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Basics of Anesthesia > Week 9 - Burns > Flashcards

Week 9 - Burns Flashcards

1
Q

What is the ABCDE emergency management of sever burns?

A

Airway – c-spine
Breathing – 100% O2
Circulation – hemorrhage control and IV access
Disability – AVPU & Pupils
Exposure – environmental control and estimate TBSA

*Fluids, Analgesia, Tests, Tubes

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2
Q

Who is at higher risk for burns?

A
  • The very young (children 4 and under)
  • The very old (65+)
  • The very careless
  • African Americans & Native Americans
  • The poor
  • Rural Americans
  • People living in substandard housing
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3
Q

What are the functions of the skin?

A
  • Protects underlying tissues from injury
  • Assists with temperature regulation
  • Acts as a water seal, keeping body fluids inside the body
  • Sensing organ
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4
Q

What does perforation, burns, and other injuries to the skin lead to?

A

Infection

Inability to maintain fluid and electrolyte homeostasis

Inability to maintain normal body temp

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5
Q

What are the layer of the skin?

A

Epidermis (outer layer)

  • outer most layer is made up of dead skin cells
  • underneath layers seal and protect the body

Dermis (layer below the epidermis)

*only the EPIDERMIS can regenerate

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6
Q

What are the different classifications of thermal (heat) burns?

A

Depth: superficial vs partial thickness (superficial or deep) vs full

Degree: 1st, 2nd, 3rd, 4th

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7
Q

What are the signs and symptoms of a superficial 1st degree burn?

A
  • Erythema
  • Pain at the site
  • Only involves epidermis
  • No blisters
  • Heals in 3-6 days

*Sunburn

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8
Q

What are the signs and symptoms of a partial thickness 2nd degree burn?

A
  • Entire epidermal layer is burned
  • Some of the dermis may be involved
  • Mottled, red, painful blisters
  • Heals in 10-21 days
  • Epithelium will still regenerate

*BAD sunburn

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9
Q

What are the signs and symptoms of a full thickness 3rd degree burn?

A
  • Epidermis and dermis destroyed
  • Burns into the subQ and fat
  • Skin is charred, leathery & woody
  • NOT painful (nerve endings burned
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10
Q

What are the signs and symptoms of a full thickness 4th degree burn?

A
  • Extend into the muscle, bones, and tendons
  • Black and dry
  • No Pain
  • Eschar forming/formed
  • Frequently involves amputation
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11
Q

What is the rule of nines for the adult?

A 
Head = 9%
Each arm = 9%
Torso = 18%
Back = 18%
Each leg = 18%
Genitalia = 1%
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12
Q

What is the rule of nines for a child?

A 
Head = 18%
Each arm = 9%
Torso = 18%
Back = 18%
Each leg = 14%
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13
Q

What is an electrical burn?

A

Electricity flows from an area of high to low concentration through a conducting material

  • the body is the conducting material
  • the duration of contact determines the extent of the burn
  • the width of the current pathway determines damage
  • the tissue through which it passes determines the damage

*nerve damage can develop/worsen over years

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14
Q

What cardiovascular issues occur with electrical burns?

A
  • V-fib
  • Aystole
  • Conduction abnormalities
  • Trauma to cardiac muscle

*survivors have long-term arrhythmias, sinus tachy, PVCs

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15
Q

What respiratory issues occur with electrical burns?

A
  • Tetanic contraction of the chest wall muscles may cause respiratory arrest
  • Injury to the cerebral respiratory control centers may cause respiratory arrest
  • Lungs usually don’t conduct well so they do OK
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16
Q

What neurological issues occur with electrical burns?

A
  • Spinal fractures and other CNS injuries due to blunt force from secondary falls, etc
  • Transient confusion, amnesia, confusion, lack of recall
  • Long-term may include seizures, nerve damage, psych issues
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17
Q

What musculoskeletal issues occur with electrical burns?

A
  • Fractures from blunt trauma and falls secondary to being burned
  • Compartment syndrome from burns
  • Massive muscle damage may cause Rhabdomyolysis and kidney failure
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18
Q

What head issues occur with electrical burns?

A

Entry point for electricity

  • Facial burns
  • Tympanic membrane rupture
  • C-spine injuries
  • Cataracts ~6% of electrical burn pts
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19
Q

What type of injuries does acid chemical burns cause? Basic chemical burns?

A

Acids produce a coagulation necrosis by denaturing proteins
-forms eschar which then limits the depth of acid penetration

Basic chemicals produce liquefaction necrosis – more severe

*chemical burns damage continues until the substance is removed (washed vigorously) or neutralized

20
Q

What is the main cause of death in burn patients?

A

Inhalation Injuries

  • secondary to airway constriction (Hagen Poiseuille law)
  • inhalation injuries are usually limited to the upper airways
21
Q

When do lower airway inhalation injuries occur?

A

Overwhelming heat exposure

Inhalation of steam

Aspiration of hot liquids

22
Q

How do you predict patient survival after a major burn?

A

Baux Score: age + TBSA or age + TBSA + 17 with inhalational burn

  • burn size >40% relative risk increases by 12
  • age >50 RR 7.3
  • inhalation injury RR 3.6
  • male RR 1.8
23
Q

When should you be concerned the patient might have an inhalation burn injury?

A
  • Fire in a closed space
  • Burn pt was entrapped
  • Pt is unconscious or other neurologic altered LOC
  • Facial burns
  • Perioral burns, singed nose hair, carbonaceous sooty sputum
  • Respiratory compromise or dropping SaO2 readings
24
Q

What do inhalation burn injuries cause?

A
  • Mucociliary impairment which leads to respiratory infections
  • Mucus hypersecretion
  • Bronchitis, laryngitis, and pneumonia
  • Epithelial sloughing in airways
  • Surfactant inactivation due to biochemical alterations
  • Increased pulmonary vascular permeability (ARDS)
  • Airway obstruction (large early and small later)
  • Carbon monoxide poisoning
25
Q

What direction does carbon monoxide shift the oxyHgB curve?

A

Shifts the OxyHgB curve to the left – leading to hypoxia

  • CO has an affinity for Hgb that is 200x greater than oxygen
  • standard pulse ox cannot detect CO so readings are WNL (reason every burn pt gets oxygen no matter what)
26
Q

How do you treat carbon monoxide poisoning?

A

Place EVERYONE on 100% non-rebreather face masks

-half life of COHgb on room air is 4 hours and on 100% O2 it is decreased to 30 min

27
Q

What is included in the airway component of burn patient resuscitation?

A
  • Avoid CO poisoning issues w/ 100% humidified non-rebreather
  • Observe face and airways for signs of impending airway obstruction (prophylactic intubation preferred to emergency intubations)
  • Continue to observe for worsening upper airway edema (first 8 hours is critical)
  • Avoid chest wall restriction via circumferential burns (escharotomies)
  • HOB elevated 30 degrees to decrease head and neck edema
28
Q

What is included in the circulatory component of burn patient resuscitation?

A
  • Intravascular volume shifts interstitial due to increased capillary permeability (hypoproteinemia, hyponatremia, interstitial edema)
  • Massive fluid resuscitation
  • Give fluids until hemodynamic stability, adequate urine output (1/2 cc/kg/hr), adjust as needed dependent upon other patient factors
29
Q

What is the parkland formula for burn patient fluid resuscitation?

A

4 mL/kg/%BSA/24 hours of LR

-half in first 8 hours and half in next 16 hours

30
Q

What are the different surgical managements for burns?

A
  • Emergent escharotomies and fasciotomies for decompression
  • Excision and skin grafting to cover open skin areas
  • Multiple debridement and skin grafting for reconstruction
  • Others include trach, g-tube, ortho, neuro, ect
31
Q

What are anesthetic considerations for the airway in a burn patient?

A
  • Excellent preop airway examination is a must
  • Intubated? what size tube, depth, duration
  • Not intubated? were they, when, size/depth/duration
  • Note previous ventilator mode and PIP used
  • May need a smaller ETT than expected
  • How will you secure the airway? – tape, suture, wire
32
Q

What are pulmonary anesthetic considerations in a burn patient?

A
  • Beware pulmonary edema and ARDS
  • Burn patient are usually HYPERmetabolic by skin graft time (increased O2 use and CO2 production) – this increases minute ventilation
  • May require high levels of PEEP to keep airways open
  • May have chest wall compliance issues (decreased FRC, increased CoHgb, increased MetHgb)
33
Q

What are cardiovascular anesthetic considerations in a burn patient?

A
  • Beware of the timing since the burn and phase of fluid resuscitation (12-24 hrs post burn, pt is still losing lots of fluid and edema)
  • Microvascular permeability = edema
  • Water, electrolytes, proteins in the extravascular spaces
  • Hypovolemic shock (burn shock) despite lots of fluids given
  • Increased circulating catecholamines (increased HR and CO)
34
Q

What are NMJ and relaxant anesthetic considerations in a burn patient?

A
  • Damaged muscles due to burned tissue
  • Increased nACHr density (up regulation)
  • Possibly fatal increase in K+ if SUX is used
  • AVOID succinylcholine in burn pts for 2 years post burn
  • Non depolarizers have decreased action and require higher and more frequent dosing in burn patients
35
Q

What are intraoperative anesthetic considerations for burn patients?

A
  • Transport: sedation as needed but maintain the airway
  • Anxiolytics as needed (most pts need it)
  • Induction: generous opioids
  • propofol, etomidate, or ketamine depending on volume status
  • Maintain with agent of choice
  • Emergence: long acting opioid for analgesia (they will take a lot more than you think)
36
Q

What are the blood loss and replacement considerations in burn patients?

A
  • If low H&H have blood in the OR
  • Tangential excision loses 4mL/cm2 of excised skin
  • Fascial excision loses 1.5mL/cm2 of excised skin
  • Surgeons use vasoconstrictor solution on all excisions and skin harvest sites
  • Burn surgeons are usually very reasonable about EBL and replacement
37
Q

What is the purpose of the vasoconstrictor solution used in burn surgeries? What do you need to be aware of?

A

Either epinephrine or phenylephrine solution on all sponges

  • reduces EBL from debridement sites
  • reduces EBL from skin harvest sites

WILL cause peripheral vasoconstriction and increase BP

  • don’t be fooled into complacency of good vitals when they should not be
  • when effects of epi solution wear off, the BP drops and you have a problem
38
Q

What types of burns are classified as minor burns?

A

<10% TBSA burn in adults

<5% TBSA burn in young or old

<2% full thickness burn

*can treat outpatient

39
Q

What types of burns are classified as moderate burns?

A

10-20% TBSA burn in adults
5-10% TBSA burn in young or old
2-5% full thickness burn

  • High voltage burn
  • Suspected inhalation injury
  • Circumferential burn
  • Medical problem predisposing to infection

*admit to hospital

40
Q

What types of burns are classified as major burns?

A

> 20% TBSA burn in adults
10% TBSA burn in young or old
5% full thickness burn

  • High voltage injury
  • Known inhalation injury
  • Significant burn to face, eyes, ears, genitalia, hands, feet, or joints
  • Significant associated injuries (fracture or other major trauma)

*Refer to burn center

41
Q

What are the four mechanisms of burn injury?

A

Inhalation (beware with any fire in enclosed spaces)

Thermal (flame, steam, scald)

Electrical (beware concomitant trauma injuries)

Chemical (type, concentration, and duration)

42
Q

What factors of a burn injury are indications for hospitalization and strongly suggest a burn center?

A
  • Affects > 20% of total body surface area in adults or > 10% in children or elderly
  • Full thickness burns on >5% TBSA
  • Known electrical, chemical, or inhalation injury
  • Significant burns to face, eyes, ears, genitalia, hands, feet, joints
  • Associated injuries, pregnancy, suspected child abuse or neglect
  • Comorbid conditions that will affect recovery
43
Q

What are the three stages of burn injury?

A
  1. Resuscitation (0-36 hours)
  2. Post-Resuscitation (2-6 days) – hypermetabolism starts
  3. Inflammation/Infection (7 days to wound closure)
44
Q

What physiologic changes do you see during the post-resuscitation hypermetabolic stage of a burn injury?

A
  • Massive surge in catecholamines and corticosteroids (10-50x normal)
  • Increased MvO2 and cardiac work (CO 150% normal)
  • Persistent Tachycardia
  • HTN
  • Hyperventilation until wound closure
  • Muscle protein degradation
  • Insulin resistance
  • Increased core temp
  • Liver dysfunction
45
Q

What renal changes are seen with burn injuries?

A
  • Decreased GFR secondary to hypovolemia/hypotension, myoglobinuria after electrical burn, or hemoglobinuria after large body surface area burns
  • Oliguria (inadequate fluid resuscitation) – diuretics shouldn’t be used to treat unless high voltage electrical burn or muscle burns
  • Diuresis begins 3-5 days post burn due to increased GFR due to increased CO
  • TBSA >40% result in renal tubular dysfunction and the inability to concentrate urine

Basics of Anesthesia (35 decks)

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