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44 Cards in this Set
- Front
- Back
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What are the 3 main classes of dangerous chemicals? How to treat?
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-Alkalis
-Acids -Organic compounds -Protect self 1st, remove powder substance, then irrigation |
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What are the risks of petroleum exposure?
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full thickness injury, systemic toxicity within 6-24hrs that manifests as pulmonary insufficiency, hepatic and renal failure
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How do local tissues respond to burn injury?
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-Zone of coagulation: innermost
-Zone of stasis -Zone of hyperemia |
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What are the pulmonary effects of burn injuries?
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-Inhalation above glottis
-Inhalation below glottis -CO poisoning -Cyanide poisoning |
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Inhalation injury above glottis:
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heat or chemical, severe edema & obstruction
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Inhalation injury below glottis
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steam, explosions
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Pathophysiologic changes in infraglottic injury:
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impaired ciliary activity, inflammation, hypersecretion, edema, ulceration of airway mucosa, increased blood flow, spasm of bronchi, impaired immunne defense
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Carbon Monoxide poisoing
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-CO binds to Hgb 200-250x > affinity than O2
-Carboxyhemoglobin levels 40-60% cause obtundation and loss of consciousness; levels of 15-40% cause varying levels; >60 fatal -CO can be measured on ABG -Formed by incomplete combustion of organic compounds |
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Cyanide poisoning
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-Hydrogen cyanide produced by burning high nitrogen plastics such as polyurethane
-Diagnosis is difficult, suggestive if hx and: aninon gap metabolic acidosis, not responsive to O2 present, SvO2 is elevated -testing for blood cyanide is possible: thiocyanate level |
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What are the cardiovascular effects of burns?
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-Burn shock
-Increased SVR -Decreased cardiac contractility d/t myocardial depressant factor yet to be identified, normal levels return 12-18hrs post-burn |
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What is burn shock?
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-Burn shock is hypovolemic shock resulting from increased microvascular permeability and leakage of protein rich fluid into interstitial space; greatest in 1st six hrs after burn
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What happens to the contents of the vascular space early in the course of a burn?
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RBC's are destroyed but Hct increases d/t loss of plasma volume; crystalloids and proteins are lost from the intravascular space to the interstitial space early in a burn
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When does normal capillary integrity return?
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24-48hrs after burn, colloids remain in intravscular compartment; fluids move from interstitial space to the intravascular space after the 1st 48hrs
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Is edema limited to the burned tissues?
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No, generalized edema results secondary to the loss of proteins from the vascular compartment and the resulting decrease in plasma oncotic pressure
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How do burns effect metabolism?
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a hypermetabolic state develops in proportion to the severity of the burn
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List 6 signs/symptoms of hypermetabolism:
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hyperthermia, increased catabolism, increased O2 consumption, tachypnea, tachycardia, elevated catecholamine levels
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Why do burn patients lose heat?
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hypermetabolism, evaporative fluid loss, exposure
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How is heat lost in the burn patient?
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most is lost from evaporation, 580 calories of heat is lost for each gram of H2O that evaporates
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How do burns effect the renal system?
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ARF can occur in as high as 38% of cases, hypovolemia, increased levels of catecholamines, angiotensin, aldosterone, and vasopressin as well as sepsis and myoglin can contribute
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How should the airway be managed in a burn patient?
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Intubate early
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Mnemonic "AMPLE"
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Allergies
Medications Previous hx Last meal Events |
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Airway assessment in burn patient:
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very important to evaluate facial burns, inhalation exposure, singed nasal hairs, stridor, s/s of hypoxia
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What labs should be ordered on a burn patient?
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H&H, lytes, BUN/creatinine, ABC with carboxyhemoglobin, U/A, CXR
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What are initial burn management concerns?
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stop the burn, fluid resuscitation, insert n/g tube, assess perfusion of extremities, treat pain, universal precautions, monitor v/s, insert foley, assess ventilatory status and tx inhalation injury, address psych issues
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How is CO poisoning treated?
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-admin 100% O2
-reduce carboxyhemoglobin to <10% -half life of CO in blood is 4-5hrs for patients on room air -half life of CO in reduced to ~1hr for patients on 100% O2 -the value of hyperbaric is unproven |
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How is cyanide poisoning treated?
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-mechanical ventilation in animals adequate
-Sodium thiosulfate (150mg/kg) administered IV can enhance hepatic metabolism of cyandie by converting cyanide to thiocyanate; Sodium nitrate 5mg/kg can be used in severe cases |
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What are the post-burn fluid requirements in the first 24hr?
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Adults: LR 2-4ml x kg x %burn
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What rate is fluid given?
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-50% in first 8 hours
-50% in following 16hrs *time frame starts from burn occurance |
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What is the minimal urine output for adults?
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0.5mg/kg/hr
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How is heat loss reduced?
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-ambient room temp 28-30
-warmed IVF -forced air warmer |
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How can catecholamine secretion be minimized?
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adequate pain control, thermoneurtral environment, prevention/treatment of infection
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When should feeding be started?
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enteral feeding within 4hrs post-resuscitation, decreases muscle catabolism and may reduce bacterial translocation thru gut
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What are the indications for an escharotomy?
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Circumferential burns of the trunk or extremities
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What is the anesthetic management of escharotomy?
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-acute, bedside procedure; eschar of a 3rd degree burn is insensate; small doses of narcotic or ketamine may be used
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Burn wound excision and grafting
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for 3rd degree burns, following initial stabilization ~48hrs, burn is excised to expose viable tissue bed; surgery is limited by: size (20%BSA), blood loss (10units), time (2-3hrs), hypothermia (<35); over agressive excision invites coagulopathy & VS instability
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Anesthetic management of burn wound excision & grafting:
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airway, may be on ICU percussive ventilator--TIVA, high CO2 may be normal; blood loss may be large (~200ml/1% BSA); IVF 8-10ml/kg/hr; NO SUCCS AFTER 24HRS; become RESISTANT to NDNMR's
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What are the s/s of SUCCS induced hyperkalemia?
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Peaked T waves, prolonged QRS duration
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What is the treatment of SUCCS induced hyperkalemia?
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-insulin/glucose or calcium with: hyperventilation, lasix, kayexalate
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How are drugs effected by burns?
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-hypoalbuminemia leads to increased free fraction of drug
-hypovolemia and decreased CO can lead to decreased organ blood flow -hypermetabolism can lead to increased blood flow -edema can lead to increased volume of distribution -resistance to drugs can develop |
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How do adults & children differ in relation to burns?
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children have increased body surface area, adult weight/BSA relationships are established by age 15
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How if fluid resuscitation managed in a child?
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*3-4ml/kg/BSA
*in addition to LR, D5LR should be given at maintenance rate *half of volume in first 8 hours, then other half next 16 *fluid resuscitation adequate if U.O. >1ml/kg/hr |
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Electrical burns:
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-bone poor conductor of electricity, burn is usually in tissue to outside skin
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Fluid requirements for electrical burns:
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need to monitor U.O. b/c may underestimate BSA d/t deep tissue injuries not visible-1-1.5ml/kg/hr
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What are the criteria for referral to a burn center?
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-partial thickness >10%
-3rd degree in any age group -burns to face, hands, feet, genitalia -electrical -chemical -inhalation |
