Burn Patients Flashcards
What are the 3 main end goals for surgical excision in large burns?
limit to 2-3 hr operative time
core temp of 35 C
limit surgery to 10 units of PRBCs
Both the epidermis & dermis are involved with what type of burn?
Heat Burns
An acidic chemical burn will cause:
necrosis by coagulation
An alkali chemical burn will cause:
necrosis by liquefaction
What type of radiation burns causes damage?
Ionization radiation
What are some examples of ionizing radiation burns?
sunburns, therapeutic radiation, diagnostic procedures, nuclear power plant workers
Why is burn classification important?
to determine healing potential & need for surgical grafting
How long does it take for burns to reveal their true depth?
12-48 hrs
Which burn classification is not counted in the TBSA % for fluid calculations?
Superficial (1st degree) burns
Superficial (1st degree) burns usually heal in approximately:
3-6 days
Burn that involves the epidermis and part of the dermis that is very painful with mottled/blotchy red color, blisters or weeping.
Superficial partial thickness (2nd degree burn)
Superficial Partial Thickness (mild 2nd degree burn) usually heals within:
10-14 days w/o surgery & leaves minimal scarring
Burn that extends more deeply through the epidermis & dermis with patches of white, less painful, decreased moisture b/c sweat glands destroyed:
Deep Partial thickness (2nd degree burn)
Deep partial thickness (2nd degree burn) usually heals in about:
21-28 days ~ 1 month
Burn that can have consequences of temperature control when graft is place?
Deep partial thickness (2nd degree burn) – the skin becomes hot but cannot sweat b/c the sweat glands were destroyed from burn
Burn that destroys both layers of dermis, translucent, dry, painless, charred, non-blanching
Full thickness (3rd degree burn)
Which burn classifications are included in the TBSA % calculation?
2nd degree & higher
Palmer (hand) method – the palm with fingers together are what BSA %
1%
Pediatric pts, the head & neck constitute what BSA%
21%
Genital area on an adult and pediatric patient are ___% BSA
1%
Each arm on a pediatric patient is ___% BSA
10%
The abdomen & back of a pediatric patient are ___% BSA
13
Pediatrics buttocks is ___% BSA
5%
Each leg on a pediatric patient is ___% BSA
13.5%
Accuracy of estimation of TBSA % may vary if pt is _____ or has ______.
obese
large breasts (cup size D or higher)
Burn pathophysiology involves managing 2 conflicting priorities:
SHOCK & EDEMA
What are the consequences of fluid under-resuscitation?
decreased perfusion
burn shock
end organ failure
Abdominal compartment syndrome, pulmonary edema/ARDS, & peripheral tissue edema are consequences of:
fluid over-resuscitation
Auto-cannibalism refers to:
hypermetabolic phase =
lipolysis
proteolysis (loss of protein/muscle)
gluconeogenesis
hypermetabolism
insulin resistance
What metabolic responses occur with >40% TBSA burns?
Metabolic rate doubles
cannibalism for months
immunodepression, recurrent infections, & poor wound healing
What causes an acceleration in hepatic gluconeogenesis & peripheral insulin resistance with burn trauma pts?
Increases in cortisol, catecholamines, & glucagon
**Can last up to 3 yrs
Accelerated lipolysis is due to:
B2 & B3 stimulation from increased cAMP
Elevated glucagon, TNG, Interleukin
elevated levels of free fatty acids cause increased production of ATP
Beta blockers help manage:
HR & BP/cardiac demand from excess catecholamines
decrease lipid oxidation (lipolysis) = decreases metabolic rate
Protein (lean body mass) loss in burn pts is affected by:
degree of stress
accelerated proteolysis of skeletal muscles
immobility = tissue strictures develop
Initial stabilization of burn pts includes:
respiratory/airway 1st
fluid resuscitation
pain control (high dose IV opioids)
local care of burn wounds
What approach is taken for Pain control in the burn patient
multimodal – opioids (start long acting asap - methadone), NSAIDs, PCA, ketamine, anti-anxiety drugs
**No IM drugs b/c absorption is uncertain
Why do we start off with low doses of pain medications for burn pts?
PK/PD altered in the burn pt & can be unpredictable – may need to deviate from normal doses to avoid toxicity & decreased efficacy
Why does weeping occur with burn injuries?
Impaired endothelial barrier
increased capillary permeability
Loss of intravascular oncotic pressure
What mediators cause vasodilation?
histamine
prostaglandins
cytokines
nitric oxide
As a rule of thumb, start thinking about doing aggressive IV fluid resuscitation if the pt has ___% or greater TBSA burn.
15% or greater
Which burn pts need higher volumes of fluid resuscitation?
inhalation injuries
electrical burns
pts who have delayed resuscitation
When UO adequate, advocate to start titrating fluid formula down and consider small amounts of _____
colloids (on day 2)
Parkland Formula
4ml / kg / %BSA
- 1st 8 hrs = 2 ml/kg/%
- next 16 hrs = 2 ml/kg/%
US Army ISR Rule of 10 for adults
10 mL/hr x TBSA
>80kg = add 100mL/10kg
US Army ISR Rule of 10 for pediatrics
3 x TBSA x kg = vol for 1st 24 hrs
1/2 total volume over 8 hrs
US Army ISR formula goal target:
UO of 1 ml/kg to avoid fluid creep
What might you need to add along with the normal LR basal infusion for resuscitation?
albumin
pressors
LR is titrated every hour according to UO goal of ______
30-50 mL/hr
For crystalloid resuscitation in the pediatric population, use the adult formula if:
child is >40kg
Pediatric colloid administration rate?
4-7 ml/kg at the rate of 0.5 mL/min (reduce maintenance isotonic crystalloid by an equal volume per hour)
At 8-12 hrs post burn, if the hourly IVF rate is >1500ml/hr or if projected 24 hr total fluid volume approaches 250ml/kg then initiate ______.
5% albumin infusion
What are the 2 phases burn pts go through?
hypodynamic state = low CO, hypovolemic, increased SVR, myocardial ischemia
Hyperdynamic state (72-96 hrs post burn) = increased CO & HR, decreased SVR
What is a common pulmonary occurence with burn pts?
bronchospasm – give bronchodilators
Carboxyhemoglobin level >10% symptoms?
overt signs of toxicity – HA, N/V…
For facial burns, what are 2 ointments that are useful for the eye lids & eyes?
bacitracin - apply to eye lids
erythromycin - apply in the eyes
fuel & natural gas byproduct
carbon monoxide (CO)
incomplete combustion of any material containing nitrogen –> such as plastic, vinyl, wool or silk can lead to
cyanide (CN) toxicity
Treatment for cyanide toxicity
cyanocobalamin injection
Pharmacological changes in the burn pt:
decreased plasma proteins (especially albumin) which increases free drug & Vd
alterations in drug receptors (nAChR)
CO changes (hypo vs hyperdynamic phases)
major burns cause up-regulation of what receptors?
n-ACh-R
takes months to years (1-2) to recover
upregulation of n-ACh-R from burns will have what affects on paralytic agents?
ND-NMBA = resistant
depolarizing (Succ) = increased sensitivity
If burn is > 24 hrs, avoid which paralytic & why?
SUCC – markedly increased serum K+
the degree of sensitivity to depolarizing NMBA (succ) does not correlate with _____
severity of burn
Temperature loss from burns = can lose up to ____ degree C every _____
1 degree C for q15min
What are 3 signs of impending airway obstruction that requires immediate intubation?
Stridor
Hoarseness
Dysphagia
Which airway device is NOT used in burn pts?
LMAs
Medication often used for burn dressing changes and induction?
Ketamine (but caution if pt is in hyperdynamic phase)
2.6% total blood volume lost for every:
1% burn excised or autograft harvested
Goal CVP for burn pts
6-8 mmHg (if not at goal CVP increase IVF rate by 20-25%)
Vasopressors for post fluid resuscitation if pt still hypotensive
vasopressin
norepi
What is tumescent LA?
technique to infiltrate large volumes of LA into subQ tissue
Effects of tumescent LA (infiltrate large vol of LA subQ) include:
decreased blood loss
easy excision of granulation tissue
shorter surgical times
no hematoma or bruising postop
Target PCO2 on mechanical ventilated burn pt
30-35 mmHg or pH > 7.20
Inhalation injury pts are high risk for blood clots within airway, what can we do to prevent this?
Nebulized 5000 units Heparin + albuterol Q4H
A burn pt has a 90% mortality rate with ______
an open abdomen (in the case of treatment for compartment syndrome
If bladder pressure is > 20mmHg, what might be going on?
Abdominal compartment syndrome
diagnosis of abdominal compartment syndrome?
bladder pressure monitoring
Why does abdominal compartment syndrome possibly occur in burn pts?
intestines become edematous from the fluid resuscitation
Keep these pts intubated in the 1st 72 hrs postop
inhalation burns
what benzo is a useful adjunct in opioid analgesia in the burn pt?
lorazepam (long acting benzo)
Procedure that free’s up chest pressure so lungs are able to move & ventilate adequately?
escharotomy
burn pts require GI prophylaxis because:
they are high risk for stress ulcers
Insert foley immediately on these pts?
pts with genitalia/perineum burns
swelling may be impressive in these region, but does not require specific treatment (self resolving with time)
scrotal swelling
Burns are _____ prone wounds
tetanus
booster if >5 yrs since last booster
booster + TIG if no prev vaccine
What 2 pharmacological agents are NOT indicated as standard of care with burn pts?
IV antibiotics
Steroids — may use these for multimodal analgesic adjunct
If UO not picking up once fluid goals met, what is the next step for the patient?
know that kidneys are taking a hit, don’t flood pt with more fluid, just get them on dialysis asap to avoid more problems.
Why should we AVOID remifentanil in burn pts?
can cause opiate-induced hyperalgesia
What MUST be in the OR before induction?
T&C 2-4 units PRBCs to keep ahead
If pt is intravascularly volume depleted what 2 induction agents are recommended?
Etomidate (0.3 mg/kg)
ketamine (1-3 mg/kg)
When does the hypermetabolic/hyperdynamic phase begin?
48-72 hrs post burn
Preop pain mgmt for burn pts?
high dose opioids initially
low dose ketamine gtt (0.1-0.5 mg/kg/hr)
In burns without inhalation injury, what can reduce mortality & length of hospital stay?
early excision & grafting (days 1-5)
might be staged procedures
Pts receiving > 250 ml/kg IVF are at high risk for:
Abdominal compartment syndrome
When monitoring for abdominal compartment syndrome:
perform bladder pressure Q4H
if bladder pressure >20mmHg = consider therapeutic paracentesis
What criteria is considered a MINOR BURN?
<10% TBSA burn in adults
<5% TBSA burn in young or old
<2% full-thickness burn
What criteria is considered a MODERATE BURN?
10-20% TBSA burn in adults
5-10% TBSA burn in young or old
2-5% full thickness burn
High voltage burns
suspected inhalation injury
circumferential burn
medical problem predisposing to infection (DM, Sickle cell..)
**admit to hospital
What criteria is considered a MAJOR BURN and pt needs to go to burn center?
> 20% TBSA adults
10% TBSA young or old
5% full-thickness burn
High voltage injury
Known inhalation injury
Significant burn to face, eyes, ears, genitalia, hands, feet, or joints
Significant associated injuries (fracture or other major trauma)
