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N934 Advanced Principles of Anesthesia II > Burns > Flashcards

Burns Flashcards

1
Q

functions of the skin

A
  • barrier (body fluids/infection)
  • temperature
  • elasticity
  • appearance
  • sensory organ
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2
Q

three layers of skin

A
  • epidermis
  • dermis
  • subcutis (hypodermis or sub q tissue)
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3
Q

types of burn in jury

A
  • thermal –> flash, flame, scald
  • chemical
  • electrical
  • radiological
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4
Q

classification of burns

A
  • depth - extent of skin and tissue destruction
  • superficial, partial thickness, full thickness
  • TBSA - total body surface area involved (rule of nines)
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5
Q

superficial burn (1st degree)

A

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

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6
Q

partial thickness burn (2nd degree)

A
  • depth - superficial or deep; epidermis up to deep dermal element
  • pain level - very painful (because exposure of nerve endings)
  • appearance - bright cherry red, pink or pale ivory, usually with fluid filled blisters
  • characteristics - hair follicle intact, may require skin graft
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7
Q

full thickness burn (3rd degree)

A
  • depth - all of the epidermis, dermis, and down to the subQ tissue
  • pain level - little or no pain
  • appearance - khaki brown, white or charred/cherry red (in peds cherry)
  • characteristics - loss of hair follicles, will DEF need skin graft
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8
Q

fourth degree

A
  • depth is full thickness extending into the muscle and bone
  • will 100p require skin graft and maybe need to be amputated
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9
Q

Rule of nines

A
  • a way to classify the TBSA burned

- NOTE = different for peds and obese individuals

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10
Q

head rule of nines

A

9% TBSA

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11
Q

upper extremities rule of nines

A

18% TBSA

each arm = 9%

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12
Q

trunk rule of nines

A

36% TBSA

front/back = 18% each

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13
Q

lower extremities rule of nines

A

36% TBSA

each leg = 18%

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14
Q

genitals rule of nines

A

1% TBSA

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15
Q

burns that should be transferred to burn center

A
  • full thickness in ANY age group
  • partial thickness >10% TBSA
  • burns of special areas
  • extreme of age
  • burns of face, hands, feet, perineum or major joint
  • inhalation, chemical or electrical burns
  • those burns associated with co-existing disease
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16
Q

mortality of burns

A
  • if the age of the patient plus the TBSA % is greater than 115 the mortality is greater than 80%
  • associated injuries increase mortality (inhalation injury and other trauma)
  • premorbid condition
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17
Q

resuscitative phase burns

A
  • similar to trauma

- initial treatment involves airway, breathing, circulation, coexisting trauma

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18
Q

assessment of burn patient source of injury

A
  • closed space thermal injury equates to airway injury
  • open space accidental injury (campfire) or MVC = multiple co-existing injuries
  • electrical injury may lead to occult - severe fractures, hematoma, visceral injury, skeletal, cardiac injury, neurologic injury
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19
Q

airway management in burn patient

A
  • aggressively r/o upper airway injury in patient at risk (closed space injury, unconsciousness)
  • diagnosis is made by history and physical exam
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20
Q

S/S airway complications

A
  • singed facial hair
  • facial burns
  • dysphonia/hoarseness
  • cough/carbonacous sputum
  • soot in mouth/nose
  • swallowing impairment
  • oropharynx inflammation
  • CXR initially normal (until pulmonary edema or infiltration develops)
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21
Q

inhalation injury

A

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

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22
Q

upper airway involvement inhalation injury

A
  • thermal damage to soft tissues of the respiratory tract and trachea can make intubation difficult
  • thermal injury plus fluid resuscitation
  • increases the risk or glottic edema
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23
Q

lower airway involvement inhalation injury

A
  • pulmonary edema/ARDS develops 1-5 days post-burn

- pneumonia and pulmonary embolism >5 days post burn

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24
Q

smoke inhalation

A
  • occurs in conjunction with face/neck burns and closed space fires
  • chemical pneumonitis similar to gastric aspiration occurs after smoke/toxic fume inhalation
  • honeymoon period in 1st 24 hours with clear CXR
  • decreased PaO2 on RA is 1st sign
  • increased sputum with rales/wheeze
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25
Q

first 36 hours inhalation injury

A

high risk of pulmonary edema

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26
Q

days 2-5 inhalation injury

A

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

27
Q

> 5 days post-burn inhalation injury

A

nosocomial pneumonia, respiratory failure, ARDS

28
Q

circumferential burns of chest/upper abdomen

A
  • restricted chest wall motion as eschar contracts and hardens
  • may need escharotomies to allow for proper chest expansion with respiration
29
Q

pulm/airway management in inhalation injury

A
  • serial laryngoscopic/bronchoscopic exams
  • CXR
  • ABGs
  • PFTs
  • 100% FiO2
  • prophylactic intubation if deterioration likely
  • intubation technique depends on patient factors, extent of damage, age, and co-existing disease
  • adults = fiberoptic intubation under adequate topical anesthesia is safest is they can cooperate
  • peds = smaller diameter airway so LOW threshold for intubation
30
Q

ETT indicators for inhalation injury

A
  • massive burn
  • stridor
  • respiratory distress
  • hypoxia/hypercarbia
  • altered LOC
31
Q

treatment of hypoxia in those with inhalational injury

A
  • PEEP
  • airway humidification
  • bronchial suctioning/lavage
  • bronchodilators
  • abx
  • chest physiotherapy
32
Q

carbon monoxide toxicity

A
  • CO poisoning and smoke inhalation usually found together
  • CO 200x affinity for Hgb as O2
  • CO shifts Hgb dissociation curve LEFT so impairs O2 unloading at tissue
  • may act as myocardial toxin and prevent survival of cardiac arrest
  • SaO2 may be normal
  • respiratory effort may appear normal
  • cherry red blood color may not be present if CO is < 40% and/or patient is cyanotic and hypoxic
33
Q

CO interferes with…

A
  • mitochondrial function
  • uncouples oxidative phosphorylation
  • reduces ATP production
  • result is metabolic acidosis
34
Q

CO toxicity treatments

A
  • high FiO2 on all burns until CO tox ruled out

- hyperbaric chamber if COHgb is > 30% and patient is hemodynamically and neurologically stable

35
Q

CO <15-20%

A

HA, dizziness, confusion

36
Q

CO 20-40%

A

nausea, vomiting, disorientation, visual impairment

37
Q

CO 40-60%

A

agitation, combative, hallucinations, coma, shock

38
Q

CO >60%

A

death

39
Q

cyanide toxicity + BURNS

A
  • cyanide (CN) is produced as synthetic materials burn
  • victims inhale and absorb it through mucuous membranes
  • metabolic acidosis is result with elevated lactate levels
40
Q

S/S cyanide toxicity

A
  • altered LOC w/ agitation, confusion, coma

- CV depression + arrhythmia risk

41
Q

diagnosis cyanide toxicity

A

blood cyanide levels of >0.2 mg/L

LETHAL = 1.0 mg/L

42
Q

cyanide toxicity treatment

A
  • O2 is treatment of choice

- others = hydroxycobalamine (vit B12 derivative), amyl nitrate, sodium nitrate, thiosulfate

43
Q

CN half life

A

60 min

44
Q

systemic effects of burn injury

A
  • release of inflammatory mediators locally at the burned tissue and systemically contribute to edema associated with burn injury
  • increase in microvascular permeability –> fluid leak and loss of proteins
  • increased intravascular hydrostatic pressure/decreased interstitial hydrostatic pressure
  • interstitial osmotic pressure increases
  • surgery and infections can perpetuate this mediator induced systemic inflammatory response that may lead to multiple organ failure
45
Q

CV stresses with burns

A
  • severe decrease in CO lasts first 24 hours
  • circulating TNF causes myocardial depression
  • diminished response to catecholamines
  • increased microvascular permeability hypovolemia
  • intense vasoconstriction compensation
  • decreased tissue oxygen supply and coronary blood flow
  • hemolysis of erythrocytes
  • after 24-48 hours hyperdynamic state (high output CHF) - increased BP, HR, CO 2x normal
46
Q

overall systemic results with burns

A
  • immune suppression
  • activation of the hypothalamo-adrenal axis and the RAAS
  • hypermetabolism
  • protein catabolism
  • sepsis
  • MSOF
47
Q

metabolism in burn patient

A
  • increased metabolic rate is proportional to TBSA burned (can double in 50% TBSA)
  • increased core body temp reflects increased metabolic thermostat
  • loss of skin = loss of vasoactivity, piloerection, insulation functions
  • daily evaporative fluid loss is 4000 mL/m2
  • caloric consumption is increased
48
Q

GI end organ complications with burns

A

ileus
ulceration
cholecystitis

49
Q

renal end organ complications with burns

A

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

50
Q

endocrine end organ complications with burns

A

increased corticotropin, ADH, renin, angiotensin, aldosterone, increased glucagon, insulin resistance, hyperglycemia (at risk of nonketotic hyperosmolar coma)

51
Q

blood/coagulation end organ complications with burns

A

increased viscosity, increase in clotting factors including fibrinogen, V and VIII, fibrin split products at risk fo DIC development, HCT usually decreases

52
Q

burns fluid resuscitation

A
  • loss of fluid from vascular compartment 1st 24 hours –> replace with 2-4 mL/kg for each 1% TBSA burned
  • titrate fluids to u/o 0.5-1 mL/kg/hr
  • dont over do it!!!! over aggressive fluids can worsen airway edema, increase chest wall restriction, and contribute to abd compartment syndrome
  • 1st 24 hours cyrstalloid ONLY
  • > 24 hours colloids at 0.3-0.5 mL/kg/% burn, with 5% dextrose in water
53
Q

parkland formula

A

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

54
Q

modified brooke formula

A

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

55
Q

calculated volumes are given

A
  • 50% 1st 8 hour
  • 25% 2nd 8 hour
  • 25% 3rd 8 hour
56
Q

albumin 5%

A

can give after 1st 24 hours

0.3-0.5 mL/kg dose on burn extent

57
Q

goals of fluid resuscitation

A
  • UOP 0.5-1 mL/kg/hr
  • HR 80-140 bpm
  • MAP adults > 60 mmHg
  • base deficit < 2
  • normal Hct
58
Q

fluids not enough for burns?

A
  • low dose dopa 5 mcg/kg/min

- consider other vasopressor

59
Q

anesthesia considerations in burn patient

A
  • repeated surgeries
  • maintain HCT multiple transfusions
  • coagulopathy
  • temperature
  • fluids and lytes
  • hypermetabolic state = increase O2, ventilation, nutrition
  • increased risk for GI ileus, aspiration/hyperalimentation
60
Q

anesthesia challenges in burn patient

A
  • monitors, burned tissue = limited access for ECG, SaO2, PNS, NIBP
  • need large bore IV access - may consider alternative areas for placement
  • compensate for evaporative/exposure heat loss - room temp 28-32 degrees C
  • minimize blood loss - topical/SQ epi, only 15-20% TBSA q procedure, tourniquets
  • treat the complications of massive transfusion
61
Q

pre-op evaluation

A
  • airway
  • phase of resuscitation
  • monitoring
  • intravascular access
  • equipment
62
Q

anesthesia considerations for the high voltage electrical injury

A
  • follows path of least resistance, bone most resistant
  • cardiac arrhythmias
  • respiratory arrest
  • seizure
  • fractures
  • muscle damage –> myoglobinurea –> renal failure
63
Q

pharm for burn patients

A
  • HIGH opioid requirement
  • ideal anesthetic choice is iso + large dose opioid
  • serial debridments = ketamine in incremental doses
  • regional not normally option
  • muscle relaxants - in first 24 hours can use depolarizing and NDMR
  • after first 24 hours cannot use succ d/t mass K+ release b/c proliferation of nAChR
  • resistance to most NDMR if >30% TBSA

N934 Advanced Principles of Anesthesia II (17 decks)

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