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N934 Adv Principles Fa 21 > Burn > Flashcards

Burn Flashcards

1
Q

functions of skin

A 
barrier to body fluids and infection
temperature
elasticity
appearance
sensory organ
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2
Q

types of burn injury

A

thermal (flash, flame, scald)
chemical
electrical (entry and exit wound)
radiological (alpha, gamma, delta)

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3
Q

severity of burn injury: depth (4 categories)

A

superficial, partial thickness, deep partial thickness, full thickness

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4
Q

partial thickness burn 2nd degree

A

epidermis to deep dermal element
very painful
bright cherry red, pink or pale ivory, usually blisters**
hair follicle intact, may require skin graft
5-21 days healing superficial, 21-35 days deep
minimal to no scarring, may have discoloration

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5
Q

full thickness (3rd degree)

A

all of epidemics, dermis, down to SQ tissue
little or no pain because nerve endings destroyed
khaki brown, white, or charred/cherry red (pedes)
loss of hair follicles, will require skin graft
still will “feel pain”-psychological
small areas-months to heal. large areas-need grafting
scarring present

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6
Q

4th degree

A

full thickness to muscle and bone, will require skin graft and possible amputation

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7
Q

rule of nines

A 
head 9%
upper extremities: 9% each, 18% total
trunk 36% (front 18%, back 18%)
lower extremities 36% (18% each leg)
perineal 1%
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8
Q

burns that should be transferred to burn center

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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9
Q

national burn registry mortality >80% correlates with

A

if age of patient plus TBSA is greater than 115

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10
Q

burns: resuscitative phase involves

A

ABC’s + coexisting trauma

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11
Q

closed space thermal injury equates to

A

airway injury

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12
Q

source of injury consideration: closed space thermal injury equates to

A

airway injury- anytime they’re in a closed/close contact space consider this ex) house fire.

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13
Q

source of injury consideration: open space “accidental” injury means

A

multiple co existing injury ex) campfire, motor vehicle crash

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14
Q

source of injury consideration: electrical injury may lead to occult (6)

A 
severe fracture
hematoma
visceral injury 
skeletal (contraction)
cardiac injury (arrhythmias)
neurologic injury (seizures)
-electrical current will follow path of least resistance
-entrance AND exit wound
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15
Q

airway management of the burn patient

A

aggressively r/o upper airway injury (soot in nose and face, singed nasal hairs or eyebrows, hoarse, having trouble swallowing, coughing up carbonaceous sputum)
dx made by hx/physical (DVL or fiberoptic)
-singed nasal hairs/facial burns-intubate

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16
Q

phases of burns

A

resuscitative, debridement and grafting, and ____

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17
Q

initial CXR for AW

A

normal until pedema or infiltration develops

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18
Q

inhalation injury

A

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

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19
Q

upper airway inhalation injiry

A

thermal damage to soft tissues of respiratory tract and trachea can make intubation difficult. thermal injury plus fluid resuscitation=worse pedema. increases risk of glottic edema

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20
Q

lower airway inhalation injury

A

pedema/ards develops 1-5 days post burn

pna/pembolism >5days post burn

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21
Q

high risk of pedema is in

A

first 36 hours

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22
Q

days 2-5 after inhalation injury, expect

A

atelectasis, bronchopneumonia, AW edema maximum secondary to sloughing of aw mucosa, thick secretions, distal aw obstruction

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23
Q

> 5d post burn inhalation injury, expect

A

nosocomial PNA, resp failure, ARDS

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24
Q

chest/upper abdomen circumferential burns considerations

A

restricted chest wall motion as eschar contracts and hardens. will need to do chest escharotomies

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25
Q

AW management in burn patient includes

A

patent aw=max FiO2 via face mask
serial larygoscopic/bronchoscopic exams** (tube loaded on scope so you could slip in if needed. 8.0 tube usually the move), CXR, ABG’s, PFT’s in suspected inhalation AW injury
ETT indicated if massive burn, stridor, resp distress, hypoxia/hypercarbia, altered LOC
prophylactic intubation if deterioration likely
intubation technique depends on patient factors, extent of aw damage, age, co existing disease
adults fiberoptic intubation under adequate topical anesthesia is safest approach
pedes patients small diameter airways and low threshold for intubations

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26
Q

AW management in burn patient includes

A

patent aw=max FiO2 via face mask
serial larygoscopic/bronchoscopic exams** (tube loaded on scope so you could slip in if needed. 8.0 tube usually the move), CXR, ABG’s, PFT’s in suspected inhalation AW injury
ETT indicated if massive burn, stridor, resp distress, hypoxia/hypercarbia, altered LOC
prophylactic intubation if deterioration likely
intubation technique depends on patient factors, extent of aw damage, age, co existing disease
adults fiberoptic intubation under adequate topical anesthesia is safest approach
pedes patients small diameter airways and low threshold for intubations**

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27
Q

tx of hypoxia in burn patient with inhalation injuy

A 
PEEP
aw humidification
bronchial suctioning/lavage
bronchodilators
abx (when PNA develops)
CPT
N2O can be administered as short term vasodilator
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28
Q

CO has ______ the affinity as compared to O2

A

200x

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29
Q

CO shifts HGB dissociation curve to the

A

LEFT

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30
Q

Co interferes with

A

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

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31
Q

CO and cardiac

A

may act as myocardial toxin and prevent survival of cardiac arrest

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32
Q

CO and sx

A

SaO2 may be normal
resp effort may appear normal
“cherry red” blood color may not be present if CO <40% and/or patient is cyanotic and hypoxic
measure with ABG and carboxyHGB concentrations

33
Q

CO toxicity management

A

high FiO2 on all burn patients until CO toxicity ruled out
hyperbaric chamber if COHgb is >30% and patient is hemodynamically and neurologically stabilized
-can get rid of it in about an hour if at 100% FiO2

34
Q

COHbg >___ is incompatible with life

A

60%

35
Q

CO-assume it is possible if

A

facial burns

36
Q

Carbon monoxide toxicity: <15-20%

A

HA, dizziness, confusion

37
Q

Carbon monoxide toxicity: 20-40%

A

n/v, DO, visual impairment

38
Q

Carbon monoxide toxicity: 40-60%

A

agitation, combative, hallucinations, coma, shock

39
Q

cyanide toxicity

A

produced as synthetic materials burn. victims inhale and absorb through mucous membranes
ex) phones, wool, silk, plastic

40
Q

metabolic acidosis results with elevated ______

A

lactate levels

41
Q

cyanide toxicity s/sx

A

altered LOC, agitation, confusion, coma, CV depression/arrhythmia risk

42
Q

half life of cyanide

A

1 hour

43
Q

blood cyanide levels

A

> .2mg/L confirms diagnosis

1mg/L is lethal

44
Q

tx of cyanide toxicity

A

oxygen**

hydroxycobalamine, amyl nitrate, sodium nitrate, thiosulfate

45
Q

burn injury and systemic effects

A

release of inflammatory mediators locally at burned tissue and systemically contribute to edema associated with burn injury
increase in microvascular permeability-fluid leak/loss of proteins, increased intravascular hydrostatic pressure/decreased interstitial hydrostatic pressure
interstitial osmotic pressure increases
-leaking of proteins from intravascular space creates increased colloidal pull in extravascular space
-migrates to unburned tissues (generalized edema)
surgery and infections can perpetuate this mediator induced systemic inflammatory response that may lead to multiple organ failure

46
Q

cardiovascular stresses with burn injury

A

severe decrease in CO in first 24h
circulating tumor necrosis factor creates myocardial depression
diminished response to catecholamines
increased microvascular permeability-hypovolemia
intense vasoconstriction compensation (decreased flow to tissues extends/worsens burn wound)
decreased tissue O2 supply and coronary blood flow
hemolysis of erythrocytes (patients usually anemic throughout their stay)
-after 24h capillary leak “heals”

47
Q

hyper dynamic state after

A

24-48h. (increased BP, HR, CO 2x normal)

48
Q

overall systemic results from burns

A

immune suppression (depressed leukocyte activity)
activation of hypothalami-adrenal axis and RAAS
hyper-metabolism
protein catabolism (breakdown products of skin itself)
sepsis
MSOF
electrical injury-myoglobinurea

49
Q

metabolism in burn patient

A

increased metabolic rate is proportional to TBSA burned (can double in 50% TBSA)
increased core body temp reflects increased metabolic thermostat
loss of skin=loss of vasoactivity, piloerection, insulation functions
caloric consumption increased (nutrition after resuscitative feeds, high carb to conserve protein)

50
Q

daily evaporative fluid loss is

A

4000ml/m^2

51
Q

end organ complications: GI

A

ileus, ulceration, cholecystitis

52
Q

end organ complications: renal

A

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

53
Q

end organ complications: endocrine

A

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

54
Q

end organ complications: blood and coagulation

A

increased viscosity, increase in clotting factors including fibrinogen, V, and VII, fibrin split products at risk of DIC development, HCT usually decreases (RBC’s decreased half life)

55
Q

fluid resuscitation: 1st 24h

A

replace with 2-4ml/kg for each 1% TBSA burned. crystalloid only

56
Q

fluid resuscitation and UOP

A

titrate to .5-1ml/kg/h. try not to overdo it because you can worsen aw edema.
-really titrate based on UOP. if decreased in 1st 24h, replete at necessary. this UOP maintenance is on top of resuscitation calculation

57
Q

fluid resuscitation: >24h

A

colloids at .3-.5ml/kg/% burn, with 5% dextrose in water

58
Q

fluid resuscitation: parkland formula

A

4ml/kg LR per % burn in 1st 24h

59
Q

fluid resuscitation: modified brooke formula

A

2ml/kg LR per % burn in 1st 24h

60
Q

fluid resuscitation: calculated volumes administration over 24h

A

50% in 1st 8h
25% in 2nd 8h
25% in 3rd 8h
(given over 24h)

61
Q

can you give albumin in first 24h

A

no because it increases extravascular pull

62
Q

fluid resuscitation: albumin 5%

A

after 1st 24h, .3-.5ml/kg dose

63
Q

fluid resuscitation: goals

A 
UOP .5-1ml/kg/h
HR 80-140 (consider age)
MAP=adults >60mmHg
base deficit <2
normal Hct
64
Q

when to consider low dose dopa or vasopressor

A

if perfusion/UOP is inadequate despite >6ml/kg/%TBSA burn or

normal/high CVP

65
Q

dopamine gtt dose

A

5mcg/kg/min

66
Q

anesthesia considerations for the burn patient includes

A

maintain HCT (multiple transfusions)
coagulopathy
temperature (room temp 28-32c, compensate for evaporative/exposure heat loss)
fluids/lytes
need large bore IV access (CVC may be poop access)
hyper metabolic state (increase O2, ventilation, nutrition)
increased risk for GI ileum, aspiration/hyperalimentation
duodenal tube feeds->dont have to stop preop but ensure its in duodenum

67
Q

anesthesia: monitors considerations

A

burned tissue=limited access for ECG, SaO2, PNS, NIBP

ECG on sylvadine works well because conducts well

68
Q

silvadine for burn dressings

A

can cause hypernatremia and leukopenia

69
Q

anesthesia and blood loss consideration

A

topical/SQ epinephrine can help decrease this
200-400mL blood loss for each % body surface area excised (ex 10%, 2-4L blood)
only do 15-20% TBSA per procedure
tourniquets (hard to see when you get to healthy tissue aka tissue that bleeds)
thrombin soaked sponges also an option

70
Q

preop eval includes

A 
airway
phase of resuscitation
monitoring (aline probs good idea)
intravascular access
equipment (pumps, pressors, bair hugger, fluid warmer, infuser in room if you think you'd need)
71
Q

anesthesia considerations for high voltage electrical injury

A

follows past of least resistance, bone most resistant
cardiac arrhythmias/arrest
respiratory arrest
seizure
fractures
muscle damage->myoglobinurea->renal failure

72
Q

anesthesia in burn patient: pharmacology and opioids

A

high opioid requirement

73
Q

anesthesia in burn patient: ideal anesthetic choice

A

isoflurane and large dose opioid

74
Q

anesthesia in burn patient: serial debridements

A

ketamine in incremental doses, regional anesthesia

remi good for dressing changes as well in OR

75
Q

anesthesia in burn patient: muscle relaxant in 1st 24h

A

unaltered response to depolarizing and non depolarizing paralytics

76
Q

anesthesia in burn patient: muscle relaxant 24h-1y post burn

A

avoid succ r/t proliferation of Ach receptors, can also develop extrajunctional Ach receptors
resistance to most NDMR if >30% TBSA burned r/t increase in Ach receptors

77
Q

burns and regional

A

usually not option, cant give regional through burn tissue ma’am

78
Q

anesthesia in burn patient: drug binding

A

altered catabolism, decreased albumin, decrease in protein and therefore altered drug binding

N934 Adv Principles Fa 21 (23 decks)

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