Burns- management and anesthetic considerations Flashcards
What are the phases seen after a burn injury?
What are the phases of treatment?
- Biphasic response
- Burn shock develops 6-8 hours after injury
- Hypermetabolic phase develops in several days to weeks
- Treatment in 3 phases:
- 1) resuscitative
- 2) debridement and grafting
- 3) reconstructive
What do the different organs/systems do during the early and later phases post burn injury? (table)
CV
urinary
GI
musculoskeletal
pulmonary
endocrine
immunologic
CNS
Another table about the systemic response during the early phase vs the late phase.
CV
Pulm
renal
endocrine and metabolic
hepatic
hematologic
GI
neurologic
What should you consider during initial airway assessment of a pt with burns?
- Consider liklihood of inhalation injury
- inspect the neck and oral cavity for overt issues
- Gold standard assessment: fiberoptic bronchoscopy
- Chest x-ray is usually normal in early phase
- Early intubation when upper airway injury is suspected, do NOT wait for pt to decompensate
Who is at risk for inhalation injury?
- Facial burns
- hoarseness
- evidence of smoke exposure
- other classical signs of inhalation injury
What should you consider regarding airway management in a burn patient?
- Intubation will be easier if not delayed
- Awake, spontaneously breathing fiberoptic intubation if any airway abnormality is suspected
- topical anesthesia plus hypnotic that preserves spontaneous ventilation (ketamine, dexmedetomidine)
- use opioids and sedatives judiciously
- If there is no airway abnormality, RSI can be used, but NO SUCC after first 24 hours post injury
- Severe airway burns may require immediate surgical airway/trach
- Cuffed tubes are standard of care
- MUST have humidification–secretions are thick and tenacious, very likely to form mucous plug
What is the initial management during the burn shock phase?
- This is a combination of distributive, hypovolemic, and cardiogenic shock
- Priorities: airway management and fluid resuscitation
- Fluid losses greatest in first 12 hours and stabilize at 24 hours
- Volume loss and edema
- transudation of plasma proteins directly from wound bed
- interstitial fluid shifts in unburned tissue secondary to capillary leak
- Crystalloids are fluid of choice in 1st 24 hours
What can happen with over-resuscitation?
- over-resuscitation can lead to complicationsintraabdominal hypertension- is reversible
- >12
- abdominal compartment syndrome- leads to organ damage
- >20
- pleural and pericardial effusions
- pulmonary edema
- fasciotomy
- conversion of partial thickness to full thickness (think of the jackson burn zones)
What is the Parkland fluid resuscitation formula?
- 4 ml/kg per percentage of TBSA burned in 1st 24 hours
- half of calculated volume should be administered in first 8 hours
- LR preferred
What is the hypermetabolic phase?
- Develops over several days to weeks, changes can persist up to two years
- Caused by immense surge in catecholamines and corticosteroids (10-50x baseline)
- Persistent tachycardia, systemic hypertension, tachypnea, increased muscle protein degredation, insulin resistance, elevated core temp, liver dysfunction increased risk of infection
- Can lead to physical exhaustion and death without treatment
What are the symptoms seen during hypermetabolic phase?
What are treatments?
- Symptoms
- Persistent tachycardia
- systemic hypertension
- tachypnea
- increased muscle protein degredation
- insulin resistance
- elevated core temp
- liver dysfunction increased risk of infection
- Treatment:
- early excision and grafting
- warming strategies (burn or kept at 87-90 degrees)
- nutritional support
- insulin
- beta blockers
How is excision (escharotomies) and grafting done?
- Aggressively cut off dead tissue until they get to massive blood loss, then they lay epi soaked flaps over the bleeding area
- Can have up to 2L blood loss in 15 minutes
- Surgery done every 2-3 days
- Early debridement preferred, often done in stages
- started on 2nd day to 2nd week of unjury
- Blood loss can be significant.
What are indications to suspend excision surgery?
- 20% of BSA excised (may extend this to larger area if pt is stable)
- time length of 2-3 hours
- temperature drop to 35 C
- blood loss requiring 10 units or mor PRBCs
What should be included in preoperative evaluation?
(9)
- Age, weight
- Pre-existing co-morbidities
- review labs including acid/base
- airway assessment, vent settings
- TBSA burned, note inhalation injury and co-existing trauma
- Mechanism of injury (flame, explosion, chemical, electrical, scald) and time since injury
- Vascular access and adequacy of resuscitation (current fluid requirements, UOP, vasopressor requirements)
- Surgical plan
- review previous anesthetic records
How long should burn patients be NPO?
- NPO after midnight is NOT appropriate for these patients!
- Adequate caloric intake is critical
- No need to d/c enteral feeds for intubated patient
- unintubated patients can have feeds continue up to 4 hours before surgery
- Once in OR, decompress NG tube/check residuals
- Parenteral feeds should be continued intraoperatively and do not use the specific line for them
- For procedure with unprotected airway like placing a trach, should adhere to more standard NPO guidelines
How should you set up pre-operatively for a burn patient?
