Burn Injuries

Question 1

functions of the skin

Answer 1

barrier (body fluids and infection)
temperature 
elasticity
appearance
sensory organ

Question 2

layers of skin

Answer 2

stratum coreneum, epidermis, dermis, subcutaneous tissue

Question 3

types of burn injury

Answer 3

thermal (flash, flame, scald)
chemical (can progress until flushed out or neutralized)
electrical
radiological (alpha, beta, gamma radiation)

Question 4

severity of burn injury and how they are classified

Answer 4

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

Question 5

superficial burn 1st degree

Answer 5

depth - destruction of epidermis
pain level - very painful
appearance - red
characteristics - dry, flaky, will heal spontaneously in 3-5 days

Question 6

partial thickness burn 2nd degree

Answer 6

depth - superficial or deep, epidermis up to deep dermal element
pain level - very painful
appearance - bright cherry red, pink or pale ivory, usually with fluid filled blistering
characteristics - hair follicle intact, may require skin graft

Question 7

full thickness burn 3rd degree

Answer 7

depth - all of the epidermis, dermis, down into the subcutaneous tissue
pain level - little or no pain
appearance - khaki brown, white, or charred/cherry red is pediatrics
characteristics - loss of hair follicles, will require skin graft

Question 8

fourth degree

Answer 8

depth - full thickness extending into muscle and bone

will require skin graft or amputation

Question 9

rule of 9’s for adults

Answer 9

head = 9 %
upper extremities = 18% (each arm 9%)
trunk = 36% (front = 18%, back = 18%)
lower extremities = 36% (each leg 18%)
genitalia = 1%

Question 10

rule of 9’s for pediatrics

Answer 10

head = 18%
upper extremities = 20% (each arm 10%)
trunk = 32% (front = 16%, back = 16%)
lower extremities = 28% (each leg 14%)
genitalia = 1%

Question 11

burns that should be transferred to burn center

Answer 11

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

Question 12

determining mortality with age and TBSA

Answer 12

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

Question 13

in a closed space thermal injury think…

Answer 13

airway injury

Question 14

electrical injury may lead to occult

Answer 14

severe fracture, hematoma, visceral injury, skeletal, cardiac injury, neurologic injury

Question 15

signs and symptoms of airway complications

Answer 15

singed facial hair, facial burns, dysphonia/hoarseness, cough/carbonaceous sputum, soot in mouth/nose, swallowing impairment, oropharynx inflammation, CXR initially normal

Question 16

inhalation injury refers to

Answer 16

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

Question 17

upper airway inhalation injury involvement

Answer 17

thermal damage to soft tissues of the respiratory tract and trachea can make intubation difficult
increased risk of glottic edema with injury and fluid resuscitation

Question 18

lower airway inhalation injury involvement

Answer 18

pulmonary edema/ARDS develops 1-5 days post burn

pneumonia and pulmonary embolism > 5 days post burn

Question 19

smoke inhalation occurs in conjunction with

Answer 19

face/neck burns and closed space fires

Question 20

chemical pneumonitis occurs after

Answer 20

smoke/toxic fume inhalation

Question 21

honeymoon period for smoke inhalation that will show clear CXR

Answer 21

1st 48 hours

Question 22

symptoms of smoke inhalation

Answer 22

increased sputum and rales/wheezing

Question 23

hypoxia in the first 36 hours after inhalational injury

Answer 23

high risk of pulmonary edema

Question 24

hypoxia in day 2-5 after inhalational injury

Answer 24

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

Question 25

hypoxia >5 days post inhalational injury

Answer 25

nosocomial pneumonia, respiratory failure, ARDS

Question 26

implications of circumferential burns of chest/upper abdomen

Answer 26

restricted chest wall motion as eschar contracts and hardens

Question 27

if inhalation injury or facial burns are suspected or known

Answer 27

intubate and secure the airway early!

Question 28

ETT indicated in a burn patient if

Answer 28

pediatric, massive burn, stridor, respiratory distress, hypoxia/hypercarbia, altered level of consciousness, if deterioration likely

Question 29

safest approach for intubation in burn patient

Answer 29

fiberoptic intubation under adequate topical anesthesia

Question 30

treatment of hypoxia in burn patient with inhalational injury

Answer 30

PEEP, airway humidification, bronchial suctioning/lavage, bronchodilators, antibiotics, chest physiotherapy

Question 31

restriction of respiratory excursion may necessitate

Answer 31

escharotomy

Question 32

carbon monoxide is ____ times the affinity for Hgb as O2

Answer 32

200

Question 33

CO shifts the hemoglobin dissociation curve to the ___

Answer 33

left impairing O2 unloading at the tissue level

Question 34

CO interferes with

Answer 34

mitochondrial function, uncouples oxidative phosphorylation, reduces ATP production = metabolic acidosis

Question 35

carbon monoxide treatment

Answer 35

high FiO2 | hyperbaric chamber if > 30% and patient is hemodynamically and neurologically stabilized

Question 36

a COHbg greater than ___ is incompatible with life

Answer 36

60%

Question 37

CO < 15-20% symptoms

Answer 37

HA, dizziness, confusion

Question 38

CO 20-40% symptoms

Answer 38

nausea, vomiting, disorientation and visual impairment

Question 39

CO 40-60% symptoms

Answer 39

agitation, combative, hallucinations, coma, shock

Question 40

blood cyanide levels of ____ confirm diagnosis of cyanide toxicity

Answer 40

> 0.2 mg/L

Question 41

lethal blood cyanide level

Answer 41

1.0 mL/L

Question 42

cyanide has a half life of

Answer 42

60 minutes

Question 43

treatment for cyanide toxicity

Answer 43

O2, hydroxycobalamine, amyl nitrate, sodium nitrate, thiosulfate

Question 44

burns and systemic effects

Answer 44

release of inflammatory mediators locally and systemically = edema increase in microvascular permeability = fluid leak and loss of proteins increased intravascular hydrostatic pressure and decreased interstitial hydrostatic pressure increased interstitial osmotic pressure

Question 45

cardiovascular stresses with burn injury

Answer 45

severe decrease in CO lasts 1st 24 hours circulation tumor necrosis factor = myocardial depression diminished response to catecholamines increased microvascular permeability = hypovolemia intense vasoconstriction compensation = decrease flow to tissues decreased tissue O2 supply and coronary blood flow

Question 46

after 24-48 hours of burn patients are in a ____ state

Answer 46

hyperdynamic state (high output CHF), CO is 2x normal

Question 47

metabolism in burn patient

Answer 47

increased metabolic rate is proportional to TBSA burned increased core body temp reflects increased metabolic thermostat, loss of skin = loss of vasoactivity, piloerection, insulation functions

Question 48

GI complications

Answer 48

ileus, ulceration, cholecystitis

Question 49

Renal complications

Answer 49

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

Question 50

endocrine complications

Answer 50

increased corticotropin, ADH, renin, angiotensin, aldosterone, increased glucagon, insulin resistance, hyperglycemia

Question 51

blood and coagulation complications

Answer 51

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

Question 52

fluid resuscitation 1st 24 hours

Answer 52

crystalloid only replace with 2-4 mL/kg for each 1% TBSA burned titrate fluids to U/O 0.5 - 1 mL/kg/hr

Question 53

over aggressive fluid resuscitation can lead to

Answer 53

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

Question 54

fluid resuscitation after 1st 24 hours

Answer 54

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

Question 55

Parkland formula

Answer 55

4 mL of LR/kg/% burn/1st 24 hours

Question 56

Modified Brooke formula

Answer 56

2 mL of LR/kg/% burn/1st 24 hours

Question 57

calculated volumes are given in the 1st 24 hours

Answer 57

50% first 8 hours 25% second 8 hours 25% third 8 hours

Question 58

goals of resuscitation

Answer 58

``` urine output = 0.5-1 mL/kg/hr HR = 80-140 MAP = >60 in adults base deficit = < 2 normal Hct ```

Question 59

what can we give if fluids are not enough?

Answer 59

low dose Dopamine 5 mcg/kg/min

Question 60

anesthesia considerations/concerns

Answer 60

``` often need repeated surgeries maintain Hct coagulopathy temperature fluids and electrolytes hypermetabolic state increased risk for GI ileus ```

Question 61

challenges for anesthesia in burn patients

Answer 61

burned tissue = limited access for ECG, SaO2, PNS, NIBP need large bore IV compensate for evaporative/exposure heat loss (room temp 28-32 C) minimize blood loss (topical/SQ epi, only 15-20% TBSA each procedure, tourniquets) treat complications of massive transfusion (coagulopathy, hypocalcemia)

Question 62

anesthesia considerations for high voltage electrical injury

Answer 62

follows path of least resistance (bone most resistant) cardiac arrhythmias respiratory arrest seizure fractures muscle damage = myoglobinurea and renal failure

Question 63

muscle relaxants in 1st 24 hours

Answer 63

unaltered response to depolarizing and non-depolarizing muscle relaxants

Question 64

muscle relaxants in 24 hours to 1 year post burn

Answer 64

``` avoid succinylcholine (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 ```