Plastics Burns Toronto Notes Flashcards
Metabolism of a burn pt. - how many ph of metabolism
3 - acute, hypermetabolis (Catabolism), recovery (anabolic)
Acute phase of burn metabolism - what happens to the liver?
hepatic production acute ph pro and inflamm ck
Acute phase of burn metabolism - endocrine changes
decr insulin production
incr GH, cortisol, catecholamines, PRL
*hypometabolic ph
Hypermetabolic ph of burn metabolism - when does this cont until?
wounds are closed
Hypermetabolic ph - endocrine changes
tissue R to insulin
incr glucose production via glycogenolysis and gluconeogenesis
incr lipolysis and catabolism of skel m
immune suppression
Hypermetabolic ph - how to minimize?
warm environ
pain relief
early wound closure
prevent sepsis
propranolol
Recovery ph: __ formation and __. building
scar
muscle
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
Caloric RQ depend on burn size - ex 20% burn is an incr or _% EE vs >40%
50
100
Why is nutrtion so important in burn pt?
impaired wound heal
decr immune func
generalized cellular dysfunc and organ failure
Best marker to assess metabolism and estimation of EE: blood test?
BUN
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
Glucose in burn pt - want to maintain…
</=10 as otherwise have higher complications
Consequences of a high carb diet in burn pt -
altered liver func
incr resp demands
inhibits neutrophil func and therefore risk of infection
Which vitamins are important for burn pt?
vitamin a and c
zinc
d
cu, se, zn reduce L of stay
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
When to give propranolol?
pt major brn tbsa >40%
Why give propranolol in burns?
attenuates hypermetabolitc response
reverse catabolism
imrpoves wound healing
m pro kinetics
metabolic rate
liver function
body comp
Indications for enteral feeding in burn pt
> 20% tbsa
inadequate oral intake
insuff nutrition pre surgery
Burn zones - 3 - names?
zone of coagulation
zone of stasis
zone of hyperemia
Zone of coagulation: what occurs here?
earlyproteindenaturation,irreversibledestructionproteinarchitecture,coagulation.Mainfeatureis coagulation necrosis. Zone of NO blood flow
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.
Zone of hyperemia - what happens here?
minimal cell injury
prominant vasodilation
complete cellular recovery
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:
9
Rule of 9s: head
9 total
face is 4.5
Rule of 9s: neck
1%
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 ?%
20
Best fluid for burns?
RL
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?
- u/o 0.5-1ml/kg/hour
- base deficit: normal -3 to +3?
- serum lactate N
- BP map >60
Adjunct to fluid resus: 5 options
- vit C (?risk aki and osmotic diuresis risk)
- histamine inhib (cimetidine)
- PG inhib (indomet/ibuprofen)
- thromboxane inhib
- free radical scavenger
Fluid creeo/risk of fluid resus exceeding Parkland causing edema - consequences?
- abdo compartment syndrome
- massive pleural and pericardial effusion
- compartmental compression in unburned extremities
- prolonged intubation without inh or facial burns
- incr intra ocular pressure
- 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
