 criteria for need to transfer to a burn center?

A
  1. Full thickness > 10% BSA
  2. high voltage electrical burns
  3. chemical burns
  4. associated inhalation injury
  5. face, hands, feet, perineum, major joints
75
Q

Fluid Resuscitation

How long are the formulas good for?

Who may they not be appropriate for?

A
  • good for 1st 24 hrs
  • not good for pts w/ comorbidities or non-responders to fluid
76
Q

Fluid needs

What types of fluids do we use?

What is a risk w/ high saline amount?

A
  • crystalloid (LR/isotonic)
  • saline - hypernatremic hyperchloremic metabolic acidosis
  • no boluses w/ crystalloid
77
Q

Fluid Needs

How are crystalloids/fluids titrated?

A
  • every hour according to UOP goal
  • 30-50mL/hr or 1mL/kg/hr
  • titrate 20-25% up or down
78
Q

At what amount of fluid administration do we start to see fluid overload symptoms?

What are the symptoms?

A
  • 1500mL/hr or 250mL/kg in 24hrs
  • ACS, pulmonary edema
79
Q

Fluid Needs

At what weight do we use the adult formula for fluids?

What is the formula for kids <14kg and <40kg?

What do we need to add for kids <20kg?

What is the UO goal for pedi?

A
  • > 40kg use adult formula
  • 2-4mL x kg x % TBSA (2nd and 3rd)
  • maintenance of D5LR for <20kg
  • 0.5-1mL/kg/hr
80
Q

Fluid Status in Burns

When should we start colloid infusions?
What is the DOC?

A
  • 8-12 hrs post burn if >1500mL/hr
    or
  • projected 24 hr total volume >250mL/kg in 24 hrs

use albumin 5%

81
Q

Fluid Status

What is the pedi albumin rate?
What do we need to reduce?

A
  • 4-7mL/kg
  • rate: 0.5mL/min
  • reduce maintenance isotonic crystalloid by equal volume per hour
82
Q

Cardiac Status

What happens in the hypodynamic “ebb” state?

A
  • CO low (reduced by 60% of baseline)
  • relative hypovolemia
  • reduced response to catecholamines
  • increased SVR d/t vasopressin levels
  • myocardial ischemia (decreased coronary flow)
  • very risky period for someone w/ cardiac disease
83
Q

Cardiac Status

What happens in the “hyperdynamic state”?

A
  • increased CO, tachycardia
  • increased myocardial O2 consumption = myocardial ischemia
  • decreased SVR
  • give BB
84
Q

Pulmonary Status

What leads to pulmonary HTN/edema?

A

systemic inflammatory processes
* pulmonary capillary alveolar membrane disruption
* decreased plasma oncotic pressure
* extravascular lung water - impairs gas exchange
* bronchospasm common

84
Q

Pulmonary Status

What can be used to maintain pulmonary integrity in intubated burn pts?

What is the tx for bronchospasm?

A
  • PEEP
  • scheduled bronchodilator therapy - give before induction esp. if instrumenting airway
85
Q

Pulmonary Status

What restrictive lung defects happen with burn injuries?

A
  • impaired ventilation from circumferential burns/scars
  • monitor airway pressure
  • pt will get relative hypoxia/hypercarbia
  • intra-op escharotomy
86
Q

What are the symptoms of inhalation injury?

A
  • singeing of face/nasal hairs, black soot in mouth
  • oropharyngeal carbon
  • Carboxyhemoglobin levels >10%
  • wheezing
  • confirm w/ bronch
87
Q

What are the main concerns for facial burns?

A
  • management of devices difficult
  • umbilical ties for ETT securement
  • remove contacts
  • optho consult: globe/corneal injury
88
Q

Facial Burns

Where is bacitracin applied?

Where is erythromycin applied?

What is NOT applied to the face?

A
  • baci - eyelids
  • erythro - eyes
  • no silvadene
89
Q

Symptoms of CO poisoning:

A
  • HA, nausea, seizing, ARF, myocardial ischemia/depression
90
Q

Treatment for CO:

A

100% O2

caused by fuels

91
Q

Treatment for CN:

A
  • cyanokit
  • B12 (cyanocobalamin)
    caused by plastics
92
Q

What are the nutrition concerns after burn injuries? (elevated….)

What can we do to meet their needs?

A
  • elevated protein, vitamin, energy needs
  • insulin resistance
  • tube feeds to jejunum (decreased asp. risk)
93
Q

What are the main 3 causes of PK/PD changes in burn pts?

A
  1. changes in plasma protein concentration (albumin) = increased free fraction and Vd
  2. Alterations in drug receptors (nAch)
  3. CO changes (ebb/flow)
94
Q

What happens w/ burn pts and nAch R’s?

A
  • upregulation of receptors (increased # and sensitivity)
  • resistant to non-depolarizers (>25% TBSA)
  • sensitive to depolarizers (after 24-72hrs)
95
Q

Intra-op care of Burns

Monitoring Standards
* EKG:
* pulse-ox:
* BP cuffs:
* ABG:
* UOP:

A
  • EKG: stapled, alligator clips
  • pulse-ox: accuracy w/ COHb? edema/weeping interference
  • BP cuffs: inaccuracy from edema
  • ABG: Base Deficit alternative to lactate, used for oxygenation
  • UOP: watch trends!
96
Q

Intra-op Care of Burns: monitoring

What temperature changes happen?

What interventions can we provide?

A
  • loss of up to 1 degree C every 15 min b/c loss of skin integrity
  • warm IVF, warm OR, convection warming devices
97
Q

Intra-op Care of Burns

What are 5 indications of inhalation injury?

What do these necessitate?

A
  1. Hoarseness, wheezing, SOB
  2. carbonaceous sputum
  3. singed nasal & facial hair
  4. comatose pt
  5. > 40% TBSA

early intubation

98
Q

Intra-op Care of Burns: Airway

What are signs of impending airway obstruction?

A
  • stridor
  • hoarseness
  • dysphagia
99
Q

Intra-op Care of Burns: Airway

What makes laryngoscopy difficult?

What makes BVM ventilation difficult?

A

laryngoscopy:
* edema (inhalation)
* limited mobility: pain, contractures, eschar

BVM ventilation:
* burn dressings prevent adequate seal

consider awake intubation = sedate/topicalize airway

100
Q

Intra-op Care of Burns: Airway

What size ETT is preferred for intubation and why?

A
  • 8 or largest size possible
  • facilitates subsequent bronchoscopy & pulmonary toilet
  • decreases risk of occlusion from casts (blood, mucous, debris)
101
Q

Intra-op Care of Burns: Airway

What are 2 ways the ETT can be secured?

A
  1. cotton umbilical tape
  2. wire to teeth
  3. no LMAs - only a back up
102
Q

Intra-op Care of Burns: Airway

Induction
* when to use prop:
* when to use ketamine:
* concerns w/ etomidate:
* opioids:

A
  1. prop: hyperdynamic state
  2. ketamine: hypodynamic state - stimulates SNS
  3. etomidate: adrenal insufficiency concern, supplement w/ steroids
  4. opioids: maintain hemodynamic stability but tx pain!
103
Q

Intra-Op Care of Burns

What causes hemodynamic instability?

What 2 things can we do in the OR?

A
  • hypovolemia (decreased preload & CO)
  • Resuce TEE
  • R/O cardiogenic or distributive shock, MI
104
Q

intra-Op Care of Burns: Blood Transfusions

How much blood volume can be lost?

When do we transfuse? ACS?

A
  • 2.6% total blood volume lost for every 1% burn excised or autograft harvested
  • transfuse: keep Hgb 7-8g/dL
  • ACS: Hgb 10g/dL
105
Q

Intra-Op Care of Burns:

What MAP diagnoses burn shock?

A
  • <55mmHg depsite fluid resuscitation
106
Q

Intra-Op Care of Burns: Blood Trasfusions

How can we provide hemostasis in these pts?

A
  • topical thrombin
  • staged procedures - mult. OR trips
  • subQ vasoconstrictors (bad for graft take!)
  • rFVII & TXA = thrombosis risk
107
Q

Intra-Op Care of Burns:

What is the shock treatment?

A

Vasopressors
* Vasopressin
* Norepinephrine
* CVP: only useful for trends (6-8mmHg)

108
Q

Intra-Op Care of Burns

What is Tumescent LA used for?

A
  1. used for taking the skin graft
  2. infiltrated into subQ tissue
    effects
    * decreased blood loss
    * easy excision of granulation tissue
    * shorter surgical times
    * no hematoma or bruising post-op
109
Q

Intra-Op Care of Burns

What is the Tumescent LA dose?

A
  • Lidocaine 1g w/ epi + 10mEq NaHCO3/1000mL NaCl

55mg/kg max

110
Q

Intra-op Care of Burns

What is the target PCO2 and pH?

A
  • PCO2: 30-35mmHg
  • pH: >7.20
111
Q

Intra-Op Care of Burns

Why do we give intubated patients nebulized Heparin/Albuterol?

How often?

A
  • pts w/ inhalation have ulceration/sloughing of airways
  • Heparin prevents clumping of the epithelial cells
  • Albuterol: Heparin can cause bronchospasm

give q4h

112
Q

Intra-Op Care of Burns

What happens with ACS?

What is the mortality rate of an open abdomen?

What are the bladder pressures associated w/ ACS?

A
  1. abdominal pressure displaces diaphragm up by bowel edema
  2. 90% mortality
  3. > 12mmHg = early intra-abd. HTN; >20mmHg = ACS
113
Q

Post-op Care of Burns

Why do we leave pts intubated post-op?

A
  1. inhalation burn s
  2. @ risk of continued bleeding
  3. additional surgery plans
  4. need to minimize movement/graft disruption
114
Q

Post-Op Care of Burns

What other modalities need to be provided to burn pts?

A
  • DVT prophylaxis
  • BB admin
  • nutritional support
  • temp control
115
Q

Post-op Care of Burns

What pain treatment options do we provide to burn pts?

A
  • long-acting meds
  • scheduled anxiolytics
  • IV, enteral, transmucosal, PO
  • additives PRN for burn care/dressing changes
  • NO 50/50
  • peripheral nerve blocks
116
Q

Post-Op Care of Burns

What special care is needed r/t extremities?

A
  • elevate 30-45 degrees (pillows, slings)
  • examine pulses hourly
117
Q

When are escharotomies performed?

A
  • loss of perfusion to extremities
  • ventilator compromise/decreased CO
118
Q

Adjuncts to Burn Resuscitation:

A
  • GI prophylaxis
  • Sew/staple venous and arterial lines
  • insert foley immediately - maintain urethral patency
  • tetanus
  • IV Abx/steroids not indicated!
119
Q

Burn dressings
* topical Abx:
* other dressings:
* skin substitutes:
* silvadene:

A
  1. silvadene & sulfamylon
  2. silver dressings, silverton water or saline q8hrs, silver nitrate
  3. biobrane
  4. NO SILVADENE TO FACE!!!

Principles of Anesthesia II - Fall 2024 (10 decks)

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