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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
AW management in burn patient includes
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
26
AW management in burn patient includes
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**
27
tx of hypoxia in burn patient with inhalation injuy
``` PEEP aw humidification bronchial suctioning/lavage bronchodilators abx (when PNA develops) CPT N2O can be administered as short term vasodilator ```
28
CO has ______ the affinity as compared to O2
200x
29
CO shifts HGB dissociation curve to the
LEFT
30
Co interferes with
mitochondrial function uncouples oxidative phosphorylation reduces ATP production resulting in metabolic acidosis
31
CO and cardiac
may act as myocardial toxin and prevent survival of cardiac arrest
32
CO and sx
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
CO toxicity management
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
COHbg >___ is incompatible with life
60%
35
CO-assume it is possible if
facial burns
36
Carbon monoxide toxicity: <15-20%
HA, dizziness, confusion
37
Carbon monoxide toxicity: 20-40%
n/v, DO, visual impairment
38
Carbon monoxide toxicity: 40-60%
agitation, combative, hallucinations, coma, shock
39
cyanide toxicity
produced as synthetic materials burn. victims inhale and absorb through mucous membranes ex) phones, wool, silk, plastic
40
metabolic acidosis results with elevated ______
lactate levels
41
cyanide toxicity s/sx
altered LOC, agitation, confusion, coma, CV depression/arrhythmia risk
42
half life of cyanide
1 hour
43
blood cyanide levels
>.2mg/L confirms diagnosis | 1mg/L is lethal
44
tx of cyanide toxicity
oxygen** | hydroxycobalamine, amyl nitrate, sodium nitrate, thiosulfate
45
burn injury and systemic effects
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
cardiovascular stresses with burn injury
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
hyper dynamic state after
24-48h. (increased BP, HR, CO 2x normal)
48
overall systemic results from burns
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
metabolism in burn patient
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
daily evaporative fluid loss is
4000ml/m^2
51
end organ complications: GI
ileus, ulceration, cholecystitis
52
end organ complications: renal
decreased GFR, RBF, loss of Ca, K, Mg with retention of Na, H2O
53
end organ complications: endocrine
increased corticotropin, ADH, renin, angiotensin, aldosterone, increased glucagon, insulin resistance, hyperglycemia (at risk nonketotic hyperosmolar coma esp TPN)
54
end organ complications: blood and coagulation
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
fluid resuscitation: 1st 24h
replace with 2-4ml/kg for each 1% TBSA burned. crystalloid only
56
fluid resuscitation and UOP
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
fluid resuscitation: >24h
colloids at .3-.5ml/kg/% burn, with 5% dextrose in water
58
fluid resuscitation: parkland formula
4ml/kg LR per % burn in 1st 24h
59
fluid resuscitation: modified brooke formula
2ml/kg LR per % burn in 1st 24h
60
fluid resuscitation: calculated volumes administration over 24h
50% in 1st 8h 25% in 2nd 8h 25% in 3rd 8h (given over 24h)
61
can you give albumin in first 24h
no because it increases extravascular pull
62
fluid resuscitation: albumin 5%
after 1st 24h, .3-.5ml/kg dose
63
fluid resuscitation: goals
``` UOP .5-1ml/kg/h HR 80-140 (consider age) MAP=adults >60mmHg base deficit <2 normal Hct ```
64
when to consider low dose dopa or vasopressor
if perfusion/UOP is inadequate despite >6ml/kg/%TBSA burn or | normal/high CVP
65
dopamine gtt dose
5mcg/kg/min
66
anesthesia considerations for the burn patient includes
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
anesthesia: monitors considerations
burned tissue=limited access for ECG, SaO2, PNS, NIBP | ECG on sylvadine works well because conducts well
68
silvadine for burn dressings
can cause hypernatremia and leukopenia
69
anesthesia and blood loss consideration
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
preop eval includes
``` 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
anesthesia considerations for high voltage electrical injury
follows past of least resistance, bone most resistant cardiac arrhythmias/arrest respiratory arrest seizure fractures muscle damage->myoglobinurea->renal failure
72
anesthesia in burn patient: pharmacology and opioids
high opioid requirement
73
anesthesia in burn patient: ideal anesthetic choice
isoflurane and large dose opioid
74
anesthesia in burn patient: serial debridements
ketamine in incremental doses, regional anesthesia | remi good for dressing changes as well in OR
75
anesthesia in burn patient: muscle relaxant in 1st 24h
unaltered response to depolarizing and non depolarizing paralytics
76
anesthesia in burn patient: muscle relaxant 24h-1y post burn
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
burns and regional
usually not option, cant give regional through burn tissue ma'am
78
anesthesia in burn patient: drug binding
altered catabolism, decreased albumin, decrease in protein and therefore altered drug binding

N934 Adv Principles Fa 21 (23 decks)

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