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n934: advanced principles of anesthesia > Exam 2 Burns > Flashcards

Exam 2 Burns Flashcards

1
Q

What are the functions of the skin (5)

A

barrier (body fluids & infection)
temperature
elasticity
appearance
sensory organ

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2
Q

What are the types of burn injury? (4)

A

thermal (flash, flame, scald)
chemical
electrical
radiological

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3
Q

How do you grade the severity of the burn?

A

regardless of the etiology, burns are classified according to
depth- extent of skin and tissue destruction (superficial, partial thickness, full thickness)
total body surface area involved (rule of nines)

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4
Q

Describe the depth, pain level appearance, characteristics of a superficial or 1st degree burn?

A

depth- destruction of epidermis
pain level- very painful
appearance- red
characteristics- dry, flaky, will heal spontaneously in 3-5 days

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5
Q

Describe the depth, pain level appearance, characteristics of a partial thickness burn 2nd degree?

A

depth (superficial or deep)- epidermis up to deep dermal element
painful- very painful
appearance- bright cherry red, pink or pale ivory, ususally with fluid filled blistering
Characteristics: hair follicle intact- may require skin graft

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6
Q

Describe the depth, pain level appearance, characteristics of a full thickness/3rd degree burn?

A

depth- all of the epidermis, down into the subcutaneous tissue
pain level- little or no pain
appearance- khaki brown, white or charred/cherry red is pediatrics
characteristics: loss of hair follicles; will require skin graft

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7
Q

Describe the depth of the fourth degree burn

A

fill thickness extending into muscle adn bone
will require skin graft and possible amputation

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8
Q

How deep is a first degree burn?

A

epithelium

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9
Q

How deep is a second degree burn?

A

epithelium and top aspects of the dermis

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10
Q

How deep is a third degree burn?

A

epithelium and dermis

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11
Q

How does as a first degree burn look?

A

no blisters, dry pink

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12
Q

How does a second degree burn look?

A

moist, oozing blisters, moist white pink to red

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13
Q

How does a third degree burn look?

A

leathery, dry no elasticity, charred appearance

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14
Q

What are the causes of the first degree burn?

A

sunburn, scald, flash fame

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15
Q

What are the causes of the second degree burn?

A

scalds, flash burns, chemicals

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16
Q

What are the causes of the third degree burn?

A

contact with flame, hot surface, hot liquids, chemical, electric

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17
Q

What is the level of pain/sensation for a first degree burn?

A

painful, tender, and sore

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18
Q

What is the level of pain/sensation for a second degree burn?

A

very painful

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19
Q

What is the level of pain/sensation for a third degree burn?

A

very little pain, or no pain

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20
Q

What is the healing time for a first degree burn?

A

two to five days; peeling

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21
Q

What is the healing time for second degree burn?

A

superficial: 5-21 days
deep: 21-35 days

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22
Q

What is the healing time for third degree burn?

A

small areas may take months to heal; large areas need grafting

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23
Q

What is the scarring for first degree burns?

A

no scarring; may have discoloration

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24
Q

What is the scarring for a second degree burn?

A

minimal to no scarring; may have discoloration

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25
Q

What is the scarring for a third degree burn?

A

scarring present

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26
Q

What is the % of TBSA for the head?

A

9%

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27
Q

What is the % of TBSA of the upper extremities/ each?

A

18% TBSA
9% each arm

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28
Q

What is the % of the TBSA for the trunk per rule of nines?

A

trunk 36%
front/ back 18% each

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29
Q

What is the % TBSA for the lower extremities per rule of nines?

A

36%
each leg 18%

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30
Q

What is the exception to the rule of nines?

A

pediatric exceptions

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31
Q

What is the % TBSA of head for pediatric?

A

18%

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32
Q

What is teh % TBSA of the trunk for pediatrics?

A

16% each side
32%

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33
Q

What are the peripheries % of TBSA for a pediatrics?

A

arms 10% each
legs 14% each

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34
Q

When should burns be transferred to burn center?

A

full thickness burns of any age group
partial thickness burns > 10% TBSA
burns of special areas (at extremes of age, burns of face, hands, feet, perineum, or major joints, inhalation, chemical or electrical burns) and burns associated with co-existing disease

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35
Q

What should the initial treatment of the burn patient involve?

A

airway
breathing
circulation
co-existing trauma

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36
Q

Describe the considerations regarding the source of injury

A

closed space thermal injury equates to airway injury
open space or accidental injury (campfire) motor vehicle crash= multiple co-exisiting injuries

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37
Q

What can electrical injury lead to occult?

A

severe fracture
hematoma
visceral injury
skeletal
cardiac injury
neurological injury

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38
Q

What are signs and symptoms of airway complications? (8)

A

singed facial hair
facial burns
dysphonia/hoarseness
cough/carbonaceous sputum
soot in mouth/nose
swallowing impairment
oropharynx inflammation
CXR initially normal -> until pulmonary edema or infilatration develops

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39
Q

What patients are suspicious for upper airway injury?

A

close space injury
unconciousness

40
Q

How can you diganose upper airway injury?

A

history, physical exam (DVL or fiberoptic bronchoscope)

41
Q

Define inhalation injury

A

refers to damage to the respiratory tract or lung tissue from heat, smoke, chemical irritants carried into the airway during inspiration

42
Q

Define inhalation injury of the upper airway

A

thermal damage to the soft tissues of the respiratory tract and trachea can make intubation difficult
thermal injury plus fluid resuscitation
increases the risk of glottic edema

43
Q

Define inhalation injury of lower airway involvement

A

pulmonary edema/ARDS develops 1-5 days post burn
pneumonia and pulmonary embolism > 5 days post burn

44
Q

What are signs of smoke inhalation?

A

decreased PaO2 on RA (1st sign)
increased sputum with rales/wheeze

45
Q

When can smoke inhalation occur?

A

occurs in conjunction with face/neck bruns and close space fires
chemical pneumonitis similar to gastric aspiration occurs after smoke/toxic fume inhalation
honeymoon period 1st 48 hours wiht clear CXR

46
Q

In the first 36 hours of the burn patient with inhalation injury, what is the high risk?

A

pulmonary edema

47
Q

What is expected in the first 2-5 days of the burn patient with inhalation injury?

A

expect ateletactasis, bronchopneumonia, airway edema maximum secondary to sloughing of airway muscosa, thick secretions, distal airway obstruction

48
Q

What is expected >5 days post burn?

A

nosocomial pneumonia, respiratory failure, ARDS

49
Q

What can occur with cirumferential burns of chest/upper abdomen

A

restricted chest wall motion as eschar contracts and hardens

50
Q

What is most important with inhalation injury or facial burns?

A

secure airway early!

51
Q

Describe airway management in the burn patient?

A

patent airway= maximum fio2 via facemask
serial laryngoscopic/broncho exams, CXR, ABGs, and PFTs in suspected inhalational airway injury
ETT indicated if- massive burn, stridor, respiratory distress, hypoxia/hypercarbia, altered level of consciousness
prophylatic intubation if deteriotation likely
intubation technique depends on patient factors,extent of airway damage, age, co-existing disease
adults fiberoptic intubation under adequate topical anesthesia is safest approach

52
Q

How has a low threshold for intubation for burn patients?

A

pediatrics because they have small diameter airways

53
Q

What is the treatment of hypoxia in burn patients with inhalation injury?

A

PEEP
airway humidification
bronchial suctioning/ lavage
bronchodilators
antibiotics
chest physiotherapy

54
Q

What should nessitate a escharotomy?

A

restriction of respiratory excursion

55
Q

What is carbon monoxide toxicity?

A

CO poisoning and smoke inhalation usally are found together

56
Q

How many times more is CO affilated to Hgb then O2?

A

200

57
Q

What does CO do on the hemoglobin dissociation curve?

A

shift hemoglobin disassociation curve left impairing o2 unloading to the tissue

58
Q

What does CO interfere with?

A

mitchondrial function
uncouples oxidative phosphorlyation
reduces ATP production
resulting in medabolic acidosis

59
Q

How does CO2 prevent survival in cardiac arrest?

A

CO may act as myocardial toxin

60
Q

What are symptoms are carbon monotoxicity?

A

sao2 may be normal
respiratory effort may appear normal
cherry-red blood color may not be present if Co of <40% and/or the patient is cyanotic and hypoxic

61
Q

How do you treat carbon monoxide toxicity?

A

high Fio2 on all burn patients until CO toxicity ruled out
hyperbaric chamber if COHg is >30% and patient is hemodynamically and neurologically sstabilized
COhgb >60% is incompatible with life

62
Q

What are they symptoms of carbon monoxide toxicity at 15-20%

A

headache, dizziness, confusion

63
Q

What are they symptoms of carbon monoxide toxicity at 20-40%

A

nausea, vomiting, disorientation and visual impairement

64
Q

What are they symptoms of carbon monoxide toxicity at 40-60%

A

agitation, combative, hallucination, coma and shock

65
Q

What are they symptoms of carbon monoxide toxicity at >60%

A

death

66
Q

What is produces as synthetic materials burn?

A

cyanide
victims inhale and absorb it through mucous membranes

67
Q

What are symptoms of cyanide toxicity

A

metabolic acidosis results with elevated lactate levels
altered LOC with agitation, confusion or coma
CV depresssion/ arrhythmia risk
blood cyanide levels of >0.2mg/L confirm diagnosis and 1.0ml/L lethal

68
Q

What is the treatment of cyanide toxicity?

A

O2 treatment of choice
hydroxycobalamine, amyl nitrate, sodium nitrate, thiosulfate

69
Q

What is the half life of cyanide

A

1/2 life of 60 minutes

70
Q

What are the systemic effect of the burn injury?

A

release of inflammatory mediators locally at the burned tissue and systemically contribute to edema associated with burn injury
increase in microvascular permeability-> fluid leak loss of proteins
increased intravascular hydrostatic pressure/ decreased interstitial hydrostatic pressure
interstitial osmotic pressure increases
surgery and infections can perpetuate this mediator induced SIRS that may lead to MOF

71
Q

Describe the cardiovascular stresses with burn injury

A

severe decrease in cardiac output lasts 1st 24 hours
circulating TNF causes myocardial depression
diminished response to catecholamines
increased microvascular permeability-> hypovolemia
intense vasoconstriction compensation
decreased tissue O2 supply and coronary blood flow
hemolysis of erythrocytes
after 24-48 hours: hyperdynamic state (high output CHF) increase BP, HR, CO 2x normal

72
Q

What are the overall systemic results

A

immune suppression
activation of the hypothalamo-adrenal axis and the renin-angtiotensin/aldosterone system
hypermetabolism
protein catabolism
sepsis
multisystem organ failure

73
Q

Describe the metabolism of the burn patient

A

increased metabolic rate is porportional to TBSA burned (can doubled up in 50% TBSA)
increased core body temp reflects increasd metabolic thermostat
loss of skin=loss of vasoactivity, pilorection, insulation functions
daily evaporative fluid loss is 4000ml/m2
caloric consumption is increased

74
Q

What are complications of the GI system

A

ileus, ulceration, cholecystitis

75
Q

What are complications of the renal system

A

decreased GFR, RBF, loss of Ca, K , mg with retention of Na and H20

76
Q

What are complications of the endocrine system?

A

increased corticotropin, ADH, renin, angiotensin, aldosterone, increased glucagon, insulin resistance, hyperglycemia (at risk for nonketotic hyperosmolar coma esp. TPN)

77
Q

What are complications of blood and cogaulation system

A

increased viscosity, increased in clotting factors including fibrinogen, V and VIII fibrin spilt products at risk for DIC development, HCT usually decreases (RBCs decreased 1/2 life)

78
Q

What is the initial fluid resuscitation of burns?

A

loss of fluid from vascular compartment
2-4 ml/kg for each 1% TBSA burned
crystalloid only

79
Q

What is the goal of fluid management?

A

UOP 0.5-1ml/kg/hr

80
Q

What can aggressive fluids cause?

A

worsen airway edema, increase chest wall restriction, and contribute to abdominal compartment syndrome

81
Q

What should fluid resuscitation be after 24 hours?

A

colloid at 0.3-0.5mg/kg/% burn with 5% dextrose in water

82
Q

What is the parkland formula?

A

4ml LR/kg/% burn first 24 hours

83
Q

What is the modified brooke formula?

A

2ml LR/kg/% burned in 1st 24 hours

84
Q

How are the calculated volumes administered?

A

50% in the first 8 hours
25% in the second 8 hours
25% in the 3rd 8 hours

85
Q

What dose of albumin is administered after the first 24 hours?

A

albumin 5%
0.3-0.5ml/kg dose on extent of burn

86
Q

What are the goals of fluid resuscitation?

A

urine output 0.5-1ml/kg/hr
Hr 80-140(consider age)
MAP (adults) >60mmhg
base deficit =<2
normal Hct

87
Q

What if fluids aren’t enough?

A

if perfusion or urine output is inadequate despite >6ml/kg/%TBSA burned
nromal or high CVP
consider low dose dopamine 5mcg/kg/min
consider other vasopressor

88
Q

What are anesthesia considerations for the burn patient

A

repeated surgeries
maintain hct
coagulopathy
temperature
fluids and electrolytes
hypermetabolic state- increase O2, ventilation, nutrition
increase risk of GI ileus (aspiration and hyperalimentation)

89
Q

What are the challenges of anesthesia in the burn patient?

A

monitors- burned tissue, limited access for EKG, SaO2, PNS, NIBP
need for large bore IV access
compensate for evaporative/exposure heat loss
minimize blood loss (topical/sq epinepherine, 15-20% TBSA q procedure, tourniquets)
treat the complications of massive tranfusion (coagulopathy and hypocalemia)

90
Q

What should be pre-op evaluated?

A

airway
phase of resuscitation
monitoring
intravascular access
equipment

91
Q

What are anesthesia considerations for the high voltage electrical injury

A

follows path of least resistance; bone most resistance
cardiac arrhythmias
respiratory arrest
seizures
fractures
muscle damage-> myoglobinurea-> renal failure

92
Q

What is circulation like in the burn patient?

A

shock/hyperdynamic circulation

93
Q

What is the ideal anesthetic for burn patient?

A

high opioid requirement
isoflurane and large doses of opioid

94
Q

What can be administered for serial debridements?

A

ketamine in incremental doses
regional anesthesia

95
Q

Discuss muscle relaxants with burns

A

1st 24 hours- unaltered response to depolarizing and non-depolarizing muscle relaxants
24 hours to 1 year post burn
succinylcholine massive release of K, may be due to the proliferation of acetylcholine receptors along the entire muscle membrane
resistance to most NDMR if >30% burned

n934: advanced principles of anesthesia (16 decks)

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