Mod XII: Burn Management & Carbon Monoxide Poisoning in Anesthesiology

Question 1

_{Burn Management in Anesthesiology}

Please review classifications of burn injuries

Answer 1

…

Question 2

_{Burn Management in Anesthesiology​}

Please review “Rule of nines” which was first described by Lund and Browder

Answer 2

…

Question 3

_{Burn Management in Anesthesiology​}

Please review the four (4) types of burns

Answer 3

Chemical

Electrical

Thermal

Inhalational

^{As the NAR I would like the focus will be more on inhalational burns and how it may compromise the lungs - Mortality associated with burn victims is approximately doubled if inhalation injury is sustained in conjunction with a thermal burn.​}

Question 4

_{Burn Management in Anesthesiology​}

Please review the Parkland Fluid Resuscitation Formula

Answer 4

…

Question 5

_{Burn Management in Anesthesiology​}

Remember that electrical burns can be most damaging to which parts of the body?

Answer 5

Skin and surrounding tissues

Question 6

_{Burn Management in Anesthesiology​}

What is responsible for renal failure a/w electrical burns?

Answer 6

Myoglobinuria

Tissue damage from electrical burns release myoglobin into circulation which can cause renal failure secondary to myoglobinuria

Burn Management in Anesthesiology​

Question 7

_{Burn Management in Anesthesiology​}

As the NAR I would like the focus will be more on inhalational burns and how it may compromise the lungs - Mortality associated with burn victims is approximately doubled if inhalation injury is sustained in conjunction with a

Answer 7

Thermal burn

Question 8

_{Inhalational Burns}

Damage to the airway can vary depending on

Answer 8

whether the upper airway or lower airway is affected

Question 9

_{Inhalational Burns}

How is the upper airway affected by Inhalational Burns?

Answer 9

The upper airway is affected by having the epiglottis or larynx to be exposed to dry air or steam at temperatures that it shouldn’t be exposed to

This exposure can lead to massive edema and rapid airway obstruction

Question 10

_{Inhalational Burns}

Lower airway injuries commonly arise from Inhalation of:

Answer 10

Soot particles and/or

Chemicals produced by a fire

Question 11

_{Inhalational Burns}

Inhaled toxins react with the airway mucosa and thus forming

Answer 11

Acidic and alkali substances

Question 12

_{Inhalational Burns}

Extensive alveolar and epithelial damage can occur with the trachea and bronchi becoming

Answer 12

Necrotic

Question 13

_{Inhalational Burns}

Burn patients have to be emergently intubated - why?

Answer 13

Swelling can occur

Which could impede successful intubation

All burn patients are at risk for severe pulmonary compromise

Question 14

_{Inhalational Burns}

Which type and size of ET tube should be utilized when establishing an airway in children?

Answer 14

Uncuffed tube that is one size smaller

Question 15

_{Inhalational Burns}

Which type and size of ET tube should be utilized when establishing an airway For adults?

Answer 15

For adults place a cuffed tube one size smaller

Question 16

_{Inhalational Burns}

Securing the tube is critical in these patients due to the

Answer 16

Anticipation of swelling

Question 17

_{Inhalational Burns}

The burn surgeons usually perform which airway procedure to the patient after a few days in the hospital?

Answer 17

Tracheostomy

Question 18

_{Inhalational Burns}

There is much literature to support avoiding which drug in these patients from 24 hours to 2 years?

Answer 18

Succinylcholine

However, some literature says its ok to use Succs in the first 24 hours

Question 19

_{Inhalational Burns}

What’s the major reason in support of avoiding Succinylcholine from 24 hours to 2 years?

Answer 19

Recall that the increased K+ levels in the bloodstream from damaged cells in the addition to those released from the use of Succs can lead to cardiac arrest

Question 20

_{Inhalational Burns}

Also, these patients may require more paralytic medication due to

Answer 20

Variations in acetylcholine receptors

This causes decreased sensitivity to nondepolarizing drugs

Question 21

_{Carbon Monoxide Poisoning}

Burn patients rescued from which types of spaces should be considered high risk for carbon monoxide poisoning?

Answer 21

Enclosed-space

Any burn patient rescued from an enclosed-space should be considered high risk for carbon monoxide poisoning

Question 22

_{Carbon Monoxide Poisoning}

What’s the pathophysiology of Carbon Monoxide Poisoning?

Answer 22

Carbon monoxide binds to the hemoglobin molecule with 200 times greater affinity than oxygen

This leads to a fall in oxyhemoglobin saturation as tissues become unable to extract oxygen

The end result is metabolic acidosis at the cellular level

A leftward shift in the oxyhemoglobin curve is noted

Question 23

_{Carbon Monoxide Poisoning}

Carbon monoxide binds to the hemoglobin molecule with how much greater affinity than oxygen?

Answer 23

200 times more!

Question 24

_{Carbon Monoxide Poisoning}

What’s the the end result of Carbon Monoxide Poisoning?

Answer 24

Metabolic acidosis at the cellular level

Question 25

_{Carbon Monoxide Poisoning}

How is the oxyhemoglobin dissociation curve shifted with Carbon Monoxide Poisoning?

Answer 25

A leftward shift in the oxyhemoglobin curve is noted

Question 26

_{Carbon Monoxide Poisoning}

Interventions used to combat Carbon Monoxide Poisoning include:

Answer 26

Administering 100% oxygen to displace carbon monoxide

Hyperbaric oxygen treatments are an alternative if the carboxyhemoglobin level exceeds 25%

Question 27

_{Carbon Monoxide Poisoning}

Why is co-oximeter needed to obtain an accurate oximetry saturation?

Answer 27

The O2 sat probe may provide a false (normal or high) reading as it cannot detect carboxyhemoglobin

Question 28

_{Other Pertinent Burn Information}

What are critical interventions in preventing renal failure

Answer 28

Aggressive fluid administration and

Restoration of the blood volume

Question 29

_{Other Pertinent Burn Information}

When are Fluid losses are greatest

Answer 29

in the first 12 hours after the burn and

begin to stabilize after 24 hours

Question 30

_{Other Pertinent Burn Information}

In burn patients what causes fluid shifts from the intravascular space into the interstitium of unburned tissue?

Answer 30

Capillary leaks

Question 31

_{Other Pertinent Burn Information​}

For fluid resuscitation which formula is recommended for replacement with crystalloid solutions?

Answer 31

Parkland formula

Parklands formula 4ml LR x kg body weight x % TBSA burned

½ total fluid within first 8 hours

½ total fluid over remaining 16 hours

Question 32

_{Other Pertinent Burn Information​}

Why are Colloids avoided within the first 24 hours?

Answer 32

Damaged nature of capillary permeability.

Question 33

_{Other Pertinent Burn Information​}

For Urine Output in Burn Patients for Adults and for children (< 30 kg):

Answer 33

Adults 0.5 ml/kg/hr

Children (< 30 kg) = 1ml/kg/hr

Question 34

_{Other Pertinent Burn Information}

***At Grady in the burn unit, the Burn Surgeons also maintain burn patients on infusion of which blood product to help with volume status & to assist with the reduction of renal failure

Answer 34

FFP drip @ 60cc/hr

These patients usually come to the OR with their FFP gtts as a continuous infusion

Question 35

_{Other Pertinent Burn Information}

After the first 48 hours burn patients may experience a systemic inflammatory syndrome called:

Answer 35

Hypermetabolic/hyperdynamic phase

This is associated with increased blood flow to organs and tissues

Patients usually present with tachycardia, tachypnea, increased serum catecholamines, O2 consumption etc.

This may persist for several weeks after the initial burn.

Question 36

_{Inside the Operating Room with the Burn Patient}

Connect Patient to:

Answer 36

Monitor & Ventilator

Make sure EKG leads are stapled in place

Avoid areas that need debridement

Question 37

_{Inside the Operating Room with the Burn Patient}

KEEP THE PATIENT WARM

Answer 37

Warm the room

Make sure all fluids are warm

Use heating lamps, etc.

Question 38

_{Inside the Operating Room with the Burn Patient}

Blood products:

Answer 38

Have all blood products

Anticipate giving a lot of blood products for these patients

Monitoring I&Os is crucial

Question 39

_{Inside the Operating Room with the Burn Patient}

Central Venous Access/Invasive lines

Answer 39

Some of these patients do not have peripheral lines due to severity of burns

Make sure the arterial line is sewn in by the surgeon