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CSI Yr 3 > Burns and Shock > Flashcards

Burns and Shock Flashcards

1
Q

What is distributive shock

A

-Damaged tissue releases permeability factors→ neutrophils release more permeability factors and cytokines
- If large body surface area affected (i.e. 15-20% TBSA burns) → more permeability factors → can diffuse into bloodstream to become systemic
Even areas unaffected by the burn injury have leaky capillaries
-Protein leaks into the interstitial space reducing colloid osmotic pressure → less reabsorption of fluid at venous end
-Volume is not lost, just redistributed within interstitium around body → causes blood volume and then BP to fall leading to shock
Blood becomes hypercoagulable as RBC count is still the same in lower blood volume

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2
Q

What is hypovolaemic shock

A
  • Fluid is lost from exposed tissues and skin via evaporation
  • Normally skin is a barrier to help retain fluid
  • Loss of fluid can cause hypovolaemia
  • Can add to problem of distributive shock in burns injuries
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3
Q

What is cardiogenic shock

A
  • Massive drop in blood volume → reduced venous return → reduced preload → reduced heart contractility
  • Cytokines released as part of inflammatory response can also get into the blood and become systemic → some cytokines e.g. TNF-alpha, reduce cardiac contractility
  • Cardiac stress leads to cardiogenic shock
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4
Q

What are the examination and observations/trend results for:

  • Trauma/bleeding
  • Dehydration/poor intake
  • Vomiting and diarrhoea
  • Sepsis
A

EXAMINATION | OBS & TRENDS |

Signs of fluid loss
SBP < 100mmHg

Cool peripheries
HR > 90bpm

CRT > 2 secs
RR >20 breaths per min

45 degree leg raise +ve
NEWS = 5 or more

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5
Q

What are examples of volume loss and volume shift?

A
  • Volume loss
    • trauma/bleeding
    • dehydration/poor intake
    • vomiting and diarrhoea
  • Volume shift
    • sepsis
    • anaphylaxis
    • neurogenic
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6
Q

What is the Parkland Formula

A

2 - 4 ml x actual body weight (kg) x %TBSA burned

Used to work out fluid requirements in burn patients.

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7
Q

What type of burn is the Parkland Formula not used for

A

Doesn’t include epidermal (first degree) burns

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8
Q

How is the fluid given to the patient after calculated with the Parkland Formula

A
  • From the time the burn was sustained, give 1/2 of fluid requirement in first 8 hours
  • Give other 1/2 in subsequent 16 hours
  • This is fluid given in addition to maintenance fluid
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9
Q

Why is it important to not give too much fluid

A
  • Leaky capillaries means lots of fluid can still get into interstitium leading to excess oedema in tissues
  • Increased risk of compartment syndrome → where oedema compresses vessels in muscle compartments, leading to ischaemia within that compartment
  • Ultimately it is important to always use end points for patients to tailor their fluid treatment.
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10
Q

What is the rule of nines for TBSA for burns

A

Pretty much everything is 9%
Each leg is 18%, with front being 9% and back being 9%
Each arm is 9%, with front being 4.5% and back being 4.5%
Front of abdomen is 9%
Front of chest is 9%
Upper back is 9%
Lower back is 9%
Genitals is 1%

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11
Q

How do the resus fluids differ from each other

A

Different types of fluid distribute differently across intravascular, interstitial and intracellular fluid.

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12
Q

How does Dextrose distribute across the body’s tissues?

A

Assuming the glucose transporter is passive, glucose is distributed across all fluid compartments until equilibrium is reached

  • It aligns with the 1/3 and 2/3 split of fluid across interstitial fluid and intravascular fluid
  • This means dextrose is not very good for dehydration as it doesn’t really bulk up blood volume
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13
Q

How does Saline distributed across the body’s tissues?

A
  • Cells have lots of sodium transporters to prevent cell swelling and lysis and cellular dysfunction
  • Cells actively pump sodium out if there’s excess
  • This means very little of sodium gets into cells and sodium is pumped out with fluid following via osmosis.
  • Saline gets split with 3/4 in intersitital fluid and 1/4 intravascularly.
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14
Q

How is Ringers Lactate distributed across body tissues

A

Increase in intracellular volume
- as it contains Ca and K
so osmolarity is lower than in cells
so a bit of fluid will enter cells

Lactate helps to correct acidosis as it can be used to make bicarbonate

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15
Q

How does saline and Hartmann’s compare in terms of
- Intracellular volume
- Extracellular volume
- Acidosis
- Coagulation
- Fluid balance

A

Intracellular:
Saline- no increase
Hartmann’s- mild increase

Extracellular- both increase

Saline- Hyperchloremic Metabolic Acidosis
Hartmann’s- lactate corrects acidosis

Saline- associated with HYPOcoagulopathy
Hartmann’s- clumping of RBC if infused alongside blood products

Saline- Unbalanced fluid (high CL-)
Hartmann’s- Balanced fluid (Ca, Cl, K)

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16
Q

What does an epidermal burn mean

A

Epidermal → only involves the epidermis

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17
Q

What is a superficial partial burn and does this require surgery

A

Superficial partial thickness burn:
Upper dermis damaged but the vascular plexus and most adnexal structures remain intact
- does not often require surgery

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18
Q

What is a deep partial burn and does this require surgery

A

Deep partial thickness burn:
Extends into deep dermis affecting vascular plexus but not all of dermis is destroyed. Only deep adnexal structures are intact
- often require surgery to replace skin or remove dead skin

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19
Q

What is a Full thickness burn and does this require surgery

A

Full thickness burn → has extended through entire thickness of dermis and no dermal tissue remains

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20
Q

What is a Fourth degree burn and does this require

A

Fourth degree → extends to bone, skin is waxy and completely damaged, loses sensation

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21
Q

After resus, what other aspects of care need to be considered

A
  1. Admission to a specialist burns centre?
    • Burns require MDT management
    • Need to think of size, depth and location of burn
      • > 10% TBSA could be enough for burn centres to admit patients as higher percentage suggests more cardiovascular involvement
      • Full or deep thickness burns require surgical intervention
      • Burns on the face, groin or hands and circumferential burns which could limit function need specialist treatment
  2. Ongoing fluid resuscitation
  3. Supportive care
  4. Tetanus immunisation → patients with burns at high risk due to large exposed wound
  5. Surgery → required for deeper burns e.g. skin grafts, fasciotomy
  6. VTE prophylaxis → due to immobility
  7. Pain and anxiety → managed with analgesic, anaesthetics, psychological support
22
Q

What are some psychological impacts of major burns ?

A
  • Flashbacks → vividly remembering a past time or incident
  • Dissociation → mental process of disconnecting from one’s thoughts, feelings, memories and sense of identity
  • Avoidance → maladaptive form of coping in which a person changes their behaviours to avoid thinking about, feeling or doing difficult things
  • Insomnia → sleep disorder where trouble falling and/or staying asleep
  • Hyperarousal → increased responsiveness to simuli with various physiological and psychological symptoms
  • Hypoarousal → decreased responsiveness
23
Q

What are some examples of psychological support that can be offered

A

Some support that could be offered includes CBT, psychoanalytic therapy, support networks, pharmacological treatments of insomnia etc.

24
Q

How does Saline cause Acidosis

A
  • Saline can start to dilute blood bicarbonate significantly which normally buffers blood so have to be careful of acidosis in patients with too much saline intake
25
Q

What is the most common mechanism of injury requiring admissions and most common cause of major burns

A
  • most common mechanism of injury requiring admissions = scalds
  • most common cause of major burns = flame injuries
25
Q

What is the Baux score

A

main scoring system used to predict mortality and length of hospitalisation in adult burns injury

25
Q

What are the risk factors for burns

A
  • worldwide risk factors for burn injury:
    • low socioeconomic status
    • overcrowding
    • cooking with kerosene
    • generalised poor health
    • poor safety practices
  • injuries more common in patients w/pre-existing psychiatric diagnoses, substance use problems and extremes of age
  • children = accidental and non-accidental
  • older and frail individuals with pre-existing medical conditions can present as collapse
26
Q

What is the first aid process for a burn

A

burn should be managed under cool or tepid running water for 20 min even up to 4hrs after injury sustained
Stop burning process, cool burn and cover in non-adherent dressing e.g. clingfilm
rest of patient must be warmed to prevent hypothermia

27
Q

What are the layers of the skin

A

5 layers of epidermis
2 layers of dermis
subcutaneous fat
connective tissue
muscle

28
Q

What are the functions of the epidermis

A

immune function
barrier to entry
sensation and pain
prevent fluid loss
social and psychological

29
Q

What are the functions of the dermis

A

Regulation of temperature
- sweating
- dermal vascular plexus
- piloerection
skin durability and flexibility

30
Q

What is a first degree burn and how easily treated is it

A

First degree → epidermal/superficial partial thickness
- has good blood supply + sufficient regenerating epidermal cells
- with proper Rx can heath w/o scarring in 1-2 weeks

31
Q

What are second and third degree burns and how easily treated are they

A

Second degree → deep partial thickness
Third degree → full thickness
- deep partial thickness and full thickness have lost dermal vascular plexus and cells to heal
- generally Rx inc. excision and skin grafting

32
Q

What is a fourth degree burn

A

burn that affects tissue deeper than dermis, fat and muscle - muscle injury can lead to compartment syndrome and rhabdomyolysis

33
Q

What factors affect the amount of tissue damage caused from a burn

A

Can be burn related or patient related:
- burn related factors inc. aetiology, temp, duration of exposure e.g. wet heat causes greater damage than dry heat
- patient related factors inc. skin thickness, age, if first aid was given

34
Q

What are the three zones of tissue injury for local effects

A

zone of coagulation = dead tissue as result of direct injury
zone of stasis = hypoperfusion due to vasoconstriction in response to injury, vulnerable to ischaemia, infection and necrosis
zone of hyperaemia = dead tissue prompts release of inflammatory mediators, act locally to cause vasodilation leading to increased vascular permeability and oedema

35
Q

What is the first aid process for a chemical burn

A

Same as for the other burns, with an added step:

patient should be removed from exposure and all contaminated clothing removed, irrigate with running water or sterile fluids

- acid 45 mins, alkali 1 hr irrigation
36
Q

When would you suspect hydrogen cyanide poisoning

A

If inhalation injury, cardiovascular instability and increasing blood lactate levels not responding to treatment
- specific antidote - hydroxycobalamin - should be given

37
Q

How many cannulas are necessary for IV fluid resus

A

2 large bore cannulas are necessary

38
Q

Why do you need to look for the cause of reduced GCS in burns

A
  • reduced GCS at presentation in major burns not caused by burn itself
  • must search for cause and appropriate management, could be
    • poisoning by inhaled toxins e.g. CO, hydrogen cyanide
    • overdose
    • trauma inc. head injury
    • medical comorbidities leading to collapse
39
Q

What is an Escharotomy

A

Escharotomies are surgical incisions through non-compliant full thickness burn, which restricts ventilation on chest and abdomen or causes sig. reduced perfusion in circumferential burns to limbs

40
Q

What is needed for an escharotomy

A

Escharotomies to produce decompression should be performed as soon as needed for ventilation or perfusion

  • incision longitudinal from unburned skin to unburned skin if possible, deep enough to reach subcutaneous fat and release eschar
  • need anaesthesia, diathermy to keep blood loss minimal, and prophylactic antibiotics
41
Q

When are fasciotomies most indicated

A

Involves cutting through subcut tissues and fascial layers around muscle compartments

most commonly indicated in high-voltage electrical burns where tissue necrosis of muscle causes compartment syndrome.

42
Q

How do you examine corneal damage from a burn

A

examined with fluorescein stain

43
Q

How do you asses rhabdomyolysis

A

Electrical burns
Measure CK level

44
Q

What are the benefits of early wound excision

A

shown to decrease blood loss, burn wound sepsis and length of stay

45
Q

What is the next step in surgical management after the skin has been excised

A

once burned tissue is excised, wound closure must be achieved to decrease fluid loss, prevent further wound desiccation and infection and reduce hypermetabolism

- temp covering with allograft (skin from organ donors) or synthetic skin subsitutes
- permanent with autologous split skin grafts = gold standard for burn wounds
46
Q

What is a hypermetabolic response

A

Hyperdynamic circulatory, physiological, catabolic and immune system responses

47
Q

How does acute hypermetabolic response occur

A

marked and sustained increase in catecholamines, glucocorticoid, glucagons and dopamine secretion initiate cascade

48
Q

What are some some examples for what occurs in hypermetabolic response

A
  • massive protein and lipid catabolism
  • total body protein loss
  • muscle wasting
  • peripheral insulin resistance
  • increased energy expenditure
  • increased body temp
  • increased infection risks
  • stimulated synthesis of acute phase proteins in liver and intestinal mucosa
49
Q
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50
Q
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CSI Yr 3 (3 decks)

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