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Principles III > Burn Injuries and Anasthesia > Flashcards

Burn Injuries and Anasthesia Flashcards

1
Q

what are pediatric burn injuries most often d/t?

A

scalding

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2
Q

what are the main causes of early death (less than 48 hrs.)?

A
  • shock

- inhalation injury

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3
Q

after 48 hrs., what are the main causes of death?

A

multi-organ failure and sepsis

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4
Q

describe superficial thickness burns

A
  • 1st degree burns
  • depth: epidermis involvement
  • clinical findings: erythema, minor pain, lack of blisters
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5
Q

describe partial thickness-superficial burns

A
  • 2nd degree burn
  • depth: superficial (papillary) dermis
  • clinical findings: blisters, clear fluid, pain
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6
Q

describe partial thickness-deep burns

A
  • 2nd degree burns
  • depth: deep (reticular) dermis
  • clinical findings: whiter appearance, decreased pain
  • difficult to distinguish from full thickness
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7
Q

describe full thickness burns

A
  • 3rd or 4th degree burns
  • depth: dermis and underlying tissue, possibly fascia, bone, and muscle
  • clinical findings: hard, leather like eschar; purple fluid; no sensation (insensate)
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8
Q

describe the rule of nines values for an adult

A
  • head 9% (front and back)
  • back 18%
  • chest 18%
  • r. arm 9%
  • l. arm 9%
  • r. leg 18%
  • l. leg 18%
  • peritoneum 1%
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9
Q

describe rule of nine values for a child

A
  • head 18% (front and back)
  • back 18%
  • chest 18%
  • r. arm 9%
  • l. arm 9%
  • r. leg 13.5 %
  • l. leg 13.5 %
  • peritoneum 1%
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10
Q

what does the ABA Severity Grading System consider as major burns?

A
  • 2nd degree: greater than 20% TBSA (adult) or greater than 10 % at age extremes (very young or old)
  • 3rd degree: greater than 10% TBSA (adult)
  • electrical burn
  • any burn w/ inhalation injury
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11
Q

According to the National Burn Registry, how can mortality risk be determined w/ burns?

A
  • patient age plus TBSA%
  • if greater than 115, there is a greater than 80% mortality risk
  • ex: 70 y/o w/ 50% TBSA burn equal 120, so risk over 80%
  • older the patient, and greater the % of burn, increases risk
  • mortality doubles with inhalation injury
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12
Q

what are the four types of burn injury?

A
  • chemical
  • electrical
  • thermal (flame, scald)
  • inhalation
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13
Q

describe electrical burn injury

A
  • damage concentrated at entry and exit wounds
  • major internal tissue damage not seen (heart conduction?)
  • significant electrical burn leads to myoglobin release from tissue damage which leads to renal failure
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14
Q

describe inhalation burn injury

A
  • suspect until ruled out
  • classified as upper airway, lower airway, or metabolic asphyxiation (carbon monoxide or cyanide)
  • brief exposure to hot, dry air or steam causes rapid airway tissue destruction and edema
  • interesting phenomenon: heat in upper airway is dissipated but causes reflex laryngospasm, so lower airway damage uncommon
  • most lower airway damage d/t toxins (carbon monoxide, cyanide)
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15
Q

what are warning signs of inhalation burn injury?

A
  • hoarseness
  • sore throat
  • dysphagia
  • hemoptysis
  • tachypnea
  • respiratory distress
  • elevated carbon monoxide levels
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16
Q

what is burn treatment for airway burns?

A
  • airway exam: direct visualization via laryngoscopy or fiberoptic bronchoscopy (gold standard)
  • if upper airway damage present, EARLY intubation, even when asymptomatic
  • avoid Succs if over 24 hrs.
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17
Q

why should Succs be avoided after 24 hrs.?

A
  • burns lead to receptor up regulation (increase) of extrajunctional ACh receptors
  • causes massive hyperkalemia since these receptors keep potassium channel open longer than normal
  • hyperkalemia leads to cardiac arrest/death
  • significant up regulation occurs after 1st 24 hrs.
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18
Q

if swelling/obstruction is present upon airway assessment, hour should the pt. be intubated?

A
  • awake intubation
  • topicals, incremental ketamine, or dexmedetomidine
  • no relaxants
  • fiberoptic, LMA assisted, blind nasal, retrograde wiring, light wand, GlideScope, surgical tracheostomy
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19
Q

what is an indication that airway swelling is subsiding?

A

progressive air leak around the ETT

*in ICU may have to change out tube since smaller size may have been initially used d/t swelling

20
Q

describe treatment for burns d/t carbon monoxide?

A
  • suspect CO poisoning if victim rescued from enclosed space (house fires)
  • CO bind to Hgb 200x the affinity of O2 (left shift)
  • decreased SaO2
  • metabolic acidosis
  • behavior of CO poisoning looks like a drunk
  • pulse oximetry does not detect CoHgb and shows falsely high O2 sat
  • arterial CoHgb must be analyzed to obtain accurate measurement
  • treatment: 100% O2
21
Q

describe treatment for burns d/t cyanide

A
  • burned plastic, paint, some fabrics lead to hydrogen cyanide (HCN)
  • HCN causes blocked intracellular O2 use leading to metabolic acidosis
  • symptoms: changes in LOC, seizures, dilated pupils, hypotension, apnea, high lactate levels
  • tx: hydroxocabalamin (B12a)
  • 2-3 min lead to resp depression and arrest
  • 6-8 min lead to cardiac arrest
22
Q

how is shock r/t burn treated?

A
  • after securing airway, aggressive fluid resuscitation begins
  • burn lead to loss of circulating plasma causing: hemoconcentration, massive edema, decreased urine output, CV depression/collapse
  • fluid resuscitation required to prevent hypovolemic shock but also increases edema formation
  • *beware of compartment syndrome (tissue tightened d/t edema; but DONT restrict fluids to prevent)
23
Q

when is the greatest fluid loss d/t burns?

A
  • 1st 12 hrs.

- begins to stabilize after 24 hrs.

24
Q

describe fluid resuscitation w/ burn injury

A
  • heavy isotonic crystalloid (NO colloid or blood during resuscitation period unless other traumatic injury present)
  • Parkland guideline
  • caution fluid management w/ children; fluid management must be precise
  • need large bore IV access
25
Q

describe the Parkland formula

A

4 mL x kg x % TBSA burned

ex: 70 kg pt w/ 30% TBSA burn = 8,400 mL over 1 st 24 hrs. (350 ml/hr)

26
Q

what do children require along with resuscitation fluids?

A
  • maintenance glucose infusion (on a pump)

* or will become hypoglycemic

27
Q

describe hypermetabolism d/t burns

A
  • highest stress response 1st 3 days of injury
  • plasma catecholamines 10-50x higher than usual
  • if not managed, physiologic exhaustion (death)
  • around 48 hrs. post injury, pronounced hypermetabolic phase sets in
  • hypermetabolic phase for up to 2 yrs. after 40% TBSA burn
  • multi drugs and treatment can be used for prevention of sepsis, temp. maintenance, etc.)
28
Q

what are drugs seen in therapy of hypermetabolism d/t burns?

A
  • rhGH (improved inflammation and body composition)
  • insulin like growth factor1 (improved inflammation, body comp., net protein balance, and insulin resistance)
  • oxandrolone (improved inflammation, body comp., net protein balance)
  • insulin (inflammation, body comp., protein balance, insulin resistance)
  • fenofibrate (insulin resistance)
  • glucagon like peptide 1 (indirect improvement of insulin resistance; effects on other symptoms unknown)
  • propranolol (inflammation, stress hormones, other sx. unknown)
  • ketoconazole (stress hormones, body comp., protein, insulin resistance, hyperdynamic circulation)
  • rhGH and propranolol (all 6 sx improved)
  • oxandrolone and propranolol (all 6 sx improved)
29
Q

describe CV changes d/t burn injury

A
  • loss of plasma proteins leading to hypovolemia, hypotension (“burn shock”)
  • decreased CO initially compensated by catecholamines (increased HR, vasoconstriction)
  • in children, HTN persists for weeks after injury
  • treating hyperdynamic response may improve long-term outcomes
30
Q

describe pulmonary changes d/t burn injury

A
  • decreased function even w/ no inhalation injury
  • decreased FRC and decreased compliance d/t circumferential burns, edema, eschar
  • may require escharotomy
  • increased capillary permeability plus fluid resuscitation lead to risk of pulmonary edema that can lead to ARDS (caused by plasma proteins seeping out and stuff leaking into alveoli)
  • *current trend: low Vt, low PiPs to minimize barotrauma (may need to increase d/t decreased compliance causing issues)
31
Q

describe renal changes d/t burn injury

A

-function decreased d/t myo and hemoglobinuria
-“RIFLE” criteria used to categorize acute kidney injury
Risk, Injury, Failure, Loss, End stage kidney disease

32
Q

describe immune changes d/t burn injury

A
  • high risk of sepsis and pneumonia

- sepsis is leading cause of death in children (up to 100%) and adults (up to 75%)

33
Q

describe GI/Nutrition changes d/t burn injury

A
  • metabolic rate 2x normal
  • failure to meet nutritional requirements leads to poor healing, sepsis, multi-organ dysfunction, death
  • insulin resistance (glucose/insulin protocols common)
  • if intubated, do not stop enteral feedings pre-op (if not sure of tube placement may not want to risk aspiration)
  • continue TPN intra-op
  • monitor glucose peri-op
  • use infusion pumps for pediatrics
  • ileus common with greater than 20% TBSA burn
34
Q

describe debridement and grafting for burns

A
  • multiple procedures frequently required (debridements, grafting, amputation)
  • standard: early debridement w/ rapid coverage
  • debridement/grafting done every 2-3 days until grafting complete
  • autologous skin (best), cultured skin (small sample of skin taken and grown in lab), skin substitutes (porcine; chance of not healing well or rejection)
35
Q

what are common guidelines for burn procedures?

A
  • no more than 20% of body surface at a time
  • stop surgery if core temp cannot be maintained at greater than 35 degrees C (rewarming is impossible; OR kept really warm)
  • stop when 10 units of PRBCs given (less in children)
  • increased risk of coagulopathy
36
Q

describe pre-op for burn pts.

A
  • thorough airway (neck mobility, oral opening) and pulmonary assessment (PiPs, MV)
  • prepare for difficult airway techniques
  • minimally safe NPO orders
  • evaluate IV access (2 large bore PIVs or CVLs)
  • check labs and blood availability (have blood in OR before debridement begins, esp. w/ pediatrics)
  • plan for heavy use of narcotics, muscle relaxants (hypermetabolic state)
  • warm OR, fluids, bed, surgeon
  • plan for post-op ventilation, ICU bed
37
Q

describe monitoring during burn cases

A
  • may require needle electrodes for EKG
  • arterial line if all extremities affected or being used as donor graft sites
  • pulse ox: ear lobes, nose, toes, cheek
  • esophageal or bladder temp probe for accurate temp
  • extreme caution when transporting and moving (losing airway could be lethal; watch invasive lines ; monitor VS while transporting)
38
Q

describe airway management for burn pts.

A

if not intubated and no airway injury, induction and intubation done as usual, but NO SUCCS

39
Q

describe temp regulation during burn cases

A
  • heat everything to a very hot level

* *staying warm is much easier than rewarming

40
Q

describe fluid/blood replacement during burn cases

A
  • keep up and stay ahead
  • debridement causes heavy, rapid blood loss
  • may be at transfusion trigger on arrival; start blood as soon as blood loss begins
  • EBL is difficult; look for “hidden blood loss”
  • transfuse based on hemodynamics (hypotensive?, tachycardia?, pale?), urine output, labs (hgb, hct)
41
Q

describe induction and maintenance for burn pts.

A
  • volatiles and opioids ok to use
  • anesthetic effects may be exaggerated if hypovolemic
  • propofol ok if stable; ketamine if unstable
  • TIVAs for ICU pts. on specialized ventilators (will not use our machines)
  • NO SUCCS
  • receptor up regulation requires increased amounts of NMB
42
Q

what are concerns with regional anesthesia w/ burn pts.?

A
  • never pass a needle through burned tissue
  • associated vasodilation may lead to hemodynamic instability
  • may have burn-related coagulopathy
  • regional is a poor choice if areas of debridement and grafting cannot be anesthetized
  • caudals may be good choice for children w/ lower extremity burns (hips down)
  • if unsure of coagulation status, don’t do regional
43
Q

describe emergence after burn cases

A

-caution w/ intra-op narcotics if extubation planned, esp. w/ possible airway compromise

44
Q

describe pain management w/ burn cases

A
  • post-op PCA pumps are good choice if pt. stable
  • donor graft sites more painful than grafted sites
  • opioids best when hemodynamically labile
  • caution w/ NSAIDS (can interfere w/ hemostasis)
  • repeated painful procedures leads to analgesic tolerance (need more)
45
Q

what happens long term from burns and frequent surgeries?

A
  • scarring and contractures of mouth and neck (if burned in that area)
  • be prepared for difficult intubation
  • children w/ repeated procedures probably need pre-op sedation (procedure is associated w/ pain!)

Principles III (6 decks)

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