Burns pt2 Exam 1 Flashcards
The goal of the fluid resus. is to have U/O at _____.
1cc/Kg
Which crystalloid is typically the best choice for burns?
Lactated Ringer’s
What factors would indicate that a transfer to a certified burn center is necessary? (5)
- > 10% BSA
- High voltate electrical burns
- Chemical burns
- Concurrent inhalational injury
- Burns on the face, hands, feet, perineum, major joints
Solutions s/a 0.9% NS have a risk of _____
- Hypernatremic hyperchloremic acidosis (non-gap acidosis)
How are crystalloids titrated?
To urine output goal of 30-50 mL/hr??
Fluids should increase/decrease by ______% if urine output goals are not being met.
20-25%
When the determination is made to intubate the burn patient, use a ____ endotracheal tube (ETT), especially if inhalation injury is suspected or noted on bronchoscopy. Size ____ or larger is preferred as the larger ETT tube facilitates subsequent bronchoscopy and pulmonary toilet and decreases the risk of ____ due to casts comprised of blood, mucous and debris.
- Large bore
- 8 ETT
- Airway occlusion
If a pediatric patient is heavier than ___ kg then use the adult formulas.
40 kg
What is the fluid management for Pediatric patients < 14 yrs old and <40 kg
2-4 ml (LR)/kg x kg x %TBSA (2nd and 3rd degree)
Ex. 30kg and 20% TBSA
2x30x20 = 1200 mL over 24 hr
½ in first 8 hr (600mL over 8hr)
= 75mL/hr for first 8 hours
Children less 20kg need what fluid to support their basal metabolic rate?
D5LR
For pediatrics: Titrate IVF to maintain urine output ___
0.5-1mL/kg/hr
At ____ 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 start a ____ infusion (in adults)
- 8-12 hours
- 5% Albumin
What is the dose for pediatric colloids?
- Infuse 4-7 mL/kg at the rate of 0.5 mL per minute
- Reduce maintenance isotonic crystalloid by an equal volume per hour
In resuscitative phase CO is reduced by as much as ____%.
60%
What physiologic changes occur with cardiac status in the resuscitative phase? (4)
- Hypovolemia d/t permeability
- Reduced response to catecholamines
- Increased SVR d/t increased vasopressin levels
- Myocardial ischemia d/t decreased coronary flow
What happens with the 72-96 hr post-burn “flow” phase?
How is this treated?
- Hyperdynamic state… increased CO, Tachycardia
- ↑ myocardial O₂ consumption
- ↓ SVR
Administer beta-blockers and make sure they are appropriately managed for pain
When does the post-burn “flow state” occur?
What is this?
72-96 hours post burn a massive increase in SNS activity but decreased SVR.
What are the pulmonary systemic inflammatory processes that happen with burns? (4)
- Pulmonary hypertension
- Pulmonary capillary alveolar membrane disruption
- Decreased plasma oncotic pressure
- Increased extravascular lung water leads to impaired gas exchange
Patients should be placed in the ____ position to reduce bronchospasm due to impaired gas exchange and tissue injury and have scheduled ____ therapy.
- Prone
- Bronchodilator
Why is impaired ventilation seen in burns?
- Impaired ventilation from circumferential burns/scar
- Hypoventilation d/t decreased elasticity
What treatment is necessary for lung restriction necessary to burn tissue damage?
Escharotomy
What is the sign of possible restrictive lung deficit?
↑ airway pressures
What three “hormones” will increase with the excessive carbohydrate metabolism of burn injuries?
Increases in cortisol, catecholamines, and glucagon
Changes in carbohydrate metabolism for the burn patient results in what consequences? (3)
- Accelerated hepatic gluconeogenesis
- Peripheral insulin resistance (50-70%)
- Impaired intracellular glucose transport
Accelerated lipolysis in burns is due to what three factors?
- B2 and B3 adrenergic stimulation (↑cAMP)
- ↑ glucagon, TNF, IL
- ↑ FFA (which produces ATP)
What treatment is indicated for excessive lipolysis?
β-blockers
Beta blockers decrease ____ and ____ in order to combat accelerated lipolysis.
- Lipid oxidation
- Metabolic rate
The degree of protein loss is proportional to the ____ and is doubled in _____
- Degree of stress
- Severe burns
What are the initial steps to the stabilization of a burn injury? (5)
- Respiratory support
- Fluid resuscitation
- Cardiovascular stabilization
- Pain control
- Local care of burn wounds
What are the secondary steps to the stabilization of a burn injury? (6)
- Pain control – (Long term pain control)
- Thromboprophylaxis
- Wound closure
- Nutritional support
- Control of hypermetabolism
- Prevention of infection
With spinal injury there is an increased risk of what?
Hypovolemia secondary to massive vasodilation
Open fractures will increase ______ _______ and may require ________.
Tissue edema and may require a fasciotomy
To achieve pain control, analgesics should be ________.
scheduled
Medications used to treat pain in burn patients include (5)
- Long acting opioids (Methadone)
- NSAIDs (Acetaminophen)
- PCA infusions (Morphine)
- IV Ketamine
- Supplemental anxiolytics
Pharmacokinetics and ________ can be altered in burns. What does this mean?
Pharmacodynamics
May need to deviate from normal doses to avoid toxicity or decreased efficacy (Start low then give more)
Opioids should not be given via the ____ route due to abnormal/uncertain ___.
- IM
- Absorption
Burns cause damage to the endothelial layer leading to which two consequences?
- Increased capillary permeability
- Loss of intravascular oncotic pressure
Copious loss of intravascular fluid
Loss of intravascular fluid causes systemic inflammatory reactions which leads to the release of _____, _______, and _______.
- Histamine
- Prostaglandin
- Cytokines
Causes vasodilation of already impaired vessels
IV Fluids are needed generally for ____ TBSA or greater.
15%
The following burns/situations: ____, ____, ____ need higher volumes of fluid resuscitation than what would be indicated via their TBSA calculation.
- Inhaled burns
- Electrical burns
- Delayed resuscitation
Advocate for titrating formula down when adequate _______ ______ is achieved.
Urine output
What is the parkland burn formula?
4mL x kg x %BSA
- 2 mL/kg/%BSA (half) in 1st 8 hours
- 2 mL/kg/%BSA (half) in next 16 hours
What is US Army ISR Rule of 10 for adults?
10ml/hr x TBSA
> 80kg, add 100 mL/10kg
What is US Army ISR Rule of 10 for Pediatrics?
- 3 x TBSA x kg = vol for first 24 hrs
- ½ total volume over 1st 8 hrs
