Exam 1: Burns Flashcards
List the types of burns
- Heat
- Electrical
- Friction
- Chemical
- Radiation
CHF-ER
S2
Depth of thermal injury related to what 3 things?
- Contact temperature
- Duration of contact
- Thickness of skin
S3
The Ts of increased risk of burns
- Testosterone
- Tattoos
- Tequila (drunk)
- Teeth
- Tobacco
- Trauma History
Lecture (S3)
Heat burns usually involve which layers of tissue?
epidermis and dermis
S3
Name the most common examples of heat burn
- Flame
- Hot liquid
- Hot solid
- Steam
S3
Electrical energy transformed to heat when current passes through body tissue is classified as what type of burn?
Electrical Burn (generally more devistating because of the CV involvement)
S4
Electrical Burns disrupts?
Cell membrane potential
S4
The magnitude of electrical burn damage depends on?
- Pathway of current
- Resistance to current flow
- Strength and duration of current flow
Ohm’s Law
S4
What is the major difference between electrical and thermal burns
Electrical burns involve cardiac injury
Lecture
What are friction burns?
Combo of mechanical disruption and heat generated by friction
S5
What are the caustic reactions of chemical burns?
- PH alteration (biggest thing to worry about)
- Disruption of cell membranes
- Direct toxic effect on metabolic process
Pete Cells Toxins
S6
for the most part, dilution with water is the way to go even if there are some chemicals that become more caustic when water is added. And be careful of second rescuer injury
The magnitude of chemical burns are related to?
- Duration of exposure
- Nature of agent
S6
Acid causes tissue necrosis via ______.
Alkali causes tissue necrosis via ______
- Coagulation
- Liquefaction
S6
Radiation burns cause what type of damage?
Ionization
S7
Radiation magntiude depends on?
- Dose and Duration of exposure
- Types of particles
PDD - Please Drown Duncan
S7
Most common examples of radiation burns?
- Sunburns
- Therapeutic radiation
- Diagnostic procedures
- Nuclear industry workers
S7
____ degree burns in the center and around the fringes it drops to a ____ degree
- Higher
- Lower
S8
Burns are not ususally uniform in depth
Burns take about ____ hours to fully declare themselves
24-72
S8
What age group have deeper burns from less exposure and less intensity due to the thin skin?
- Adults >55
- Kids <5
S8
Superficial 1st degree burn characteristics
- Involves only the epidermis
- Skin intact, red in color
- Dry surface without blisters
- Painful and hypersensative skin
- no counted in the TBSA
S9
Superficial 1st Degree Burns heal in approximately how many days?
3-6 days
S9
What are the characteristics of a Superficial Partial Thickness (2nd Degree) Burn?
- Involves the epidermis and part of dermis
- Mottled red color
- Blisters or weeping
- Very painful / nerve endings exposed
- Small burns usually heal in 10 – 14 days
- Minimal scarring
S10
What are the characteristics of a Deep Partial Thickness (2nd Degree) Burn?
- Extends more deeply into the dermis
- Decreased moisture/weeping
- less pain because the nerve endings are damaged
- sweat gland have been destroyed
- hard to regulate temperature
- Pale in color – Usually a white/pinkish color
- Absent or prolong blanching – No cap refill, stays blanched for quite a while
- Healing in 21-28 days
- requires skin grafting often
S12
At what point is skin grafting typically required?
Deep partial thickness burns
S12
What are the characteristics of a Full Thickness (3rd Degree) Burn?
- Dermis and epidermis are destroyed
- Translucent, dry, painless, charred
- Non-blanching
- Requires grafting
- No bleeding when you do an escharotomy
- generally painless
S13
Differences in deep partial and full thickness is subtle and often hard to tell the exact transition areas in early hours.
Compare and Contrast the various degrees of burn injuries. (appearance, surface, sensation)
S16
What is the most painful burn?
Superficial Partial Thickness (2nd Degree Burn)
S16
What is the Rule of nines in adults?
- Head 9%
- Each arm (ant and post combined)9%
- Each leg (ant and post combined)18%
- Ant/Post trunk each 18%
- Perineum 1%
S17
The rule of nines is approximately ________ accurate
60-70% because of various depths of the burns
S17
What is the pediatric version of the rule of nines?
- Head 21%
- Arms 10%
- Back 13%
- Chest 13%
- Legs 13.5%
- Butt 5%
- Perineum 1%
S18
What is the Palmer method for TBSA?
TBSA used for patient’s palm with fingers together = 1%
S19
This is more specific that the rule of 9s
Larger burn surface areas are often overestimated. T/F?
False. They are underestimated
S20
Women with large breasts have a ____
larger surface area than what was accounted for (cup size D or>)
S20
- Obese pts are ____(under/overestimated) torso burns
- ____(under/overestimated) extremity burns
- ____ and ____ shape of body are important
- Obese pts are underestimated torso burns
- overestimated extremity burns
- Android and Gynecoid shape of body are important
S20
How does shock happen with burn patients?
- Hypovolemic shock and decreased perfusion happen because of: Loss of plasma from microvasculature into interstitium 🡪 increased permeability
- pts become very edematous because is going into the ISF
S21
Fluid losses secondary to burns are a function of ____ and ____.
- Burn size
- Patient weight
S22
Patients with ____ TBSA will develop burn shock and need IV resuscitation in an ICU.
- > 20%
S22
Inhalation injuries, Lung surface area?
- lungs internally have the surface area of a tennis court
- ~70m2 (Thanks Sir Schmidts Alot)
S22
An under fluid resuscitated patient is at risk for what?
↓ perfusion, burn shock, end organ failure
* Too little fluid = kidneys are pissed
S23
An overly fluid resuscitated patient is at risk for what?
- Abdominal compartment syndrome
- Pulmonary edema/ARDS
S23
List the 6 effects of auto-cannibalism AKA hypermetabolic state
- Loss of fat
- Loss of lean body mass (proteolysis)
- Gluconeogenesis
- Lipolysis
- Hypermetabolism
- Insulin resistance
Hyper Fat(x2) Isaac Protests Glu
S24
The Intensity and duration of auto-cannibalism depends on which two factors?
- Magnitude of injury
- Degree of pain (leads to tachycardia and HTN, thus ↑ metabolism)
S25
What happens to the metabolic rate in a >40% BSA burn?
- Metabolic rate doubles.
- Cannibalism for months-years
- Immunodepression, recurrent infections, poor wound healing
S25
What three “hormones” will increase with the excessive carbohydrate metabolism of burn injuries?
Increases in cortisol, catecholamines, and glucagon
S26
Changes in carbohydrate metabolism for the burn patient results in what consequences?
- Accelerated hepatic gluconeogenesis
- Peripheral insulin resistance (50-70%): post-receptor defect hindering uptake related to extent of the burn can last up to 3 years
- Impaired intracellular glucose transport
S26
Accelerated lipolysis in burns is due to what three factors?
- B2 and B3 adrenergic stimulation (↑cAMP)
- ↑ glucagon, TNF, IL (interleukin)
- ↑ FFA (which produces ATP)
TB-FIG
S27
What treatment is indicated for excessive lipolysis?
β-blockers: decrease lipid oxidation and therefor the metabolic rate
S27
But likely wont respond to sympathetic stimultion either (balance)
Beta blockers decrease ____ and ____ in order to combat accelerated lipolysis.
- Lipid oxidation
- Metabolic rate
S27
Protein metabolism will also cause accelerated…
Accelerated proteolysis of skeletal muscle - Provides substrate for hepatic gluconeogenesis
S28
The degree of protein loss is proportional to the ____ and is doubled in _____
- Degree of stress
- Severe burns
S28
The degree of loss of skeletal muscle is improved by? ____ and is worsened by? ____ and ____
- Improved by cortisol (partially modulated)
- Worsened by TNF and IL-1 (mediated)
S28
What are the 5 initial steps to the stabilization of a burn injury?
- Respiratory support
- Fluid resuscitation
- Cardiovascular stabilization
- Pain control
- Local care of burn wounds
Consider intubating prophylactically because the airway soft tissue will swell
Lungs, Heart, Blood, then pain and wound care
S29
What are the 6 secondary steps to the stabilization of a burn injury?
- Pain control – (Long term pain control)
- Thromboprophylaxis
- Wound closure
- Nutritional support
- Control of hypermetabolism
- Prevention of infection
Somewhat dictated by associated injuries: CHI, spinal injury, open fractures, chest/abd trauma
Would Hyper Isaac Throw Pizza Now?
S30
With spinal injury there is an increased risk of what?
Hypovolemia secondary to massive vasodilation
Lecture
Open fractures will increase ____ ____ and may require ____.
Tissue edema and may require a fasciotomy
Lecture
To achieve pain control, analgesics should be ________.
scheduled
Lecture S31
Medications used to treat pain in burn patients include
- Methadone (long acting)
- NSAIDs (Acetaminophen)
- PCA infusions (Morphine)
- IV Ketamine
- Supplemental anxiolytics
S31
Pharmacokinetics and ____ can be altered in burns.
Pharmacodynamics: May need to deviate from normal doses to avoid toxicity or decreased efficacy (Start low then give more)
S31
Opioids should not be given via the ____ route due to abnormal ____.
- IM
- Absorption
S31
Burns cause damage to the endothelial layer of vessels leading to which two consequences?
- Increased capillary permeability
- Loss of intravascular oncotic pressure
Therefore: loss of intravascular fluid
S32
Loss of intravascular fluid causes systemic inflammatory reactions which leads to the release of ____, ____ and ____.
- Histamine
- Prostaglandin
- Cytokines
Causes vasodilation of already impaired vessels
S32
IV Fluids are needed generally for ____ TBSA or greater.
15%
S33
Concerns for the pt if fluid formulas aren’t followed?
- if the pt is overhydrated (6mL/Kg/TBSA vs 4mL/kg/TBSA) we have concerns for:
* Plum Edema, and compartment syndrome
S33
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
S34
Advocate for titrating formula down when adequate ____ is achieved.
Urine output
* consider a small amount of colloids on day 2
S34
What is the parkland burn formula?
4ml x kg x %BSA
- 2 ml/kg/%BSA in 1st 8 hours
- 2 ml/kg/%BSA in next 16 hours
S34
What is US Army ISR Rule of 10 for adults?
- 10ml/hr x TBSA
- > 80kg, add 100 mL/10kg
S35- Given in the intial 24 hours
Start with 10 mL/hr of LR solution per % of total body surface area (TBSA) burned in adults weighing 40 to 80 kg.
For example, if a patient has 30% TBSA burns, they would initially receive 300 mL/hr of fluids (10 mL/hr x 30%).
For every 10 kg above 80 kg, add an additional 100 mL/hr to the initial fluid rate.
For example, a patient weighing 90 kg with 30% TBSA burns would receive 400 mL/hr of fluids (300 mL/hr + 100 mL/hr)
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
S35
For children weighing 10 to 40 kg:
Start with 3 mL x body weight in kilograms x percentage of total body surface area (TBSA) burned over the first 24 hours.
Half of this volume is administered in the first 8 hours, and the remaining half is administered over the next 16 hours.
3 things to do with anesthesia preop assessment
- Determine estimated BSA% of burn
- Determine severity of burn
- do they need to transfer to a burn center?
S37
5 Criteria to transfer to a burn center
- Full thickness > 10% BSA
- High voltage electrical burn
- Chemical burn
- Assiciated inhalation injury
- Face, hands, feet, perineum or major joints
ChEMI 10 (Chemical, Electrical, Major stuff, Inhalation, 10%)
S37
The goal of the ISR and Parkland formulas is to have U/O at ____.
1cc/Kg/hr
S38
Which crystalloid is typically the best choice for burns?
Lactated Ringer’s
S39
Isotonic solutions (NS) have a risk of ____
- Hypernatremic hyperchloremic acidosis (non-gap acidosis)
S39
How are crystalloids titrated?
To urine output goal of 30-50 mL/hr
S39
Fluids should increase/decrease by ______% if urine output goals are not being met.
20-25%
Pt is usually considered fluid overloaded if they receive 1500mL/hr or 250mL/kg in 24 hours
S39
How should fluid NOT be delivered?
No fluid boluses: volume increases edema
S39
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
S39
If a pediatric patient is heavier than ____ kg then use the adult fluid formulas.
40 kg
S40
Children less 20kg need what fluid to support their basal metabolic rate?
D5LR
S40
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
- 8-12 hours
- 5% Albumin
S41
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
S42
In resuscitative phase (first stage “ebb”) CO is reduced by as much as ____%.
60%
S43
What happens to cardiac status in the resuscitative phase “ebb”?
- Hypovolemia d/t permeability
- Reduced response to catecholamines
- Increased SVR d/t increased vasopressin levels
- Myocardial ischemia d/t decreased coronary flow
Ensure appropriate fluid resuscitation
Cate Serves Poor Idiots
S43
What happens with the post-burn “flow” phase (72-96hours post burn)?
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
S43
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.
S43
What are the pulmonary systemic inflammatory processes that begins immediately after burns?
- Pulmonary hypertension
- Pulmonary capillary alveolar membrane disruption
- Decreased plasma oncotic pressure
- Increased extravascular lung water leads to impaired gas exchange
- Bronchospasm is common - do scheduled bronchodialator therapy
HA BOW
S44
Patients should be placed in the ____ position to reduce bronchospasm due to impaired gas exchange and tissue injury
- Prone
Lecture
Why is impaired ventilation seen in burns?
- Impaired ventilation from circumferential burns/scar
- Hypoventilation d/t decreased elasticity
Acts like a restrictive lung defect
S44
What treatment is necessary for lung restriction necessary to burn tissue damage?
Escharatomy
S44
What is the sign of possible restrictive lung deficit?
↑ airway pressures
Lecture
What lab is elevated with inhalation injuries?
- Carboxyhemoglobin levels > 10%
Lecture
How are Inhalation injuries diagnosed?
- singeing of face or nasal hair
- oropharyngeal carbon
- Carboxyhemoglobin levels > 10%
- Wheezing
- Bronchoscopy is gold standard confirmation
S45
Apply bacitracin ointment to___
Apply erythromycin ointment in the ___
- Eye lids
- Eyes
Have a low threshold for an optho consult
S46
Carbon Monoxide inhalation is confirmed by what lab?
↑ COHb
S47
At what various levels of carboxyhemoglobin are differing signs and symptoms seen?
S47
If a pt is unconscious and expected inhalation injury, what 2 things should you expect and what are the treatments?
- Expect CO poisoning: Tx with 100% O2 and possible hyperbaric chamber
- Expect CN poisoning: Tx with Hydroxocobalamin
S47
After burns patients will have elevated ____, ____, and energy needs along with ____ resistance.
- protein
- vitamin
- Insulin
S48
Nutrtion within 16 hours of admission is thought to
reduce magnitude of stress response
S48
How are burn patients fed?
- High calorie, high protein feeds into the jejunum
- May not be D/C for OR if already intubated
S48
What factors can change the pharmacodynamics/kinetics of our drugs?
- Loss of plasma protein concentration (especially albumin - increases free fractions and Vd)
- Alterations in drug receptor (nAChR)
- CO changes
S49
Lots of medication floating around free because they aren’t bound to anything like albumin
Burns result in up regulation of
nACH receptors
S50
Takes Months to years (1-2) to recover
What drug needs to be avoided in the >24hrs after a burn?
Why?
Succinylcholine
Due to upregulation of nACh receptors → ↑K⁺
Does not correlate with severity of burn
Lecture S50
What paralytic agent is resisted 24hrs after a burn injury?
Non-depolarizing NMBs
Due to upregulation of nACH receptors
S50
Resistance to non-depolarizers happens when BSA is over ____%.
25%
S50
Intraop period anesthesia management
- Standard AANA monitoring
- EKG patches (staple because they wont stick with weeping)
- Pulse ox: accuracy with Carboxyhgb?
- Non-invasive BP: A-lines are better (suture them in place)
- ABG’s: get a baseline
- SVV
- Temp: can lose up to 1degree per 15min
- UOP
S51
Difficult laryngoscopy can be due to what four factors?
- Edema
- Pain
- Eschar
- Contractures
Lecture
Securing the ETT vs tracheostomy
- Cotton umbilical tape
- Wire to teeth
No LMAs
S55
What are the induction drugs for burns
- Propofol
- Etomidate
- Ketamine(Simulates SNS vs depressant effect)
- Opioids
S56
An important adverse side effect noted with Etomidate is ____.
Adrenal Insufficiency
S56
What drug is often useful as an adjunct in burn dressing changes?
Ketamine
S56
2.6% total blood volume is lost for every __% of burn excised or autograft harvested.
1%
S58
Hgb should maintained around ____ g/dL.
7-8 g/dL
S58
____ is a off label drug for burns to prevent blood loss during burn excision.
rFVII
S58
pts are at increased risk of thrombosis
List the vasopressors used in shock when MAP is <55 mmHg.
- Vasopressin
- Norepinephrine
S59
What is the CVP goal with burn patients?
- Goal 6-8 mm Hg
- If not at goal, increase IVF rate by 20-25%
CVPs are good for trends, not just 1 number
If UO remains low, give fluids. If you have enough UO and your BP is still low, start vasopressors.
What technique is utilized to infiltrate large volumes of local anesthetic subcutaneously?
Tumescent LA w/ epi
But make sure their CV system can tolerate - lido w/ epi can be problematic
S60
What is the typical dose of tumescent local anesthetic?
Lidocaine 1G + epi + 10meq NaHCO₃⁻/1000cc NaCL
S60
55mg/kg max
What are the goals of tumescent technique?
- Decreased blood loss
- Easy excision of granulation tissue
- Shorter surgical times
- No hematoma or bruising postop
S60
When mechanically ventilating a burn patient, target pCO2 to ____ mm Hg or pH greater than ____.
- 30-35 mmHg
- 7.20
S61
During mechanical ventilation patients should be nebulized with what?
Albuterol w/ 5000 units Heparin Q4H
*Ensure albuterol is given with heparin since heparin can induce bronchospasm (i.e. wheezing)
S61
Abdominal Compartment Syndrome is diagnosed via what?
Bladder pressures
* This is the condition which is to be avoided given the high mortality rate if the abdomen is opened. This is why we have such strict rules in terms of fluid management.
S63
Bladder Pressure for ACS should be measured every
- Measure Q4H with >20% TBSA
S64
Bladder pressures greater than ____ mmHg indicate early intra-abdominal hypertension.
- > 12
S64
____ mmHg is diagnostic for abdominal compartment syndrome.
> 20 mmHg
S64
Burn pain treatment options include
- Additives PRN - Burn debridment and dressing changes
- Nitrous oxide 50/50 – in addition to Ketamine
- Peripheral nerve blocks for extremity injuries
S67
Extremities should be elevated ____ degrees.
30-45 degrees (pillows first, then slings)
S67
Assess pulses every ____ hour(s).
Hour – Doppler (High risk for losing perfusion and sensation due to compartment syndrome)
S69
List the adjuncts to burn Resuscitation
- GI Prophylaxis – High risk for stress ulcers
- Sew and/or staple all venous and arterial catheters in place
- Genitalia/Perineum- Insert Foley immediately to maintain urethral patency
- Tetanus status
o Burns are tetanus prone wounds
o Booster if > 5 yrs since last booster
o Booster plus TIG if no previous immuniza/on - IV antibiotics NOT indicated
- Steroids are NOT indicated
S71
What topical antibiotics are used in burn dressing changes?
Silvadene and Sulfamylon
S73
No Silvadene to the face
List the types of commonly used burn dressings.
- Silver dressings
- Silverton water or saline every 8 hours
- Silver nitrate
- Temporary skin substitutes such as Biobrane
S73
