Plastics Burns Toronto Notes Flashcards by Tegan Turner

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

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

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

hepatic production acute ph pro and inflamm ck

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Acute phase of burn metabolism - endocrine changes

decr insulin production
incr GH, cortisol, catecholamines, PRL

*hypometabolic ph

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

wounds are closed

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Hypermetabolic ph - endocrine changes

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

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Hypermetabolic ph - how to minimize?

warm environ
pain relief
early wound closure
prevent sepsis
propranolol

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Recovery ph: __ formation and __. building

scar
muscle

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

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

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

50
100

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Why is nutrtion so important in burn pt?

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

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

BUN

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

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

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Glucose in burn pt - want to maintain…

</=10 as otherwise have higher complications

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Consequences of a high carb diet in burn pt -

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

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Which vitamins are important for burn pt?

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

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When to give oxandrolone?

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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When to give propranolol?

pt major brn tbsa >40%

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Why give propranolol in burns?

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

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Indications for enteral feeding in burn pt

> 20% tbsa
inadequate oral intake
insuff nutrition pre surgery

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Burn zones - 3 - names?

zone of coagulation
zone of stasis
zone of hyperemia

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Zone of coagulation: what occurs here?

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

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Zone of stasis: what occurs here?

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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Zone of hyperemia - what happens here?

minimal cell injury
prominant vasodilation
complete cellular recovery

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Burn damage: superficial: what is this?

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

Burn damage: superficial partial thickness: what is this?

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

Burn damage: deep partial thickness what is this?

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

Burn damage: full thickness: what is this?

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

Burn damage: fourth degree burn: what is this?

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

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

deep partial thickness

Treatment of superficial burn

none and moisturizer

Tx of superficial partial thickness burn -

antimicrobial, silver dressing and or polysporin for sm wounds

Baux score: what is this?

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

Rule of 9s: arm:

Rule of 9s: head

9 total face is 4.5

Rule of 9s: neck

Rule of 9s: leg

18% front and back

Anterior trunk front vs posterior

18 each

Indications for prophylactic intubation: list 7

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

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

* 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

Initial assessment of a major burn: physical exam

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

When to use Parkland formula - burns over ?%

Best fluid for burns?

Parkland formula

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

Best parameter of fluid resuscitation for burns?

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

When might fluid RQ be more than calculated by Parkland?

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

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

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

Modified brooke formula for fluid resus - what is this?

2cc/kg/%tbsa and titrate

When to consider colloid resuscitation in burns?

start >24h may reduce fluid RQ and edema but no sign improvement albumin 5% o.3-0.5cc/kg/% TBBSA

Peds fluid resus - normal blood vol?

80ml/kg

Peds fluid resus - aim for u/o

1-1.5cc/hour

When is considered end point for fluid resus in burns?

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

Adjunct to fluid resus: 5 options

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

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

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

Intra abdominal compartment syndrome - what is this?

intra abdo pressure >20 with evidence new organ dysfunction

Intra abdominal compartment syndrome - 4 clinical signs

oliguria incr airway pressure incr metabolic acidosis HD instability

Intra abdominal compartment syndrome - investigations

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

Intra abdominal compartment syndrome - tx (conservative)

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

Intra abdominal compartment syndrome - definiitive management

escharotomy decompressive laparotomy