Burns Flashcards

Question

Why do we intubate these patients early?

Answer 1

Glottis edema will worsen with fluid administration and over time RSI with IV induction in the absence of airway abnormality Succinylcholine safe in the first 24 hours not after 24hr-2years after injury – up regulation of acetylcholine receptors can lead to hyperkalemia and cardiac arrest Non-depolarizing muscle relaxants Increased Dose Up-regulation of acetylcholine receptors, fluid shifts significantly changing the volume of distribution and decreased receptor sensitivity

Answer 2

Restoring blood volume after the airway has been secured improves chances of survival of burn victims Burns lead to increase microvascular permeability which leads to capillary leak (becomes greater with major burn inhalational injury or a delay in resuscitation) Capillary leak leads to edema Protein rich fluid lost to interstitial space decreases plasma oncotic pressure Loss of intravascular volume leads to hypovolemia and hemoconcentration

Answer 3

Edema and fluid shifts are greatest in the first 12 hours No albumin in the first 24 hours Hemolysis is common in the initial stage (hypovolemia and hemoconcentration) An elevated HCT in the first 24 hours suggests inadequate fluid resuscitation Transfuse < 20% if healthy, <30% if CV disease

Answer 4

First 24 hours: 4ml LR* X %TBSA burned X kg ½ in the first 8 hours ½ in the next 16 hours No colloid Second 24 hours: D5W maintenance and colloid 0.5ml* X %TBSA X kg

Answer 5

Adults: LR 2-4 ml * Kg weight * %TBSA burned Children: LR 3-4 ml * Kg weight * TBSA burned

Answer 6

Adults: 0.5-1 ml/kg/hr. Children (<30Kg): 1ml/kg/hr. High voltage Electrical Injury: 1-1.5ml/kg/hr.

Answer 7

Excess fluid loading is termed fluid creep, common in burn patients Can be the result of fluid miscalculation Lack of vigilance Increased use of sedation and analgesic agents Excess crystalloid over colloid replacement Associated with abdominal compartment syndrome

Answer 8

Defined as an intraabdominal pressure > 20mmHg by transduction of bladder pressure and evidence of end organ dysfunction Rx: NMBD, sedation, diuresis, abdominal decompression (ex. Lap)

Answer 9

Severe thermal injuries with burns over 40% of TBSA is followed by a pronounced hypermetabolic response that persists for up to 2 years There is a 10-50 fold increase in catecholamine and corticosteroid levels that lasts for up to 9 months post burn Increased metabolic rate, multi-organ dysfunction, blunted growth insulin resistance, and increased risk for infection

Answer 10

(first 24hrs) Hypotension Low CO Metabolic acidosis Hypoventilation Hyperglycaemia Low O2 consumption Impaired thermoregulation

Answer 11

Hypermetabolic phase Increased CO Increased HR Better O2 consumption Supranormal increases of temperature Days to weeks

Answer 12

Healing and rehabilitation Anabolism Normal function restores Weeks to months

Answer 13

Bring transport bag and ambu bag (with all equipment for reintubation) Transport Ventilator: If on high levels of PEEP, continue during transport and the OR Clamp/occlude during disconnecting from circuit to minimize de-recruitment Burn Patients are hypermetabolic for many reasons (e.g. sepsis, burn). Match minute ventilation from the ICU in the OR. Utilize lung protective ventilation when appropriate Confirm adequate pressors available for transport/starting the case. If not enough obtain prior to leaving or have pharmacy prepare and bring to the room. Fluid resuscitation should continue during transport Patients should have a free running IV line to administer medications If on dialysis review electrolytes, pH, and volume status Continue TPN during transport and intra-op Confirm blood glucose prior to surgery

Answer 14

loss from wound site anemia (hemolysis or decreased RBC survival) Reduced production of RBCs

Answer 15

Call for blood on arrival into the room Begin transfusions ahead of blood loss Blood loss can be rapid and be hidden in drapes and sponges NEVER rely on the canisters Labs may not reflect acute blood loss, so resuscitation has to be based on visual cues Transfusion triggers HGB <7, INR>1.6 etc do not apply in acute blood loss Transfusions should follow a 4:2:1 RBC:FFP:Plt ratio OK to replace RBC and FFP in 1:1 ratio. Do not forget platelets in massive transfusion

Answer 16

You must know the # of days since the burn to calculate this < 1 day = 0.45 ml/cm2 burn area 1-3 days: 0.65 ml/cm2 burn area 2-16 days: 0.75 ml/cm2 burn area > 16 days: 0.5-0.75 ml/cm2 burn area Infected Wounds: 1-1.25 ml/cm2 burn area

Answer 17

an inflammatory stimulus or microvascular damage

Answer 18

Acute gastric dilatation within 2-4days Paralytic ileus – decompression with NG tube Failure of enteral feeding and translocation of gut bacteria Curling’s ulcer: stress-induced ulcer of the stomach or duodenum that occurs in relation to extreme physical stress (massively burned patients) Abdominal compartment syndrome Acute pancreatitis, acute acalculous cholecystitis

Answer 19

Do NOT rely on inhalational anesthetics drips alone to provide pain relief Multi-modal therapy: Ketamine Methadone (if QTc appropriate) Lidocaine IV Tylenol Magnesium Dexmedetomidine Regional anesthesia

Answer 20

Grossly restricted neck movements Patients are likely to be malnourished, anemic and hypoproteinemia Restricted mouth opening and narrowed nasal passages. Difficult laryngoscopy and endotracheal intubation Compromised airway Poor oral hygiene in patients

Answer 21

Mild- Scar apparent during neck extension with the loss of the cervico-mental angle; neck extension- 95 to 110 Moderate- Scar apparent in resting position, which hinders neck extension; neck extension- 85 to 95° Severe- Neck in flexed position and limiting any neck movement; neck extension is <85°

Answer 22

succinylcholine and NDNMB’s

Answer 23

adrenocortical suppression

Answer 24

perioperative hypothermia

Answer 25

evaporation

Answer 26

increases catabolism O2 consumption HR and RR