Depth - extent skin & tissue destruction - Superficial, partial thickness, & full thickness - 1st, 2nd, & 3rd degree burns old terminology Total body surface area involved - Rule of 9s

1. Resuscitative 2. Debridement & grafting 3. Reconstructive

Burns Flashcards by Allison Sass

Burn Injury Types

Thermal - flash, flame, & scald
Chemical
Electrical (current) entry & exit wound
Radiological - radiation

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Thermal Burn Types

Flash (ex: explosion w/ high heat intensity/exposure)
Flame (ex: house fire or trapped in burning vehicle)
Scald - common in pediatric patients or diabetics (neuropathy)

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Burn Injury Severity

Depth - extent skin & tissue destruction

Superficial, partial thickness, & full thickness
1st, 2nd, & 3rd degree burns old terminology

Total body surface area involved
- Rule of 9s

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Superficial Burn

1st Degree

Depth: Epidermis destruction
Pain level: High
Appearance: Red, dry pink
Characteristics: Dry, flakey/peels; dehydrated & thirsty, heals spontaneously w/in 3-5 days
Example: Sunburn, scald, flash flame
No scarring, maybe discoloration

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Partial Thickness Burn

2nd Degree

Depth: Superficial or deep (epidermis up to deep dermal element)
Pain level: Extreme
Appearance: Bright cherry red, pink or pale ivory, usually w/ fluid-filled blistering, moist/oozing
Characteristics: Hair follicle intact, potentially requires skin graft
Example: Scald, flash burns, chemicals

Superficial burns heal w/in 5-21 days
Deep burns 21-35 days
Minimal to no scarring w/ potential discoloration

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Full Thickness Burn

3rd Degree

Depth: All epidermis, dermis down into subcutaneous tissues
Pain level: Little or no pain
Appearance: Khaki brown, charred appearance, leathery dry w/ no elasticity
Characteristics: Loss hair follicles, possibly singed hair present; requires skin graft
Example: Contact w/ flame, hot surface or liquids, chemical, electric

Small areas take mos to heal
Large areas require grafting
Scarring present

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4th Degree Burn

Full thickness extending into muscle and bone

Requires skin grafts & possible amputation

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Rule of 9s

Estimates TBSA
Head 9%
Upper extremity 9%
Anterior trunk 18%
Posterior trunk 18%
Lower extremity 18%
Perineal 1%

Pediatrics*

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What patients should be transferred to a designated burn center?

Full thickness burns (any age group)
Partial thickness > 10% TBSA
Age extremes (pediatric or elderly)
Special areas including face, hands, feet, perineum, or major joints
Burn types - inhalational, chemical, or electrical
Patients w/ co-existing disease

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What improves outcomes in burn patients?

Early interventions

Skin grafts when necessary

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What TBSA does the National Burn Registry associate w/ increased mortality?

Patient age + TBSA % = >115

Mortality > 80%

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Burn Phases

Resuscitative
Debridement & grafting
Reconstructive

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Resuscitative Phase

Admission & initial treatment
1° survey
ABCs +DE
Co-morbidities

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Closed Space Thermal Injury

Closed space thermal injury = AIRWAY injury

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Electrical Burn Complications

Electricity follows the path of least resistance (bone = most resistant)

Severe fracture(s)
Hematoma
Seizures
Visceral injury
Skeletal (contractures)
Cardiac injury (arrhythmias)
Neurological injury
Respiratory arrest
Muscle damage → myoglobinurea → renal failure

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Airway Complication S/S

Singed facial hair
Facial burns
Dysphonia/hoarseness
Cough or carbonaceous sputum 
Soot present in mouth or nose
Swallowing impairment
Oropharynx inflammation
CXR initially normal - pulmonary edema or infiltration develops days later

Patients at risk to experience upper airway injury include closed space injuries & unconscious

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Inhalational Injury

Damage to the respiratory tract or lung tissue from heat, smoke, or chemical irritants carried into the airway during inspiration

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Upper Airway

Inhalational Injury

Thermal damage to respiratory tract soft tissue & trachea - potentially difficult endotracheal intubation
Thermal injury + fluid resuscitation
↑glottic edema risk

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Lower Airway

Inhalational Injury

Pulmonary edema or ARDS develops 1-5 days post-burn

Pneumonia or pulmonary embolism > 5 days post-burn

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Smoke Inhalation

Occurs w/ face & neck burns or in closed space fires
Chemical pneumonitis similar to gastric aspiration occurs after smoke/toxic fume inhalation
Honeymoon period 1st 48hrs clear CXR (2-5 days to develop symptoms)
1st sign ↓PaO2 on RA
↑sputum w/ rales/wheeze

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Hypoxia Impact in Patients w/ Inhalational Injury

1st 36hrs ↑pulmonary edema risk
2-5 days after = expect atelectasis, bronchopneumonia, airway edema at maximum 2° to airway mucosa sloughing off, thick secretions, distal airway obstruction
> 5 days post-burn = nosocomial pneumonia, respiratory failure, ARDS
Consider chest/upper abdomen circumferential burns = restricted chest wall movement as eschar contracts & hardens (escharotomy)

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Inhalational injury or facial burns →

INTUBATE
Secure the airway early

Consider fluid resuscitation impact & potential edema

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Airway Management

Patent airway
100% FiO2
Serial laryngoscope/bronchoscope exams, CXR, ABGs, & PFTs in suspected inhalational injury

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When to intubate?

Massive burn, stridor, respiratory distress, hypoxia or hypercarbia, altered LOC
Deterioration expected

*Pediatric patient airways = smaller diameter
Lower threshold to intubate

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Hypoxia Treatment

``` PEEP Airway humidification Bronchial suctioning/lavage Bronchodilators Antibiotics Chest physiotherapy ```

Carbon Monoxide Toxicity

Carbon monoxide (CO) + smoke inhalation Acts as myocardial toxin & prevents cardiac arrest survival Normal SaO2 Breathing WNL Cherry-red blood (when CO > 40% and patient not cyanotic or hypoxic)

Carbon monoxide ___x Hgb affinity

200x

Carbon monoxide shifts the Hgb dissociation curve ______

LEFT (loves) | Impairs O2 unloading

What does carbon monoxide interferes w/ _____?

Mitochondrial function Uncouples oxidative phosphorylation Reduces ATP production → metabolic acidosis

Carbon Monoxide Toxicity | Treatment

100% FiO2 on ALL burn patients until CO toxicity ruled out COHgb > 30% → hyperbaric chamber - Patient hemodynamically & neurologically stable

Carbon Monoxide Toxicity % | S/S

< 15-20% headache, dizziness, confusion 20-40% nausea/vomiting, disorientation, visual impairment 40-60% agitation, combative, hallucinations, coma, & shock > 60% incompatible w/ life

Carbon Monoxide < 15-20%

Headache, dizziness, confusion

Carbon Monoxide 20-40%

Nausea/vomiting, disorientation, visual impairment

Carbon Monoxide 40-60%

Agitation, combative, hallucinations, coma, & shock

Carbon Monoxide > 60%

DEATH

Cyanide Toxicity

Cyanide produced when synthetic materials burn - foam, plastics, paint, wool, silk Victims inhale & absorb via mucous membranes Metabolic acidosis ↑lactate levels

Cyanide Toxicity S/S

Altered LOC w/ agitation, confusion or coma | CV depression/arrhythmia risk

What blood cyanide levels confirm toxicity diagnosis?

> 0.2 mg/L

Lethal Cyanide Levels

1 mg/L

Cyanide Half-Life

60 minutes (1 hour)

Cyanide Toxicity Treatment

OXYGEN Hydroxycobalamine Amyl nitrate Sodium nitrate Thiosulfate

Cyanide Toxicity | Systemic Effects

Inflammatory mediators released locally at the burned tissue & systemically contributes to edema associated w/ burn injury ↑microvascular permeability → fluid leak & protein loss ↑intravascular hydrostatic AND ↓interstitial hydrostatic pressure ↑interstitial osmotic pressure → BURN SHOCK

Surgery & infections perpetuate _____-______ response → multi-organ failure

Mediator-induced systemic inflammatory response

Cardiovascular

1st 24hrs ↓CO → BURN SHOCK Circulating tumor necrosis factor → myocardial depression Diminished response to catecholamines ↑microvascular permeability → hypovolemia Compensation = vasoconstriction ↓tissue O2 supply & coronary artery blood flow Erythrocyte hemolysis

Cardiovascular | AFTER 24-48 HOURS

HYPERDYNAMIC STATE ↑HR/BP/CO Cardiac output 2x normal → HIGH output heard failure

Overall Systemic Results

``` Immune suppression HPA & RAAS activation Hypermetabolism Protein catabolism Sepsis Multi-organ system failure ```

Metabolism

↑metabolic rate directly proportional to TBSA burned ↑core body temperature reflects ↑metabolic thermostat ↑caloric consumption

Skin loss → _____, _____, & _____

Loss vasoactivity, piloerection, & insulation functions

Daily evaporative fluid loss = mL

4,000mL/m^2

End Organ Complications

GI - ileus, ulceration, cholecystitis Renal - ↓GFR/RBF, loss Ca2+/K+/Mg2+, retention Na+/H2O Endocrine - ↑corticotropin, ADH, renin, angiotensin, aldosterone, ↑glucagon, insulin resistance, hyperglycemia Heme - ↑viscosity ↑clotting factors ↓Hct ↓RBC half-life

Fluid Resuscitation

Fluid loss from vascular compartment 1st 24hrs | 1st 24hrs crystalloid ONLY

Titrate fluids based on _____

UOP | 0.5-1mL/kg/hr

Adverse effects r/t over aggressive fluid resuscitation:

Worsen airway edema ↑chest wall restriction Contributes to abdominal compartment syndrome

When to replace w/ colloids?

After 24hrs Colloids 0.3-0.5 mL/kg/TBSA % burn Albumin 5%

Parkland Formula

4 mL/kg/TBSA % burn | 1st 24hrs

Modified Brooke Formula

2 mL/kg/TBSA % burn | 1st 24hrs

How quickly to replace fluids 1st 24 hours?

50% 1st 8 hours 25% 2nd 8 hours 25% 3rd 8 hours

Fluid Resuscitation GOALS

``` UOP 0.5-1 mL/kg/hr HR 80-140bpm MAP > 60mmHg (adults) Base deficit < 2 mmol/L Normal Hct ```

Inadequate UOP despite > 6mL/kg/TBSA % burn

Consider low dose Dopamine 5mcg/kg/min | Another vasopressor?

Repeat Surgery Considerations

Maintain Hct (multiple transfusions) Coagulopathy Temperature Fluid & electrolytes Hypermetabolic state ↑O2, ventilation, nutrition ↑GI ileus risk → aspiration/hyperalimentation

Challenges associated w/ burn patients in the perioperative setting:

Limited access to place monitors Multiple large bore PIVs Warm OR 28-32°C to compensate for evaporative/exposure heat loss Minimize blood loss w/ topical or SQ Epi, only 15-20% TBSA per procedure, tourniquet Massive transfusion complications - coagulopathy & hypocalcemia

OR Equipment

A-line Bair hugger & fluid warmer Rapid infuser Inotropes & IV pumps

Muscle Relaxants

1st 24hrs unaltered response (okay to admin Succinylcholine) 24hrs to 1 year post-burn avoid Succinylcholine (massive K+ release d/t nAChR upregulation) Resistance to most NDMR when > 30% TBSA burned

Burns Flashcards

(63 cards)