Burns

Question 1

Direct airway injury - pulmonary changes in burns

Answer 1

Causes direct tissue damage to upper airways by trying to absorb heat before reaching lower airways – tissue destruction & massive edema

Question 2

Indirect airway injury - pulmonary changes in burns

Answer 2

Inhalation of noxious by-products (wood = CO, sulfur or nitrous = corrosive acids)

Question 3

Circumferential burns

Answer 3

Create tourniquet effect - if on chest reduces chest compliance, FRC & mVe. May have to do escharotomy to area to prevent compartment syndrome

Question 4

Initial cardiac changes (24-48 hours) in burns

Answer 4

Decreased CO - loss of volume, tourniquet effect like clamp on vena cava, endotoxins

Question 5

Later cardiac changes (3-5 days) in burns

Answer 5

Increased CO from hypermetabolism- monitor UOP for adequate hydration!

Question 6

Renal changes in burns

Answer 6

Decreased GFR - hypovolemia, myoglobinuria (electrical), hemoglobinuria – oliguria is sign of inadequate fluid resus.

Question 7

Diuretics with burns

Answer 7

High voltage electrical burn, muscle burns or oliquria despite adequate CVP

Question 8

Hepatic changes with burns

Answer 8

Hepatic injury from reduction in CO, absorbed toxins + drug toxicity, blood borne illnesses from multiple transfusions

Question 9

Neurological changes with burns

Answer 9

Cerebral edema or increased ICP - HOB to 30, hyperventilate, maybe mannitol

Question 10

Hematological changes with burns

Answer 10

Increased blood viscosity from fluid shifts - falsely elevated hgb/hct, thrombocytopenia initially, elevated platelet counts long term, if persistent hemolytic anemia – hematopoietic system adversely effected by burn, thrombocytopenia indicates sepsis

Question 11

GI changes with burns

Answer 11

Ischemia from high levels of catecholamines, early enteral feeding to attenuate hypermetabolic response

Question 12

Dobhoff placement for burns & anesthesia

Answer 12

Past duodenal sphincter - will not aspirate - leave TF going t/o surgery

Question 13

TPN (hyperalimentation) and anesthesia

Answer 13

Don’t let it run out while in OR, check frequent sugars

Question 14

Skin changes with burns

Answer 14

Not able to thermoregulate, maintain fluid & e-lytes & fight infection. 0.58 calories for every mL of evaporative water loss– children have greater BSA:wt ratio - effects magnified

Question 15

Acute burns & albumin

Answer 15

Decreased circulating albumin = increase in plasma free fraction of drugs = more bang for your buck benzos & barbs

Question 16

Acute burns & alpha-1 acid glycoproteins (A1AG)

Answer 16

Decrease in plasma free fraction of drugs - give very high doses of analgesics, locals, NDNMBAs

Question 17

Half life of morphine with burns

Answer 17

Less than 1/3 the half life in similar child without burn

Question 18

Succinylcholine & burns

Answer 18

Should not be given after 24 hours until 2 years post burn injury – hyperkalemia & cardiac arrest

Question 19

ND-NMBAs & burns

Answer 19

Increased doses (2-5x more) - probably don’t use intubating dose unless you know you are going to have a really long surgery

Question 20

Exogenous catecholamines & burns

Answer 20

Pay attention to epi/phenylephrine soaked gauze sponges placement & when they stop placing them… serious hypotension may happen if you aren’t paying attention

Question 21

Stress ulcers & burns

Answer 21

High risk! prophylaxis with H2-receptor antagonist

Question 22

First 24 hours of burn

Answer 22

Stabilization - ABC - protect airway early bc of edema especially if perioral burns and supplemental O2 to avoid CO poisoning. Circulation: large boer IV access with large amounts of fluid resuscitation 20 mL/kg/hr (avoid IV access in burn location when possible, and not below circumferential burns), maintain UOP 0.5 mL/kg/hr

Question 23

Fluid mgmt of burns

Answer 23

Half the fluid calculated is delivered in first 8 hours, other half is next 16 hours, then maintenance

Question 24

1st degree burn

Answer 24

Superficial, partial thickness

Question 25

2nd degree brun

Answer 25

Superficial partial thickness (steam or scald, has blisters)

Question 26

3rd degree burn

Answer 26

Full thickness, extension into SQ fat

Question 27

4th degree burn

Answer 27

Full thickness involving deep tissues (even down to bone)

Question 28

Intubations with burn patients

Answer 28

Subgloticc stenosis may start occurring due to multiple intubations, make sure to record tube size & cuff inflation so next person will know if they need to start with smaller tube

Question 29

Tangential excision of burns

Answer 29

Layers of eschar shaved off until briskly bleeding tissue – rapid blood loss

Question 30

Fascial excision of burns

Answer 30

Take all tissue including lymph & fat down to muscle fascia

Question 31

Pre-determined stopping points in burn surgery

Answer 31

No greater than 15% BSA per surgical procedure,

Question 32

Electrical burns mechanism & effects

Answer 32

Flow of current through resistant tissue generates heat, deep tissue injury likely (arterial, nervous system). All tx consider protection of renal fxn - will likely get severe myoglobinuria, hyperkalemia & ART - give copious IVF, osmotic/loop diuretics, alkalinize urine, dialysis.