Burns Flashcards
classifications of burns
depth
TBSA
presence of inhalation injury
First degree
epidermis
no blisters
example: sunburn
superficial second degree
epidermis and upper dermis
red
no grafting
deep second degree
loss of epidermis and deep dermis
+ grafting
raw blistered weepy skin
blanches
painful
third degree
complete destruction of epidermis and deep dermis
+excision and grafting
white, waxy
not painful - nerve damage
fourth
complete dermal loss
tendon bone involved
muscle necrosis
limb loss
Major burn definition
2nd degree = >25% or >20% TBSA in age extremes
3rd degree= >10% TBSA
Face, Hands, Feet or Perineum
Inhalation, chemical or electrical burns
Burn victim with pre-existing medical disorders
thermal injury <4 y/o
scald injury
thermal injury >5
flame injury
chemical burn
uncommon in children.
tissue destruction until chemical is neutralized.
electrical burn
arch / flash
effect of electrical burn on kidneys
ATN from myoglobin release form muscle damage
myoglobinuria
dark pink urine
IVF 2mg/kg/hr
mannitol
lasix
bicarbonate
Lichtenberg
Lightning injury
Extravasation of blood in subcutaneous tissue fades rapidly
Inhalation injury
often with thermal burns.
doubles the mortality rate.
carbon monoxide causes what shift in O2 curve
left
how to diagnose CO poisioining
COhb oximetry
CV symptoms of CO poisioning
tachycardia
hypotension
increased CO
dysrthymia
MI
Treatment for CO
100% –> 4 hr to 60-90m
hypercarbic o2
classic cherry red color of blood is absent in what patients with COhb unless they have levels above
40%.
not a reliable indicator
Cyanide is made from
Nitrogenous : wool, silk, cotton, nylon, paper, plastic, polymers
CO is made from
carbon containing materials
wood, coal, gas, paper, cotton
colorless, almond smell
cyanide
colorless, odorless
CO
Why is cyanide lethal
stops cellular oxygenation.
binds to mitochondrial cytochrome oxidase blocking the last step in the oxidative phosphorylation, preventing the use of oxygen for conversion of pyruvate to adenosine triphosphate.
presentation of cyanide
metabolic acidosis
CV depression
dysrhythmias
increased MvO2
diagnosis of cyanide
Blood cyanide >0.2mg/l
lethal >1mg/L
treatment of cyanide
100% fio2
B12 Hydroxocobalamin
Amyl Nitrite
Sodium Nitrite
Sodium thiosulfate
Parkland formula
LR 4 mL x kg x TBSA % burn
First half over 8 hours
Second half over 16 hours
modified brookes
2mg x kg x tbsa x % burn of LR
First half over 8 hours
Second half over 16 hours
how quickly to resusitate
1/2 over 8 hours
1/2 over 16 hours
criteria for good resus
Normal BP
UO 1-2 m/k/h
Lactate <2
Base deficit <5
CI 4.5 L/min
bad fluid resus
increase in hematocrit on 1st day of thermal injury
Burn shock patho
Decreased CO
Increased SVR/PVR
Decreased perfusion
Hemoconcentration
Reduced Drug Elimination
RBC volume loss
HCT rises
Decreased UO
Decreased CV function
Loss of Plasma
Generalized edema –> fluid shifts.
How to protiens move during burn shock?
albumin decrease
A1AG increases
decreases albumin increases what medications?
Benzos
Phenytoin
Salicylic acid
a1ag decreases what meds?
lidocaine
meperidine
propanolol
muscle relaxants
Hyperdynamic/hypermetabolic phase pathophysiology
increased CO & CO2
increased O2 consumption
decreased SVR/PVR
tachycardia
tachypnea
drop in immune system function
protein wasting
increased blood flow to liver and kidneys
catecholamine surge
capillary integrity returns
induction in hyperdynamic burn patients
KOP rocks
+ Rocur 1.5mg/kg for RSI takes 90s
+ Ketamine (increased)
+ Propofol (increased)
+ opioids (increased)
+ volatiles
- avoid succinylcholine after 24 hours because of increased exJunct receptors and upregulation.
most heat loss in burn patients occurs due to
evaporation
Effects of hypothermia
- Cardiac arrhythmias and ischemia
- Increased PVR
- Left shift of hemoglobin oxygen saturation curve
- Reversible coagulopathy
- Increase protein catabolism and stress
- Altered mental status
- Delayed drug metabolism
- Impaired wound healing
- Increased risk of infection
MAC BAR
BLOCK ADRENERGIC RESPONSE
warmed topical
90 mg of Epinephrine in 1000 cc NSS Achieves Stasis
Tachycardia w/ epi:
Avoid this through MAC BAR
How Much Epinephrine is in One Bulb Syringe?
5mg ???
90mg per 1000cc
bulb syring is 60 cc
Blood replacement
Hct <15-20
Hct <25 healthy w/ extensive procedure
Hct <30 preexisting condition
1:1 PRBC & FFP
minimize cystalloid
CaCl > phenylephrine
Blood loss is continual
What are the rule of 9s?
Head: 9%
Each arm: 9%
Anterior chest and abdomen: 18%
Posterior chest and back: 18%
Each leg: 18%
Perineum: 1%
= 100%
different in children
What is the pathophysiology of carbon monoxide poisoning?
CO + Hgb = carboxyhemoglobin
→ Left shift
200x greater affinity for hemoglobin than O2
how is CO poisioning treated?
100% FiO2 decreases COhb from 4 hours to 60-90min
Hyperbaric O2 therapy
What fluid should be used for fluid resuscitation of a burn patient?
Crystalloids should be used in most cases of fluid resuscitation of a burn patient
what are the possible complications of fluid resuscitation?
Tissue edema
Hypoprotienemia
Compartment syndrome ACS
Pleural and pericardial effusions
Pulmonary edema
Fasciotomies
Conversion to partial to full thickness lesions.
What is smoke inhalation injury?
singed nasal hairs
facial burns
dysphonia
cough
soot in the nose or mouth
difficulty swallowing
what are the implications of inhalation injury
causing swelling of the airway and obstruction. This is managed by a very low threshold for intubation in order to be proactive in protecting the airway before inflammation and edema set in from the treatment of burns.
What complications are associated with electrical burns?
myocardial damage
muscle damage
myoglobin release –> renal failure
myoglobinuria
Dark pink urine indicated muscles damage
IV fluids
2ml/kg/hr + NaHCO3 + mannitol + lasix
What pathophysiologic changes accompany major thermal injury?
Name some of the known mediators released with thermal injury. What are the responses to those mediators?
histamine: cap permeability–> edema fluid loss
Prostaglandins: inflammation, pain, fever.
cytokines aka interleukins and TNF: inflammation, SIRS.
what is cyanide poisioning?
Cyanide binds to the terminal cytochrome on the electron transport chain, causing hypoxia, lactic acidosis, and elevated mixed venous oxygen saturation.
loss of consciousness, dilated pupils, seizures, hypotension, tachypnea followed by apnea, and increased lactate levels
How is cyanide poisoning treated?
100% fio2
hydroxocobalamin (B12)
amyl nitrite
sodium nitrite
sodium thiosulfate
What is normothermia for a burned patient?
International Society for Burn Injuries (ISBI) guidelines recommend maintaining a core temperature of at least 36°C at all times with some burn centers recommending a temperature as high is 38.5 +/- 1C.
How is temperature best maintained?
keep the OR between 80-100F
warmed fluid for IVF and skin preparations
HME adapters
low gas flows
forced-air warming blankets
over body heating lamps
plastic bags covering burned areas
What derangements occur with hypothermia?
cardiac arrhythmias
increased PVR
left shift of hemoglobin-oxygen saturation curve
reversible coagulopathy
increased post op protein catabolism and stress response
altered mental status
delayed drug metabolism
impaired wound healing
increased risk for infection.
why are we concerned about hypothermia in burn patients?
deleterious effects of vasoconstriction occur
what is the definition of major burn?
1.) 2nd degree burn >20% TBSA
2.) 3rd degree burn involving more than 10% TBSA
3.) face, hands, feet, and perineum
4.) inhalation, chemical, or electrical burn
5.) pre-existing medical disorders.
What are Curling ulcers? How can they be prevented?
ulcerations of the gastric or duodenal mucosa from gurns that can be prevented by the administration of H2 blockers, PPIs, and antacids.
What techniques may be used to secure the airway for airway management of burn patients?
If endotracheal intubation is not possible due to injury, then a surgical airway such as a tracheotomy is indicated.
Is succinylcholine acceptable for a rapid-sequence intubation?
To secure the airway a rapid sequence intubation is recommended with the use of succinylcholine in the first 24 hours or the use of a nondepolarizing muscle relaxant such as Rocuronium.
