Burns Flashcards
Burn Injury Types
Thermal - flash, flame, & scald
Chemical
Electrical (current) entry & exit wound
Radiological - radiation
Thermal Burn Types
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)
Burn Injury Severity
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
Superficial Burn
1st Degree
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
Partial Thickness Burn
2nd Degree
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
Full Thickness Burn
3rd Degree
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
4th Degree Burn
Full thickness extending into muscle and bone
Requires skin grafts & possible amputation
Rule of 9s
Estimates TBSA Head 9% Upper extremity 9% Anterior trunk 18% Posterior trunk 18% Lower extremity 18% Perineal 1%
Pediatrics*
What patients should be transferred to a designated burn center?
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
What improves outcomes in burn patients?
Early interventions
Skin grafts when necessary
What TBSA does the National Burn Registry associate w/ increased mortality?
Patient age + TBSA % = >115
Mortality > 80%
Burn Phases
- Resuscitative
- Debridement & grafting
- Reconstructive
Resuscitative Phase
Admission & initial treatment
1° survey
ABCs +DE
Co-morbidities
Closed Space Thermal Injury
Closed space thermal injury = AIRWAY injury
Electrical Burn Complications
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
Airway Complication S/S
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
Inhalational Injury
Damage to the respiratory tract or lung tissue from heat, smoke, or chemical irritants carried into the airway during inspiration
Upper Airway
Inhalational Injury
Thermal damage to respiratory tract soft tissue & trachea - potentially difficult endotracheal intubation
Thermal injury + fluid resuscitation
↑glottic edema risk
Lower Airway
Inhalational Injury
Pulmonary edema or ARDS develops 1-5 days post-burn
Pneumonia or pulmonary embolism > 5 days post-burn
Smoke Inhalation
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
Hypoxia Impact in Patients w/ Inhalational Injury
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)
Inhalational injury or facial burns →
INTUBATE
Secure the airway early
Consider fluid resuscitation impact & potential edema
Airway Management
Patent airway
100% FiO2
Serial laryngoscope/bronchoscope exams, CXR, ABGs, & PFTs in suspected inhalational injury
When to intubate?
Massive burn, stridor, respiratory distress, hypoxia or hypercarbia, altered LOC
Deterioration expected
*Pediatric patient airways = smaller diameter
Lower threshold to intubate
Hypoxia Treatment
PEEP Airway humidification Bronchial suctioning/lavage Bronchodilators Antibiotics Chest physiotherapy
Carbon Monoxide Toxicity
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)
Carbon monoxide ___x Hgb affinity
200x
Carbon monoxide shifts the Hgb dissociation curve ______
LEFT (loves)
Impairs O2 unloading
What does carbon monoxide interferes w/ _____?
Mitochondrial function
Uncouples oxidative phosphorylation
Reduces ATP production
→ metabolic acidosis
Carbon Monoxide Toxicity
Treatment
100% FiO2 on ALL burn patients until CO toxicity ruled out
COHgb > 30% → hyperbaric chamber
- Patient hemodynamically & neurologically stable
Carbon Monoxide Toxicity %
S/S
< 15-20% headache, dizziness, confusion
20-40% nausea/vomiting, disorientation, visual impairment
40-60% agitation, combative, hallucinations, coma, & shock
> 60% incompatible w/ life
Carbon Monoxide < 15-20%
Headache, dizziness, confusion
Carbon Monoxide 20-40%
Nausea/vomiting, disorientation, visual impairment
Carbon Monoxide 40-60%
Agitation, combative, hallucinations, coma, & shock
Carbon Monoxide > 60%
DEATH
Cyanide Toxicity
Cyanide produced when synthetic materials burn - foam, plastics, paint, wool, silk
Victims inhale & absorb via mucous membranes
Metabolic acidosis ↑lactate levels
Cyanide Toxicity S/S
Altered LOC w/ agitation, confusion or coma
CV depression/arrhythmia risk
What blood cyanide levels confirm toxicity diagnosis?
> 0.2 mg/L
Lethal Cyanide Levels
1 mg/L
Cyanide Half-Life
60 minutes (1 hour)
Cyanide Toxicity Treatment
OXYGEN
Hydroxycobalamine
Amyl nitrate
Sodium nitrate
Thiosulfate
Cyanide Toxicity
Systemic Effects
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
Surgery & infections perpetuate _____-______ response → multi-organ failure
Mediator-induced systemic inflammatory response
Cardiovascular
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
Cardiovascular
AFTER 24-48 HOURS
HYPERDYNAMIC STATE
↑HR/BP/CO
Cardiac output 2x normal → HIGH output heard failure
Overall Systemic Results
Immune suppression HPA & RAAS activation Hypermetabolism Protein catabolism Sepsis Multi-organ system failure
Metabolism
↑metabolic rate directly proportional to TBSA burned
↑core body temperature reflects ↑metabolic thermostat
↑caloric consumption
Skin loss → _____, _____, & _____
Loss vasoactivity, piloerection, & insulation functions
Daily evaporative fluid loss = mL
4,000mL/m^2
End Organ Complications
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
Fluid Resuscitation
Fluid loss from vascular compartment 1st 24hrs
1st 24hrs crystalloid ONLY
Titrate fluids based on _____
UOP
0.5-1mL/kg/hr
Adverse effects r/t over aggressive fluid resuscitation:
Worsen airway edema
↑chest wall restriction
Contributes to abdominal compartment syndrome
When to replace w/ colloids?
After 24hrs
Colloids 0.3-0.5 mL/kg/TBSA % burn
Albumin 5%
Parkland Formula
4 mL/kg/TBSA % burn
1st 24hrs
Modified Brooke Formula
2 mL/kg/TBSA % burn
1st 24hrs
How quickly to replace fluids 1st 24 hours?
50% 1st 8 hours
25% 2nd 8 hours
25% 3rd 8 hours
Fluid Resuscitation GOALS
UOP 0.5-1 mL/kg/hr HR 80-140bpm MAP > 60mmHg (adults) Base deficit < 2 mmol/L Normal Hct
Inadequate UOP despite > 6mL/kg/TBSA % burn
Consider low dose Dopamine 5mcg/kg/min
Another vasopressor?
Repeat Surgery Considerations
Maintain Hct (multiple transfusions)
Coagulopathy
Temperature
Fluid & electrolytes
Hypermetabolic state ↑O2, ventilation, nutrition
↑GI ileus risk → aspiration/hyperalimentation
Challenges associated w/ burn patients in the perioperative setting:
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
OR Equipment
A-line
Bair hugger & fluid warmer
Rapid infuser
Inotropes & IV pumps
Muscle Relaxants
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
