2nd Principles > Burns > Flashcards

Burns Flashcards

Unit 1 (76 cards)

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1
Q

What are the 5 types of burns?

A
  1. heat
  2. electrical
  3. friction
  4. chemical
  5. radiation
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2
Q

Heat burns usually involve which skin layers?

A

the epidermis and the dermis

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3
Q

The magnitude of an electrical burn is dependent on what?

A

the pathway of the current
resistance to flow
strength and duration of the flow of current

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4
Q

What is in jeopardy when you have a hand-to-hand electrical injury?

A

The heart and lungs are en route and may sustain burn injuries and dysrhythmias (electricity disrupts membrane potential)

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5
Q

What are characteristics of friction burns?

A

They tend to be more minor but extremely painful

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6
Q

How do chemical burns cause damage?

A

by altering pH, disrupting cell membranes or by having a direct toxic effect on metabolic processes

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7
Q

a chemical burn by acid causes necrosis by__________.

A

coagulation

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8
Q

a chemical burn by an alkali causes necrosis by_____________.

A

liquification

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9
Q

How do you treat a chemical burn?

A

Dilution (is the solution to pollution)

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10
Q

How does radiation cause damage?

A

ionization causes damage to tissues.

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11
Q

list a few examples of radiation burns?

A

sunburns
therapeutic radiation
diagnostic procedures
nuclear industry workers

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12
Q

Who is at risk for deeper burns? Why?

A

Adults >55 and children <5 due to thinner skin

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13
Q

How long does it take for burns to fully declare themselves?

A

24-48 hours

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14
Q

1st degree burns involve which layer of skin? Are there blisters? Are these burns counted in TBSA?

A

epidermis
No
No

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15
Q

How long do 1st degree burns take to heal?

A

3-6 days

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16
Q

What layers of the skin are involved in 2nd degree burns? Are there blisters?

A

the epidermis and the dermis
Yes

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17
Q

How long do superficial or partial thickness 2nd degree burns typically take to heal?

A

10-14 days

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18
Q

Which type of burn is considered the most painful and carries a high risk for infection?

A

superficial 2nd degree burns (third degree burns have burned off nerve endings)

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19
Q

How long do deep 2nd degree burns take to heal?

A

21-28 days

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20
Q

How can you differentiate a deep from a superficial 2nd degree burn?

A

there is less moisture (sweat glands destroyed), paler in color with patches of white, less pain

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21
Q

what are some characteristics of a 3rd degree burn?

A

dermis is destroyed. Non-blanching. Translucent, dry, inelastic and painless.

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22
Q

Which types of burns require grafting?

A

deep 2nd degree burns and 3rd degree burns

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23
Q

How accurate is the rule of nines?

A

only 60-70% accurate d/t various burn depths

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24
Q

Rule of nines: what is the % of TBSA of the head? An arm? A leg? Back? Perineum?

A

Head: 9%
Arm: 9%
Leg: 18%
Back: 18%
Perineum: 1%

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25
What is the TBSA of an infants head and neck?
21%
26
What is the Palmer method for estimating TBSA burned?
Use the patient's palm to measure the burn = 1%
27
What is unique about the fluid status of a patient with a major burn injury?
They may experience both hypovolemic shock and loss of plasma from microvasculature to interstitium d/t increased permeability causing peripheral edema
28
Which burn patients experience shock and are admitted to the ICU?
TBSA burn size > 20%
29
What does under-resuscitation lead to?
decreased perfusion, burn shock and end organ failure
30
What does over-resuscitation lead to?
abdominal compartment syndrome, pulmonary edema and ARDS
31
What is the metabolic response to a major burn injury?
Auto-cannibalism which leads to loss of fat, lean body mass, gluconeogenesis, lipolysis, and insulin resistance
32
With a TBSA burn > 40% what happens to the metabolic rate?
the metabolic rate doubles, auto-cannibalism for months leads to immunodepression, recurrent infections and poor wound healing
33
Increased carbohydrate metabolism in burn patients can lead to what?
increased cortisol, catecholamines, and glucagon. Increased insulin resistance that can last up to 3 years.
34
Increased lipolysis leads to increased levels of cAMP, how is this treated?
treated with beta blockade which decreases lipid oxidation and decreased metabolic rate
35
proteolysis of skeletal muscles is accelerated with burn injuries, what hormones and cytokines modulate this?
cortisol improves it TNF, IL-1 and IL-6 worsen it
36
List scheduled pain medications that can be given to burn patients
long acting opioids such as methadone NSAIDs PCA infusions IV Ketamine anti-anxiety medications
37
What types of drugs should be avoided with burn patients?
IM medications (as absorption is uncertain)
38
What are two mechanisms that lead to fluid loss with massive burn injuries?
1. Impaired endothelial barrier leading to leaky capillaries 2. Vasodilation from systemic inflammatory response
39
what is the Parkland formula for fluid resuscitation?
4 mL/kg/%BSA over 24 hours give the first half in the first 8 hours followed by the second half over the next 16 hours
40
What is the formula the US Army uses for fluid resuscitation for burns? (IRS Formula)
Adult: 10mL/hr x TBSA (if >80 kg add 100 mL/ 10 kg) Peds <14 years old or < 40 kg: 3 x TBSA x Kg for first 24 hr (half total volume in first 8 hr)
41
Goal directed care = advocate titrating down on fluids when urine output is adequate. When is UO adequate?
at 0.5-1cc/kg
42
When intubating a burn patient what size ETT should you use? Why?
Size 8 or larger is preferred to facilitate bronchoscopy and pulmonary toilet. It also decreases risk of later airway occlusions due to casts of blood, mucus and debris.
43
When should you initiate 5% albumin?
at 8-12 hr post-burn if hourly IVF rate is > 1500 mL/hr or if the projected 24 hr total fluid volume reaches 250 mL/kg
44
How fast should you infuse 5% albumin in children? What do you do with the maintenance crystalloid infusion?
4-7 mL/kg at a rate of 0.5 mL/min reduce the maintenance crystalloid by an equal volume per hour
45
What differentiates the resuscitative "ebb" phase from the "flow" phase in regards to cardiac status?
Ebb: low CO, hypovolemia, reduced response to catecholamines, vasopressin release and increased SVR, myocardial ischemia d/t decreased coronary flow Flow: increased CO, tachycardia, increased myocardial consumption, decreased SVR
46
How do we treat the ebb phase? How do we treat the flow phase?
Ebb: fluid resuscitation Flow: beta blockers
47
How do burns impact pulmonary status?
pulmonary hypertension d/t systemic inflammatory process restrictive lung defect d/t decreased elasticity (escharotomy) bronchospasms (bronchodilator)
48
When should you suspect an inhalation injury?
if there is singing of the face or nasal hairs oropharynx carbon carboxyhemoglobin levels > 10% wheezing fire was in closed space
49
What are some anesthesia considerations with facial burns?
secure ETT protect the eyes consult optho apply bacitracin to eye lids apply erythromycin to eyes
50
With carbon monoxide poisoning, what symptoms do you see with carboxyhemoglobin levels at 15-20%? 20-25%? Greater than 25%? What are normal levels? What do smokers have?
15-20%: headache, N/V 20-25%: seizures, acute renal failure, myocardial ischemia >25%: unconsciousness or death normal <4%, smokers 4-9%
51
Do you need to DC tube feeds if the patient is already intubated?
No not if the NG tube feeds into the jejunum
52
Why a pharmacodynamics and pharmacokinetics effected in burn patients?
increased free fractions of the drug d/t decreased plasma proteins (mainly albumin), alterations in nACh-R and CO changes
53
What happens to nACh-R in burn patients?
there is an upregulation of nACh-r that lasts months to years
54
What happens to paralytics in response to an up-regulation of nACh-r?
resistance to non-depolarizers increased sensitivity to depolarizers (markedly increased serum K+)
55
When can you give a depolarizing NMB like succinylcholine to a burn patient? Why?
in the first 24 hrs (upregulation of nACh-r begins at about 24 hrs and is most significant 48-72 hr after the burn)
56
What are some considerations anesthesia should have in regards to monitoring a burn patient?
may need to staple EKG patches and suture arterial lines, is pulse ox accurate (carboxyhemoglobin), might want to know SVV and need UO. Temperature is very important to monitor (pt. can lose 1 C q 15 min)
57
What is the best method for warming a burn patient?
convection warming devices and keeping the OR warm
58
What are some warning signs of an impending airway obstruction?
stridor, hoarseness, dysphagia
59
Which airway devices should not be used in burn patients?
LMA's
60
Which induction drugs are better to use during the Ebb phase? The flow phase? What is the concern with Etomidate?
Ebb (low CO): Ketamine (stimulates SNS) Flow (high CO): Propofol, Opioids Etomidate can cause adrenal insufficiency
61
How much total blood volume is lost for every 1% burn excised or autograft harvest?
2.6%
62
How much PRBC's should you transfuse in a burn patient? What if they have acute coronary syndrome?
7-8 g/dL Hb 10 g/dL Hb if ACS
63
What can you use to mitigate blood loss from burn injuries?
topical thrombin, staged procedures (multiple OR trips are better tolerated than one long one), subcutaneous vasoconstrictors
64
What is the CVP goal for shock management? What should you do if not attaining this goal?
CVP: 6-8 mmHg if not at goal -> increase IVF rate by 20-25%
65
How can you infiltrate large volumes of LA subcutaneously?
by adding Epi
66
What is tumescent LA?
1g Lidocaine + epi + 10 mEq NaHCO3 / 1000cc NaCl
67
What is the max amount of Tumescent LA you can use?
55 mg/kg
68
What are some of the advantages of tumescent LA?
decreased blood loss, easier excision of granulation tissue, shorter surgical times, no hematoma or bruising postOp
69
What are some things we can do to optimize ventilation for burn patients?
elevate HOB to 30 degrees target pCO2 of 30-35 mmHg or pH > 7.2 pre-oxygenate and suction 2x nebulize 5000 units of heparin w/ albuterol q4hr to create pulmonary toilet
70
Why give nebulized heparin? Why is it important to also give albuterol?
Heparin prevents clumping of epithelial cells, but can also trigger bronchospasms, which is why we give albuterol
71
What can over-resuscitation lead to? How can you diagnose this?
abdominal compartment syndrome. This can be diagnosed with bladder pressure. (>20mmHg indicates abdominal compartment syndrome)
72
What is the mortality rate of a burn patient with an open abdomen?
90%
73
How often should bladder pressures be measured in patients with a burn > 20% TBSA?
q4 hr
74
What are some thermoregulation devices you can use on burn patients in the OR?
HPMK/ Blizzard Heat Aircraft temp control Belmont Buddy Lite Wool blanket
75
How to manage extremities with significant burns?
elevate extremities 30-45 degrees (pillows > slings) doppler pulses hourly
76
When should you give a tetanus booster to burn patients?
if its been > 5 years since their last tetanus shot
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