burns Flashcards
pediatric burn injuries most often d/t
scalding
up to 20% of peds burns d/t _______ or _______
abuse or neglect
main cause of early death r/t burns (<48 hours):
shock and/or inhalation injury
after 48 hours, main cause of death is:
multi-organ failure and sepsis
first degree/superficial thickness burn
epidermis involvement
erythema, minor pain, no blisters
second degree/partial thickness - superficial
superficial (papillary) dermis
blisters, clear fluid, and pain
second degree/partial thickness - deep
deep (reticular) dermis
whiter appearance, with decreased pain, difficult to distinguish from full thickness
third or fourth degree/full thickness
dermis and underlying tissue and possibly fascia, bone, or muscle
hard, leather-like eschar, purple fluid, no senstation
ABA severity grading system
major burn =
2nd or 3rd degree burn
> 10% TBSA
electrical burns
inhalation injury (regardless of degree)
patient ______ + ________ > ________ means > 80% mortality
patient age + % TBSA is > 115 means > 80% mortality
ex: 70 yr old with 50% TBSA burn = 120
mortality __________ with inhalation injury
doubles
4 types of burn injuries
- chemical
- electrical
- thermal
- inhalation
electrical injury
- damage concentrated at entry & exit wounds
- major internal tissue damage seen
significant electrical burn leads to increased _________ leading to risk of _____________
myoglobin
renal failure
thermal injury
heat, flame, scald
suspect ____________ until ruled out
inhalation injury
inhalation injury classifications
upper airway, lower airway, or metabolic asphyxiation (carbon monoxide or cyanide)
brief exposure to hot dry air or steam leads to:
rapid airway destruction and edema
interesting phenomenon - heat in upper airway is dissipated but ______ _________ can occur so ________ _______ damage is uncommon
reflex laryngospasm
lower airway
most airway damage is d/t
toxins
inhalation injury warning signs
hoarseness
sore throat
dysphagia
hemoptysis
tachypnea
respiratory distress
elevated carbon monoxide levels
airway burn exam
direct visualization via laryngoscopy or fiberoptic bronchoscopy
gold standard airway exam
fiberoptic
if upper airway damage is present:
early intubation is indicated even when asymptomatic
avoid __________ if > __________ hours post injury
succinylcholine
24 hours
burns lead to _______________ which leads to _______________ which leads to cardiac arrest
receptor up-regulation (increased ACh receptors)
massive hyperkalemia
significant up-regulation occurs AFTER
first 24 hours
if airway swelling/obstruction is present, _________________ is best choice
awake intubation
awake intubation medications
topicals
ketamine
dex
no relaxants
spontaneous ventilation
avoid heavy sedation
awake intubation instruments
VL
FO
LMA assisted
blind nasal
retrograde wiring
light wand
surgical tracheostomy
progressive airway leak around ETT indicates
airway swelling is subsiding
suspect __________ if victim is rescued from an enclosed space
carbon monoxide poisoning
CO binds to _____ with _____ the affinity of O2 leading to decreased SaO2 and ___________________
Hgb
200x
metabolic acidosis
pulse oximetry does
NOT detect CoHgb which results in falsely high O2 saturation levels
______________ must be analyzed to obtain accurate measurement
arterial CoHgb
CO toxicity treatment
100% O2
burned plastic, paint, and some fabrics can cause
hydrogen cyanide (HCN)
HCN blocks intracellular O2 use leading to
metabolic acidosis
symptoms of HCN toxicity
changes in LOC
seizures
dilated pupils
hypotension
apnea
high lactate levels
treatment for HCN toxicity
hydroxocobalamin (vit B12a)
after securing airway, _____ _______ ______ begins
aggressive fluid resuscitation begins
burns cause loss of ______ _______, leading to ___________, _______ ________, decreased urine output, ______ depression, and collapse
circulating plasma
hemoconcentration
massive edema
decreased urine output
CV depression
fluid loss is greatest
during first 12 hours
fluid loss stabilizes after
24 hours
fluid resuscitation is required to prevent ______ ______ which leads to ________ ______ formation
hypovolemic shock
increased edema
also called the “fluid creep”
beware of ______ _______
compartment syndrome
2 commonly used guidelines for fluid resuscitation
Parkland and Brooke
heavy _______ _______ with no ________ or _______ (unless other traumatic injuries are present) during the resuscitation period
isotonic crystalloid
colloid
blood
parkland formula
4mL/kg/% TBSA burned
give first half over 8 hours and second half over the next 16 hours
caution with _________ - fluid management must be precise
children
children require maintenance ________ infusion along with __________ ______
glucose
resuscitation fluids
highest stress response
first 3 days of injury
plasma catecholamines ___ to ___ higher than usual
10-50x
if not managed, physiologic exhaustion leads to
death
around 48 hours post injury, pronounced
hypermetabolic phase sets in
hyper metabolic phase can last ___________ after _________ burn
up to 2 years after 40% TBSA burn
drugs/treatments for prevention of sepsis, temp maintenance, and hypermetabolism
antibiotics
warming devices
nutritional support
anabolic agents
beta blockers
anti-hyperglycemics
loss of plasma protein leads to _________ and ________ “burn shock”
hypovolemia and hypotension
decreased CO is initially
compensated by catecholamines (increase HR and vasoconstriction)
in children, ______ persists for weeks after injury
HTN
treating __________ ________ may improve long-term outcomes
hyperdynamic response
decreased ______ ______ even with no inhalation injury
pulmonary function
_____ _______ _______ common
acute lung injury
decreased ______ and ________ d/t circumferential burns, edema, eschar
decreased FRC and compliance
may require escharotomy
increased ______ _______ + ______ _______ = risk of pulm edema/ARDS
increased capillary permeability + fluid resuscitation = risk of pulm edema/ARDS
current trend to minimize barotrauma
low Vt
low PiP ventilation to minimize barotrauma
renal fxn decreased r/t
myo- and hemoglobinuria
up to 40% develop
acute kidney injuries (AKI)
“RIFLE” criteria used to categorize AKI
R - risk
I - injury
F - failure
L - loss
E - end-stage kidney disease
high risk of _____ and ______
sepsis and pneumonia
______ is leading cause of death in children (up to 100%) and adults (up to 75%)
sepsis
metabolic rate
2x normal
failure to meet nutritional requirements leads to (4)
- poor healing
- sepsis
- multi-organ dysfunction
- death
burns lead to ________ resistance. _______/______ protocols common.
insulin resistance
glucos/insulin
if intubated, do not
stop enteral feedings preoperatively (controversial)
continue _____ intraop
TPN
monitor _____ perioperatively
glucose
use _______ ______ for pediatrics
infusion pumps
ileus common with >_____ TBSA burn
20%
multiple procedures frequently required
debridement
grafting
amputation
standard procedure
early debridement with rapid coverage
debridement/grafting is done every ___-___ ____ until grafting is complete
2-3 days
3 types grafts
autologous skin
cultured skin
skin substitutes (porcine)
common guidelines (3)
no more than 20% of body surface at a time
stop surgery at core temp < 35 C
stop when 10 units (3500 mL) PRBCs given (EBV of 50 kg pt). less in children.
pre op assessment, thorough airway _________, __________, and pulm assessment ____, _________. prepare for possible ________ ________ ________.
neck mobility, oral opening
PiPs, minute ventilation
difficult airway techniques
minimally safe _____ ______
NPO orders
evaluate ___ _____
IV access (2 large bore PIVs or CVLs)
check ______ and ______ ______
labs
blood availability
have ______ in the OR BEFORE ________ begins, especially geriatrics
blood
debridement
_______ the OR, fluids, bed, surgeon
WARM
plan for _______ _______ and __ ______
post-op ventilation and ICU bed
may need ____ ______ for EKG
needle electrodes
______ _______ if all extremities affected or are being used for donor grafts
arterial lines
creative pulse oximetry
ear lobes
nose
toes
cheek
_______ or ______ temp probe for accurate core temp
esophageal or bladder
EXTREME CAUTION when
transporting and moving
airway loss can be
LETHAL
watch ______ ____, monitor ______ while transporting
invasive lines
monitor VS
for non-intubated patients with no airway injury, induction and intubation done ___ ________ EXCEPT _____________________.
as usual
SUX MUST BE AVOIDED
BIG problem
temp regulation
heat everything to
a miserable level
keep up and stay ahead, debridement causes ______, ______ _______ loss
heavy, rapid blood loss
may be at transfusion trigger on
arrival
start blood transfusion as soon as
blood loss begins
_____ is difficult
EBL
look for ______ blood loss
hidden
transfuse based on
hemodynamics, urine output, labs
____ _______ method preferred for induction and maintenance
no single
______, _______, _______ okay to use
volatiles, opioids, TIVA okay to use
anesthetic events may exaggerated if
hypovolemic
_________ if stable, ________ if unstable
propofol
ketamine
_______ for ICU patients on specialized ventilators
TIVAs (anesthesia machine will not be used)
ABSOLUTELY NO
SUX
receptor ___-________ requires increased amounts of MRs
up-regulation
never _______ a ______ through burned skin
never pass a needle
associated vasodilation with regional may lead to ________ ________
hemodynamic instability
may have burn-related _________
coagulopathy
regional is a _______ choice if areas of debridement/grafting can not be anesthetized
poor
________ may be good choice for children with lower extremity burns
caudals
caution with intraop _________ if extubation is planned, especially with possible airway compromise
narcotics
vigilance during ________ of intubated patients
transport
post op _____ _____
PCA pumps
_________ graft sites more painful than _______ sites
donor
grafted
opioids best when
hemodynamically stable
CAUTION with __________ - can interfere with hemostasis
NSAIDs
repeated painful procedures leads to
analgesic tolerance
later on, scarring and neck contractures of mouth and neck lead to
difficult intubations
consider pre-op sedation for children __________
needing repeated procedures
child legs
adult legs
13.5%
18%
child head
adult head
18%
9%
