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Mar: Sem 4 - Principles II > Exam 1: Burns > Flashcards

Exam 1: Burns Flashcards

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1
Q

List the types of burns

A
  • Heat
  • Electrical
  • Friction
  • Chemical
  • Radiation

CHF-ER

S2

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2
Q

Depth of thermal injury related to what 3 things?

A
  • Contact temperature
  • Duration of contact
  • Thickness of skin

S3

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3
Q

The Ts of increased risk of burns

A
  • Testosterone
  • Tattoos
  • Tequila (drunk)
  • Teeth
  • Tobacco
  • Trauma History

Lecture (S3)

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4
Q

Heat burns usually involve which layers of tissue?

A

epidermis and dermis

S3

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5
Q

Name the most common examples of heat burn

A
  • Flame
  • Hot liquid
  • Hot solid
  • Steam

S3

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6
Q

Electrical energy transformed to heat when current passes through body tissue is classified as what type of burn?

A

Electrical Burn (generally more devistating because of the CV involvement)

S4

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7
Q

Electrical Burns disrupts?

A

Cell membrane potential

S4

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8
Q

The magnitude of electrical burn damage depends on?

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

Ohm’s Law

S4

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9
Q

What is the major difference between electrical and thermal burns

A

Electrical burns involve cardiac injury

Lecture

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10
Q

What are friction burns?

A

Combo of mechanical disruption and heat generated by friction

S5

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11
Q

What are the caustic reactions of chemical burns?

A
  • 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

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12
Q

The magnitude of chemical burns are related to?

A
  • Duration of exposure
  • Nature of agent

S6

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13
Q

Acid causes tissue necrosis via ______.
Alkali causes tissue necrosis via ______

A
  • Coagulation
  • Liquefaction

S6

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14
Q

Radiation burns cause what type of damage?

A

Ionization

S7

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15
Q

Radiation magntiude depends on?

A
  • Dose and Duration of exposure
  • Types of particles

PDD - Please Drown Duncan

S7

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16
Q

Most common examples of radiation burns?

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

S7

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17
Q

____ degree burns in the center and around the fringes it drops to a ____ degree

A
  • Higher
  • Lower

S8

Burns are not ususally uniform in depth

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18
Q

Burns take about ____ hours to fully declare themselves

A

24-72

S8

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19
Q

What age group have deeper burns from less exposure and less intensity due to the thin skin?

A
  • Adults >55
  • Kids <5

S8

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20
Q

Superficial 1st degree burn characteristics

A
  • Involves only the epidermis
  • Skin intact, red in color
  • Dry surface without blisters
  • Painful and hypersensative skin
  • no counted in the TBSA

S9

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21
Q

Superficial 1st Degree Burns heal in approximately how many days?

A

3-6 days

S9

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22
Q

What are the characteristics of a Superficial Partial Thickness (2nd Degree) Burn?

A
  • 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

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23
Q

What are the characteristics of a Deep Partial Thickness (2nd Degree) Burn?

A
  • 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

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24
Q

At what point is skin grafting typically required?

A

Deep partial thickness burns

S12

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25
Q

What are the characteristics of a Full Thickness (3rd Degree) Burn?

A
  • 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.

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26
Q

Compare and Contrast the various degrees of burn injuries. (appearance, surface, sensation)

A

S16

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27
Q

What is the most painful burn?

A

Superficial Partial Thickness (2nd Degree Burn)

S16

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28
Q

What is the Rule of nines in adults?

A
  • Head 9%
  • Each arm (ant and post combined)9%
  • Each leg (ant and post combined)18%
  • Ant/Post trunk each 18%
  • Perineum 1%

S17

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29
Q

The rule of nines is approximately ________ accurate

A

60-70% because of various depths of the burns

S17

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30
Q

What is the pediatric version of the rule of nines?

A
  • Head 21%
  • Arms 10%
  • Back 13%
  • Chest 13%
  • Legs 13.5%
  • Butt 5%
  • Perineum 1%

S18

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31
Q

What is the Palmer method for TBSA?

A

TBSA used for patient’s palm with fingers together = 1%

S19

This is more specific that the rule of 9s

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32
Q

Larger burn surface areas are often overestimated. T/F?

A

False. They are underestimated

S20

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33
Q

Women with large breasts have a ____

A

larger surface area than what was accounted for (cup size D or>)

S20

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34
Q
  • Obese pts are ____(under/overestimated) torso burns
  • ____(under/overestimated) extremity burns
  • ____ and ____ shape of body are important
A
  • Obese pts are underestimated torso burns
  • overestimated extremity burns
  • Android and Gynecoid shape of body are important

S20

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35
Q

How does shock happen with burn patients?

A
  • 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

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36
Q

Fluid losses secondary to burns are a function of ____ and ____.

A
  • Burn size
  • Patient weight

S22

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37
Q

Patients with ____ TBSA will develop burn shock and need IV resuscitation in an ICU.

A
  • > 20%

S22

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38
Q

Inhalation injuries, Lung surface area?

A
  • lungs internally have the surface area of a tennis court
  • ~70m2 (Thanks Sir Schmidts Alot)

S22

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39
Q

An under fluid resuscitated patient is at risk for what?

A

↓ perfusion, burn shock, end organ failure
* Too little fluid = kidneys are pissed

S23

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40
Q

An overly fluid resuscitated patient is at risk for what?

A
  • Abdominal compartment syndrome
  • Pulmonary edema/ARDS

S23

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41
Q

List the 6 effects of auto-cannibalism AKA hypermetabolic state

A
  • Loss of fat
  • Loss of lean body mass (proteolysis)
  • Gluconeogenesis
  • Lipolysis
  • Hypermetabolism
  • Insulin resistance

Hyper Fat(x2) Isaac Protests Glu

S24

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42
Q

The Intensity and duration of auto-cannibalism depends on which two factors?

A
  • Magnitude of injury
  • Degree of pain (leads to tachycardia and HTN, thus ↑ metabolism)

S25

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43
Q

What happens to the metabolic rate in a >40% BSA burn?

A
  • Metabolic rate doubles.
  • Cannibalism for months-years
  • Immunodepression, recurrent infections, poor wound healing

S25

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44
Q

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

A

Increases in cortisol, catecholamines, and glucagon

S26

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45
Q

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

A
  • 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

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46
Q

Accelerated lipolysis in burns is due to what three factors?

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

TB-FIG

S27

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47
Q

What treatment is indicated for excessive lipolysis?

A

β-blockers: decrease lipid oxidation and therefor the metabolic rate

S27

But likely wont respond to sympathetic stimultion either (balance)

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48
Q

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

A
  • Lipid oxidation
  • Metabolic rate

S27

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49
Q

Protein metabolism will also cause accelerated…

A

Accelerated proteolysis of skeletal muscle - Provides substrate for hepatic gluconeogenesis

S28

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50
Q

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

A
  • Degree of stress
  • Severe burns

S28

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51
Q

The degree of loss of skeletal muscle is improved by? ____ and is worsened by? ____ and ____

A
  • Improved by cortisol (partially modulated)
  • Worsened by TNF and IL-1 (mediated)

S28

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52
Q

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

A
  • 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

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53
Q

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

A
  • 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

54
Q

With spinal injury there is an increased risk of what?

A

Hypovolemia secondary to massive vasodilation

Lecture

55
Q

Open fractures will increase ____ ____ and may require ____.

A

Tissue edema and may require a fasciotomy

Lecture

56
Q

To achieve pain control, analgesics should be ________.

A

scheduled

Lecture S31

57
Q

Medications used to treat pain in burn patients include

A
  • Methadone (long acting)
  • NSAIDs (Acetaminophen)
  • PCA infusions (Morphine)
  • IV Ketamine
  • Supplemental anxiolytics

S31

58
Q

Pharmacokinetics and ____ can be altered in burns.

A

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

S31

59
Q

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

A
  • IM
  • Absorption

S31

60
Q

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

A
  • Increased capillary permeability
  • Loss of intravascular oncotic pressure

Therefore: loss of intravascular fluid

S32

61
Q

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

A
  • Histamine
  • Prostaglandin
  • Cytokines

Causes vasodilation of already impaired vessels

S32

62
Q

IV Fluids are needed generally for ____ TBSA or greater.

A

15%

S33

63
Q

Concerns for the pt if fluid formulas aren’t followed?

A
  • if the pt is overhydrated (6mL/Kg/TBSA vs 4mL/kg/TBSA) we have concerns for:
    * Plum Edema, and compartment syndrome

S33

64
Q

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

A
  • Inhaled burns
  • Electrical burns
  • Delayed resuscitation

S34

65
Q

Advocate for titrating formula down when adequate ____ is achieved.

A

Urine output
* consider a small amount of colloids on day 2

S34

66
Q

What is the parkland burn formula?

A

4ml x kg x %BSA

  • 2 ml/kg/%BSA in 1st 8 hours
  • 2 ml/kg/%BSA in next 16 hours

S34

67
Q

What is US Army ISR Rule of 10 for adults?

A
  • 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)

68
Q

What is US Army ISR Rule of 10 for Pediatrics?

A
  • 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.

69
Q

3 things to do with anesthesia preop assessment

A
  • Determine estimated BSA% of burn
  • Determine severity of burn
  • do they need to transfer to a burn center?

S37

70
Q

5 Criteria to transfer to a burn center

A
  • 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

71
Q

The goal of the ISR and Parkland formulas is to have U/O at ____.

A

1cc/Kg/hr

S38

72
Q

Which crystalloid is typically the best choice for burns?

A

Lactated Ringer’s

S39

73
Q

Isotonic solutions (NS) have a risk of ____

A
  • Hypernatremic hyperchloremic acidosis (non-gap acidosis)

S39

74
Q

How are crystalloids titrated?

A

To urine output goal of 30-50 mL/hr

S39

75
Q

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

A

20-25%

Pt is usually considered fluid overloaded if they receive 1500mL/hr or 250mL/kg in 24 hours

S39

76
Q

How should fluid NOT be delivered?

A

No fluid boluses: volume increases edema

S39

77
Q

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.

A
  • Large bore
  • 8 ETT
  • Airway occlusion

S39

78
Q

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

A

40 kg

S40

79
Q

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

A

D5LR

S40

80
Q

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

A
  • 8-12 hours
  • 5% Albumin

S41

81
Q

What is the dose for pediatric colloids?

A
  • 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

82
Q

In resuscitative phase (first stage “ebb”) CO is reduced by as much as ____%.

A

60%

S43

83
Q

What happens to cardiac status in the resuscitative phase “ebb”?

A
  • 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

84
Q

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

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

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

S43

85
Q

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

A

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

S43

86
Q

What are the pulmonary systemic inflammatory processes that begins immediately after burns?

A
  • 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

87
Q

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

A
  • Prone

Lecture

88
Q

Why is impaired ventilation seen in burns?

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

Acts like a restrictive lung defect

S44

89
Q

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

A

Escharatomy

S44

90
Q

What is the sign of possible restrictive lung deficit?

A

↑ airway pressures

Lecture

91
Q

What lab is elevated with inhalation injuries?

A
  • Carboxyhemoglobin levels > 10%

Lecture

92
Q

How are Inhalation injuries diagnosed?

A
  • singeing of face or nasal hair
  • oropharyngeal carbon
  • Carboxyhemoglobin levels > 10%
  • Wheezing
  • Bronchoscopy is gold standard confirmation

S45

93
Q

Apply bacitracin ointment to___

Apply erythromycin ointment in the ___

A
  • Eye lids
  • Eyes

Have a low threshold for an optho consult

S46

94
Q

Carbon Monoxide inhalation is confirmed by what lab?

A

↑ COHb

S47

95
Q

At what various levels of carboxyhemoglobin are differing signs and symptoms seen?

A

S47

96
Q

If a pt is unconscious and expected inhalation injury, what 2 things should you expect and what are the treatments?

A
  1. Expect CO poisoning: Tx with 100% O2 and possible hyperbaric chamber
  2. Expect CN poisoning: Tx with Hydroxocobalamin

S47

97
Q

After burns patients will have elevated ____, ____, and energy needs along with ____ resistance.

A
  • protein
  • vitamin
  • Insulin

S48

98
Q

Nutrtion within 16 hours of admission is thought to

A

reduce magnitude of stress response

S48

99
Q

How are burn patients fed?

A
  • High calorie, high protein feeds into the jejunum
  • May not be D/C for OR if already intubated

S48

100
Q

What factors can change the pharmacodynamics/kinetics of our drugs?

A
  • 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

101
Q

Burns result in up regulation of

A

nACH receptors

S50

Takes Months to years (1-2) to recover

102
Q

What drug needs to be avoided in the >24hrs after a burn?
Why?

A

Succinylcholine

Due to upregulation of nACh receptors → ↑K⁺

Does not correlate with severity of burn

Lecture S50

103
Q

What paralytic agent is resisted 24hrs after a burn injury?

A

Non-depolarizing NMBs

Due to upregulation of nACH receptors

S50

104
Q

Resistance to non-depolarizers happens when BSA is over ____%.

A

25%

S50

105
Q

Intraop period anesthesia management

A
  • 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

106
Q

Difficult laryngoscopy can be due to what four factors?

A
  • Edema
  • Pain
  • Eschar
  • Contractures

Lecture

107
Q

Securing the ETT vs tracheostomy

A
  • Cotton umbilical tape
  • Wire to teeth

No LMAs

S55

108
Q

What are the induction drugs for burns

A
  • Propofol
  • Etomidate
  • Ketamine(Simulates SNS vs depressant effect)
  • Opioids

S56

109
Q

An important adverse side effect noted with Etomidate is ____.

A

Adrenal Insufficiency

S56

110
Q

What drug is often useful as an adjunct in burn dressing changes?

A

Ketamine

S56

111
Q

2.6% total blood volume is lost for every __% of burn excised or autograft harvested.

A

1%

S58

112
Q

Hgb should maintained around ____ g/dL.

A

7-8 g/dL

S58

113
Q

____ is a off label drug for burns to prevent blood loss during burn excision.

A

rFVII

S58

pts are at increased risk of thrombosis

114
Q

List the vasopressors used in shock when MAP is <55 mmHg.

A
  • Vasopressin
  • Norepinephrine

S59

115
Q

What is the CVP goal with burn patients?

A
  • 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.

116
Q

What technique is utilized to infiltrate large volumes of local anesthetic subcutaneously?

A

Tumescent LA w/ epi

But make sure their CV system can tolerate - lido w/ epi can be problematic

S60

117
Q

What is the typical dose of tumescent local anesthetic?

A

Lidocaine 1G + epi + 10meq NaHCO₃⁻/1000cc NaCL

S60

55mg/kg max

118
Q

What are the goals of tumescent technique?

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

S60

119
Q

When mechanically ventilating a burn patient, target pCO2 to ____ mm Hg or pH greater than ____.

A
  • 30-35 mmHg
  • 7.20

S61

120
Q

During mechanical ventilation patients should be nebulized with what?

A

Albuterol w/ 5000 units Heparin Q4H

*Ensure albuterol is given with heparin since heparin can induce bronchospasm (i.e. wheezing)

S61

121
Q

Abdominal Compartment Syndrome is diagnosed via what?

A

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

122
Q

Bladder Pressure for ACS should be measured every

A
  • Measure Q4H with >20% TBSA

S64

123
Q

Bladder pressures greater than ____ mmHg indicate early intra-abdominal hypertension.

A
  • > 12

S64

124
Q

____ mmHg is diagnostic for abdominal compartment syndrome.

A

> 20 mmHg

S64

125
Q

Burn pain treatment options include

A
  • Additives PRN - Burn debridment and dressing changes
  • Nitrous oxide 50/50 – in addition to Ketamine
  • Peripheral nerve blocks for extremity injuries

S67

126
Q

Extremities should be elevated ____ degrees.

A

30-45 degrees (pillows first, then slings)

S67

127
Q

Assess pulses every ____ hour(s).

A

Hour – Doppler (High risk for losing perfusion and sensation due to compartment syndrome)

S69

128
Q

List the adjuncts to burn Resuscitation

A
  • 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

129
Q

What topical antibiotics are used in burn dressing changes?

A

Silvadene and Sulfamylon

S73

No Silvadene to the face

130
Q

List the types of commonly used burn dressings.

A
  • Silver dressings
  • Silverton water or saline every 8 hours
  • Silver nitrate
  • Temporary skin substitutes such as Biobrane

S73

Mar: Sem 4 - Principles II (23 decks)

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