Plastics/Burns

Question 1

PLASTICS – burns / house fire

[21B07] An adult is brought to your district hospital after a house fire. They have sustained burns to 75% of their TBSA. Discuss your management prior to their transfer to a burns unit.

Answer 1

*Early mx of major burns
*Risk of smoke inh/AW burn

Key / structure
ABCDE
Early int
Fluid resus formula
Avoid hypothermia
Burns unit

Burns px
- BOBI
- FLAMES

Large SA burn + MOI –> ETT Required

AW burn signs
- singed nasal hair
- burnt MM
- soot sputum
- productive cough
- voice change/hoarse voice

PARKLAND
1. 3mL * TBSA% * wt
2. 1st 1/2 - 8hrs
3. 2nd 1/2 - 16hrs

Question 2

PLASTICS & BURNS – 4YO IN HOUSE FIRE

[18A01] Describe your assessment of a 4-yo child who has been rescued from a house fire

Answer 2

Key is Ax not Mx *

Ax
1. Inh inj
2. Pot of CO poisoning
3. LOC
4. Extent burn
5. Extent pain

Burn - ax and rx concurrently
Severe 10% paed 20% adults
AW key - catastrophic deterioration

1o / Initial
* PPE
* R/o other inj
A:
Supraglottic (stridor) = gas vs
Infraglottic (low O2, confusion) = toxic chem / soot
B
C
D
E - TBSA

FATT (b/w 1o and 2o survery)
*Fluids
Analg
Test
Tubes

2o
- AMPLE
- head to toe
tetanus

Special cons
1. CO poisoning
2. Chem burn
3. Circum burn –> escharotomy
4. Electrical burn –> haemochromogenaemia

Question 3

PLASTICS & BURNS - Hyperkalaemia

[15B14]
A 65 year old female patient is two hours into debridement and skin grafting for a 40% burn to her thorax and legs.

She is intubated and paralysed. An arterial blood gas now shows: pH 7.12 / PaO2 150 / PaCO2 45 / HCO3 15 / K 6.3

a. Outline the potential causes for this patient’s hyperkalaemia. (30%)

b. Describe your management of this hyperkalaemia. (70%).

Answer 3

Cause related to burn
1. Tissue damage
2. Renal impair

Cause unrelated
1. Anaes
2. K shift
3. Excess
4. Pharm

Mx
Trigger
* K >6.5 or ECG changes

1. Stab myocardium
   - cal gluc
2. Shift K
   - salbutamol
   - insulin
3. Exc K
   - resonium
   - furosemide

Other:
NS > CSL
ABG/ECG
ICU ?dialysis

Question 4

PLASTICS & BURNS – Inhalational injury

[10A10]
a) Describe the pathophysiological effects of an inhalational injury following a house fire. (60%)

b) What implications would this have for anaesthesia one week after the injury? (40%

Answer 4

Pathophys

Mech
1. Thermal
2. Chemical
3. Systemic
4. Asphyxia

b. Anaes 1/52 later
Optimise + ABCDE

O: Cn tox (Na Thio, B12); MHb (methylene blue)
A: ICU + ETT inistu
B: barotrauma risk - low Pplat
C: Ongoing fluids
D: TIVA>VA (RF/VQMM), CI to sux
E: warm, treat CO and infection

Question 5

PLASTICS & BURNS – DEEP INFERIOR EPIGASTRIC PERFORATOR FREE FLAP

[19A02] A 60-year-old woman is having breast reconstruction surgery using a deep inferior epigastric perforator free flap six months following a mastectomy for breast cancer.

Discuss the issues of anaesthetic management relevant for this procedure.

Answer 5

Key:
1. Prolonged sx
2. Free flap survival
- blood flow = H-P

Free flap:
- t/f vascularised tissue to new site
- circ restored by microvascular anastamosis
- TRAM and DIEP for breast recon

Microcirc* (reasons for failure)
1. Arterioles
2. Capillaries
3. Venules

Blood flow - aim laminar flow
H-P equation
Q = PxR4/8nl

3 things to inc BF
1. Press gradient
2. Vasodilation (Radius)
3. Viscosity

Anaes / fluid / drugs

A

https://resources.wfsahq.org/atotw/anaesthesia-for-tissue-free-flap-surgery/

https://academic.oup.com/bjaed/article/16/5/162/2389878?login=false

Question 6

PLASTICS & BURNS – Prolonged procedure

[16B11] A 30-year-old male is scheduled to undergo complex lower limb reconstructive surgery expected to last 18 hours. Discuss the issues associated with this prolonged procedure.

Answer 6

Prolonged =
1. Temp
2. Pressure care
3. Fluid mx
4. Fatigue/vigilance
5. Monitoring

Pre
- optimised
- Ix
- PIVC x2
- IAL
- consent

Intra
- IDC+temp probe + BIS + TOF
- Pressure areas
- Anaes
- remi + long acting
- If sevo, switch to TIA
- Fluids
- Prophylaxis

Post
*HDU