Presentation for Anesthesia in Burn patient

1. BURN นร.สุทธิพงษ์ นาวาจะ
ร.ท.หญิง ฝนทิพย์ จันทร์ณรงค์
อาจารย์ที่ปรึกษา
อาจารย์ พ.ท. ธีรวัฒน์ ภูจิญญาณ์

2. Structure of the skin

3. Structure of the skin

4. BURN DEPTH

5. ClassificationofBurnDepth
“First-Degree”
a. Involves injury to
epidermal layer
b. Erythema(pink to red)
c. Skin blanches absenceof
blisters
d. Painful with tingling
sensation,
pain is eased by cooling
e. Discomfort lasts 48 hrs
healing occurs 3 to 5 days
f. No scarring; intact skin

6. ClassificationofBurnDepth
“First-Degree”

7. 2. Superficialpartial-thicknessburn
a. Involves injuryto the epidermis and the superficiallayers of
the dermis
b. Large blisters maycoveran extensive area
c. Pink to red base and broken epidermis, withwet,
shiny and weepingsurface
d. ExcruciatingPain
e. Heals in 10 to 21 days
f. Some scarringandminor
pigment changes may occur
2 degree BURN DEPTH
Superficial partial – thckness burn

8. 2 degree BURN DEPTH
Superficial partial – thckness burn

9. 2 degree BURN DEPTH
Deeppartial – thcknessburn
3. Deep partial-thickness
burn
a. Involves injury of most of
the dermal layer
b. Pain is reduced
c. Wound surface is red and
dry with white areasin
deeperparts, no blisters
d. Generallyheals in 3-6
weeks

10. 2 degreeBURN DEPTH
Deeppartial – thcknessburn

11. Seconddegree
BURN DEPTH
Superficialpartial-thickness:
•Usuallyquitepainful
•Erythemetouswithblebsandbullae
•Evenairmotionacrossskinhurts
Deeppartial-thickness:
•Sensationimpairedtoavariabledegree

12. Seconddegree
BURN DEPTH

13. ClassificationofBurnDepth
“third-Degree”
4. Full -thickness burn
a. Involves injury and destruction of the epidermis and
the dermis, the wound will not heal by re-
epithelialization and grafting may be required
b. Appears dry,hard, leathery eschar
c. Appears as a waxywhite, deepred,
yellow, brown,or blackd.
Absenceof sensation because of nerve
ending destruction
e. Scarring and woundcontractures are likely
to developwithout preventivemeasures

17. ClassificationofBurnDepth
“fourth-Degree”
5. Deep full-thicknessburn (subcutaneous)
a. Extendsbeyond the skininto
underlying fasciaand tissues anddamage to
the muscle, bone, and tendons occurs
b. Injuredareaappears blackand
sensation is completely absent
c.Eschar is hard and inelastic
d. Healingtime takes months and grafts
are required

18. Severityofburn
1.Minor Burn
Injury
2.ModerateBurn
Injury

19. Minor Burn Injury
MinorBurn Injury
• Second-degree burn ofless than
15% total body surface area(TBSA) in adults
10% TBSAin children
• Third-degree burn of less than
2% TBSAnot involving special care areas
(eyes,ears,face, hands, feet, perineum,
joints)

20. ModerateBurn Injury
Moderate,UncomplicatedBurn
Injury
• Second-degree burns of
15%–25% TBSAin adults or
10%–20%in children
• Third-degree burns of less than
10% TBSA not involving special care areas

21. Major BurnInjury
MajorBurnInjury
• Second-degree burns exceeding
25% TBSA in adults or
20% in children
• All third-degree burns exceeding 10% TBSA
• All burns involving eyes,ears,face,hands,
feet,
perineum, joints
• All inhalation injury, electrical injury

24. Adult Rule of Nines Chart

25. Child Rule of Nines Chart

26. Infant Rule of Nines Chart

28. Lund & Browder Chart 5yrs - Adult

29. Lund & Browder Chart Infant - 5yrs

30. Berkow Chart

31. BURN LOCATION
1. Burns of the head, neck, and chest are associated with
pulmonary
complications
2. Burns of the face are associated with corneal abrasion
3. Burns of the ear are associated with auricular chondritis
4. Hands and joints require intensive therapy toprevent
disability
5. Theperineal area is prone toautocontamination by urine
and feces
6. Circumferential burns of the extremities can produce a
tourniquet-like
effect and lead to vascular compromise (compartment

32. Type of BURN
A.Thermalburns are causedbyexposure to
flames, hot liquids, steam, or hot objects
InhalationInjury???
B.Chemicalburns
1. Burnsare caused by tissue contact with
strong acids, alkalis, or organic compounds
2. Systemic toxicity from cutaneous absorption
can occur

33. Type of BURN
C.Electricalburns
1. Burns are caused by heat generated by electrical energy as it passes
through the body
2. Electrical burns resultin internal tissue damage
3. Cutaneous burns cause muscle and soft tissue damage that may be
extensive,
particularly in high-voltage electric injuries
4. The voltage, type of current, contact site, and duration of contact are
important to
identify
5. Alternating current is more dangerousthan direct current because it is
associated with
cardiopulmonary arrest, ventricular fibrillation, tetenic muscle contrations,
and long bone

34. INHALATIONINJURIES

36. Smoke inhalation injury
1. Description: Injuryresultswhen thevictim istrapped in an
enclosed,hot,smoke-filled space.
2. Assessment:
a. Facial burns
b. Erythema
c. Swelling of oropharynxand nasopharynx
d. Singednasalhairs
e. Flaringnostrils
f. Stridor,wheezing, anddyspnea
g. Hoarsevoice
h. Sooty(carbonaceous) sputumand cough
i. Tachycardia
j. Agitationand anxiety

37. Carbon monoxide poisoning
1. Desciption
a. Carbon monoxide is colorless, odorless, and tasteless gas that
has an affinity
for hemoglobin 200 times than that of oxygen
b. Oxygen molecules are displace and carbon monoxide reversibly
binds to
hemoglobin to form carboxyhemoglobin
c. Tissue hypoxia occurs
Mild:headache, nausea
Moderate: dizziness,confusion,ataxia, visualchanges,
pallor

38. Signs ofCarboxyhaemoglobinaemia
COHb levels Symptoms
0-10% Minimal (normal level in heavy smokers)
10-20% Nausea, headache
20-30% Drowsiness, lethargy
30-40% Confusion, agitation
40 -50% Coma, respiratory depression
>50% Death

39. QUESTIONS ?
 What assessment of the patient would youmake?
 Discuss airwayassessment,
 The significance of perform SaO2 and other
investigations youwould perform (COHb).
 What are theindicationsfor intubations.
 Whatfluidrequirements willpatients have ?
 What fluidwouldyou give, whenyou give, and why?
 Discuss analgesia, are burns painful?
 Whereshouldthe patient be lookedafter ?

40. Step1: InitialAssessment
Airway:does the patienthave a patent airway?
Breathing: is the patientbreathingadequately?
Circulation:Is the patient’scirculatoryand cardiacstatus
stable?
Neurologicalstatus:EVM
Note: burns doNOT alter mentation—if the patient is
un-alert or
disoriented,something else is going on!
Exposethe patient, and treat for hypothermia

41. Step 2: DeterminingBurn Severity
•Burn severity is determined primarily by
assessing the
extent of the burn as percentage of total body
surface
area, and its depth
•‘Partial/full thickness’and ‘1st/2nd/3rd degree’ are
acceptable terminology
•First and second degree burns are partial

42. Fluid Resuscitation
• Parkland formula
– 4cc X weight X % burn
– ½ volume in first 8 hours
– Second ½ over last 16 hours
• Brooke formula
– 2cc X weight X % burn
– ½ volume in first 8 hours
– Second ½ over last 16 hours
• Daily maintenance fluids

43. Fluid Resuscitation
EndpointUrineoutput
in adults 0.5-1.0 ml/kg/hour
in children 1.0-1.5 ml/kg/hour

44. Stages of Thermal Injuries
1st Stage –
Edema
2nd Stage –

45. 1st Stage –Edema
First24hours
Fluid leak: vascular space interstitial space
 osmotic pressure
 capillary permeability
Vasoactive substances released
 interstitial edema and intravascular

46. 1st Stage –Edema
Burns >30% BSA causecapillarychanges in both burnedand
non-burnedtissue
Burnedtissue edema
Directthermal injuryto endothelialcells
and burn tissue osmolarity
Non-burn tissue edema
Severe hypoproteinemia
Smallwound
Edema greatest 8-12 hrs post injury
Largewound
Edema greatest 18-24 hrs post injury

47. 2nd Stage –Diuresis
24-36 hours after burn, fluidand electrolytes begin to
remobilizeback into intravascularspace
Capillaryseal reestablishes
Diuresis occursdue to  GFRin response to  intravascular
volume
Maysee hypernatremiaand hypokalemia
Cardiacoutput may  200-300% normal
O consumption

48. burn effect
1.Localized Effect
2.Systemic Effect

49. Localized Effect

50. Systemic Effect
Cardiovascular
Blood
Electrolyte, Acid& Base
Respiratory
Endocrine
Immune
Gastrointestinal
Muscls& Skeleton

51. cardiovascular system
CardioVascular System (first 24 hrs)
Activation of CNS system and catecholamine release:
Tachycardia
Vasoconstriction
During early phase:
Classic S/S of compensated shock
Dramatic decrease in cardiac output
Volume loss and decreasedvenousreturn:
 preload
 cardiac filling pressure
 CVP and PCWP
After 24hrs = increased blood flow to tissues, HTN

52. Immune andhemtolpgic system
Immune System
Alters immunecells abilityto function
killingpower of neutrophils
Macrophages andlymphocytes do not work well
Hematologic System
Destruction of RBCs
Hemoglobinuria
 Hgb level  viscosity
WBC level
Coagulation altered

53. Endocrineand neurologicalsystem
EndocrineSystem
Massive release of catecholamines,glucagon, ACTH, ADH,
Renin,Angiotensin,& Aldosterone
Hyperglycemia
NeurologicalSystem
 cerebral perfusion
Cerebral edema occurs from Na shifts
Carbon monoxide or associated headinjurymay cause
neurochanges

54. Respiratory System
Upper airwayinjury
Involvesall of airwayto level of true vocal cords
Initially due toinflammationfrom heat of inspiredsmoke
Exacerbated by accumulationof excess interstitialfluid
Majorairwayinjuries
Involvestracheaand bronchi
Parenchymalinjury
Involvesentire respiratory tractdownto,
and including,alveolar membrane
Commonlylethal withinfirst few hoursafter injury
due toprofound bronchospasmsandhypoxia

55. Respiratory System
Respiratory SystemCon’t
0-24hrs
Edema
Obstruction
Carbon Monoxide Poisoning
2-5 Days
May developARDS
Signs & Symptoms
Stridor / Hoarseness / Facial burns / Singed nasal hairs /
Carbonaceous sputum / Impaired level of consciousness
S/Sof deteriorating ABGs &increasing respiratory distress

56. Renal System
Renal System
RBF& GFR
Activationof RAS
Release of ADH
retain water& Na
lose of K, Ca, & Mg
ARF
Acute TubularNecrosis 2o hemoglobinuria&
myoglobinuriad/t hemolysis& tissue necrosis
Maintainhigh u/o (2ml/kg/hr)w/fluids/ osmotic

57. GI and hepatic System
GI System
Slow peristalsis and possible ileus
 HCL acid secretion fromstress response
Narcotics forpain management further slow
peristalsis
Hepatic System
Decreasedhepatic synthesis

58. Induction Medications
-Burnpatients require higherthan normal doses
of non depolarizing musclerelaxants dueto
altered protein binding and increasein
extrajunctional acetylcholine receptors.

59. Muscle Relaxants
Depolarizers–safe in the 1st 24hrs
(afterwhich hyperkalemia may be a problem
up to a year or the burn is healed)
Non-depolarizers –burn patient’s tend to
beresistant to the effects ofnon-
depolarizing musclerelaxants
May need 2-5 x’sthe normal

60. Common Operations
- Decompression procedures
escharotomies& fasciotomies
- Burnexcision & skin grafting
- Reconstruction operations
- Supportive procedures
tracheostomy, gastrostomy, vascular
access

61. Review – Anesthetic Management
Preop Meds
Provideadequate analgesia
Fluids
Establish Adequate VascularAccess
Consider InvasiveMonitoring
Airway Management
Consider Alternatives to Direct
Laryngoscopy
Awake FOB
Ventilation
Increasedminute ventilation
increased metabolic rate
Fluids & Blood
Anticipate rapid, large blood loss
Parkland Formula
TemperatureRegulation
Increaseambient temperature
WarmIV fluids
AnestheticDrugs
Includeopioids
Consider effects ofincreased
circulatingcatecholamines
MuscleRelaxants
Avoid Succinyl
Anticipate resistanceto
nondepolarizing musclerelaxants
Postoperative
Anticipate increasedanalgesic
requirements

63. THANK YOU FOR YOUR
INTERESTING
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