Exam 2 Burns Flashcards
(95 cards)
1
Q
What are the functions of the skin (5)
A
barrier (body fluids & infection)
temperature
elasticity
appearance
sensory organ
2
Q
What are the types of burn injury? (4)
A
thermal (flash, flame, scald)
chemical
electrical
radiological
3
Q
How do you grade the severity of the burn?
A
regardless of the etiology, burns are classified according to
depth- extent of skin and tissue destruction (superficial, partial thickness, full thickness)
total body surface area involved (rule of nines)
4
Q
Describe the depth, pain level appearance, characteristics of a superficial or 1st degree burn?
A
depth- destruction of epidermis
pain level- very painful
appearance- red
characteristics- dry, flaky, will heal spontaneously in 3-5 days
5
Q
Describe the depth, pain level appearance, characteristics of a partial thickness burn 2nd degree?
A
depth (superficial or deep)- epidermis up to deep dermal element
painful- very painful
appearance- bright cherry red, pink or pale ivory, ususally with fluid filled blistering
Characteristics: hair follicle intact- may require skin graft
6
Q
Describe the depth, pain level appearance, characteristics of a full thickness/3rd degree burn?
A
depth- all of the epidermis, down into the subcutaneous tissue
pain level- little or no pain
appearance- khaki brown, white or charred/cherry red is pediatrics
characteristics: loss of hair follicles; will require skin graft
7
Q
Describe the depth of the fourth degree burn
A
fill thickness extending into muscle adn bone
will require skin graft and possible amputation
8
Q
How deep is a first degree burn?
A
epithelium
9
Q
How deep is a second degree burn?
A
epithelium and top aspects of the dermis
10
Q
How deep is a third degree burn?
A
epithelium and dermis
11
Q
How does as a first degree burn look?
A
no blisters, dry pink
12
Q
How does a second degree burn look?
A
moist, oozing blisters, moist white pink to red
13
Q
How does a third degree burn look?
A
leathery, dry no elasticity, charred appearance
14
Q
What are the causes of the first degree burn?
A
sunburn, scald, flash fame
15
Q
What are the causes of the second degree burn?
A
scalds, flash burns, chemicals
16
Q
What are the causes of the third degree burn?
A
contact with flame, hot surface, hot liquids, chemical, electric
17
Q
What is the level of pain/sensation for a first degree burn?
A
painful, tender, and sore
18
Q
What is the level of pain/sensation for a second degree burn?
A
very painful
19
Q
What is the level of pain/sensation for a third degree burn?
A
very little pain, or no pain
20
Q
What is the healing time for a first degree burn?
A
two to five days; peeling
21
Q
What is the healing time for second degree burn?
A
superficial: 5-21 days
deep: 21-35 days
22
Q
What is the healing time for third degree burn?
A
small areas may take months to heal; large areas need grafting
23
Q
What is the scarring for first degree burns?
A
no scarring; may have discoloration
24
Q
What is the scarring for a second degree burn?
A
minimal to no scarring; may have discoloration
25
What is the scarring for a third degree burn?
scarring present
26
What is the % of TBSA for the head?
9%
27
What is the % of TBSA of the upper extremities/ each?
18% TBSA
9% each arm
28
What is the % of the TBSA for the trunk per rule of nines?
trunk 36%
front/ back 18% each
29
What is the % TBSA for the lower extremities per rule of nines?
36%
each leg 18%
30
What is the exception to the rule of nines?
pediatric exceptions
31
What is the % TBSA of head for pediatric?
18%
32
What is teh % TBSA of the trunk for pediatrics?
16% each side
32%
33
What are the peripheries % of TBSA for a pediatrics?
arms 10% each
legs 14% each
34
When should burns be transferred to burn center?
full thickness burns of any age group
partial thickness burns > 10% TBSA
burns of special areas (at extremes of age, burns of face, hands, feet, perineum, or major joints, inhalation, chemical or electrical burns) and burns associated with co-existing disease
35
What should the initial treatment of the burn patient involve?
airway
breathing
circulation
co-existing trauma
36
Describe the considerations regarding the source of injury
closed space thermal injury equates to airway injury
open space or accidental injury (campfire) motor vehicle crash= multiple co-exisiting injuries
37
What can electrical injury lead to occult?
severe fracture
hematoma
visceral injury
skeletal
cardiac injury
neurological injury
38
What are signs and symptoms of airway complications? (8)
singed facial hair
facial burns
dysphonia/hoarseness
cough/carbonaceous sputum
soot in mouth/nose
swallowing impairment
oropharynx inflammation
CXR initially normal -> until pulmonary edema or infilatration develops
39
What patients are suspicious for upper airway injury?
close space injury
unconciousness
40
How can you diganose upper airway injury?
history, physical exam (DVL or fiberoptic bronchoscope)
41
Define inhalation injury
refers to damage to the respiratory tract or lung tissue from heat, smoke, chemical irritants carried into the airway during inspiration
42
Define inhalation injury of the upper airway
thermal damage to the soft tissues of the respiratory tract and trachea can make intubation difficult
thermal injury plus fluid resuscitation
increases the risk of glottic edema
43
Define inhalation injury of lower airway involvement
pulmonary edema/ARDS develops 1-5 days post burn
pneumonia and pulmonary embolism > 5 days post burn
44
What are signs of smoke inhalation?
decreased PaO2 on RA (1st sign)
increased sputum with rales/wheeze
45
When can smoke inhalation occur?
occurs in conjunction with face/neck bruns and close space fires
chemical pneumonitis similar to gastric aspiration occurs after smoke/toxic fume inhalation
honeymoon period 1st 48 hours wiht clear CXR
46
In the first 36 hours of the burn patient with inhalation injury, what is the high risk?
pulmonary edema
47
What is expected in the first 2-5 days of the burn patient with inhalation injury?
expect ateletactasis, bronchopneumonia, airway edema maximum secondary to sloughing of airway muscosa, thick secretions, distal airway obstruction
48
What is expected >5 days post burn?
nosocomial pneumonia, respiratory failure, ARDS
49
What can occur with cirumferential burns of chest/upper abdomen
restricted chest wall motion as eschar contracts and hardens
50
What is most important with inhalation injury or facial burns?
secure airway early!
51
Describe airway management in the burn patient?
patent airway= maximum fio2 via facemask
serial laryngoscopic/broncho exams, CXR, ABGs, and PFTs in suspected inhalational airway injury
ETT indicated if- massive burn, stridor, respiratory distress, hypoxia/hypercarbia, altered level of consciousness
prophylatic intubation if deteriotation likely
intubation technique depends on patient factors,extent of airway damage, age, co-existing disease
adults fiberoptic intubation under adequate topical anesthesia is safest approach
52
How has a low threshold for intubation for burn patients?
pediatrics because they have small diameter airways
53
What is the treatment of hypoxia in burn patients with inhalation injury?
PEEP
airway humidification
bronchial suctioning/ lavage
bronchodilators
antibiotics
chest physiotherapy
54
What should nessitate a escharotomy?
restriction of respiratory excursion
55
What is carbon monoxide toxicity?
CO poisoning and smoke inhalation usally are found together
56
How many times more is CO affilated to Hgb then O2?
200
57
What does CO do on the hemoglobin dissociation curve?
shift hemoglobin disassociation curve left impairing o2 unloading to the tissue
58
What does CO interfere with?
mitchondrial function
uncouples oxidative phosphorlyation
reduces ATP production
resulting in medabolic acidosis
59
How does CO2 prevent survival in cardiac arrest?
CO may act as myocardial toxin
60
What are symptoms are carbon monotoxicity?
sao2 may be normal
respiratory effort may appear normal
cherry-red blood color may not be present if Co of <40% and/or the patient is cyanotic and hypoxic
61
How do you treat carbon monoxide toxicity?
high Fio2 on all burn patients until CO toxicity ruled out
hyperbaric chamber if COHg is >30% and patient is hemodynamically and neurologically sstabilized
COhgb >60% is incompatible with life
62
What are they symptoms of carbon monoxide toxicity at 15-20%
headache, dizziness, confusion
63
What are they symptoms of carbon monoxide toxicity at 20-40%
nausea, vomiting, disorientation and visual impairement
64
What are they symptoms of carbon monoxide toxicity at 40-60%
agitation, combative, hallucination, coma and shock
65
What are they symptoms of carbon monoxide toxicity at >60%
death
66
What is produces as synthetic materials burn?
cyanide
victims inhale and absorb it through mucous membranes
67
What are symptoms of cyanide toxicity
metabolic acidosis results with elevated lactate levels
altered LOC with agitation, confusion or coma
CV depresssion/ arrhythmia risk
blood cyanide levels of >0.2mg/L confirm diagnosis and 1.0ml/L lethal
68
What is the treatment of cyanide toxicity?
O2 treatment of choice
hydroxycobalamine, amyl nitrate, sodium nitrate, thiosulfate
69
What is the half life of cyanide
1/2 life of 60 minutes
70
What are the systemic effect of the burn injury?
release of inflammatory mediators locally at the burned tissue and systemically contribute to edema associated with burn injury
increase in microvascular permeability-> fluid leak loss of proteins
increased intravascular hydrostatic pressure/ decreased interstitial hydrostatic pressure
interstitial osmotic pressure increases
surgery and infections can perpetuate this mediator induced SIRS that may lead to MOF
71
Describe the cardiovascular stresses with burn injury
severe decrease in cardiac output lasts 1st 24 hours
circulating TNF causes myocardial depression
diminished response to catecholamines
increased microvascular permeability-> hypovolemia
intense vasoconstriction compensation
decreased tissue O2 supply and coronary blood flow
hemolysis of erythrocytes
after 24-48 hours: hyperdynamic state (high output CHF) increase BP, HR, CO 2x normal
72
What are the overall systemic results
immune suppression
activation of the hypothalamo-adrenal axis and the renin-angtiotensin/aldosterone system
hypermetabolism
protein catabolism
sepsis
multisystem organ failure
73
Describe the metabolism of the burn patient
increased metabolic rate is porportional to TBSA burned (can doubled up in 50% TBSA)
increased core body temp reflects increasd metabolic thermostat
loss of skin=loss of vasoactivity, pilorection, insulation functions
daily evaporative fluid loss is 4000ml/m2
caloric consumption is increased
74
What are complications of the GI system
ileus, ulceration, cholecystitis
75
What are complications of the renal system
decreased GFR, RBF, loss of Ca, K , mg with retention of Na and H20
76
What are complications of the endocrine system?
increased corticotropin, ADH, renin, angiotensin, aldosterone, increased glucagon, insulin resistance, hyperglycemia (at risk for nonketotic hyperosmolar coma esp. TPN)
77
What are complications of blood and cogaulation system
increased viscosity, increased in clotting factors including fibrinogen, V and VIII fibrin spilt products at risk for DIC development, HCT usually decreases (RBCs decreased 1/2 life)
78
What is the initial fluid resuscitation of burns?
loss of fluid from vascular compartment
2-4 ml/kg for each 1% TBSA burned
crystalloid only
79
What is the goal of fluid management?
UOP 0.5-1ml/kg/hr
80
What can aggressive fluids cause?
worsen airway edema, increase chest wall restriction, and contribute to abdominal compartment syndrome
81
What should fluid resuscitation be after 24 hours?
colloid at 0.3-0.5mg/kg/% burn with 5% dextrose in water
82
What is the parkland formula?
4ml LR/kg/% burn first 24 hours
83
What is the modified brooke formula?
2ml LR/kg/% burned in 1st 24 hours
84
How are the calculated volumes administered?
50% in the first 8 hours
25% in the second 8 hours
25% in the 3rd 8 hours
85
What dose of albumin is administered after the first 24 hours?
albumin 5%
0.3-0.5ml/kg dose on extent of burn
86
What are the goals of fluid resuscitation?
urine output 0.5-1ml/kg/hr
Hr 80-140(consider age)
MAP (adults) >60mmhg
base deficit =<2
normal Hct
87
What if fluids aren't enough?
if perfusion or urine output is inadequate despite >6ml/kg/%TBSA burned
nromal or high CVP
consider low dose dopamine 5mcg/kg/min
consider other vasopressor
88
What are anesthesia considerations for the burn patient
repeated surgeries
maintain hct
coagulopathy
temperature
fluids and electrolytes
hypermetabolic state- increase O2, ventilation, nutrition
increase risk of GI ileus (aspiration and hyperalimentation)
89
What are the challenges of anesthesia in the burn patient?
monitors- burned tissue, limited access for EKG, SaO2, PNS, NIBP
need for large bore IV access
compensate for evaporative/exposure heat loss
minimize blood loss (topical/sq epinepherine, 15-20% TBSA q procedure, tourniquets)
treat the complications of massive tranfusion (coagulopathy and hypocalemia)
90
What should be pre-op evaluated?
airway
phase of resuscitation
monitoring
intravascular access
equipment
91
What are anesthesia considerations for the high voltage electrical injury
follows path of least resistance; bone most resistance
cardiac arrhythmias
respiratory arrest
seizures
fractures
muscle damage-> myoglobinurea-> renal failure
92
What is circulation like in the burn patient?
shock/hyperdynamic circulation
93
What is the ideal anesthetic for burn patient?
high opioid requirement
isoflurane and large doses of opioid
94
What can be administered for serial debridements?
ketamine in incremental doses
regional anesthesia
95
Discuss muscle relaxants with burns
1st 24 hours- unaltered response to depolarizing and non-depolarizing muscle relaxants
24 hours to 1 year post burn
succinylcholine massive release of K, may be due to the proliferation of acetylcholine receptors along the entire muscle membrane
resistance to most NDMR if >30% burned
