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Principles of Anes II > Burn Patients > Flashcards

Burn Patients Flashcards

1
Q

What are the 3 main end goals for surgical excision in large burns?

A

limit to 2-3 hr operative time
core temp of 35 C
limit surgery to 10 units of PRBCs

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2
Q

Both the epidermis & dermis are involved with what type of burn?

A

Heat Burns

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3
Q

An acidic chemical burn will cause:

A

necrosis by coagulation

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4
Q

An alkali chemical burn will cause:

A

necrosis by liquefaction

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5
Q

What type of radiation burns causes damage?

A

Ionization radiation

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6
Q

What are some examples of ionizing radiation burns?

A

sunburns, therapeutic radiation, diagnostic procedures, nuclear power plant workers

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7
Q

Why is burn classification important?

A

to determine healing potential & need for surgical grafting

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8
Q

How long does it take for burns to reveal their true depth?

A

12-48 hrs

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9
Q

Which burn classification is not counted in the TBSA % for fluid calculations?

A

Superficial (1st degree) burns

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10
Q

Superficial (1st degree) burns usually heal in approximately:

A

3-6 days

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11
Q

Burn that involves the epidermis and part of the dermis that is very painful with mottled/blotchy red color, blisters or weeping.

A

Superficial partial thickness (2nd degree burn)

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12
Q

Superficial Partial Thickness (mild 2nd degree burn) usually heals within:

A

10-14 days w/o surgery & leaves minimal scarring

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13
Q

Burn that extends more deeply through the epidermis & dermis with patches of white, less painful, decreased moisture b/c sweat glands destroyed:

A

Deep Partial thickness (2nd degree burn)

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14
Q

Deep partial thickness (2nd degree burn) usually heals in about:

A

21-28 days ~ 1 month

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15
Q

Burn that can have consequences of temperature control when graft is place?

A

Deep partial thickness (2nd degree burn) – the skin becomes hot but cannot sweat b/c the sweat glands were destroyed from burn

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16
Q

Burn that destroys both layers of dermis, translucent, dry, painless, charred, non-blanching

A

Full thickness (3rd degree burn)

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17
Q

Which burn classifications are included in the TBSA % calculation?

A

2nd degree & higher

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18
Q

Palmer (hand) method – the palm with fingers together are what BSA %

A

1%

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19
Q

Pediatric pts, the head & neck constitute what BSA%

A

21%

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20
Q

Genital area on an adult and pediatric patient are ___% BSA

A

1%

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21
Q

Each arm on a pediatric patient is ___% BSA

A

10%

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22
Q

The abdomen & back of a pediatric patient are ___% BSA

A

13

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23
Q

Pediatrics buttocks is ___% BSA

A

5%

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24
Q

Each leg on a pediatric patient is ___% BSA

A

13.5%

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25
Q

Accuracy of estimation of TBSA % may vary if pt is _____ or has ______.

A

obese
large breasts (cup size D or higher)

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26
Q

Burn pathophysiology involves managing 2 conflicting priorities:

A

SHOCK & EDEMA

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27
Q

What are the consequences of fluid under-resuscitation?

A

decreased perfusion
burn shock
end organ failure

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28
Q

Abdominal compartment syndrome, pulmonary edema/ARDS, & peripheral tissue edema are consequences of:

A

fluid over-resuscitation

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29
Q

Auto-cannibalism refers to:

A

hypermetabolic phase =
lipolysis
proteolysis (loss of protein/muscle)
gluconeogenesis
hypermetabolism
insulin resistance

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30
Q

What metabolic responses occur with >40% TBSA burns?

A

Metabolic rate doubles
cannibalism for months
immunodepression, recurrent infections, & poor wound healing

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31
Q

What causes an acceleration in hepatic gluconeogenesis & peripheral insulin resistance with burn trauma pts?

A

Increases in cortisol, catecholamines, & glucagon
**Can last up to 3 yrs

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32
Q

Accelerated lipolysis is due to:

A

B2 & B3 stimulation from increased cAMP
Elevated glucagon, TNG, Interleukin
elevated levels of free fatty acids cause increased production of ATP

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33
Q

Beta blockers help manage:

A

HR & BP/cardiac demand from excess catecholamines
decrease lipid oxidation (lipolysis) = decreases metabolic rate

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34
Q

Protein (lean body mass) loss in burn pts is affected by:

A

degree of stress
accelerated proteolysis of skeletal muscles
immobility = tissue strictures develop

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35
Q

Initial stabilization of burn pts includes:

A

respiratory/airway 1st
fluid resuscitation
pain control (high dose IV opioids)
local care of burn wounds

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36
Q

What approach is taken for Pain control in the burn patient

A

multimodal – opioids (start long acting asap - methadone), NSAIDs, PCA, ketamine, anti-anxiety drugs

**No IM drugs b/c absorption is uncertain

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37
Q

Why do we start off with low doses of pain medications for burn pts?

A

PK/PD altered in the burn pt & can be unpredictable – may need to deviate from normal doses to avoid toxicity & decreased efficacy

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38
Q

Why does weeping occur with burn injuries?

A

Impaired endothelial barrier
increased capillary permeability
Loss of intravascular oncotic pressure

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39
Q

What mediators cause vasodilation?

A

histamine
prostaglandins
cytokines
nitric oxide

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40
Q

As a rule of thumb, start thinking about doing aggressive IV fluid resuscitation if the pt has ___% or greater TBSA burn.

A

15% or greater

41
Q

Which burn pts need higher volumes of fluid resuscitation?

A

inhalation injuries
electrical burns
pts who have delayed resuscitation

42
Q

When UO adequate, advocate to start titrating fluid formula down and consider small amounts of _____

A

colloids (on day 2)

43
Q

Parkland Formula

A

4ml / kg / %BSA
- 1st 8 hrs = 2 ml/kg/%
- next 16 hrs = 2 ml/kg/%

44
Q

US Army ISR Rule of 10 for adults

A

10 mL/hr x TBSA
>80kg = add 100mL/10kg

45
Q

US Army ISR Rule of 10 for pediatrics

A

3 x TBSA x kg = vol for 1st 24 hrs
1/2 total volume over 8 hrs

46
Q

US Army ISR formula goal target:

A

UO of 1 ml/kg to avoid fluid creep

47
Q

What might you need to add along with the normal LR basal infusion for resuscitation?

A

albumin
pressors

48
Q

LR is titrated every hour according to UO goal of ______

A

30-50 mL/hr

49
Q

For crystalloid resuscitation in the pediatric population, use the adult formula if:

A

child is >40kg

50
Q

Pediatric colloid administration rate?

A

4-7 ml/kg at the rate of 0.5 mL/min (reduce maintenance isotonic crystalloid by an equal volume per hour)

51
Q

At 8-12 hrs post burn, if the hourly IVF rate is >1500ml/hr or if projected 24 hr total fluid volume approaches 250ml/kg then initiate ______.

A

5% albumin infusion

52
Q

What are the 2 phases burn pts go through?

A

hypodynamic state = low CO, hypovolemic, increased SVR, myocardial ischemia

Hyperdynamic state (72-96 hrs post burn) = increased CO & HR, decreased SVR

53
Q

What is a common pulmonary occurence with burn pts?

A

bronchospasm – give bronchodilators

54
Q

Carboxyhemoglobin level >10% symptoms?

A

overt signs of toxicity – HA, N/V…

55
Q

For facial burns, what are 2 ointments that are useful for the eye lids & eyes?

A

bacitracin - apply to eye lids
erythromycin - apply in the eyes

56
Q

fuel & natural gas byproduct

A

carbon monoxide (CO)

57
Q

incomplete combustion of any material containing nitrogen –> such as plastic, vinyl, wool or silk can lead to

A

cyanide (CN) toxicity

58
Q

Treatment for cyanide toxicity

A

cyanocobalamin injection

59
Q

Pharmacological changes in the burn pt:

A

decreased plasma proteins (especially albumin) which increases free drug & Vd

alterations in drug receptors (nAChR)

CO changes (hypo vs hyperdynamic phases)

60
Q

major burns cause up-regulation of what receptors?

A

n-ACh-R
takes months to years (1-2) to recover

61
Q

upregulation of n-ACh-R from burns will have what affects on paralytic agents?

A

ND-NMBA = resistant
depolarizing (Succ) = increased sensitivity

62
Q

If burn is > 24 hrs, avoid which paralytic & why?

A

SUCC – markedly increased serum K+

63
Q

the degree of sensitivity to depolarizing NMBA (succ) does not correlate with _____

A

severity of burn

64
Q

Temperature loss from burns = can lose up to ____ degree C every _____

A

1 degree C for q15min

65
Q

What are 3 signs of impending airway obstruction that requires immediate intubation?

A

Stridor
Hoarseness
Dysphagia

66
Q

Which airway device is NOT used in burn pts?

A

LMAs

67
Q

Medication often used for burn dressing changes and induction?

A

Ketamine (but caution if pt is in hyperdynamic phase)

68
Q

2.6% total blood volume lost for every:

A

1% burn excised or autograft harvested

69
Q

Goal CVP for burn pts

A

6-8 mmHg (if not at goal CVP increase IVF rate by 20-25%)

70
Q

Vasopressors for post fluid resuscitation if pt still hypotensive

A

vasopressin
norepi

71
Q

What is tumescent LA?

A

technique to infiltrate large volumes of LA into subQ tissue

72
Q

Effects of tumescent LA (infiltrate large vol of LA subQ) include:

A

decreased blood loss
easy excision of granulation tissue
shorter surgical times
no hematoma or bruising postop

73
Q

Target PCO2 on mechanical ventilated burn pt

A

30-35 mmHg or pH > 7.20

74
Q

Inhalation injury pts are high risk for blood clots within airway, what can we do to prevent this?

A

Nebulized 5000 units Heparin + albuterol Q4H

75
Q

A burn pt has a 90% mortality rate with ______

A

an open abdomen (in the case of treatment for compartment syndrome

76
Q

If bladder pressure is > 20mmHg, what might be going on?

A

Abdominal compartment syndrome

77
Q

diagnosis of abdominal compartment syndrome?

A

bladder pressure monitoring

78
Q

Why does abdominal compartment syndrome possibly occur in burn pts?

A

intestines become edematous from the fluid resuscitation

79
Q

Keep these pts intubated in the 1st 72 hrs postop

A

inhalation burns

80
Q

what benzo is a useful adjunct in opioid analgesia in the burn pt?

A

lorazepam (long acting benzo)

81
Q

Procedure that free’s up chest pressure so lungs are able to move & ventilate adequately?

A

escharotomy

82
Q

burn pts require GI prophylaxis because:

A

they are high risk for stress ulcers

83
Q

Insert foley immediately on these pts?

A

pts with genitalia/perineum burns

84
Q

swelling may be impressive in these region, but does not require specific treatment (self resolving with time)

A

scrotal swelling

85
Q

Burns are _____ prone wounds

A

tetanus

booster if >5 yrs since last booster
booster + TIG if no prev vaccine

86
Q

What 2 pharmacological agents are NOT indicated as standard of care with burn pts?

A

IV antibiotics
Steroids — may use these for multimodal analgesic adjunct

87
Q

If UO not picking up once fluid goals met, what is the next step for the patient?

A

know that kidneys are taking a hit, don’t flood pt with more fluid, just get them on dialysis asap to avoid more problems.

88
Q

Why should we AVOID remifentanil in burn pts?

A

can cause opiate-induced hyperalgesia

89
Q

What MUST be in the OR before induction?

A

T&C 2-4 units PRBCs to keep ahead

90
Q

If pt is intravascularly volume depleted what 2 induction agents are recommended?

A

Etomidate (0.3 mg/kg)
ketamine (1-3 mg/kg)

91
Q

When does the hypermetabolic/hyperdynamic phase begin?

A

48-72 hrs post burn

92
Q

Preop pain mgmt for burn pts?

A

high dose opioids initially
low dose ketamine gtt (0.1-0.5 mg/kg/hr)

93
Q

In burns without inhalation injury, what can reduce mortality & length of hospital stay?

A

early excision & grafting (days 1-5)
might be staged procedures

94
Q

Pts receiving > 250 ml/kg IVF are at high risk for:

A

Abdominal compartment syndrome

95
Q

When monitoring for abdominal compartment syndrome:

A

perform bladder pressure Q4H
if bladder pressure >20mmHg = consider therapeutic paracentesis

96
Q

What criteria is considered a MINOR BURN?

A

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

97
Q

What criteria is considered a MODERATE BURN?

A

10-20% TBSA burn in adults
5-10% TBSA burn in young or old
2-5% full thickness burn
High voltage burns
suspected inhalation injury
circumferential burn
medical problem predisposing to infection (DM, Sickle cell..)
**admit to hospital

98
Q

What criteria is considered a MAJOR BURN and pt needs to go to burn center?

A

> 20% TBSA adults
10% TBSA 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)

99
Q
A

Principles of Anes II (3 decks)

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