Burns- management and anesthetic considerations Flashcards Preview

Advanced Principles- Fall 2018 > Burns- management and anesthetic considerations > Flashcards

Flashcards in Burns- management and anesthetic considerations Deck (20)
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What are the phases seen after a burn injury?


What are the phases of treatment?

  • Biphasic response
    • Burn shock develops 6-8 hours after injury
    • Hypermetabolic phase develops in several days to weeks
  • Treatment in 3 phases:
    • 1) resuscitative
    • 2) debridement and grafting
    • 3) reconstructive


What do the different organs/systems do during the early and later phases post burn injury? (table)










Another table about the systemic response during the early phase vs the late phase.




endocrine and metabolic






What should you consider during initial airway assessment of a pt with burns?

  • Consider liklihood of inhalation injury
  • inspect the neck and oral cavity for overt issues
  • Gold standard assessment: fiberoptic bronchoscopy
    • Chest x-ray is usually normal in early phase
  • Early intubation when upper airway injury is suspected, do NOT wait for pt to decompensate


Who is at risk for inhalation injury?


  • Facial burns
  • hoarseness
  • evidence of smoke exposure
  • other classical signs of inhalation injury


What should you consider regarding airway management in a burn patient?

  • Intubation will be easier if not delayed
  • Awake, spontaneously breathing fiberoptic intubation if any airway abnormality is suspected
    • topical anesthesia plus hypnotic that preserves spontaneous ventilation (ketamine, dexmedetomidine)
    • use opioids and sedatives judiciously
  • If there is no airway abnormality, RSI can be used, but NO SUCC  after first 24 hours post injury
  • Severe airway burns may require immediate surgical airway/trach
  • Cuffed tubes are standard of care
  • MUST have humidification--secretions are thick and tenacious, very likely to form mucous plug


What is the initial management during the burn shock phase?


  • This is a combination of distributive, hypovolemic, and cardiogenic shock
  • Priorities: airway management and fluid resuscitation
  • Fluid losses greatest in first 12 hours and stabilize at 24 hours
  • Volume loss and edema
    • transudation of plasma proteins directly from wound bed
    • interstitial fluid shifts in unburned tissue secondary to capillary leak
  • Crystalloids are fluid of choice in 1st 24 hours


What can happen with over-resuscitation?

  • over-resuscitation can lead to complicationsintraabdominal hypertension- is reversible
    • >12
  • abdominal compartment syndrome- leads to organ damage
    • >20
  • pleural and pericardial effusions
  • pulmonary edema
  • fasciotomy
  • conversion of partial thickness to full thickness (think of the jackson burn zones)



What is the Parkland fluid resuscitation formula?

  • 4 ml/kg per percentage of TBSA burned in 1st 24 hours
    • half of calculated volume should be administered in first 8 hours
    • LR preferred


What is the hypermetabolic phase?

  • Develops over several days to weeks, changes can persist up to two years
  • Caused by immense surge in catecholamines and corticosteroids (10-50x baseline)
  • Persistent tachycardia, systemic hypertension, tachypnea, increased muscle protein degredation, insulin resistance, elevated core temp, liver dysfunction increased risk of infection
  • Can lead to physical exhaustion and death without treatment


What are the symptoms seen during hypermetabolic phase?

What are treatments?

  • Symptoms
    • Persistent tachycardia
    • systemic hypertension
    • tachypnea
    • increased muscle protein degredation
    • insulin resistance
    • elevated core temp
    • liver dysfunction increased risk of infection
  • Treatment:
    • early excision and grafting
    • warming strategies (burn or kept at 87-90 degrees)
    • nutritional support
    • insulin
    • beta blockers


How is excision (escharotomies) and grafting done?


  • Aggressively cut off dead tissue until they get to massive blood loss, then they lay epi soaked flaps over the bleeding area
    • Can have up to 2L blood loss in 15 minutes
  • Surgery done every 2-3 days
  • Early debridement preferred, often done in stages
    • started on 2nd day to 2nd week of unjury
  • Blood loss can be significant.


What are indications to suspend excision surgery?

  • 20% of BSA excised (may extend this to larger area if pt is stable)
  • time length of 2-3 hours
  • temperature drop to 35 C
  • blood loss requiring 10 units or mor PRBCs


What should be included in preoperative evaluation?


  • Age, weight
  • Pre-existing co-morbidities
  • review labs including acid/base
  • airway assessment, vent settings
  • TBSA burned, note inhalation injury and co-existing trauma
  • Mechanism of injury (flame, explosion, chemical, electrical, scald) and time since injury
  • Vascular access and adequacy of resuscitation (current fluid requirements, UOP, vasopressor requirements)
  • Surgical plan
  • review previous anesthetic records


How long should burn patients be NPO?

  • NPO after midnight is NOT appropriate for these patients!
  • Adequate caloric intake is critical
  • No need to d/c enteral feeds for intubated patient
    • unintubated patients can have feeds continue up to 4 hours before surgery
    • Once in OR, decompress NG tube/check residuals
  • Parenteral feeds should be continued intraoperatively and do not use the specific line for them
  • For procedure with unprotected airway like placing a trach, should adhere to more standard NPO guidelines


How should you set up pre-operatively for a burn patient?


What should you consider during induction of a burn patient?

  • Need all standard monitors, may need to have ekg leads stapled to pt
  • It is rare to see burn pt in first 24 hours, if you do, reduce dosage of induction agents d/t shock
  • Expect resistance to NDMB, will need higher/more frequent dosing
  • May be unable to take off vent d/t required settings, if so , use TIVA


What should you consider intraoperatively for a pt with burns?


  • Arterial blood pressure required if >20-30% TBSA involved
  • Accurate temperature monitoring essential/avoid hypothermia/actively warm patient and room
  • Continue ICU infusions, including narcotics and O2 during transport
  • Ensure ETT securement is infallible
    • may need to wire to teeth or screw into mandible 
  • Blood loss can be rapid and tremendous- need adequate product immediately available and checked in room
  • Anticipate use of epi-soaked gauze--may see systemic effects
  • pain control


Why are the effects of neuromuscular blockers different in patients who have burns?

  • Proliferation of extrajunctional nicotinic acetylcholine receptors
    • causes resistance to nondepolarizing muscle relaxants
    • increased sensitivity to depolarizing muscle relaxants (succ)
  • Succ >24 hours post injury is PROHIBITED
    • potentially lethal hyperkalemic response
    • may persist for up to 18 months post injury
  • Resistance to non-depolarizing muscle relaxants may develop within a week of burn injury
    • persist up to 1 year
    • 2-5x greater dose
    • Rocuronium in large doses up to 1.2 mg/kg can be used for RSI
    • Resistance does not prolong recovery times or alter efficacy of reversal agents


What should you consider with ventilator management of a burn patient?

  • Anticipate pulmonary compromise
    • RAD, laryngospasm, bronchospasm, ventilation-perfusion mismatch, decrease in pulmonary compliance , PNA, ALI, ARDS
  • may need high FiO2 and frequent suctioning
  • Lung protective ventilation
    • target TV 4-8 ml/kg
    • plateau pressure = 30 cm H2O
    • permissive hypercapnia up to pH of 7.2
  • HFOV- may require TIVA