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AS - N934 Advanced Principles II > Burns > Flashcards

Burns Flashcards

1
Q

Burn Injury Types

A

Thermal - flash, flame, & scald
Chemical
Electrical (current) entry & exit wound
Radiological - radiation

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2
Q

Thermal Burn Types

A

Flash (ex: explosion w/ high heat intensity/exposure)
Flame (ex: house fire or trapped in burning vehicle)
Scald - common in pediatric patients or diabetics (neuropathy)

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3
Q

Burn Injury Severity

A

Depth - extent skin & tissue destruction

  • Superficial, partial thickness, & full thickness
  • 1st, 2nd, & 3rd degree burns old terminology

Total body surface area involved
- Rule of 9s

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4
Q

Superficial Burn

1st Degree

A 
Depth: Epidermis destruction
Pain level: High
Appearance: Red, dry pink
Characteristics: Dry, flakey/peels; dehydrated & thirsty, heals spontaneously w/in 3-5 days
Example: Sunburn, scald, flash flame
No scarring, maybe discoloration
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5
Q

Partial Thickness Burn

2nd Degree

A

Depth: Superficial or deep (epidermis up to deep dermal element)
Pain level: Extreme
Appearance: Bright cherry red, pink or pale ivory, usually w/ fluid-filled blistering, moist/oozing
Characteristics: Hair follicle intact, potentially requires skin graft
Example: Scald, flash burns, chemicals

Superficial burns heal w/in 5-21 days
Deep burns 21-35 days
Minimal to no scarring w/ potential discoloration

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6
Q

Full Thickness Burn

3rd Degree

A

Depth: All epidermis, dermis down into subcutaneous tissues
Pain level: Little or no pain
Appearance: Khaki brown, charred appearance, leathery dry w/ no elasticity
Characteristics: Loss hair follicles, possibly singed hair present; requires skin graft
Example: Contact w/ flame, hot surface or liquids, chemical, electric

Small areas take mos to heal
Large areas require grafting
Scarring present

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7
Q

4th Degree Burn

A

Full thickness extending into muscle and bone

Requires skin grafts & possible amputation

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8
Q

Rule of 9s

A 
Estimates TBSA
Head 9%
Upper extremity 9%
Anterior trunk 18%
Posterior trunk 18%
Lower extremity 18%
Perineal 1%

Pediatrics*

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9
Q

What patients should be transferred to a designated burn center?

A

Full thickness burns (any age group)
Partial thickness > 10% TBSA
Age extremes (pediatric or elderly)
Special areas including face, hands, feet, perineum, or major joints
Burn types - inhalational, chemical, or electrical
Patients w/ co-existing disease

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10
Q

What improves outcomes in burn patients?

A

Early interventions

Skin grafts when necessary

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11
Q

What TBSA does the National Burn Registry associate w/ increased mortality?

A

Patient age + TBSA % = >115

Mortality > 80%

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12
Q

Burn Phases

A
  1. Resuscitative
  2. Debridement & grafting
  3. Reconstructive
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13
Q

Resuscitative Phase

A

Admission & initial treatment
1° survey
ABCs +DE
Co-morbidities

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14
Q

Closed Space Thermal Injury

A

Closed space thermal injury = AIRWAY injury

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15
Q

Electrical Burn Complications

A

Electricity follows the path of least resistance (bone = most resistant)

  • Severe fracture(s)
  • Hematoma
  • Seizures
  • Visceral injury
  • Skeletal (contractures)
  • Cardiac injury (arrhythmias)
  • Neurological injury
  • Respiratory arrest
  • Muscle damage → myoglobinurea → renal failure
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16
Q

Airway Complication S/S

A 
Singed facial hair
Facial burns
Dysphonia/hoarseness
Cough or carbonaceous sputum 
Soot present in mouth or nose
Swallowing impairment
Oropharynx inflammation
CXR initially normal - pulmonary edema or infiltration develops days later

Patients at risk to experience upper airway injury include closed space injuries & unconscious

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17
Q

Inhalational Injury

A

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

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18
Q

Upper Airway

Inhalational Injury

A

Thermal damage to respiratory tract soft tissue & trachea - potentially difficult endotracheal intubation
Thermal injury + fluid resuscitation
↑glottic edema risk

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19
Q

Lower Airway

Inhalational Injury

A

Pulmonary edema or ARDS develops 1-5 days post-burn

Pneumonia or pulmonary embolism > 5 days post-burn

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20
Q

Smoke Inhalation

A

Occurs w/ face & neck burns or in closed space fires
Chemical pneumonitis similar to gastric aspiration occurs after smoke/toxic fume inhalation
Honeymoon period 1st 48hrs clear CXR (2-5 days to develop symptoms)
1st sign ↓PaO2 on RA
↑sputum w/ rales/wheeze

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21
Q

Hypoxia Impact in Patients w/ Inhalational Injury

A

1st 36hrs ↑pulmonary edema risk
2-5 days after = expect atelectasis, bronchopneumonia, airway edema at maximum 2° to airway mucosa sloughing off, thick secretions, distal airway obstruction
> 5 days post-burn = nosocomial pneumonia, respiratory failure, ARDS
Consider chest/upper abdomen circumferential burns = restricted chest wall movement as eschar contracts & hardens (escharotomy)

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22
Q

Inhalational injury or facial burns →

A

INTUBATE
Secure the airway early

Consider fluid resuscitation impact & potential edema

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23
Q

Airway Management

A

Patent airway
100% FiO2
Serial laryngoscope/bronchoscope exams, CXR, ABGs, & PFTs in suspected inhalational injury

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24
Q

When to intubate?

A

Massive burn, stridor, respiratory distress, hypoxia or hypercarbia, altered LOC
Deterioration expected

*Pediatric patient airways = smaller diameter
Lower threshold to intubate

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25
Q

Hypoxia Treatment

A 
PEEP
Airway humidification
Bronchial suctioning/lavage
Bronchodilators
Antibiotics
Chest physiotherapy
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26
Q

Carbon Monoxide Toxicity

A

Carbon monoxide (CO) + smoke inhalation
Acts as myocardial toxin & prevents cardiac arrest survival
Normal SaO2
Breathing WNL
Cherry-red blood (when CO > 40% and patient not cyanotic or hypoxic)

27
Q

Carbon monoxide ___x Hgb affinity

A

200x

28
Q

Carbon monoxide shifts the Hgb dissociation curve ______

A

LEFT (loves)

Impairs O2 unloading

29
Q

What does carbon monoxide interferes w/ _____?

A

Mitochondrial function
Uncouples oxidative phosphorylation
Reduces ATP production
→ metabolic acidosis

30
Q

Carbon Monoxide Toxicity

Treatment

A

100% FiO2 on ALL burn patients until CO toxicity ruled out
COHgb > 30% → hyperbaric chamber
- Patient hemodynamically & neurologically stable

31
Q

Carbon Monoxide Toxicity %

S/S

A

< 15-20% headache, dizziness, confusion
20-40% nausea/vomiting, disorientation, visual impairment
40-60% agitation, combative, hallucinations, coma, & shock
> 60% incompatible w/ life

32
Q

Carbon Monoxide < 15-20%

A

Headache, dizziness, confusion

33
Q

Carbon Monoxide 20-40%

A

Nausea/vomiting, disorientation, visual impairment

34
Q

Carbon Monoxide 40-60%

A

Agitation, combative, hallucinations, coma, & shock

35
Q

Carbon Monoxide > 60%

A

DEATH

36
Q

Cyanide Toxicity

A

Cyanide produced when synthetic materials burn - foam, plastics, paint, wool, silk
Victims inhale & absorb via mucous membranes
Metabolic acidosis ↑lactate levels

37
Q

Cyanide Toxicity S/S

A

Altered LOC w/ agitation, confusion or coma

CV depression/arrhythmia risk

38
Q

What blood cyanide levels confirm toxicity diagnosis?

A

> 0.2 mg/L

39
Q

Lethal Cyanide Levels

A

1 mg/L

40
Q

Cyanide Half-Life

A

60 minutes (1 hour)

41
Q

Cyanide Toxicity Treatment

A

OXYGEN

Hydroxycobalamine
Amyl nitrate
Sodium nitrate
Thiosulfate

42
Q

Cyanide Toxicity

Systemic Effects

A

Inflammatory mediators released locally at the burned tissue & systemically contributes to edema associated w/ burn injury
↑microvascular permeability → fluid leak & protein loss
↑intravascular hydrostatic AND ↓interstitial hydrostatic pressure
↑interstitial osmotic pressure
→ BURN SHOCK

43
Q

Surgery & infections perpetuate _____-______ response → multi-organ failure

A

Mediator-induced systemic inflammatory response

44
Q

Cardiovascular

A

1st 24hrs ↓CO
→ BURN SHOCK
Circulating tumor necrosis factor → myocardial depression
Diminished response to catecholamines
↑microvascular permeability → hypovolemia
Compensation = vasoconstriction
↓tissue O2 supply & coronary artery blood flow
Erythrocyte hemolysis

45
Q

Cardiovascular

AFTER 24-48 HOURS

A

HYPERDYNAMIC STATE
↑HR/BP/CO
Cardiac output 2x normal → HIGH output heard failure

46
Q

Overall Systemic Results

A 
Immune suppression
HPA & RAAS activation
Hypermetabolism 
Protein catabolism
Sepsis
Multi-organ system failure
47
Q

Metabolism

A

↑metabolic rate directly proportional to TBSA burned
↑core body temperature reflects ↑metabolic thermostat
↑caloric consumption

48
Q

Skin loss → _____, _____, & _____

A

Loss vasoactivity, piloerection, & insulation functions

49
Q

Daily evaporative fluid loss = mL

A

4,000mL/m^2

50
Q

End Organ Complications

A

GI - ileus, ulceration, cholecystitis
Renal - ↓GFR/RBF, loss Ca2+/K+/Mg2+, retention Na+/H2O
Endocrine - ↑corticotropin, ADH, renin, angiotensin, aldosterone, ↑glucagon, insulin resistance, hyperglycemia
Heme - ↑viscosity ↑clotting factors ↓Hct ↓RBC half-life

51
Q

Fluid Resuscitation

A

Fluid loss from vascular compartment 1st 24hrs

1st 24hrs crystalloid ONLY

52
Q

Titrate fluids based on _____

A

UOP

0.5-1mL/kg/hr

53
Q

Adverse effects r/t over aggressive fluid resuscitation:

A

Worsen airway edema
↑chest wall restriction
Contributes to abdominal compartment syndrome

54
Q

When to replace w/ colloids?

A

After 24hrs
Colloids 0.3-0.5 mL/kg/TBSA % burn
Albumin 5%

55
Q

Parkland Formula

A

4 mL/kg/TBSA % burn

1st 24hrs

56
Q

Modified Brooke Formula

A

2 mL/kg/TBSA % burn

1st 24hrs

57
Q

How quickly to replace fluids 1st 24 hours?

A

50% 1st 8 hours
25% 2nd 8 hours
25% 3rd 8 hours

58
Q

Fluid Resuscitation GOALS

A 
UOP 0.5-1 mL/kg/hr
HR 80-140bpm
MAP > 60mmHg (adults)
Base deficit < 2 mmol/L
Normal Hct
59
Q

Inadequate UOP despite > 6mL/kg/TBSA % burn

A

Consider low dose Dopamine 5mcg/kg/min

Another vasopressor?

60
Q

Repeat Surgery Considerations

A

Maintain Hct (multiple transfusions)
Coagulopathy
Temperature
Fluid & electrolytes
Hypermetabolic state ↑O2, ventilation, nutrition
↑GI ileus risk → aspiration/hyperalimentation

61
Q

Challenges associated w/ burn patients in the perioperative setting:

A

Limited access to place monitors
Multiple large bore PIVs
Warm OR 28-32°C to compensate for evaporative/exposure heat loss
Minimize blood loss w/ topical or SQ Epi, only 15-20% TBSA per procedure, tourniquet
Massive transfusion complications - coagulopathy & hypocalcemia

62
Q

OR Equipment

A

A-line
Bair hugger & fluid warmer
Rapid infuser
Inotropes & IV pumps

63
Q

Muscle Relaxants

A

1st 24hrs unaltered response (okay to admin Succinylcholine)

24hrs to 1 year post-burn avoid Succinylcholine (massive K+ release d/t nAChR upregulation)
Resistance to most NDMR when > 30% TBSA burned

AS - N934 Advanced Principles II (18 decks)

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