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Rosens > Plastics Burns Toronto Notes > Flashcards

Plastics Burns Toronto Notes Flashcards

1
Q

Metabolism of a burn pt. - how many ph of metabolism

A

3 - acute, hypermetabolis (Catabolism), recovery (anabolic)

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2
Q

Acute phase of burn metabolism - what happens to the liver?

A

hepatic production acute ph pro and inflamm ck

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3
Q

Acute phase of burn metabolism - endocrine changes

A

decr insulin production
incr GH, cortisol, catecholamines, PRL

*hypometabolic ph

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4
Q

Hypermetabolic ph of burn metabolism - when does this cont until?

A

wounds are closed

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5
Q

Hypermetabolic ph - endocrine changes

A

tissue R to insulin
incr glucose production via glycogenolysis and gluconeogenesis
incr lipolysis and catabolism of skel m
immune suppression

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6
Q

Hypermetabolic ph - how to minimize?

A

warm environ
pain relief
early wound closure
prevent sepsis
propranolol

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7
Q

Recovery ph: __ formation and __. building

A

scar
muscle

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8
Q

Which of 3 phases of burns leads to a high risk of sepsis, and why?

A

hypermetabolic (2)
severe catabolsim, loss lean bm, sign decline imm responses

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9
Q

Caloric RQ depend on burn size - ex 20% burn is an incr or _% EE vs >40%

A

50
100

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10
Q

Why is nutrtion so important in burn pt?

A

impaired wound heal
decr immune func
generalized cellular dysfunc and organ failure

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11
Q

Best marker to assess metabolism and estimation of EE: blood test?

A

BUN

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12
Q
A
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13
Q

General nutrition plan for a burn pt includes:
pro %
carb
fat

A

20 * adult gets 1g/pro per kg of ideal BW + 1g/%TBSA
45-50
30-35

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14
Q

Glucose in burn pt - want to maintain…

A

</=10 as otherwise have higher complications

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15
Q

Consequences of a high carb diet in burn pt -

A

altered liver func
incr resp demands
inhibits neutrophil func and therefore risk of infection

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16
Q

Which vitamins are important for burn pt?

A

vitamin a and c
zinc
d
cu, se, zn reduce L of stay

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17
Q

When to give oxandrolone?

A

major TBSA burn >40%
st benefit is reduce acute ph reactants and improve albumin, improve BM content

LT: improve lean body mass, content and density, regain weight

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18
Q

When to give propranolol?

A

pt major brn tbsa >40%

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19
Q

Why give propranolol in burns?

A

attenuates hypermetabolitc response
reverse catabolism
imrpoves wound healing
m pro kinetics
metabolic rate
liver function
body comp

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20
Q

Indications for enteral feeding in burn pt

A

> 20% tbsa
inadequate oral intake
insuff nutrition pre surgery

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21
Q

Burn zones - 3 - names?

A

zone of coagulation
zone of stasis
zone of hyperemia

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22
Q

Zone of coagulation: what occurs here?

A

earlyproteindenaturation,irreversibledestructionproteinarchitecture,coagulation.Mainfeatureis coagulation necrosis. Zone of NO blood flow

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23
Q

Zone of stasis: what occurs here?

A

reducedtissueperfusionandcompromisedcells;resuscitationaimstoimproveperfusioninthiszone. Additional insult with hypotension, edema or infection risks conversion to irreversible destruction This is a zone of compromised, sluggish blood flow (hence, “stasis). It typically progresses into coagulation necrosis over 1st 48 h and it is the zone responsible for generating systemic inflammation and burn shock acutely. New insults like hypotension, edema, hypoxia can convert the zone into necrosis but this is distinct from progression.

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24
Q

Zone of hyperemia - what happens here?

A

minimal cell injury
prominant vasodilation
complete cellular recovery

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25
Q

Burn damage: superficial: what is this?

A

damage epidermis only - erythema, slough, pain, NO blister

26
Q

Burn damage: superficial partial thickness: what is this?

A

epidermis and superf dermis - blister +, moist bink base with brisk cap refill
+ painful

27
Q

Burn damage: deep partial thickness what is this?

A

epidermis and most of dermis - no pain, delayed/no cap refill, no hairs

28
Q

Burn damage: full thickness: what is this?

A

epidermis and all of dermis - no sensation, thrombosed vessels, + charred

29
Q

Burn damage: fourth degree burn: what is this?

A

injury to m, tendon, bone
thick full thickness butalso contractions

30
Q

What type of burn (and beyond that) needs excision and grafting?

A

deep partial thickness

31
Q

Treatment of superficial burn

A

none and moisturizer

32
Q

Tx of superficial partial thickness burn -

A

antimicrobial, silver dressing and or polysporin for sm wounds

33
Q

Baux score: what is this?

A

nomogram predictor of mortality in a burn patient by including age, tbsa, inhalation injury = + 17

  • 50% mortality if à age + %TBSA = 110 or
  • 50% mortality if à age + %TBSA + inhalation injury = 100
34
Q

Rule of 9s: arm:

A

9

35
Q

Rule of 9s: head

A

9 total
face is 4.5

36
Q

Rule of 9s: neck

A

1%

37
Q

Rule of 9s: leg

A

18% front and back

38
Q

Anterior trunk front vs posterior

A

18 each

39
Q

Indications for prophylactic intubation: list 7

A

inhalational injury/reasonable suspicion
sign deep facial neck burn
large burn with sign fluid resus (expectant airway edema >40%)
long transport
resp failure
close range explosion
steam inhalation

40
Q

Burns >20% tbsa have a systemic response: burn shock and stress response: what are these?

A
  • BurnShockresultsinanincreaseoftotalbodycapillarypermeabilitycausedbyinterplaybetweenhypovolemiaandrelease
    of multiple inflammatory mediators
  • Subsequently, even with correction of hypovolemia, get myocardial depression, increased pulmonary and SVR
  • Stressresponse:metabolicabnormalities:increasecatabolichormones,decreaseanabolichomones,increasedmetabolicrate, unresponsiveness of catabolism to nutrition intake
  • Need to focus on controlling catabolic response
41
Q

Initial assessment of a major burn: physical exam

A

ABCDE
Fluid resus - IVF
Blood - CBC, chem 7, coags, blood group and cross match

Assess burn size and depth

If electrical ecg and trop

Inhalational - cxr, vbg

Secondary survey

Dress wound

42
Q

When to use Parkland formula - burns over ?%

A

20

43
Q

Best fluid for burns?

A

RL

44
Q

Parkland formula

A

4cc/kg/%TBSA - first half in 8 hours, second half in next 16 hours

45
Q

Best parameter of fluid resuscitation for burns?

A

u/o
aim for 0.5cc/kg for adult
1.0cc/kg for child (<50kg)

46
Q

When might fluid RQ be more than calculated by Parkland?

A

inhalational injury (incr >50%)
child
electrical
polytrauma
etoh and drug intox
delayed resus
overestimates in cpdisease

47
Q

In a crush or electrical burn, what might be useful to add to fluids to decrease risk of tubular obstruction?

A

sodium bicarb and maintain u/o 1-2cc/kg until clear (ie myoglobin/hb in urine)

48
Q

Modified brooke formula for fluid resus - what is this?

A

2cc/kg/%tbsa and titrate

49
Q

When to consider colloid resuscitation in burns?

A

start >24h
may reduce fluid RQ and edema but no sign improvement

albumin 5% o.3-0.5cc/kg/% TBBSA

50
Q

Peds fluid resus - normal blood vol?

A

80ml/kg

51
Q

Peds fluid resus - aim for u/o

A

1-1.5cc/hour

52
Q
A
53
Q

When is considered end point for fluid resus in burns?

A
  1. u/o 0.5-1ml/kg/hour
  2. base deficit: normal -3 to +3?
  3. serum lactate N
  4. BP map >60
54
Q

Adjunct to fluid resus: 5 options

A
  1. vit C (?risk aki and osmotic diuresis risk)
  2. histamine inhib (cimetidine)
  3. PG inhib (indomet/ibuprofen)
  4. thromboxane inhib
  5. free radical scavenger
55
Q

Fluid creeo/risk of fluid resus exceeding Parkland causing edema - consequences?

A
  1. abdo compartment syndrome
  2. massive pleural and pericardial effusion
  3. compartmental compression in unburned extremities
  4. prolonged intubation without inh or facial burns
  5. incr intra ocular pressure
  6. death
56
Q

Intra abdominal compartment syndrome - what is this?

A

intra abdo pressure >20 with evidence new organ dysfunction

57
Q

Intra abdominal compartment syndrome - 4 clinical signs

A

oliguria
incr airway pressure
incr metabolic acidosis
HD instability

58
Q

Intra abdominal compartment syndrome - investigations

A

serial abdo exam
vitals
renal function/ (cr, bun), u/o
bladder pressure transfuction q2h, vbg for lactate

59
Q

Intra abdominal compartment syndrome - tx (conservative)

A

urine decompress
nasogastric decompress
sedation and nm relax
pharmacological paralysis
albumin and diuretic therapy
paracentesis

60
Q

Intra abdominal compartment syndrome - definiitive management

A

escharotomy
decompressive laparotomy

Rosens (19 decks)

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