Miscellaneous topics 2 Flashcards
Patients with extensive burn injuries require
aggressive fluid resuscitation as well as surgery for debridement and skin grafting to prevent bacterial sepsis
What are the four classes of burn injury?
superficial
partial-thickness
full-thickness 3rd degree
full-thickness 4th degree
Describe a superficial burn
epidermis only
Describe a partial-thickness burn.
extends to the dermis
Describe a full thickness 3rd degree burn.
complete destruction of the epidermis and dermis
Describe a full thickness 4th degree burn
Extends to muscle and bone
We can use _________________ to assist with fluid replacement calculations
“rule of nines”
Complications of burns include
hypovolemic shock
inhalation injury
sepsis
contractures
scarring
What is the patient experience with a 1st degree burn?
stinging, tender and sore
What does the patient experience with a 2nd degree burn?
very painful
What does the patient experience with a 3rd degree full thickness burn?
no sensation
What does the patient experience with a 4th degree burn?
no sensation
For children 1-4, the rule of nine’s looks a little different in that
more percentage is given to the child’s head (19%) and slightly less to the legs (15%) and torso (16%)
What is the BEST IV fluid to administer in the initial 24 hours after a major burn?
a. D5W
b. 3% NaCl
c. 5% albumin
d. Lactated ringers
d. Lactated ringer’s
Immediately after a burn, microvascular permeability
increases and this creates a capillary leak
Capillary leak leads to
edema formation
hypovolemia
shock
Fluid shifts and edema formation are greatest in the first ______________ and begin to stabilize by _____________
12 hours; 24 hours
________________- should be avoided during the first 24 hours because it’s lost to the interstitial space
Albumin
What are the two commonly used fluid resuscitation formulas used for the acutely burned patient?
Parkland and Modified Brooke
-both use LR in the 1st 24 hrs. and then use D5W
Additional considerations for burn injuries include
abdominal compartment syndrome
carbon monoxide poisoning
airway complications
up-regulation of extrajunctional receptors after 24 hours
impaired temperature regulation
increased oxygen consumption
A rising hemoglobin in the first few days following a burn suggests
inadequate volume resuscitation
Describe the Parkland fluid resuscitation goals.
4 mL LR x %TBSA burned x kg
1/2 in first 8 hours
1/2 in next 16 hours
Describe the Modified Brooke resuscitation goals.
2 mL LR x %TBSA burned X kg
1/2 in first 8 hours
1/2 in next 16 hours
What are the clinical end points of burn resuscitation for adults?
UO: >0.5 mL/kg/hr
MAP> 60 mmHg
HR: 80-100
Base deficit <2
Oxygen delivery index: 600 mL O2/min/m2
Mixed venous oxygen tension: 35-40 mmHg
What are the clinical end points for children and infants?
UO child <30 kg: >1 mL/kg/hr
SBP 70-90 + (2x age in years)
SBP for infants >60 mmHg
What are considerations with electrical burns
dysrhythmias are common
myoglobinemia is caused by extensive muscle damage and is nephrotoxic so needs to be flushed out of the body
Abdominal compartment syndrome may result from
aggressive fluid resuscitation
Abdominal compartment syndrome is defined as
intraabdominal pressure >20 mmHg (transduction of bladder pressure) AND evidence of organ dysfunction (hemodynamic instability, oliguria, increased PIP)
Treatment of abdominal compartment syndrome includes
neuromuscular blockade
sedation
diuresis
abdominal decompression via laparotomy
With carbon monoxide poisoning, blood takes on
a cherry red appearance
The SpO2 with carbon monoxide poisoning
may give a falsely elevated result
Treatment of carbon monoxide poisoning is
100% FiO2 or hyperbaric oxygen
The first priority in all burn patients is to
administer a high FiO2
The gold standard for diagnosing the extent of airway injury is
fiberoptic bronchoscopy
A surgical airway with the patient with a burn injury increases the risk of
pulmonary sepsis and late pulmonary complications
- it should only be used as a last resort
When can succinylcholine be used with burns?
only within 24 hours; after that it can cause lethal hyperkalemia
The dose of nondepolarizing NMBs with burns should be
increased 2-3 fold b/c there are more receptors
Patients become ________________ after a burn
hypermetabolic
Hypermetabolism leads to increased
catabolism, oxygen consumption, heart rate, and respiratory rate
Choose the statement that BEST describes the anesthetic considerations for the patient undergoing electroconvulsive therapy.
a. there is an initial increase in sympathetic tone followed by an increased in parasympathetic tone
b. hypocarbia increases the seizure duration
c. pregnancy is an absolute contraindication
d. lithium shortens the duration of action of succinylcholine
b. hypocarbia increases the seizure duration
Electroconvulsive therapy is a treatment for
medication resistant depression as well as mania, catatonia, suicidal ideation, and some types of schizophrenia
________ is the gold standard induction agent for ECT
Methohexital
The efficacy of ECT is primarily dependent on
the seizure duration
The best response is obtained when the seizure lasts
> 25 seconds
__________ during induction can produce a better quality seizure
hyperventilation
Select absolute contraindications to ECT include
pheochromocytoma
unstable C-spine
brain tumor
MI within the past 4-6 months
recent intracranial surgery (<3 months)
recent stroke (<3 months)
Key relative contraindications to ECT include
pregnancy
CHF
glaucoma
presence of a pacemaker/ICD
retinal detachment
severe pulmonary disease
The physiologic response to ECT includes
initial response: increased PNS activity during the tonic phase
secondary response: increased SNS activity during the clonic phase
What drugs are avoided because they decease seizure duration?
propofol
midazolam
lorazepam
fentanyl
lidocaine
What actions are avoided because they decrease seizure duration?
hypoventilation
hypercarbia
hypoxia
What drugs increase seizure duration?
etomidate
ketamine
alfentanil with propofol
aminophylline
caffeine
____________ may be given during ECT to blunt the SNS response
Esmolol
___________________________ is used as an antisialogogue and reduces the risk of bradycardia and asystole
Glycopyrrolate
This drug prolongs the duration of action of succinylcholine AND nondepolarizing neuromuscular blockers
lithium
Patients on MAOIs who receive indirect acting sympathomimetics can experience
hypertensive crisis
