Test 1: Burns (Andy's Cards) Flashcards
List the types of burns
- Heat
- Electrical
- Friction
- Chemical
- Radiation
Depth of thermal injury related to?
- Contact temperature
- Duration of contact
- Thickness of skin
Heat burns usually involve which layers of tissue?
epidermis and dermis
Name the most common examples of heat burn
- Flame
- Hot liquid
- Hot solid
- Steam
Electrical energy transformed to heat when current passes through body tissue is classified as what type of burn?
Electrical Burn
Electrical Burns disrupts?
Cell membrane potential
The magnitude of electrical burn damage depends on?
- Pathway of current
- Resistance to current flow
- Strength and duration of current flow
What is the major difference between electrical and thermal burns
Electrical burns involve cardiac injury
What are friction burns?
Combo of mechanical disruption and heat generated by friction
What are the caustic reactions of chemical burns?
- PH alteration
- Disruption of cell membranes
- Direct toxic effect on metabolic process
The magnitude of chemical burns are related to?
- Duration of exposure
- Nature of agent
Acid causes tissue necrosis via ______.
Alkali causes tissue necrosis via ______
- Coagulation
- Liquefaction
Radiation burns cause what type of damage?
Ionization
Radiation magntiude depends on?
- Dose and time of exposure
- Types of particles
Most common examples of radiation burns?
- Sunburns
- Therapeutic radiation
- Diagnostic procedures
- Nuclear industry workers
________ degree burns in the center and around the fringes it drops to a ________ degree
- Higher
- Lower
Burns take about ____ hours to fully declare themselves
24-48
What age group have deeper burns from less exposure and less intensity due to the thin skin?
- Adults >55
- Kids <5
Superficial 1st Degree Burns heal in approximately how many days?
3-6 days
What are the characteristics of a Superficial Partial Thickness (2nd Degree) Burn?
- Involves the epidermis and part of dermis
- Mottled red color
- Blisters or weeping
- Very painful / nerve endings exposed
- Small burns usually heal in 10 – 14 days
- Minimal scarring
What burn category is not counted in the TBSA (Total Burn Surface Area) ?
1st degree (superficial) burns
What are the characteristics of a Deep Partial Thickness (2nd Degree) Burn?
- Extends more deeply into the dermis
- Decreased moisture
- Destroyed sweat glands + Impaired tissue integrity
- Difficulty regulating body temperature
- Pale in color – Usually a white/pinkish color
- Absent or prolong blanching – No cap refill, stays blanched for quite a while
- Healing in 21-28 days
At what point is skin grafting typically required?
Deep partial thickness burns
What are the characteristics of a Full Thickness (3rd Degree) Burn?
- Dermis and epidermis are destroyed
- Translucent, dry, painless, charred
- Non-blanching
- Requires grafting
- No bleeding when you do an escharotomy
Differences in deep partial and full thickness is subtle and often hard to tell the exact transition areas in early hours.
Compare and Contrast the various degrees of burn injuries.
What is the most painful burn?
Superficial Partial Thickness (2nd Degree Burn)
What is the Rule of nines in adults?
- Head 9%
- Each arm 9%
- Each leg 18%
- Ant/Post trunk each 18%
- Perineum 1%
The rule of nines is approximately ________ accurate
60-70%
What is the pediatric version of the rule of nines?
- Head 21%
- Arms 10%
- Back 13%
- Chest 13%
- Legs 13.5%
- Butt 5%
- Perineum 1%
What is the Palmer method?
TBSA used for patient’s palm with fingers together = 1%
Larger burn surface areas are often overestimated. T/F?
False. They are underestimated
Women with large breasts have a _____
larger surface area than what was accounted for
Fluid losses secondary to burns are a function of ____ and ____.
- Burn size
- Patient weight
Patients with ____ TBSA will develop burn shock and need IV resuscitation in an ICU.
> 20%
An under fluid resuscitated patient is at risk for what?
↓ perfusion, burn shock, end organ failure
An overly fluid resuscitated patient is at risk for what?
- Abdominal compartment syndrome
- Pulmonary edema/ARDS
List the 6 effects of auto-cannibalism.
- Loss of fat
- Loss of lean body mass
- Gluconeogenesis
- Lipolysis
- Hypermetabolism
- Insulin resistance
The Intensity and duration of auto-cannibalism depends on which two factors?
- Magnitude of injury
- Degree of pain (leads to tachycardia and HTN, thus ↑ metabolism)
What happens to the metabolic rate in a >40% BSA burn?
Metabolic rate doubles.
The effects of auto-cannibalism lasts how long?
Months
Immunodepression, recurrent infections, poor wound healing will also be seen
What three “hormones” will increase with the excessive carbohydrate metabolism of burn injuries?
Increases in cortisol, catecholamines, and glucagon
Changes in carbohydrate metabolism for the burn patient results in what consequences?
- Accelerated hepatic gluconeogenesis
- Peripheral insulin resistance (50-70%)
- Impaired intracellular glucose transport
Accelerated lipolysis in burns is due to what three factors?
- B2 and B3 adrenergic stimulation (↑cAMP)
- ↑ glucagon, TNF, IL
- ↑ FFA (which produces ATP)
What treatment is indicated for excessive lipolysis?
β-blockers
Beta blockers decrease ____ and ____ in order to combat accelerated lipolysis.
- Lipid oxidation
- Metabolic rate
The degree of protein loss is proportional to the ____ and is doubled in _____
- Degree of stress
- Severe burns
What are the initial steps to the stabilization of a burn injury?
- Respiratory support
- Fluid resuscitation
- Cardiovascular stabilization
- Pain control
- Local care of burn wounds
What are the secondary steps to the stabilization of a burn injury?
- Pain control – (Long term pain control)
- Thromboprophylaxis
- Wound closure
- Nutritional support
- Control of hypermetabolism
- Prevention of infection
With spinal injury there is an increased risk of what?
Hypovolemia secondary to massive vasodilation
Open fractures will increase ______ _______ and may require ________.
Tissue edema and may require a fasciotomy
To achieve pain control, analgesics should be ________.
scheduled
Medications used to treat pain in burn patients include
- Methadone (long acting)
- NSAIDs (Acetaminophen)
- PCA infusions (Morphine)
- IV Ketamine
- Supplemental anxiolytics
Pharmacokinetics and ________ can be altered in burns.
Pharmacodynamics
May need to deviate from normal doses to avoid toxicity or decreased efficacy (Start low then give more)
Opioids should not be given via the ____ route due to abnormal ___.
- IM
- Absorption
Burns cause damage to the endothelial layer leading to which two consequences?
- Increased capillary permeability
- Loss of intravascular oncotic pressure
Loss of intravascular fluid causes systemic inflammatory reactions which leads to the release of _____, _______, and _______.
- Histamine
- Prostaglandin
- Cytokines
Causes vasodilation of already impaired vessels
IV Fluids are needed generally for ____ TBSA or greater.
15%
The following burns/situations: ____, ____, ____ need higher volumes of fluid resuscitation than what would be indicated via their TBSA calculation.
- Inhaled burns
- Electrical burns
- Delayed resuscitation
Advocate for titrating formula down when adequate _______ ______ is achieved.
Urine output
What is the parkland burn formula?
4ml x kg x %BSA
- 2 ml/kg/%BSA in 1st 8 hours
- 2 ml/kg/%BSA in next 16 hours
What is US Army ISR Rule of 10 for adults?
10ml/hr x TBSA
> 80kg, add 100 mL/10kg
What is US Army ISR Rule of 10 for Pediatrics?
- 3 x TBSA x kg = vol for first 24 hrs
- ½ total volume over 1st 8 hrs
The goal of the ISR is to have U/O at _____.
1cc/Kg
Which crystalloid is typically the best choice for burns?
Lactated Ringer’s
What factors would indicate that a transfer to a certified burn center is necessary?
- > 10% BSA
- High voltate electrical burns
- Chemical burns
- Concurrent inhalational injury
- Burns on the face, hands, feet, perineum, major joints
Isotonic solutions (NS) have a risk of _____
- Hypernatremic hyperchloremic acidosis (non-gap acidosis)
How are crystalloids titrated?
To urine output goal of 30-50 mL/hr
Fluids should increase/decrease by ______% if urine output goals are not being met.
20-25%
When the determination is made to intubate the burn patient, use a ____ endotracheal tube (ETT), especially if inhalation injury is suspected or noted on bronchoscopy. Size ____ or larger is preferred as the larger ETT tube facilitates subsequent bronchoscopy and pulmonary toilet and decreases the risk of ____ due to casts comprised of blood, mucous and debris.
- Large bore
- 8 ETT
- Airway occlusion
If a pediatric patient is heavier than ___ kg then use the adult formulas.
40 kg
What is the fluid management for Pediatric patients < 14 yrs old and <40 kg
2-4 ml (LR)/kg x kg x %TBSA (2nd and 3rd degree)
Ex. 30kg and 10% TBSA
2/30 x 30 x 10 = 4500 mL
Children less 20kg need what fluid to support their basal metabolic rate?
D5LR
Titrate IVF to maintain urine output ___
0.5-1ml/kg/hr
At ____ hours post-burn, if the hourly IV fluid rate exceeds 1500 mL/hr or if the projected 24 hr total fluid volume approaches 250 mL/kg start a ____ infusion
- 8-12 hours
- 5% Albumin
What is the dose for pediatric colloids?
- Infuse 4-7 mL/kg at the rate of 0.5 mL per minute
- Reduce maintenance isotonic crystalloid by an equal volume per hour
In resuscitative phase CO is reduced by as much as ____%.
60%
What happens to cardiac status in the resuscitative phase?
- Hypovolemia d/t permeability
- Reduced response to catecholamines
- Increased SVR d/t increased vasopressin levels
- Myocardial ischemia d/t decreased coronary flow
- Ensure appropriate fluid resuscitation
What happens with the post-burn “flow” phase?
How is this treated?
- Hyperdynamic state… increased CO, Tachycardia
- ↑ myocardial O₂ consumption
- ↓ SVR
Administer beta-blockers and make sure they are appropriately managed for pain
When does the post-burn “flow state” occur?
What is this?
72-96 hours post burn a massive increase in SNS activity but decreased SVR.
What are the pulmonary systemic inflammatory processes that happen with burns?
- Pulmonary hypertension
- Pulmonary capillary alveolar membrane disruption
- Decreased plasma oncotic pressure
- Increased extravascular lung water leads to impaired gas exchange
Patients should be placed in the ____ position to reduce bronchospasm due to impaired gas exchange and tissue injury and have scheduled ____ therapy.
- Prone
- Bronchodilator
Why is impaired ventilation seen in burns?
- Impaired ventilation from circumferential burns/scar
- Hypoventilation d/t decreased elasticity
What treatment is necessary for lung restriction necessary to burn tissue damage?
Escharatomy
What is the sign of possible restrictive lung deficit?
↑ airway pressures
What lab is elevated with inhalation injuries?
- Carboxyhemoglobin levels > 10%
How are Inhalation injuries diagnosed?
Bronchoscopy
Apply bacitracin ointment to___
Apply erythromycin ointment in the ___
- Eye lids
- Eyes
Carbon Monoxide inhalation is confirmed by what lab?
↑ COHb
At what various levels of carboxyhemoglobin are differing signs and symptoms seen?
After burns patients will have elevated ____, ____, and energy needs.
- protein
- vitamin
Nutrtion within 16 hours of admission is thought to
reduce magnitude of stress response
_____ resistance occurs after burn injuries (in regards to nutrition).
Insulin
How are burn patients force-fed?
High calorie, high protein feeds into the jejunum
May not be D/C for OR if already intubated
What factors can change the pharmacodynamics/kinetics of our drugs?
- Loss of plasma protein concentration
- Alterations in drug receptor (nAChR)
- CO changes
Lots of medication floating around free because they aren’t bound to anything like albumin…
Increases free fractions and volume of distributon
Burns result in up regulation of
nACH receptors
Takes Months to years (1-2) to recover
What drug needs to be avoided in the >24hrs after a burn?
Why?
Succinylcholine
Due to upregulation of nACh receptors → ↑K⁺
What paralytic agent is resisted 24hrs after a burn injury?
Non-depolarizing NMBs
Due to upregulation of nACH receptors
Resistance to non-depolarizers happens when BSA is over ____%.
25%
What signs/symptoms are indicative of airway burn or inhalational injury?
- Hoarseness, wheezing, SOB
- Carbonaceous sputum
- Singed nasal & facial hairs
- Deep facial burns
- Comatose pa/ent
- > 40% TBSA
Difficult laryngoscopy can be due to what four factors?
- Edema
- Pain
- Eschar
- Contractures
Securing the ETT vs tracheostomy
- Cotton umbilical tape
- Wire to teeth
____ should not be used as an airway management for burn patients
LMA
What are the induction drugs for burns
- Propofol
- Etomidate
- Ketamine(Simulates SNS vs depressant effect)
- Opioids
An important adverse side effect noted with Etomidate is ______ _______.
Adrenal Insufficiency
What drug is often useful as an adjunct in burn dressing changes?
Ketamine
2.6% total blood volume is lost for every __% of burn excised or autograft harvested.
1%
Hgb should maintained around ____ g/dL.
7-8 g/dL
____ is a off label drug for burns to prevent blood loss during burn excision.
rFVII
pts are at increased risk of thrombosis
List the vasopressors used in shock when MAP is <55 mmHg.
- Vasopressin
- Norepinephrine
What is the CVP goal with burn patients?
- Goal 6-8 mm Hg
- If not at goal, increase IVF rate by 20-25%
If UO remains low, give fluids. If you have enough UO and your BP is still low, start vasopressors.
What technique is utilized to infiltrate large volumes of local anesthetic subcutaneously?
Tumescent LA w/ epi
What is the typical dose of tumescent local anesthetic?
Lidocaine 1G + epi + 10meq NaHCO₃⁻/1000cc NaCL
55mg/kg max
What are the goals of tumescent technique?
- Decreased blood loss
- Easy excision of granulation tissue
- Shorter surgical times
- No hematoma or bruising postop
When mechanically ventilating a burn patient, target pCO2 to ____ mm Hg or pH >_____.
- 30-35 mmHg
- 7.20
During mechanical ventilation patients should be nebulized with what drug?
Albuterol w/ 5000 units Heparin Q4H
Ensure albuterol is given with heparin since heparin can induce bronchospasm (i.e. wheezing)
Abdominal Compartment Syndrome is diagnosed via what?
Bladder pressures
This is the condition which is to be avoided given the high mortality rate if the abdomen is opened. This is why we have such strict rules in terms of fluid management.
Bladder Pressure for ACS should be measured every
- Measure Q4H with >20% TBSA
Bladder pressures greater than ____ mmHg indicate early intra-abdominal hypertension.
- > 12
____ mmHg is diagnostic for abdominal compartment syndrome.
> 20 mmHg
Burn pain treatment options include
- Additives PRN
- Nitrous oxide 50/50 – in addition to Ketamine
- Peripheral nerve blocks for extremity injuries
Extremities should be elevated ____ degrees.
30-45 degrees (pillows first, then slings)
Assess pulses every ____ hour(s).
Hour – Doppler (High risk for losing perfusion and sensation due to compartment syndrome)
List the adjuncts to burn Resuscitation
- GI Prophylaxis – High risk for stress ulcers
- Sew and/or staple all venous and arterial catheters in place
- Genitalia/Perineum- Insert Foley immediately to maintain urethral patency
- Tetanus status
o Burns are tetanus prone wounds
o Booster if > 5 yrs since last booster
o Booster plus TIG if no previous immuniza/on - IV antibiotics NOT indicated
- Steroids are NOT indicated
What topical antibiotics are used in burn dressing changes?
Silvadene and Sulfamylon
No Silvadene to the face
List the types of commonly used burn dressings.
- Silver dressings
- Silverton water or saline every 8 hours
- Silver nitrate
- Temporary skin substitutes such as Biobrane
