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Principles II EXAM 1 (Monte) > Burns (Exam 1: Cooper) > Flashcards

Burns (Exam 1: Cooper) Flashcards

1
Q

What are the 5 types of Burns

A
  1. Heat
  2. Electrical
  3. Friction
  4. Chemical
  5. Radiation
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2
Q

The depth of injury in heat burns are related to these 3 things:

A
  1. Contact temperature
  2. Duration of contact
  3. Thickness of the skin

Thinner skin (face, genitals, hands) = more critical areas

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3
Q

Magnitude of electrical burns depend on:

A
  • Pathway of current
  • Resistance to current flow
  • Strength and duration of current flow
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4
Q

What cardiac issues are common with electrical burns?

Is A/C or D/C worse in electrical injuries?

A

V-fib

D/C is worse

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5
Q

How will necrosis occur in an acidic or alkalotic chemical burn?

A

Acid: necrosis by coagulation
Alkali: necrosis by liquefaction

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6
Q

What are the most common examples of radiation burns?

A
  • Sunburns
  • Therapeutic radiation
  • Diagnostic procedures
  • Nuclear industry workers

Nuclear = less common but far more devastating (increased cataracts)

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7
Q

How long does it take for burns to fully “declare themselves”?

A

24-72 hrs

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8
Q

True or False:

Burns are usually uniform in depth and are primarily only superficial.

A

FALSE:

Not usually uniform in depth…have a mixture of deep and superficial sections

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9
Q

These populations have deeper burns due to thinner skin:

A

> 55 yrs and < 5 yrs

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10
Q

Determine the degree of burn:

Healing in 21-28 days:
Skin in tact, red in color:
Translucent, dry, painless, charred:
Very painful / nerve endings exposed:
Not included in TBSA calculations:
Heals in 10-14 days:
Heals in 3-6 days:

A

Healing in 21-28 days: Deep Partial Thickness, 2nd degree
Skin in tact, red in color: Superficial 1st degree
Translucent, dry, painless, charred: Full Thickness, 3rd degree
Very painful / nerve endings exposed: Superficial Partial
Not included in TBSA calculations: Superficial 1st degree
Heals in 10-14 days: Superficial Partial
Heals in 3-6 days: Superficial 1st degree

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11
Q

How is adult TBSA estimated according to the rule of 9’s?

How accurate is this estimation?

A

Head: 9%
Each Arm: 9%
Each Leg: 18%
Ant/Post trunk: 18% EACH
Perineum: 1%

60-70% due to various depths

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12
Q

How is TBSA estimated for infants?

A

Head and neck: 21%
Each Arm: 10%
Abdomen: 13%
Back: 13%
Buttocks: 5%
Each Leg: 13.5%
Genital area: 1%

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13
Q

Calculate the TBSA for this adult:

Entire Left arm, Perineum, Anterior trunk, back of left leg

A

9 + 1 + 18 + 9 = 37%

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14
Q

An infant has the following areas burned:

Entire head and neck, Right leg, abdomen

A

21 + 13.5 + 13 = 47.5%

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15
Q

What is another method of estimating burn percent?

A

Palmer method: patient’s own hand = 1%

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16
Q

Are burns usually under or over estimated?

Specifically for obese patients, which areas are under/over estimated?

A

Underestimated

Obese:
* Torso = underestimated
* Extremities = overestimated

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17
Q

Fluid loss in regard to burns are a function of ___ and ___.

A

burn size and patient weight

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18
Q

Patients with > ___ TBSA develop burn shock and need ___.

A

Patients with > 20% TBSA develop burn shock and need IV resuscitation in an ICU

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19
Q

Consequences to under resuscitation:

A
  • Decreased perfusion
  • Burn shock
  • End organ failure (renal)
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20
Q

Consequences to over resuscitation:

A
  • Abdominal Compartment Syndrome
  • Pulmonary Edema
  • ARDS
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21
Q

What is another name for the General metabolic response to burn trauma?

A

“Auto-Cannibalism”

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22
Q

What are some things that happen when a BSA is greater than 40%?

A
  • Metabolic rate doubles
  • Auto-cannibalism for months
  • Immunodepression, recurrent infections, poor wound healing
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23
Q

What 3 things increase in regard to carbohydrate metabolism with burns?

What can this result in?

A

Cortisol
Catecholamines
Glucagon

Insulin resistance (50-70%), impaired glucose transport

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24
Q

Accelerated lipolysis in burns is due to what three factors?

A

B2 and B3 adrenergic stimulation (↑cAMP)
↑ glucagon, TNF, IL
↑ FFA (which produces ATP)

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25
Q

How do we treat accelerated lipolysis?

A

Beta Blockade

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26
Q

The degree of protein loss is proportional to the degree of ___.

A

Stress

Doubled in severe burns

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27
Q

Initial considerations in the stabilization phase for burn patients:

A

Respiratory support (early intubation)
Fluid Resuscitation (More early, less later)
CV Stabilization
Pain control (early and secondary)

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28
Q

Secondary Priorities for burns

Due to the fluid shifts in burn patients, they are more prone to ___ which requires ____.

A

venous emboli

thrombophylaxis

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29
Q

Which IV Pain medication is used extensively for burn patients during procedures?

A

Ketamine

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30
Q

What do we want to supplement the pain meds with for burn patients?

A

Supplement with anti-anxiety meds for synergism

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31
Q

This can be altered in burn patients and you may need to deviate from normal doses to avoid toxicity or decreased efficacy.

A

PK/PD

smaller doses usually, but may need to increase if hypermetabolic state

32
Q

Which of the following would you not give to a burn patient?

A. IV Ketamine
B. PO Tylenol
C. Morphine PCA
D. IV Methadone
E. IM Dilaudid

A

E. IM Dilaudid

No IM opioids as absorption is uncertain

33
Q

Increased or Decreased in burn patients?

Structure of the endothelial barrier
Capillary permeability
Intravascular oncotic pressure
Intravascular fluid volume

A

Structure of the endothelial barrier: Decreased
Capillary permeability: Increased
Intravascular oncotic pressure: Decreased
Intravascular fluid volume: Decreased

34
Q

Several systemic inflammatory reactions occur in burn patients including the release of these 3 hormones, causing vasodilation.

A
  1. Histamine
  2. Prostaglandin
  3. Cytokines
35
Q

Generally, at > __% BSA, fluids are indicated

A

15%

36
Q

If formulas are not followed correctly, and we are inappropriately resuscitating patients with fluid, we could cause these 2 adverse effects.

A
  1. Pulmonary Edema
  2. Compartment Syndrome
37
Q

What is the parkland formula for fluid resuscitation?

A

4 ml/kg/ % BSA:
* 2ml/kg/%BSA in 1st 8 hours (LRS)
* 2ml/kg/%BSA in next 16 hours (LRS)

38
Q

What is the US Army resuscitation formula?

A

Adult:
* 10mL/hr x TBSA
* >80kg, add 100 mL/10kg

Peds:
* 3 x TBSA x kg = vol for first 24 hrs
* ½ total volume over 8 hrs

39
Q

Using the Parkland formula, determine the fluid resuscitation amount.

65 kg Adult Patient:
Entire Left arm, Perineum, Anterior trunk, back of left leg

A

37% burn

4 x 65 x 37 = 9620 mls

1st 8 hrs = 4810 mls
Next 16 hrs = 4810 mls

40
Q

Using the US Army formula, what is the fluid resuscitation amount?

90 Kg, Adult Patient:
25% BSA

A

350 mls per hour

10 ml/hr x 25% burn = 250
Patient is also 10 kg over 80 kg, therefore we add an extra 100 mls/hr

41
Q

What are some examples as to why we would want to transfer a burn patient to a more appropriate burn center?

A
  • Full thickness > 10% BSA
  • High voltage electrical burns
  • Chemical burns
  • Associated inhalation injury
  • Face, hands, feet, perineum, major joints
42
Q

By using LR or other isotonic solutions, we run the risk of ___.

What is something we want to make sure NOT to do with crystalloid, to not worsen the edema.

A

hypernatremic hyperchloremic acidosis (non-gap acidosis)

No Boluses!

43
Q

If a child is > 40kg, what formula do we use?

What if they are < 40kg?

A

> 40 kg: Use adult formula

< 40 kg: 2-4 ml (LR)/kg x kg x %TBSA (2nd and 3rd degree)

44
Q

What should we add if the child is < 20 kg?

A

Add a maintenence dose of D5LR

45
Q

At ___ hours post-burn, if the hourly IV fluid rate exceeds ___ or if the projected 24 hr total fluid volume approaches ___ initiate ___ infusion.

A

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 infusion

46
Q

Table for hourly 5% albumin infusion rate:

A
47
Q

What are some “Cardiac Status” changes that we can see with burn patients in the “resuscitative phase”?

A
  • Reduced CO
  • Hypovolemia
  • Reduced response to catecholamines
  • Increased SVR (Vasopressin levels)
  • Myocardial Ischemia

Ensure appropriate fluid resuscitation

48
Q

What are some “Cardiac Status” changes that we can see with burn patients 72-96 hours post burn (“Flow Phase”)?

A
  • Hyperdynamic…increased CO, tachycardia
  • Increased myocardial O2 consumption
  • Decreased SVR

Administer Beta Blockers here

49
Q

Systemic inflammatory responses begin immediately after burns and can lead to these pulmonary effects:

A
  1. Pulm HTN
  2. Disruption in Pulm capillary alveolar membrane
  3. Decreased plasma oncotic pressure
  4. Impaired gas exchange

MAY NEED TO USE PEEP

50
Q

This adverse pulmonary effect is common for burn patients, therefore we may need to administer___.

A

Bronchospasm

Bronchodilator Therapy

51
Q

For inhalation injuries, COHb levels are > ___.

How can we confirm inhalation injury if unsure?

A

10%

Bronchoscopy

52
Q

Considerations for Facial Burns:

A
  • Extensive edema (difficulty managing devices)
  • Protect the eyes (remove contacts)
  • Consult Optho
  • Apply bacitracin to eyelids
  • Apply erythromycin to eyes

Do NOT use Silvadene

53
Q

These 3 “nutritional needs” are greatly increased post burn.

A
  1. Proteins
  2. Vitamins
  3. Energy
54
Q

Nasoenteric feeds into the ___ ensure high calorie, high protein intake.

A

Jejunum

55
Q

What affects do burns have on the nACH-R’s?

A
  • Up-regulation of receptors (takes months-years to recover)
  • Resistance to NDMB (25% BSA and greater)
  • Increased Sensitivity to Depolarizers (Much greater increase in K+)
56
Q

How quickly can our temperature be affected by burns?

A

1 Degree C decrease every 15 mins.

57
Q

What are some signs of Impending Airway Obstruction?
What do we do?

A

Stridor, Hoarseness, Dysphagia

Immediate intubation

58
Q

What is one technique we can use while intubating for burn patients to help preserve spontaneous ventilation?

A

Awake intubations

(Maintains better gas exchange)

59
Q

Induction drugs for intubation of burn patients:

A

Propofol (Ebb vs Flow phase)
Etomidate (Cautious, unless CV Unstable)
* Give with Steroids = Adrenal Insufficiency concern

Ketamine (SNS Stimulation)
Opioids (Ebb vs Flow)

60
Q

Increased or Decreased Preload in burn patients?

A

Decreased

61
Q

For every 1% burn excised or autograft, ___% total blood volume is lost.

A

2.6%

62
Q

What is our Hb level goal for burn patients?

Are there issues if you go higher than this level?

A

Goal: 7-8 g/dL

At 10 g/dL = Acute coronary syndrome

63
Q

Common vasopressors used for shock in burn patients?

A

Vasopressin and Norepi

64
Q

Effects of using Tumescent Local Anesthetics for burns:

A
  • Decreased blood loss
  • Easy excision of granulation tissue
  • Shorter surgical times
  • No hematoma or bruising postop
65
Q

Ventilatory considerations for burn patients:

A
  1. Target a PaCO2 of 30-35, pH of > 7.2 (Slight Hyperventilation)
  2. Nebulized Heparin 5000 units with Albuterol Q4
66
Q

Why do we combine Heparin and Albuterol? Why not just nebulized Heparin by itself?

A

Heparin will help prevent clumping of endothelial cells.
However, if not combined with Albuterol, Heparin can actually induce a bronchospasm.

67
Q

How is abdominal compartment syndrom best diagnosed?

What is the mortality of ACS in a burn patient with an open belly?

A

Best DX: Bladder pressures

90% Mortality

68
Q

Bladder pressure considerations and levels for burn patients.

A

Measure bladder pressure Q4H if TBSA > 20%

> 12 mmHg = early IAB HTN
20 mmHg = Abdominal compartment syndrome

69
Q

Post-op Anesthesia management for burn patients:

A
  • Mechanical Ventilation
  • DVT Prophylaxis
  • Beta Blocker Admin
  • Nutritional Support
  • Temp Control
70
Q

Extremity Considerations in burn Patients:

A

Elevate (30-45 degrees)
Hourly pulse checks
Escharotomy (Pulse checks, chest assessment)

71
Q

Adjunct Treatments to burn resuscitation:

A
  1. GI Prophylaxis
  2. Sew/staple all devices/catheters
  3. Early foley insertion
72
Q

Which vaccination is important to consider with burn patients and why?

A

Tetanus (need a booster if > 5yrs)

Burns are tetanus prone wounds

73
Q

Dressing Examples for burns:

A
  • Topical antibiotics  Silvadene and Sulfamylon
  • Silver dressings
  • Silverton water or saline every 8 hours
  • Silver nitrate
  • Temporary skin substitutes such as Biobrane
  • No Silvadene to the face
74
Q

These 2 pharmacologic treatments are NOT indicated for burns, per lecture.

A

IV ABX and Steroids

75
Q

Carboxyhemoglobin % levels Table:

A

Principles II EXAM 1 (Monte) (5 decks)

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