Most fire victims die from ______.

What is the most common type of burn?

smoke inhalation 

flame/fire/thermal

What type of burns have the highest mortality?

Why?

lightening burns have highest mortality

often with immediate asystole and resp. arrest

household in origin r/t mishaps with appliances

superficial skin burns 

When are high voltage (>1000V) seen? Burn?

What are serious life threatening issues that can be seen with these types of burns? (3)

What about fluid requirements?

mostly industrial, around power lines or machinery - deep burns

immediate cardiac arrest (VF)

respiratory arrest

rhabdo ass. w/ deep tissue & mm damage

fluid requirements are nearly double that of thermal burns

When are chemical burns usually seen?

How long does tissue damage continue?

usually industrial

exposure to acid/alkali/organic compounds

continued tissue damage until insulting substance is removed

Describe a First Degree Burn.

Give an example...do you count this in calculations for body surface area burned?

limited to epidermis

red and painful

no open wound is produced

heals spontaneously

minor scald or sunburn

NOT CONSIDERED WHEN BURN SIZE IS CALCULATED

Describe a Second Degree Burn.

What part of the skin does it affect?

Is it painful?

What is a common change noted in the skin?

May heal in _____?

This may progress to a 3rd degree burn if ____ and ____ changes ensue.

partial thickness - entire epidermis extending into dermis

painful

forms blisters

may heal in 2-4 weeks

may progress to 3rd degree if metabolic and fluid changes ensue

Describe a Third Degree Burn.

 What part of the skin does it affect?

Describe the appearance of the skin, blood vessels, and etc?

Is it painful?

Heals spontaneously only by ______ and requires _______?

full thickness through the dermis

pale or black appearance

vessels become cord-like and thrombosed

 hair follicles, sweat glands, and nerve endings are destroyed

**Least Painful**

Heals spontaneously only by contraction and requires grafting

Fourth Degree Burn.

Involves ____, _____, and ____ structures.

Most commonly seen with _______ burns.

involves sub q tissue, muscle and bone

electrical burns

How can you use the palm of the patients hand to estimate BSA that is burned?

What % is a child's head compared to an adult?

Legs? 

*see handout for more on slides about rule of nine

palm of patients hand is approximately 1% BSA and can be used to estimate small or spotty patches

18% vs 9%

14% vs 18%

What is a more accurate tool for burn surface area assessment?

What is the ABA criteria for a major burn?

Lund and Browder

*see slide 13

TBSA of at least 5%, 10% or 20% of the body

depending on burn severity and age, a burn causing a functional or cosmetic threat, an electrical burn, an inhalational injury or a circumferential burn

Stages of Burn management:

Do pt come to the OR during stage I?

In Stage II of burn management are the cases elective?

I. Acute resuscitation phase

II. Stabilization or surgical phase

III. Reconstructive phase

*may release contractures at this stage

Not unless an emergent surgery must be done

NOT elective cases & there are few contraindications to surgery

(cant just cancel them b/c the pts need the grafts, debridment etc for continued survival)

secondary to hypovolemia (3rd spaced)

↓ myocardial contractility

anemia

compartment syndrome

What does disruption of the integument jeopardize? (3)

______ regulation

fluid and electrolyte ________

protection against _______

Jeopardizes

thermal regulation

fluid and electrolyte homeostasis

protection against infection

*What causes tremendous fluid shifts from the intravascular space to the interstitium? Where?

Why does this occur?

How long does the cap membrane remain more permeable?

↑ in capillary permeability at the site of injury and throughout the microvasculature

Thermal injury = release of many inflammatory mediators and they cause incr. cap. permeability.

12-24hrs per lec

*What is the immediate hemodynamic response to burns?

What about within 30 minutes?

immediate HD response is vasoconstriction & ↓CO

*this occurs b/c so much intravascular fluid is leaking out making the pt hypovolemic*

CI ↓ by 50% within 30 min if resuscition is not immediately addressed

overall HD picture is reversed and patient becomes vasodilated and hyperdynamic

↑CO, ↓SVR, fever, ↑WBC's, hyperglycemia

↑catecholamines, ↑cortisol, ↑ADH, ↑renin & angiotensin, ↑glucagon & glucocorticoids, inflammatory cytokines (the stress response)

**What is the Parkland Formula for Fluid Resusciation?

How do you administer the fluid?

What kind of fluid do you use?

4ml/kg body wt X %BSA

*add %BSA of 2° & 3º together; dont inc. 1° burns*

1/2 given over the 1st 8 hours

1/2 given over the next 16 hours

LR

What is the MOST reliable indicator of adequate volume resuscitation with burns?

What is the goal UOP for adults & kids?

If the UOP is significantly greater then above goals it reflects _____ volume which may exacerbate _______ and ________?

urine output

Adults: 0.5ml/kg/hr

Kids: 1ml/kg/hr (<30kg)

reflects excess volume which may exacerbate edema and impair ventilation

SO SLOW DOWN THE FLUIDS!!

UOP may be unreliable in pt with _______ and/or chronic _____ use.

UOP may be unreliable in pt with ETOH intoxication and chronic diuretic use

Inhalation injuries:

Directly irritate resp epithelium and thus impair function of _______, ______, and cause __________.

All of the above can lead to _______?

Unfortunately _____ ___ dont decrease the incidence & _______ may worsen the infection/pneumonia.

Sooo how do you treat these pts??

Type II pneumocytes (↓surfactant production)

↓ciliary function (pooling of secretions)

cause chemical tracheobronchiolitis

infection

Unfortunately prophylactic abx dont decrease the incidence & steroids may worsen the infection/pneumonia.

Tx is low TV(ie 6-8ml/kg), PEEP, & vigorous pulm. toilet

T/F size of a burn has more impact on determining a pts survival than inhalation injuries?

List 2 causes of airway swelling and possible obstruction d/t inhalation injury.

False...duh =-)

Heat itself

Toxic byproducts of smoke

(CO, cyanide, ammonia, nitrogen dioxide, sulfur dioxide, chlorine, benzene, etc all dissolve in tissue and cause irritation and swelling)

T/F initial inhalational injuries usually don't show up on an XRay; thus XRay not really useful till about 48hrs later.

Complications of inhalational injuries include: obstruction, bronchospasm, edema, atelectasis, VQ mismatch etc....all of these may not show up until _____ after injury sustained.

True per lec

6-48hrs per lec

decrease chest wall compliance

increase PIP's

Headache 

Hypoxia

Hoarseness

LOC

dyspnea

tachypnea

wheezing/stridor

COHbg > 15-20%

Describe CO poisoning?

What is CO's affinity for Hgb compared to O2?

CO combines with Hgb & displaces oxygen

CO has 200x greater affinity for binding sites on Hgb compared to oxygen

 CO poisoning causes a ____ shift of the oxyHgb dissociation curve

What does this cause physiologically?

huge shift to the left

 inhibits the release of oxygen to the tissues (profound tissue hypoxia)

Is SpO2 reliable in CO poisoning?

 T/F in CO poisoning PaO2 and alveolar oxygen tensions are normal but the O2 content is decreased?

SpO2 is unreliable

True -- same amt is dissolved in the blood, but less is being carried by Hgb & Hbg is our major mechanism to transport O2.

Does CO poisoning affect metabolism?

How?

Why yes indeed it does!

Binds to mitochondrial cytochrome oxidase syst.

↓

Profoundly impairs aerobic metabolism

*How can COHgb levels be analyzed?

Normals 

Mild levels 

Moderate levels

Severe levels

Fatal level

can be analyzed by lab

Normal level - <1.5%(non smokers) < 10%(smokers)

Mild levels  - 10-20%

Moderate levels - 20-40%

Severe levels - 40-60%

Fatal level - >60%

What is the relationship of the half life of COHgb to inspired O2?

If pt is on room air?

If pt is on 100% FiO2?

half life is inversely proportional to the inspired oxygen concentration

room air - half-life 5-6 hours

100% FiO2 - half-life 30-60 minutes

What is one way that severe cases of COHgb  have been treated?

How long do you keep oxygen on pts w/ CO poisoning?

In severe cases, the use of hyperbaric oxygen has been reported

maintain 100% FiO2 until COHgb <10% 

and

Cytochrome oxidase system is normalized

Do whatever it takes to keep your burn patient ____?

Consider ____ to intubate a pt with facial burns and use _____ to secure ETT.

WARM!!!!

Heat loss through burned/denuded skin is serious and will cause coagulopathy etc.

Consider awake fiberoptics to intubate a pt with facial burns and use cloth ties to secure ETT.

Ventilating may be more difficult with burned pts, so you may consider ______ ________?

If utilizing this technique you need to keep the pH____ & limit _______. 

May see ______ vents with these pts.

consider permissive hypercapnia

(lower TV & higher RR)

keep pH>7.25

limit positive pressure

may see hi-frequency oscillator vents

How does hypermetabolism affect the drugs you are going to be giving?

These pts have a higher tolerance for ______ with a low incidence of ___ and ________.

Remember that the initial level of pain is inversely proportional to ___________?

yields need for larger doses of sedatives, opioids, and induction agents

These pts have a higher tolerance for opioids with a low incidence of NV and hypotension

initial level of pain is inversely proportional to depth of burn consider Ketamine in addition to fentanyl & MS

RSI with Succs in first 24 hours of injury only

Rocuronium used thereafter d/t up-regulation of Ach receptors

What is the issue with Succs after the 1st 24hrs?

This phenomena has even been documented in burns ____% BSA?

has caused cardiac arrest due to lethal hyperkalemia

 denervation and immobilization leads to proliferation of extra-junctional ACh receptors

 depol causes major release of K

has even been documented in burns <10% BSA

no there are exceptions with burn pts

greater emphasis on nutriton and wound healing following acute phase

achieving adequate caloric intake is a challenge

protected airways (ETT or trach) have tube feeds continued until they come to OR 

Is regional anesthesia an option with burn pts?

D/t up-regulation with burn pts you need to remember to give a _____ dose of NDMR.

yes, it is appropriate for some pts

LARGER DOSE