burns Flashcards
what is the appropriate assessment of any level 1 trauma patient?
rapid assessment: determine if the patient was stable, unstable, dying or dead.
primary survey: assess and stabilize the patients Airway, Breathing, Circulation, Disability, and Exposure (remove patients clothing to assess for additional injuries).
if stable enough, secondary survey: head-to-toe examination, radiographs, diagnostic procedures, lab testing.
tertiary survey: within first 24 hours, reexamine patient to identify any clinically significant injuries that were missed
what is a primary survey?
- airway and c-spine: examine for obstruction -may need intubation and stabilize c-spine
- breathing/ventilation: examine chest wall for subQ emphysema or tracheal deviation
- circulation: start two large-bore IV catheters and start IVF resuscitation if HD unstable, may need O- blood
- disability: GCS (consider intubation for GCS
name some cause of life-threatening chest trauma?
airway obstruction tension ptx massive hemothroax open ptx flail chest cardiac tamponade
how do you calculate GCS?
Eyes: does not open (1), opens to pain (2), opens to voice (3), opens spotaneously (4)
Verbal: makes no sound (1), incomprehensible sounds (2), inappropriate words (3), confused/disoriented (4), normal (5)
Motor: no movement (1), extension to pain/decerebrate (2), flexion to pain/decorticate (3), withdrawal (4), localizes (5), normal (6)
what is the secondary survey?
should only be performed once patient is stabilizing, otherwise resuscitation efforts should be continued.
head-to-toe history and physical. further testing as indicated (lab, radiology, diagnostic procedures)
name some immediate concerns for a burn patient.
potential for difficult airway (c-collar, inhalation injury, third-spacing of fluid leading to progressive airway edema), significant hypovolemia (hemorrhage, edema, third-spacing), hyperglycemia (endocrine response to burn injury), hyperkalemia (tissue destruction), carbon monoxide poisoning.
name some immediate concerns for crush injury.
DVT, vascular trauma (pain, pulselessness, pallor, paresthesia, paresis), fat embolus, occult hemorrhage, compartment syndrome, rhabdomyolysis
how do you calculate TBSA affected by a burn?
9% for each arm, chest, abdomen, head
18% each leg, back
1% groin
for children 9% arms, chest, abdomen 18% back, head 13.5% legs 1% groin
a burn patient has an initial BP of 98/62. does he require fluid resuscitation and how would you guide your therapy?
as he has suffered an over 30% TBSA burn, adequate fluid resuscitation will be necessary to prevent hypovolemic shock. however, resuscitation should be managed judiciously to avoid over resuscitation which can worsen edema in the airway, lungs, and limbs. it can even lead to abdominal compartment syndrome.
i would titrate resuscitation to urine output with goal output at 0.5-1 ml/kg/hr, hr 60 mmHg, and base excess
how does burn injury cause hypovolemia?
increased vascular permeability (esp in injured areas) with extravasation of proteins. the subsequent decrease in intravascular oncotic pressure leads to large volumes of fluid shifting out of the vascular compartment and into the interstitial space.
additionally, following a burn, circulating myocardial depressants, decreased coronary BF, increased SVR and diminished response to catecholamines can contribute to hypovolemic shock.
how do you calculate tbw?
2/3 intracellular 25L
1/3 extracellular 15L
1/5 plamsa 3L
4/5 interstitial 12L
very small amount (2.5%) transcellularhow could a pulm art catheter be used to guide resuscitation?
it can assess if the filling pressures are acceptable as well as an adequate mixed venous oxygen tension (normal 35-45 mmHg.
what is base excess and how does it indicate volume status?
+2 - alkalosis
what are the normal PA catheter values for: CVP PAP PCWP CO PvO2 MvO2
CI
SVI
SVR
PVR
CVP (right atrial pressure) - 1-6 mmHg
PAP - systolic 15-30 mmHg, diastolic 6-12 mmHg
PCWP (left atrial pressure, LVEDP) - 6-12 mmHg
CO (HR x SV) - 3.5-7.5 L/min
PvO2 (tension) - 35-45 mmHg
MvO2 (how well O2 is extracted) - 65-75%
CI = CO/BSA = 2.4-4.0 L/min/m2
BSA = sq root[Ht-cm x Wt-kg)]/60
SVI = CI/HR = 40-70 mL/beat/m2
SVR = 80(MAP-CVP)/CI = 1600-2400 dynes.sec.m2/cm5
PVR = 80(PAP-PCWP)/CI = 200-400 dynes.sec.m2/cm5
what is the Parkland formula?
formula used as guideline fluid resuscitation following burn injury.
4 mL/kg/percentage of TBSA in the first 24 hours
deliver half in first 8 hours and other half over 16 hours
how are burns classified?
1st degree - injury limited to epidermis
2nd degree - epidermis and dermis
3rd degree - full thickness, complete destruction of epidermis and dermis
4th degree - muscle, fascia, bone
what is considered a major burn in an adult?
> 10% TBSA if full-thickness
>25% TBSA if partial-thickness
list some indications for intubation of an adult after burn injury?
hypoxemia, hypercarbia, resp distress, stridor, loss of consciousness (inability to protect airway), altered mental status, major burn injury(>10% TBSA of third-degree), signs of inhalation injury
suppose you decide not to intubate a patient with 20% TBSA partial-thickness burns. what further evaluation, if any does he need?
fiberoptic bronchoscope to examine glottic and periglottic structures for edema or inhalation injury
ABG to check PaO2 (low PaO2 is suggestive of inhalation injury)
CXR, PFTs for baseline comparison (may appear normal in immediate post-burn period)
suppose the patient has 15% TBSA third-degree burns and 5% partial-thickness and you notice carbaceous material in his sputum. would you intubate now?
given the increased risk of respiratory compromise with major burn (>10% TBSA third-degree burns) and inhalation injury (as indicated by the carbaceous material in his sputum) I would prepare for immediate intubation.
he is at risk for difficult airway management for multiple reasons.
- airway obstruction due to third-spacing of fluid and subsequent airway edema, coupled with having a c-collar in place
- aspiration secondary to trauma and possible full stomach
- questionable neurologic damage (cannot assess due to distracting injuries)
to intubate this patient i would:
- administer aspiration prophylaxis - H2 blocker, metoclopramide
- dry his airway with glycopyrrolate to more adequately topically anesthetize his airway (lidocaine jelly in the oropharynx, aerosolized lidocaine, possible transtracheal block)
- adequate preoxygenation
- sedation as tolerated
- difficult airway equipment, in-line stabilization
- FOI
do you suspect significant inhalation injury?
the history of burn in a closed space (in a building) combined with carabaceous material in the sputum are suggestive of inhalation injury. i would examine for additional signs of injury, such as singed facial hair, burned mucosa, cough, stridor, hoarseness, difficulty swallowing, and pharyngeal edema.
what are the main concerns with upper airway inhalation injury?
glottic and periglottic edema, copious/thick secretions. edema is worsened by the aggressive fluid resuscitation necessary for the stabilization of the severely burned patient.
