Burns pt2 Exam 1

Question 1

The goal of the fluid resus. is to have U/O at _____.

Answer 1

1cc/Kg

Question 2

Which crystalloid is typically the best choice for burns?

Answer 2

Lactated Ringer’s

Question 3

What factors would indicate that a transfer to a certified burn center is necessary? (5)

Answer 3

• > 10% BSA
• High voltate electrical burns
• Chemical burns
• Concurrent inhalational injury
• Burns on the face, hands, feet, perineum, major joints

Question 4

Solutions s/a 0.9% NS have a risk of _____

Answer 4

• Hypernatremic hyperchloremic acidosis (non-gap acidosis)

Question 5

How are crystalloids titrated?

Answer 5

To urine output goal of 30-50 mL/hr??

Question 6

Fluids should increase/decrease by ______% if urine output goals are not being met.

Answer 6

20-25%

Question 7

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.

Answer 7

• Large bore
• 8 ETT
• Airway occlusion

Question 8

If a pediatric patient is heavier than ___ kg then use the adult formulas.

Answer 8

40 kg

Question 9

What is the fluid management for Pediatric patients < 14 yrs old and <40 kg

Answer 9

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

Question 10

Children less 20kg need what fluid to support their basal metabolic rate?

Answer 10

D5LR

Question 11

For pediatrics: Titrate IVF to maintain urine output ___

Answer 11

0.5-1mL/kg/hr

Question 12

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)

Answer 12

• 8-12 hours
• 5% Albumin

Question 13

What is the dose for pediatric colloids?

Answer 13

• Infuse 4-7 mL/kg at the rate of 0.5 mL per minute
• Reduce maintenance isotonic crystalloid by an equal volume per hour

Question 14

In resuscitative phase CO is reduced by as much as ____%.

Answer 14

60%

Question 15

What physiologic changes occur with cardiac status in the resuscitative phase? (4)

Answer 15

• Hypovolemia d/t permeability
• Reduced response to catecholamines
• Increased SVR d/t increased vasopressin levels
• Myocardial ischemia d/t decreased coronary flow

Question 16

What happens with the 72-96 hr post-burn “flow” phase?
How is this treated?

Answer 16

• Hyperdynamic state… increased CO, Tachycardia
• ↑ myocardial O₂ consumption
• ↓ SVR

Administer beta-blockers and make sure they are appropriately managed for pain

Question 17

When does the post-burn “flow state” occur?
What is this?

Answer 17

72-96 hours post burn a massive increase in SNS activity but decreased SVR.

Question 18

What are the pulmonary systemic inflammatory processes that happen with burns? (4)

Answer 18

• Pulmonary hypertension
• Pulmonary capillary alveolar membrane disruption
• Decreased plasma oncotic pressure
• Increased extravascular lung water leads to impaired gas exchange

Question 19

Patients should be placed in the ____ position to reduce bronchospasm due to impaired gas exchange and tissue injury and have scheduled ____ therapy.

Answer 19

• Prone
• Bronchodilator

Question 20

Why is impaired ventilation seen in burns?

Answer 20

• Impaired ventilation from circumferential burns/scar
• Hypoventilation d/t decreased elasticity

Question 21

What treatment is necessary for lung restriction necessary to burn tissue damage?

Answer 21

Escharotomy

Question 22

What is the sign of possible restrictive lung deficit?

Answer 22

↑ airway pressures

Question 23

What three “hormones” will increase with the excessive carbohydrate metabolism of burn injuries?

Answer 23

Increases in cortisol, catecholamines, and glucagon

Question 24

Changes in carbohydrate metabolism for the burn patient results in what consequences? (3)

Answer 24

• Accelerated hepatic gluconeogenesis
• Peripheral insulin resistance (50-70%)
• Impaired intracellular glucose transport

Question 25

Accelerated lipolysis in burns is due to what three factors?

Answer 25

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

Question 26

What treatment is indicated for excessive lipolysis?

Answer 26

β-blockers

Question 27

Beta blockers decrease ____ and ____ in order to combat accelerated lipolysis.

Answer 27

• Lipid oxidation
• Metabolic rate

Question 28

The degree of protein loss is proportional to the ____ and is doubled in _____

Answer 28

• Degree of stress
• Severe burns

Question 29

What are the initial steps to the stabilization of a burn injury? (5)

Answer 29

• Respiratory support
• Fluid resuscitation
• Cardiovascular stabilization
• Pain control
• Local care of burn wounds

Question 30

What are the secondary steps to the stabilization of a burn injury? (6)

Answer 30

• Pain control – (Long term pain control)
• Thromboprophylaxis
• Wound closure
• Nutritional support
• Control of hypermetabolism
• Prevention of infection

Question 31

With spinal injury there is an increased risk of what?

Answer 31

Hypovolemia secondary to massive vasodilation

Question 32

Open fractures will increase ______ _______ and may require ________.

Answer 32

Tissue edema and may require a fasciotomy

Question 33

To achieve pain control, analgesics should be ________.

Answer 33

scheduled

Question 34

Medications used to treat pain in burn patients include (5)

Answer 34

• Long acting opioids (Methadone)
• NSAIDs (Acetaminophen)
• PCA infusions (Morphine)
• IV Ketamine
• Supplemental anxiolytics

Question 35

Pharmacokinetics and ________ can be altered in burns. What does this mean?

Answer 35

Pharmacodynamics

May need to deviate from normal doses to avoid toxicity or decreased efficacy (Start low then give more)

Question 36

Opioids should not be given via the ____ route due to abnormal/uncertain ___.

Answer 36

• IM
• Absorption

Question 37

Burns cause damage to the endothelial layer leading to which two consequences?

Answer 37

• Increased capillary permeability
• Loss of intravascular oncotic pressure

Copious loss of intravascular fluid

Question 38

Loss of intravascular fluid causes systemic inflammatory reactions which leads to the release of _____, _______, and _______.

Answer 38

• Histamine
• Prostaglandin
• Cytokines

Causes vasodilation of already impaired vessels

Question 39

IV Fluids are needed generally for ____ TBSA or greater.

Answer 39

15%

Question 40

The following burns/situations: ____, ____, ____ need higher volumes of fluid resuscitation than what would be indicated via their TBSA calculation.

Answer 40

• Inhaled burns
• Electrical burns
• Delayed resuscitation

Question 41

Advocate for titrating formula down when adequate _______ ______ is achieved.

Answer 41

Urine output

Question 42

What is the parkland burn formula?

Answer 42

4mL x kg x %BSA

• 2 mL/kg/%BSA (half) in 1st 8 hours
• 2 mL/kg/%BSA (half) in next 16 hours

Question 43

What is US Army ISR Rule of 10 for adults?

Answer 43

10ml/hr x TBSA
> 80kg, add 100 mL/10kg

Question 44

What is US Army ISR Rule of 10 for Pediatrics?

Answer 44

• 3 x TBSA x kg = vol for first 24 hrs
• ½ total volume over 1st 8 hrs