Burns Flashcards
Heat Burns depth is related to_____(3)
Contact temperature
Duration of contact
Thickness of skin
Heat burns usually involves what skin layers?
Usually involve epidermis and dermis
How are friction burns created?
Combo of mechanical disruption and heat generated by friction
How are electrical burns created? And what does it cause?
Electrical energy transformed to heat when current passes through body tissue
Disrupts membrane potential
Things that affect the severity of the electrical burns? (3)
Pathway of current
Resistance to current flow
Strength and duration of current flow
Electrical burns are more likely to cause______ issues than thermal burns
Cardiac
What can chemical burns cause?
alterations of the pH and cause the salt membranes to lose integrity and because of that destruction = metabolic processes are impeded.
What is the severity of the chemical burn related to?
Duration of exposure
Nature of agent
Acidic agents can cause what?
necrosis by coagulation
Basic agents can cause what?
necrosis by liquefacation
How is the severity of radiation burns influenced? (3)
dose and time of exposure
types of particles
Sunburns are what type of burn
radiation burns
How long does it take for burns to fully declare themselves?
24-48 hrs
What patient population are burns detrimental to?
Areas of thin skin and adults > 55 or kids < 5
Have deeper burns with less exposure/ intensity because of the thin skin
How are superficial burns manifested and what skin layers are involved?
Involving only the epidermis
Skin intact, red in color
Dry surface, no blisters
Painful, hypersensitive
How long does it take 1st degree burns to heal?
Heals in approximately
3–6 days
What burn is not counted in TBSA?
1st degree (superficial burns)
How are superficial partial Thickness burns manifested and what skin layers are involved?
Involves the epidermis and part of dermis
Mottled red color
Blisters or weeping
Very painful / nerve endings exposed
How long does it take of superficial partial thickness burns to heal?
Usually heals in 10 – 14 days
Minimal scarring
Deep partial thickness burns manifestation and skin layers involved?
Extends more deeply into the dermis
Decreased moisture
Pale in color
Absent or prolong blanching
How long does it take for Deep partial-thickness burns to heal? and what is usually required?
Healing in 21-28 days
Requires skin grafting
Why is there less moisture with deep partial thickness burns than superficial partial thickness burns?
Less pain is usually present in the deeper burn. Since the sweat glands have been destroyed, there is decreased moisture. This can also have consequences of temperature control when a graft is placed (i.e. the skin becomes hot but cannot sweat)
How are full thickness burns manifested and what skin layers are involved?
Full thickness (dermis is destroyed)
Translucent, dry, painless, charred
Non-blanching
What burns are included in burn surface calculations?
All 2nd and 3rd degree burns
escharotomy
done through escar/ burned tissue
cutting down through the escar
Fasciotomy
dont through tissue that has an injury but not a surface injury, cutting down through the fascia
Rule of 9s burn injuries adults
Adult;
Head 9%
Each arm 9%
Each leg 18%
Ant/Post trunk each 18%
Perineum 1%
Rule of 9s burn injuries peds
head and heck 21%
arms; 10%
back: 13%
abdomen; 13%
each leg; 13.5%
buttocks; 5%
genitals; 1%
Palmer method
PATIENTS palm Fingers together = 1%
What are the two conflicting properties that burns can cause
Hypovolemic shock and decreased perfusion
Loss of plasma from microvasculature into interstitium -> increased permeability
Patients with ________ TBSA develop burn shock and need IV resuscitation in an ICU
> 20%
Fluid losses are a function of _____ and _____
Fluid losses are a function of burn size and patient weight
Concerns for under resuscitating burns
↓ perfusion, burn shock, end organ failure
Concerns for over resuscitation burns
Abdominal compartment syndrome, pulmonary edema/ARDS
General metabolic response to trauma (burns)
Auto-cannibalism;
Loss of fat
Loss of lean body mass
Proteolysis
Gluconeogenesis
Lipolysis
Hypermetabolism;because of volume loss/ because of the pain
Insulin resistance
BSA ______ causes metabolic rate to double and can lead to________ (3)
40%
Cannibalism for months;
Immunodepression, recurrent infections, poor wound healing
How does Carbohydrate metabolism changes with burns?
Increases in cortisol, catecholamines, and glucagon resulting in;
Accelerated hepatic gluconeogenesis
Peripheral insulin resistance (50-70%increase )
Impaired intracellular glucose transport
How long can the increased gluconeogenesis and the insulin resistance last in burn pts?
last up to 3 years
What changes do burns cuase to lipid metabolism?
Accelerated lipolysis
d/t B2 and B3 adrenergic stimulation…⬆️ cAMP
d/t elevated glucagon, TNF, IL
… elevated levels of FFA…produce ATP
Treatment for accelerated lipolysis from Burns? and how does it work?
Treatment with beta-blockade
Decreases lipid oxidation and decrease metabolic rate
How is protein metabolism changed with burns?
Accelerated proteolysis of skeletal muscle
Provides substrate for hepatic gluconeogenesis
burns and bed ridden -> tissue strictures/ contractures
Degree of loss skletal muscle loss is proportional to degree of______
stress
Initial Stabilization of burn pts (5)
Respiratory support- airway
Fluid resuscitation
Cardiovascular stabilization
Pain control
Local care of burn wounds
Secondary stabilization in burn pts (6)
Pain control
Thromboprophylaxis
Wound closure
Nutritional support
Control of hypermetabolism
Prevention of infection
consider associated injuries
Pain control meds for burn pts
Long-acting opioids (methadone)
NSAIDs (acetaminophen)
PCA infusions (morphine)
IV Ketamine
Supplemented with anti-anxiety drugs
What can be altered in burns to cause changes to the dose of medications?
PK/PD can be altered in burns
May need to deviate from normal doses to avoid toxicity or decreased efficacy, and relative shrinkage of the vascular system
also consider lack of plasma proteins = more free drug.
change of volume of distribution
changes in receptor
Burns cause what changes cellularly resulting in large fluid loss? (3)
Impaired endothelial barrier
Increased capillary permeability
Loss of intravascular oncotic pressure
Therefore….copious loss of intravascular fluid
Release of systemic inflammatory reactions of histamine, prostaglandin and cytokines from burns Cause:
vasodilation of vessels
Aggressive IVF resuscitation at what BSA?
Generally for 15% BSA or >
Parkland Formula
4ml/kg x %BSA;
2ml/kg/%BSA in 1st 8 hours (LRS)
2ml/kg/%BSA in next 16 hours (LRS)
titrate IVF formula down when ______ and consider small amount of________ on day ____
Advocate titrating formula down when U/O adequate
Consider small amount of colloids on day 2
US Army ISR Rule of 10 for adult
Adult;
10mL/hr x TBSA
>80kg, add 100 mL/10kg
US Army ISR Rule of 10 for peds
Pediatric;
3 x TBSA x kg = vol for first 24 hrs
½ total volume over 8 hrs
Anesthesia Management: Preop Assessment
Determine estimated BSA% burn
Determine severity of burn
Assess need for transfer to a certified burn center
Burns to take to burn center
Full thickness > 10% BSA
High voltage electrical burns
Chemical burns
Associated inhalation injury
Face, hands, feet, perineum, major joints
Goal for UOP and titration if outside that goal
Goal targeted to U/O of 1cc/kg
Titrated every hour according to UOP goal 30-50 ml/hr, 20- 25% up or down if outside the parameters
What is the risk of ns for burn pts
Risk of hypernatremic hyperchloremic acidosis (non-gap acidosis)
Max mls to give
1500 mL/hr or 250 mL/kg in 24 hours
No fluid boluses as volume increases edema
fluid resuscitation for peds with crystalloids
> 40 kg - Use adult formula
< 14 yrs old and <40 kg:
2-4 ml (LR)/kg x %TBSA (2nd and 3rd degree)
Children <20 kg add maintenance rate of D5LR at 421 rule
Goal for peds UOP
Titrate IVF to maintain urine output 0.5-1mL/kg/hr
At _________hours post-burn, if the hourly IV fluid rate exceeds________ mL/hr or if the projected 24 hr total fluid volume approaches _________ mL/kg, initiate 5%_______
At 8-12 hours post-burn, if the hourly IV fluid rate exceeds 1500 mL/hr or if the projected 24 hr total fluid volume approaches 250 mL/kg, initiate 5% albumin
Colloids for peds burn pts and what titrations should be made with the isotonic cystalloid?
Children - infuse 4-7 mL/kg at the rate of 0.5 mL per minute.
Reduce maintenance isotonic crystalloid by an equal volume per hour
resuscitative cardiac state
low co from hypovolemia decreased coronary flow (MI)
decreased response to catecholamines
increase SVR
At cardiac status 72-96 post-burn and what to give
Hyperdynamic/ increased O2 consumption and decreased SVR
administer Beta-blockers
Pulmonary status post burn and treatment
inflammation -> pulm htn -> impaired gas exchange -> broncho spasms (give bronchodilators)
Restrictive lung defect post burn
Impaired ventilation from circumferential burns/scar
Hypoventilation d/t decreased elasticity
…escharotomies potentially necessary
normal carboxy hb and symptoms with changes
1-3%
smokers; 4-9%
20% = symptoms (HA, N/V)
long term injury = 20-25%
> 25% = unconsiousness and death
What is the goal for getting the burn pts nutrition and how will we get it to them>
Within 16 hours of admission; Thought to reduce magnitude of stress response
Nasoenteric feeds into the jejunum
Ensures high calorie, high protein
Treatment for CN toxicity
cyanocobalamin
When do we avoid succ in burn pts?
avoid after first 24 hrs of burns. Peaks at 48-72 hrs.
upregulation of NACR can last for how long?
Months to years (1-2) to recover
What happens as a result of the depolarizing agents on the upregulated nachrs?
Markedly increased serum K+
Begins approx. 24 hrs post burn
Significant after 48-72 hours
Does not correlate with severity of burn
Burn pts cause lose up to ______ degree _____ q ______min
Can lose up to 1 degree C q 15 min
airway burn s/s
Hoarseness, wheezing, SOB,
Stridor, dysphagia
Carbonaceous sputum
Singed nasal & facial hairs
Deep facial burns
Comatose patient
>40% TBSA
induction meds and concerns for burn pts
Prop and opioids; consider the cardiac state
Etomidate; adrenal insufficiency concern
Ketamine; SNS reserve
Resistance to non depolarizer occurs at what BSA?
25% BSA and >
Paramaters to give blood to burn pts
2.6% total blood volume lost for every
1% burn excised or autograft harvest
PRBCs to 7-8 g/dL hemoglobin
(10g/dL acute coronary syndrome)
things to give to reduce the risk of hemorrhage (3)
Use of topical thrombin, staged procedures, subq vasoconstrictors
Shock treatment and goal CVP and whta to do if not in goal
Shock MAP <55 mmHg ; Vasopressin and Norepinephrine
CVP;
Goal 6-8 mm Hg
If not at goal, increase IVF rate by 20-25%
Technique to infiltrate large volumes of LA subq
Tumescent LA
Tumescent LA dose
Lidocaine 1G + epi + 10meq NaHCO3/1000cc NaCL
55mg/kg max?
Effects of tumescent
Decreased blood loss
Easy excision of granulation tissue
Shorter surgical times
No hematoma or bruising postop
target abgs for burn pts
Target pCO2 30-35 mm Hg or pH >7.20
Meds to give for break up blood clots/ mobilize secretions
Nebulized 5000 units Heparin with Albuterol Q4H
Abdominal Compartment Syndrome
Abdominal pressure displaces diaphragm up by bowel (high airway pressures)
ACS are best diagnosed by bladder pressures
A burn patient has a 90% mortality with an open abdomen
S/s for abd compartment syndrome
Measure Q4H with >20% TBSA
Bladder pressures >12 mm Hg indicate early intra-abdominal hypertension
> 20 mm Hg is c/w abdominal compartment syndrome
Post op burn pts
Postop mechanical ventilation
Inhalation burns
At risk for ongoing bleeding
Additional surgery plans
Need to minimize movement/graft disruption
DVT prophylaxis, Beta blocker admin, Nutritional support, Temp control
Where is silvadene cream not applied?
face
What are Txa and Factor 7 at risk of
thrombosis
What eye ointment is applied and where
bacitracin = outside
erythromycin = inside
421 rule
4 ml/kg/hr for first 10 kg
2 ml/kg/hr for next 10Kg
1 ml/kg/hr for each kg >20 kg
