Anesthesia for Burn Patient dictated slides 1-25

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Anesthesia for the Burn Patient:

Anesthesia for the Burn Patient Maribeth Massie, CRNA, MS, PhD(c) University of new England Master of Science in Nurse Anesthesia Program

Thermal injury 2011 Statistics:

Thermal injury 2011 Statistics > 2 million patients will be brought to trauma centers for burns and associated injuries globally Incidence in US has decreased steadily in past decades Majority are thermal injuries in children < 5 years Burn injuries requiring treatment: 450,000 Fire and burn deaths: 3500 Hospitalizations for burn injury: 45,000 About 55% of the estimated 45,000 U.S. acute hospitalizations for burn injury in recent years were admitted to 125 hospitals with specialized facilities for burn care ("burn centers") Admission Cause: 44% fire/flame, 33% scald, 9% contact, 4% electrical, 3% chemical, 7% other Place of Occurrence: 68% home, 10% occupational, 7% street/highway, 15% other http://www.ameriburn.org/resources_factsheet.php

Indications For Hospitalization For Burns:

Indications For Hospitalization For Burns Burns affecting >15% of body surface area 3rd-degree burns Electrical burns caused by high-tension wires or lightening Chemical burns Inhalation injury, regardless of the amount of body surface area burned Inadequate home or social environment Suspected child abuse or neglect Burns to the face, hands, feet, perineum, genitals, or major joints Burns in patients with preexisting medical conditions that may complicate the acute recovery phase Associated injuries (fractures) Pregnancy

Types of burns:

Types of burns Thermal Flame Steam Scald Electrical: cause tissue damage by thermal injury and injury to underlying structures and heart Contact with live wires or lightening Skin appearance may not reflect extent of injuries Myoglobinuria common Peripheral neuropathies and spinal cord injuries may develop Cardiac dysrhythmias can occur up to 48 hours post-injury Apnea may occur from tetanic contraction of respiratory muscles or damage to medulla Chemical Degree of injury depends on type of chemical, concentration, and duration Inhalation

Structure of the skin:

Structure of the skin

Classification of Burn Depth “First-Degree”:

Classification of Burn Depth “ First-Degree” First–degree (epidermal) Superficial involving upper layers of epidermis; skin red and edematous and painful like sunburn Erythema, pain, absence of blisters Heals within 3 to 6 days

Classification of Burn Depth “Second-Degree”:

Classification of Burn Depth “Second-Degree” Second-degree (partial thickness) Burns extend damage through dermis; regeneration can occur; edema and blisters develop and have white (mottled) or red areas that are painful Entire epidermal layer Part of underlying dermis Healing in 10 to 21 days

Classification of Burn Depth “Second-Degree”:

Classification of Burn Depth “Second-Degree” Superficial partial-thickness (dermal burn): Usually quite painful Erythemetous with blebs and bullae Even air motion across skin hurts Deep partial-thickness: Sensation impaired to a variable degree

Classification of Burn Depth “Second-Degree”:

Classification of Burn Depth “Second-Degree”

Classification of Burn Depth Third-Degree:

Classification of Burn Depth Third-Degree Third-degree (Full thickness) Characterized by destruction of all layers of skin (all epidermal and dermal elements), including nerve endings; skin will not regenerate and healing does not occur unless dead tissue debrided and skin grafts placed Burn into subcutaneous fat or deeper Skin is charred and leathery (woody) Pearly-white sheen / waxy Generally not painful (nerve endings are dead)

Third degree burn (sub-dermal burn):

Third degree burn (sub-dermal burn)

Third-Degree Burn:

Third-Degree Burn

Classification of Burn Depth Fourth-Degree:

Classification of Burn Depth Fourth-Degree Fourth-degree (full thickness) Destruction of all layers of skin and extend into subcutaneous tissue, fascia, muscle, and bone Typically involves appendage Black and dry No pain

Fourth degree burn:

Fourth degree burn

Diagram of different burn depths:

Diagram of different burn depths

Electrical Burns:

Electrical Burns Similar to thermal burns True extent of the damage is often hidden Entry / exit wound best  worst conductors = nerve, blood, muscle, skin, tendon, fat, bone Clinical Findings Hyperkalemia Acidosis Myoglobinuria is common Maintain high u/o to avoid renal damage Peripheral neuropathies or spinal cord deficits Cataract formation Cardiac dysrhythmias up to 48 o post injury

Chemical Burns:

Chemical Burns Caused by strong acid or alkaline solution Damage continues until the substance is removed or neutralized Type 2 pneumocytes will lead to loss of surfactant production and alveolar volume May take time to take effect & may continue to penetrate 24-48hrs Full-thickness burns appear superficial Flush with copious amounts of water Specific Antidotes: Hydrofluoric Acid  10% Calcium Gluconate Phenols  polyethylene glycol & methylated spirits Phosphorus  1% copper sulfate identifies residual phosphorus

Inhalation Burns:

Inhalation Burns Smoke inhalation Heat inhalation injury Asphyxiation Carbon monoxide (CO) poisoning Toxic gas inhalation

Inhalation injury:

Inhalation injury High index of suspicion if loss of consciousness at scene and if fire occurred in closed space Results in edema, erythema, and ulceration S/S of inhalation injury Respiratory irritation (coughing)/distress Singed or burned nasal hair or oral mucosa Soot or foreign matter in airway Sore throat Dysphagia Hemoptysis Carbon-colored sputum Tachypnea, use of accessory muscles, wheezing Crepitus

Inhalation injury:

Inhalation injury Hoarseness demands immediate attention  means airway becoming edematous and can quickly obstruct glottis Diagnosis made with carboxyhemboglobin levels Should be intubated immediately if any suspicion of injury Potential for pulmonary edema Early sx: dyspnea, diffuse rhonchi, wheezing Late sx: moist rales, decreased lung sounds all fields, poor gas exchange, cardiomegaly

Inhalation Injury:

Inhalation Injury Supportive Care Maintain oxygenation Manage bronchospasms Chest escharotomy: chest burns may cause restrictive problems Fluid replacement Pulmonary toilet Intubation / tracheostomy Low volume, high PEEP

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