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Questions and Answers
Which of the following treatments actively binds cyanide and forms cyanocobalamin for excretion by the kidneys?
Which of the following treatments actively binds cyanide and forms cyanocobalamin for excretion by the kidneys?
What is the primary complication associated with cyanide binding to cytochrome in the electron transport chain?
What is the primary complication associated with cyanide binding to cytochrome in the electron transport chain?
Which method accounts for the highest percentage of heat loss in burn patients?
Which method accounts for the highest percentage of heat loss in burn patients?
In the context of preoperative anesthesia planning for burn patients, why is it critical to have blood products immediately available in the operating room?
In the context of preoperative anesthesia planning for burn patients, why is it critical to have blood products immediately available in the operating room?
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What is the recommended temperature range for warming the operating room prior to surgery on burn patients?
What is the recommended temperature range for warming the operating room prior to surgery on burn patients?
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What percentage of burn-related deaths occur at the accident scene?
What percentage of burn-related deaths occur at the accident scene?
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According to fluid resuscitation guidelines for adults, what is the correct formula for administering Lactated Ringer's solution based on TBSA burned?
According to fluid resuscitation guidelines for adults, what is the correct formula for administering Lactated Ringer's solution based on TBSA burned?
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What is the minimum urinary output (UOP) recommended for adults following a burn injury?
What is the minimum urinary output (UOP) recommended for adults following a burn injury?
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Which factor is NOT included in the criteria for adequate fluid resuscitation in burn patients?
Which factor is NOT included in the criteria for adequate fluid resuscitation in burn patients?
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What is the appropriate fluid resuscitation guideline for pediatric patients based on TBSA burned?
What is the appropriate fluid resuscitation guideline for pediatric patients based on TBSA burned?
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What potential complication can arise due to aggressive fluid resuscitation in burn patients?
What potential complication can arise due to aggressive fluid resuscitation in burn patients?
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Which of the following best describes the initial assessment priorities for burn patients?
Which of the following best describes the initial assessment priorities for burn patients?
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What is indicated by an intra-abdominal pressure (IAP) greater than 20 mmHg in burn patients?
What is indicated by an intra-abdominal pressure (IAP) greater than 20 mmHg in burn patients?
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What is the primary cause of upper airway injuries in inhalation burns?
What is the primary cause of upper airway injuries in inhalation burns?
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What is the expected change in the dose requirement for non-depolarizing muscle relaxants (NDMR) after 24 hours post-burn?
What is the expected change in the dose requirement for non-depolarizing muscle relaxants (NDMR) after 24 hours post-burn?
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What is the gold standard for diagnosing the extent of inhalation injury?
What is the gold standard for diagnosing the extent of inhalation injury?
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What is the primary symptom related to lower airway injuries from inhalation burns?
What is the primary symptom related to lower airway injuries from inhalation burns?
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Which method is most effective for treating carbon monoxide poisoning?
Which method is most effective for treating carbon monoxide poisoning?
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During airway management, what is the purpose of utilizing humidified inspired gases?
During airway management, what is the purpose of utilizing humidified inspired gases?
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What happens to the oxyhemoglobin dissociation curve in the presence of carbon monoxide poisoning?
What happens to the oxyhemoglobin dissociation curve in the presence of carbon monoxide poisoning?
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What is a common symptom at a carboxyhemoglobin level of 20-40%?
What is a common symptom at a carboxyhemoglobin level of 20-40%?
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What characterizes severe lower airway injury as per the grading scheme for flexible bronchoscopy?
What characterizes severe lower airway injury as per the grading scheme for flexible bronchoscopy?
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Which gas is primarily associated with systemic toxicity, leading to metabolic asphyxiation in fire scenarios?
Which gas is primarily associated with systemic toxicity, leading to metabolic asphyxiation in fire scenarios?
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What is a significant consequence during fluid resuscitation that could lead to abdominal compartment syndrome in burn patients?
What is a significant consequence during fluid resuscitation that could lead to abdominal compartment syndrome in burn patients?
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Which airway management technique is most effective when dealing with inhalation injuries in burn patients?
Which airway management technique is most effective when dealing with inhalation injuries in burn patients?
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In the treatment of carbon monoxide poisoning, what primary action is taken to improve oxygen delivery to tissues?
In the treatment of carbon monoxide poisoning, what primary action is taken to improve oxygen delivery to tissues?
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What is the most critical factor to consider when determining fluid resuscitation needs for burn patients?
What is the most critical factor to consider when determining fluid resuscitation needs for burn patients?
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What complication can arise from ineffective airway management in burn patients with inhalation injuries?
What complication can arise from ineffective airway management in burn patients with inhalation injuries?
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What is a significant complication associated with aggressive fluid resuscitation in critically ill burn patients?
What is a significant complication associated with aggressive fluid resuscitation in critically ill burn patients?
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What is the recommended action for managing suspected upper airway injuries in burn patients?
What is the recommended action for managing suspected upper airway injuries in burn patients?
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Which treatment method is most effective for addressing carbon monoxide poisoning in burn patients?
Which treatment method is most effective for addressing carbon monoxide poisoning in burn patients?
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What is the primary goal of fluid resuscitation in burn patients during the first 24 hours post-injury?
What is the primary goal of fluid resuscitation in burn patients during the first 24 hours post-injury?
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What is the defining measurement indicating intra-abdominal hypertension in burn patients?
What is the defining measurement indicating intra-abdominal hypertension in burn patients?
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In fluid resuscitation for pediatric burn patients, what is the correct volume of Lactated Ringer's solution recommended?
In fluid resuscitation for pediatric burn patients, what is the correct volume of Lactated Ringer's solution recommended?
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What condition corresponds with a base deficit of less than -5 in burn patients?
What condition corresponds with a base deficit of less than -5 in burn patients?
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What is the purpose of administering D5W maintenance fluid during the second 24 hours of fluid resuscitation in burn patients?
What is the purpose of administering D5W maintenance fluid during the second 24 hours of fluid resuscitation in burn patients?
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What is the recommended first step in managing metabolic asphyxiation due to inhalation burns?
What is the recommended first step in managing metabolic asphyxiation due to inhalation burns?
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What changes occur to the dose requirement of non-depolarizing muscle relaxants (NDMR) after 24 hours post-burn?
What changes occur to the dose requirement of non-depolarizing muscle relaxants (NDMR) after 24 hours post-burn?
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Which airway management technique is essential to avoid worsening obstruction in patients with suspected inhalation injuries?
Which airway management technique is essential to avoid worsening obstruction in patients with suspected inhalation injuries?
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What is the characteristic appearance of blood in carbon monoxide poisoning?
What is the characteristic appearance of blood in carbon monoxide poisoning?
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When treating carbon monoxide poisoning, what is the primary method to reduce carboxyhemoglobin levels?
When treating carbon monoxide poisoning, what is the primary method to reduce carboxyhemoglobin levels?
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What fluid resuscitation strategy should be advocated for adults suffering from severe burns?
What fluid resuscitation strategy should be advocated for adults suffering from severe burns?
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In cases of carbon monoxide poisoning, what false assumption might pulse oximetry provide?
In cases of carbon monoxide poisoning, what false assumption might pulse oximetry provide?
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What warning sign is NOT typically associated with lower airway injuries from inhalation burns?
What warning sign is NOT typically associated with lower airway injuries from inhalation burns?
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Which of the following inhalation injuries is primarily a result of smoke's chemical components?
Which of the following inhalation injuries is primarily a result of smoke's chemical components?
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What metabolic effect results from carbon monoxide binding to hemoglobin?
What metabolic effect results from carbon monoxide binding to hemoglobin?
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Study Notes
Burn Injury Statistics
- From 2011 to 2015, over 1.25 million people in the US sustained burn injuries
- 3,390 burn-related deaths occurred, primarily from inhalation injuries during fires and crashes
- 75% of burn-related deaths take place at the scene of the accident
- Approximately 35% of burn victims are children under 60 years old with >40% total body surface area (TBSA) burns and inhalation injuries
Burn Shock
- Burn shock can develop with TBSA burns of 20% or greater
- Burn shock leads to fluid shifts, impacting blood volume and cardiac output
- Early resuscitation is crucial to address burn shock
Fluid Resuscitation Guidelines
-
Modified Brooke & Parkland Formula:
- First 24 hours: 2-4 mL lactated ringer's (LR) solution per % burn per kg body weight (half in the first 8 hours, half in the next 16 hours)
- Second 24 hours: D5W maintenance fluid with 0.5 mL colloid per % burn per kg body weight
-
Consensus Formula:
- Adults: 2-4 mL LR per kg body weight per %TBSA burned
- Pediatrics: 3-4 mL LR per kg body weight per %TBSA burned
- Infants and Young Children: IVF with 5% dextrose at maintenance rate in addition to resuscitation fluid
Minimum Urine Output (UOP)
- Adults: 0.5-1.0 mL/kg/hr
- Children < 30 kg: 1 mL/kg/hr
- High-voltage Electrical Injury: 1-1.5 mL/kg/hr
Criteria for Adequate Resuscitation
- Normalize blood pressure
- UOP 1-2 mL/kg/hr
- Blood lactate < 2 mmol/L
- Base deficit < -5
- Gastric intramucosal pH > 7.32
- Mixed venous oxygen tension 35-40 mmHg
- Cardiac index 4.5 L/min/m2
- Oxygen delivery index (DO2I) 600 mL/min/m2
Abdominal Compartment Syndrome (ACS)
- ACS and intra-abdominal hypertension (IAH) are life-threatening complications in critically ill burn patients
- ACS is caused by aggressive fluid resuscitation
- Intra-abdominal pressure (IAP) > 20 mmHg via bladder pressure transduction with organ dysfunction (hemodynamic instability, increased peak inspiratory pressure, oliguria, worsening metabolic acidosis)
- Treatment: neuromuscular blockade, sedation, diuresis, and potentially laparotomy
- ACS is fatal without treatment
Perioperative Considerations
- Succinylcholine: Safe within 24 hours post-burn, but can cause hyperkalemia-induced cardiac arrest after 24 hours due to upregulation of extrajunctional receptors
- Non-depolarizing Muscle Relaxants (NDMR): Dose requirement increases by 2-5 times due to fluid shifts altering the volume of distribution
- Ketamine: Useful analgesic, even in unstable patients
- Hypothermia Prevention: Maintain patient temperature
Inhalation Injuries
- Inhalation injuries can accompany thermal burns and should be suspected
- Severity depends on fire location, ignition source, temperature, and toxic gas concentration
Types of Inhalation Injuries
- Upper Airway: (mouth, oropharynx, larynx) caused by thermal injury
- Lower Airway: (trachea, bronchioles, alveoli) caused by smoke's chemical and particulate constituents
- Pulmonary Parenchymal Injury:
- Metabolic Asphyxiation: Systemic toxicity (e.g., carbon monoxide or hydrogen cyanide)
Inhalation Injury Treatment
- First Priority: High FiO2
- Diagnosis: Fiberoptic bronchoscopy is the gold standard
Bronchoscopy Grading Scheme
- Grade 0: Normal
- Grade B: Positive based on biopsy only
- Grade 1: Hyperemia
- Grade 2: Severe edema and hyperemia
- Grade 3: Severe injury: ulcerations and necrosis
Lower Airway Injuries
- Inhaled toxins interact with airway mucosa, producing acidic and alkaline substances that increase capillary permeability
- Extensive alveolar and epithelial damage can lead to necrosis
Warning Signs of Inhalation Injury
- Hoarseness, sore throat, dysphagia, hemoptysis, tachypnea, wheezing, carbonaceous sputum, elevated carbon monoxide levels
Airway Management
- Awake fiberoptic intubation (FOI) is necessary for abnormal or upper airway obstruction
- Topical anesthesia, positioning, supplemental oxygen, incremental doses of ketamine or dexmedetomidine
- Sedatives should be used cautiously to prevent worsening airway obstruction
- Humidified inspired gases help clear tracheobronchial debris and prevent secretion drying
- ETT remains in place until laryngeal edema subsides
- Progressive air leak around the tube may indicate reduced edema
Nebulizer Treatments
- Nebulized heparin and N-acetylcysteine can reduce reintubation for pulmonary failure, atelectasis, and mortality
Carbon Monoxide Poisoning
- CO binds to hemoglobin with an affinity 200 times that of oxygen
- This shifts the oxyhemoglobin dissociation curve to the left, impairing oxygen offloading
- This leads to anaerobic metabolism and metabolic acidosis
- Blood has a "cherry red" appearance
Carbon Monoxide Poisoning Diagnosis
- Measure arterial carbon monoxide hemoglobin (COHb) levels via cooximeter
- Pulse oximetry alone is inaccurate and may falsely elevate saturation
Carbon Monoxide Poisoning Treatment
- The half-life of COHb is 26-148 minutes
- Administer 100% FiO2 or hyperbaric oxygen
Carbon Monoxide Poisoning Symptoms
- 0-10% COHb: Normal
- 10-20% COHb: Headache, confusion
- 20-40% COHb: Disorientation, fatigue, nausea, visual changes
- 40-60% COHb: Hallucination, combativeness, convulsions, coma, shock state
- 60-70% COHb: Coma, convulsions, weak respiration, and pulse
- 70-80% COHb: Decreasing respiration and stopping
- 80-90% COHb: Death in < 1 hour
- 90-100% COHb: Death within a few minutes
Cyanide Poisoning
- Produced from combustion of plastics, foam, paints, wool, silk etc.
- Cyanide binds to terminal cytochrome on the electron transport chain, causing hypoxia, lactic acidosis, and elevated mixed venous oxygen saturation
- Half-life is ~ 1 hour
Cyanide Poisoning Signs and Symptoms
- Loss of consciousness, mydriasis, seizures, hypotension, tachypnea followed by apnea, and elevated lactate
Cyanide Poisoning Treatment
- Hydroxocobalamin 5g over 15 minutes
- Rapid onset neutralizes cyanide without interfering with cellular oxygen use
Preoperative Anesthesia Planning
- Warm operating room ahead of time (28-33°C)
- Check availability of blood products and order more if needed (based on preoperative hemoglobin value, size of burn, and extent of debridement)
- Have blood products immediately available in the operating room
- Have at least one blood warmer primed, plugged in, and turned on (have two if the burn is large)
- Ensure adequate IV access before the surgeon begins debridement
- Plan ahead if invasive lines are required
- Plan for airway management and ventilation both intraoperatively and postoperatively
- Be flexible and ready to modify plans as needed
Heat Loss in Burn Patients
-
Source of Heat Loss:
- Radiation: 60%
- Evaporation: 25%
- Convection: 12%
- Conduction: 3%
-
Methods to Reduce Heat Loss:
- Radiation: Warm operating room to 28-33°C, use heat lamps, and reflective blankets
- Evaporation: Warm operating room
- Convection: Place the patient on an insulated or warming blanket
- Conduction: Cover the patient with watertight material, humidify ventilator gases, utilize an IV fluid warmer, and use a forced air warming blanket
Burn Statistics
- From 2011-2015, 1.25 million people sustained burn injuries in the US.
- 3,390 people died from burn injuries, mostly due to inhalation injuries in fires and crashes.
- 75% of burn-related deaths occur at the accident scene.
- 35% of burn victims are children under the age of 6.
- 40% of burn victims have burns that affect more than 40% of their total body surface area (TBSA).
- More than 40% of burn victims also have inhalation injuries.
Burn Shock
- Burns that affect 20% or more of TBSA can lead to burn shock.
- This shock impacts blood volume and carbon monoxide levels.
- Fluid resuscitation is essential to correct burn shock.
Initial Burn Patient Assessment
- Assess the airway, breathing, and circulation (ABC).
- Assess for coexisting trauma.
- Rule out upper airway injury and/or head and neck burns.
- Look for signs of edema (swelling).
- Inhaled smoke can lead to pulmonary edema and ventilation/perfusion mismatch.
Burn Diagnosis & Assessment
- Use imaging like chest X-rays and chest CTs.
Burn Treatment
- Intubate patients with upper airway injuries early on, even if they are not yet showing signs of airway decompensation.
Fluid Resuscitation Guidelines
- Two common fluid resuscitation formulas are the Modified Brooke formula and Parkland formula.
Modified Brooke Formula
- Administer 2 mL lactated Ringer's (LR) per percentage of burn per kilogram of body weight over the first 24 hours.
- Administer half the total fluid in the first 8 hours and the other half in the next 16 hours.
- Colloids are not administered in the first 24 hours but start at 0.5 mL per percentage of burn per kilogram of body weight in the second 24 hours.
Parkland Formula
- Administer 4 mL LR per percentage of burn per kilogram of body weight over the first 24 hours.
- Administer half the total fluid in the first 8 hours and the other half in the next 16 hours.
- Colloids are not administered in the first 24 hours but start at 0.5 mL per percentage of burn per kilogram of body weight in the second 24 hours.
Fluid Resuscitation Consensus Formula
- Adults: Use LR at 2-4 mL x kg body weight x %TBSA burned.
- Pediatrics: Use LR at 3-4 mL x kg body weight x %TBSA burned.
- Administer half the estimated volume in the first 8 hours and the other half in the next 16 hours.
- Infants and children should receive IV fluids with 5% dextrose at a maintenance rate in addition to resuscitation fluids.
Minimum Urine Output (UOP)
- Adults: 0.5-1.0 mL/kg/hr.
- Children under 30 kg: 1 mL/kg/hr.
- High-voltage electrical injury: 1-1.5 mL/kg/hr.
Adequate Fluid Resuscitation Criteria
- Normalization of blood pressure
- Urine output (1-2 mL/kg/hr)
- Blood lactate (< 2 mmol/L)
- Base deficit ( < -5 )
- Gastric intramucosal pH ( > 7.32)
- Mixed venous oxygen tension (35-40 mmHg)
- Cardiac index (4.5 L/min/m2)
- Oxygen delivery index (DO2I) (600 mL/min/m2)
Abdominal Compartment Syndrome (ACS)
- Can be fatal if left untreated.
- ACS is caused by increased intra-abdominal pressure (IAP) of greater than 20 mmHg. This can be measured by bladder pressure.
- High IAP can result from massive fluid resuscitation.
- ACS can lead to organ dysfunction including hemodynamic instability, increased peak inspiratory pressure (PIP), oliguria, worsening metabolic acidosis.
- Treatment includes neuromuscular blockade (NMB), sedation, diuresis, and laparotomy.
Perioperative Considerations
- Succinylcholine is safe for use within 24 hours of a burn, but after 24 hours, it can cause hyperkalemia-induced cardiac arrest.
- The dosage of nondepolarizing muscle relaxants (NDMRs) increases by 2-5 times after 24 hours because fluid shifts alter the volume of distribution.
- Ketamine is a good choice for analgesia in burn patients, even those who are unstable.
- Prevent hypothermia in burn patients because they are at increased risk.
Inhalation Injuries
- Inhalation injuries can accompany thermal burns.
- The extent of inhalation injury is based on factors including fire location, ignition source, temperature, and toxic gas concentration.
- Inhalation injuries are classified into four types based on anatomic location:
- Upper airway injuries: From thermal burns in the mouth, oropharynx, and larynx.
- Lower airway injuries: From smoke's chemical and particulate constituents in the trachea, bronchioles, and alveoli.
- Pulmonary parenchymal injury: Damage to the lung tissue.
- Metabolic asphyxiation or systemic toxicity: From exposure to gases like carbon monoxide or hydrogen cyanide.
- The first priority for treatment of inhalation injuries is high FiO2 (fraction of inspired oxygen).
Flexible Bronchoscopy Grading Scheme
- 0: Normal (no inhalation injury), 0% mortality.
- B: Positive on biopsy only, 0% mortality.
- 1: Hyperemia, 2% mortality.
- 2: Severe edema and hyperemia, 15% mortality.
- 3: Severe injury: ulcerations and necrosis, 62% mortality.
Lower Airway Injuries
- Inhaled soot particles and chemicals from fire react with the airway mucosa, creating acidic and alkaline substances that increase capillary permeability.
- Damage to the alveoli and epithelial lining of the airways can lead to necrosis.
Warning Signs of Inhalation Injury
- Hoarseness, sore throat, dysphagia, hemoptysis, tachypnea, wheezing, carbonaceous sputum, and elevated carbon monoxide levels.
Airway Management
- Use awake fiberoptic intubation (FOI) for patients with abnormal or upper airway obstruction.
- Use topical anesthesia and appropriate positioning.
- Provide supplemental oxygen.
- Administer incremental doses of ketamine or dexmedetomidine.
- Avoid excessive sedation to prevent worsening airway obstruction.
- Consider IV opioids for pain control in alert patients.
- Use humidified inspired gases to clear tracheobronchial debris.
- Continue endotracheal intubation (ETT) until laryngeal edema subsides.
- A progressive air leak around the tube may indicate reduced edema.
- Nebulisation of heparin and N-acetylcysteine may reduce the need for reintubation due to pulmonary failure, atelectasis, and mortality.
Carbon Monoxide Poisoning
- Carbon monoxide binds to hemoglobin with an affinity 200 times that of oxygen.
- This causes a leftward shift in the oxyhemoglobin dissociation curve, which impairs oxygen offloading from hemoglobin.
- This leads to anaerobic metabolism and metabolic acidosis.
- Carbon monoxide poisoning results in a cherry-red appearance of the blood.
- Diagnosis requires measuring arterial carbon monoxide hemoglobin (COhgb) levels using a cooximeter.
- Pulse oximetry alone is inaccurate and can falsely elevate readings.
- The half-life of COhgb is 26-148 minutes.
- Treatment includes 100% FiO2 or hyperbaric oxygen therapy.
Carbon Monoxide Poisoning Symptoms Based On COhgb Levels
- 0-10%: Normal.
- 10-20%: Headache, confusion.
- 20-40%: Disorientation, fatigue, nausea, visual changes.
- 40-60%: Hallucination, combativeness, convulsions, coma, shock state.
- 60-70%: Coma, convulsions, weak respiration and pulse.
- 70-80%: Decreasing respiration and stopping.
- 80-90%: Death in less than 1 hour.
- 90-100%: Death within a few minutes.
Cyanide Poisoning
- Cyanide is produced by combustion of plastics, foam, paints, wool, silk, etc.
- Cyanide binds to the terminal cytochrome in the electron transport chain, causing hypoxia, lactic acidosis, and elevated mixed venous oxygen saturation.
- Signs and symptoms include:
- Loss of consciousness.
- Mydriasis (pupillary dilation).
- Seizures.
- Hypotension.
- Tachypnea followed by apnea.
- Elevated lactate.
- Treatment includes hydroxocobalamin 5 g over 15 minutes.
- Hydroxocobalamin actively binds to cyanide, forming cyanocobalamin, which is excreted by the kidneys.
- This rapidly neutralizes cyanide without interfering with cellular oxygen use.
Preoperative Anesthesia Planning for Burn Patients
- Warm the operating room (OR) before the operation, ideally 28-33 degrees Celsius.
- Check the availability of blood products and order more if needed based on preoperative hemoglobin levels, burn size, and the extent of debridement.
- Have blood products immediately available in the OR.
- Have at least one blood warmer primed, plugged in, and turned on. If the burn is large, have two.
- Ensure adequate IV access before the surgeon begins debridement.
- Plan for invasive lines if needed.
- Plan for airway management and ventilation both intraoperatively and postoperatively.
- Be prepared to modify the plan if necessary.
Heat Loss in Burn Patients
- The majority of heat loss in burn patients is from radiation (60%).
- Evaporation accounts for 25%.
- Convection accounts for 12%.
- Conduction accounts for 3%.
Methods to Reduce Heat Loss
- Warm the OR.
- Use heat lamps.
- Use reflective blankets.
- Place the patient on an insulated or warming blanket.
- Cover the patient with watertight material.
- Humidify ventilator gases.
- Use an IV fluid warmer.
- Use a forced air warming blanket.
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Test your knowledge on the statistics related to burn injuries, including prevalence, death rates, and the demographics of victims. Additionally, evaluate your understanding of burn shock and the crucial guidelines for fluid resuscitation following significant burns.
