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Burns Flashcards

1
Q

Heat Burns depth is related to_____(3)

A

Contact temperature
Duration of contact
Thickness of skin

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2
Q

Heat burns usually involves what skin layers?

A

Usually involve epidermis and dermis

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3
Q

How are friction burns created?

A

Combo of mechanical disruption and heat generated by friction

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4
Q

How are electrical burns created? And what does it cause?

A

Electrical energy transformed to heat when current passes through body tissue

Disrupts membrane potential

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5
Q

Things that affect the severity of the electrical burns? (3)

A

Pathway of current
Resistance to current flow
Strength and duration of current flow

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6
Q

Electrical burns are more likely to cause______ issues than thermal burns

A

Cardiac

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7
Q

What can chemical burns cause?

A

alterations of the pH and cause the salt membranes to lose integrity and because of that destruction = metabolic processes are impeded.

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8
Q

What is the severity of the chemical burn related to?

A

Duration of exposure
Nature of agent

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9
Q

Acidic agents can cause what?

A

necrosis by coagulation

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10
Q

Basic agents can cause what?

A

necrosis by liquefacation

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11
Q

How is the severity of radiation burns influenced? (3)

A

dose and time of exposure
types of particles

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12
Q

Sunburns are what type of burn

A

radiation burns

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13
Q

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

A

24-48 hrs

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14
Q

What patient population are burns detrimental to?

A

Areas of thin skin and adults > 55 or kids < 5

Have deeper burns with less exposure/ intensity because of the thin skin

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15
Q

How are superficial burns manifested and what skin layers are involved?

A

Involving only the epidermis
Skin intact, red in color
Dry surface, no blisters
Painful, hypersensitive

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16
Q

How long does it take 1st degree burns to heal?

A

Heals in approximately
3–6 days

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17
Q

What burn is not counted in TBSA?

A

1st degree (superficial burns)

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18
Q

How are superficial partial Thickness burns manifested and what skin layers are involved?

A

Involves the epidermis and part of dermis
Mottled red color
Blisters or weeping
Very painful / nerve endings exposed

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19
Q

How long does it take of superficial partial thickness burns to heal?

A

Usually heals in 10 – 14 days
Minimal scarring

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20
Q

Deep partial thickness burns manifestation and skin layers involved?

A

Extends more deeply into the dermis
Decreased moisture
Pale in color
Absent or prolong blanching

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21
Q

How long does it take for Deep partial-thickness burns to heal? and what is usually required?

A

Healing in 21-28 days
Requires skin grafting

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22
Q

Why is there less moisture with deep partial thickness burns than superficial partial thickness burns?

A

Less pain is usually present in the deeper burn. Since the sweat glands have been destroyed, there is decreased moisture. This can also have consequences of temperature control when a graft is placed (i.e. the skin becomes hot but cannot sweat)

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23
Q

How are full thickness burns manifested and what skin layers are involved?

A

Full thickness (dermis is destroyed)
Translucent, dry, painless, charred
Non-blanching

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24
Q

What burns are included in burn surface calculations?

A

All 2nd and 3rd degree burns

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25
escharotomy
done through escar/ burned tissue cutting down through the escar
26
Fasciotomy
dont through tissue that has an injury but not a surface injury, cutting down through the fascia
27
Rule of 9s burn injuries adults
Adult; Head 9% Each arm 9% Each leg 18% Ant/Post trunk each 18% Perineum 1%
28
Rule of 9s burn injuries peds
head and heck 21% arms; 10% back: 13% abdomen; 13% each leg; 13.5% buttocks; 5% genitals; 1%
29
Palmer method
PATIENTS palm Fingers together = 1%
30
What are the two conflicting properties that burns can cause
Hypovolemic shock and decreased perfusion Loss of plasma from microvasculature into interstitium -> increased permeability
31
Patients with ________ TBSA develop burn shock and need IV resuscitation in an ICU
> 20%
32
Fluid losses are a function of _____ and _____
Fluid losses are a function of burn size and patient weight
33
Concerns for under resuscitating burns
↓ perfusion, burn shock, end organ failure
34
Concerns for over resuscitation burns
Abdominal compartment syndrome, pulmonary edema/ARDS
35
General metabolic response to trauma (burns)
Auto-cannibalism; Loss of fat Loss of lean body mass Proteolysis Gluconeogenesis Lipolysis Hypermetabolism;because of volume loss/ because of the pain Insulin resistance
36
BSA ______ causes metabolic rate to double and can lead to________ (3)
40% Cannibalism for months; Immunodepression, recurrent infections, poor wound healing
37
How does Carbohydrate metabolism changes with burns?
Increases in cortisol, catecholamines, and glucagon resulting in; Accelerated hepatic gluconeogenesis Peripheral insulin resistance (50-70%increase ) Impaired intracellular glucose transport
38
How long can the increased gluconeogenesis and the insulin resistance last in burn pts?
last up to 3 years
39
What changes do burns cuase to lipid metabolism?
Accelerated lipolysis d/t B2 and B3 adrenergic stimulation…⬆️ cAMP d/t elevated glucagon, TNF, IL … elevated levels of FFA…produce ATP
40
Treatment for accelerated lipolysis from Burns? and how does it work?
Treatment with beta-blockade Decreases lipid oxidation and decrease metabolic rate
41
How is protein metabolism changed with burns?
Accelerated proteolysis of skeletal muscle Provides substrate for hepatic gluconeogenesis burns and bed ridden -> tissue strictures/ contractures
42
Degree of loss skletal muscle loss is proportional to degree of______
stress
43
Initial Stabilization of burn pts (5)
Respiratory support- airway Fluid resuscitation Cardiovascular stabilization Pain control Local care of burn wounds
44
Secondary stabilization in burn pts (6)
Pain control Thromboprophylaxis Wound closure Nutritional support Control of hypermetabolism Prevention of infection consider associated injuries
45
Pain control meds for burn pts
Long-acting opioids (methadone) NSAIDs (acetaminophen) PCA infusions (morphine) IV Ketamine Supplemented with anti-anxiety drugs
46
What can be altered in burns to cause changes to the dose of medications?
PK/PD can be altered in burns May need to deviate from normal doses to avoid toxicity or decreased efficacy, and relative shrinkage of the vascular system also consider lack of plasma proteins = more free drug. change of volume of distribution changes in receptor
47
Burns cause what changes cellularly resulting in large fluid loss? (3)
Impaired endothelial barrier Increased capillary permeability Loss of intravascular oncotic pressure Therefore….copious loss of intravascular fluid
48
Release of systemic inflammatory reactions of histamine, prostaglandin and cytokines from burns Cause:
vasodilation of vessels
49
Aggressive IVF resuscitation at what BSA?
Generally for 15% BSA or >
50
Parkland Formula
4ml/kg x %BSA; 2ml/kg/%BSA in 1st 8 hours (LRS) 2ml/kg/%BSA in next 16 hours (LRS)
51
titrate IVF formula down when ______ and consider small amount of________ on day ____
Advocate titrating formula down when U/O adequate Consider small amount of colloids on day 2
52
US Army ISR Rule of 10 for adult
Adult; 10mL/hr x TBSA >80kg, add 100 mL/10kg
53
US Army ISR Rule of 10 for peds
Pediatric; 3 x TBSA x kg = vol for first 24 hrs ½ total volume over 8 hrs
54
Anesthesia Management: Preop Assessment
Determine estimated BSA% burn Determine severity of burn Assess need for transfer to a certified burn center
55
Burns to take to burn center
Full thickness > 10% BSA High voltage electrical burns Chemical burns Associated inhalation injury Face, hands, feet, perineum, major joints
56
Goal for UOP and titration if outside that goal
Goal targeted to U/O of 1cc/kg Titrated every hour according to UOP goal 30-50 ml/hr, 20- 25% up or down if outside the parameters
57
What is the risk of ns for burn pts
Risk of hypernatremic hyperchloremic acidosis (non-gap acidosis)
58
Max mls to give
1500 mL/hr or 250 mL/kg in 24 hours No fluid boluses as volume increases edema
59
fluid resuscitation for peds with crystalloids
>40 kg - Use adult formula < 14 yrs old and <40 kg: 2-4 ml (LR)/kg x %TBSA (2nd and 3rd degree) Children <20 kg add maintenance rate of D5LR at 421 rule
60
Goal for peds UOP
Titrate IVF to maintain urine output 0.5-1mL/kg/hr
61
At _________hours post-burn, if the hourly IV fluid rate exceeds________ mL/hr or if the projected 24 hr total fluid volume approaches _________ mL/kg, initiate 5%_______
At 8-12 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, initiate 5% albumin
62
Colloids for peds burn pts and what titrations should be made with the isotonic cystalloid?
Children - infuse 4-7 mL/kg at the rate of 0.5 mL per minute. Reduce maintenance isotonic crystalloid by an equal volume per hour
63
resuscitative cardiac state
low co from hypovolemia decreased coronary flow (MI) decreased response to catecholamines increase SVR
64
At cardiac status 72-96 post-burn and what to give
Hyperdynamic/ increased O2 consumption and decreased SVR administer Beta-blockers
65
Pulmonary status post burn and treatment
inflammation -> pulm htn -> impaired gas exchange -> broncho spasms (give bronchodilators)
66
Restrictive lung defect post burn
Impaired ventilation from circumferential burns/scar Hypoventilation d/t decreased elasticity …escharotomies potentially necessary
67
normal carboxy hb and symptoms with changes
1-3% smokers; 4-9% 20% = symptoms (HA, N/V) long term injury = 20-25% >25% = unconsiousness and death
68
What is the goal for getting the burn pts nutrition and how will we get it to them>
Within 16 hours of admission; Thought to reduce magnitude of stress response Nasoenteric feeds into the jejunum Ensures high calorie, high protein
69
Treatment for CN toxicity
cyanocobalamin
70
When do we avoid succ in burn pts?
avoid after first 24 hrs of burns. Peaks at 48-72 hrs.
71
upregulation of NACR can last for how long?
Months to years (1-2) to recover
72
What happens as a result of the depolarizing agents on the upregulated nachrs?
Markedly increased serum K+ Begins approx. 24 hrs post burn Significant after 48-72 hours Does not correlate with severity of burn
73
Burn pts cause lose up to ______ degree _____ q ______min
Can lose up to 1 degree C q 15 min
74
airway burn s/s
Hoarseness, wheezing, SOB, Stridor, dysphagia Carbonaceous sputum Singed nasal & facial hairs Deep facial burns Comatose patient >40% TBSA
75
induction meds and concerns for burn pts
Prop and opioids; consider the cardiac state Etomidate; adrenal insufficiency concern Ketamine; SNS reserve
76
Resistance to non depolarizer occurs at what BSA?
25% BSA and >
77
Paramaters to give blood to burn pts
2.6% total blood volume lost for every 1% burn excised or autograft harvest PRBCs to 7-8 g/dL hemoglobin (10g/dL acute coronary syndrome)
78
things to give to reduce the risk of hemorrhage (3)
Use of topical thrombin, staged procedures, subq vasoconstrictors
79
Shock treatment and goal CVP and whta to do if not in goal
Shock MAP <55 mmHg ; Vasopressin and Norepinephrine CVP; Goal 6-8 mm Hg If not at goal, increase IVF rate by 20-25%
80
Technique to infiltrate large volumes of LA subq
Tumescent LA
81
Tumescent LA dose
Lidocaine 1G + epi + 10meq NaHCO3/1000cc NaCL 55mg/kg max?
82
Effects of tumescent
Decreased blood loss Easy excision of granulation tissue Shorter surgical times No hematoma or bruising postop
83
target abgs for burn pts
Target pCO2 30-35 mm Hg or pH >7.20
84
Meds to give for break up blood clots/ mobilize secretions
Nebulized 5000 units Heparin with Albuterol Q4H
85
Abdominal Compartment Syndrome
Abdominal pressure displaces diaphragm up by bowel (high airway pressures) ACS are best diagnosed by bladder pressures A burn patient has a 90% mortality with an open abdomen
86
S/s for abd compartment syndrome
Measure Q4H with >20% TBSA Bladder pressures >12 mm Hg indicate early intra-abdominal hypertension >20 mm Hg is c/w abdominal compartment syndrome
87
Post op burn pts
Postop mechanical ventilation Inhalation burns At risk for ongoing bleeding Additional surgery plans Need to minimize movement/graft disruption DVT prophylaxis, Beta blocker admin, Nutritional support, Temp control
88
Where is silvadene cream not applied?
face
89
What are Txa and Factor 7 at risk of
thrombosis
90
What eye ointment is applied and where
bacitracin = outside erythromycin = inside
91
421 rule
4 ml/kg/hr for first 10 kg 2 ml/kg/hr for next 10Kg 1 ml/kg/hr for each kg >20 kg

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