Anesthesia for Burns & Thermal Injuries

Brad Metzenbacher Jeremy Orwin

Thermal Injury

Overview
Anatomy & Physiology Pathophysiology Pharmacology Anesthetic Technique & Management Management of Complications

Anatomy & Physiology

Anatomy & Physiology of the Skin

Functions of the Skin

Largest organ of body
Sensory organ Thermoregulation Prevents the loss of body fluids Protective barrier against microorganisms

Structures of the Airway

Pathophysiology

Types of Thermal Injuries

Thermal
Flame Steam Scald

Electrical Chemical Inhalation

Thermal Injuries
1st Degree 2nd Degree 3rd Degree 4th Degree Frostbite

Structure of the Skin

Classification of Burn Depth First-Degree

Firstdegree
Superficial (sunburn) Erythema, pain, absence of blisters Consists of epidermal damage alone

Heals within 3 to 6 days

Classification of Burn Depth Second-Degree

Second-degree
Involves: Entire epidermal layer Part of underlying dermis Mottled and red, painful, swelling and blisters

Healing in 10 to 21 days

Classification of Burn Depth Second-Degree

Superficial partial-thickness: 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 Third-Degree

Third-degree (Full thickness)
Destruction of all epidermal and dermal elements Burn into subcutaneous fat or deeper Skin is charred and leathery (woody) Pearly-white sheen / waxy Generally not painful (nerve endings are dead)

Classification of Burn Depth Third-Degree

Classification of Burn Depth Fourth-Degree

Fourth-degree
Full-thickness Extending into muscle, tendons or bones Typically involves appendage Black and dry No pain

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 48o post injury

Chemical Burns
Caused by strong acid or alkaline solution
Damage continues until the substance is removed or neutralized May take time to take effect & may continue to penetrate 2448hrs 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
Smoke inhalation Heat inhalation injury Asphyxiation Carbon monoxide (CO) poisoning Toxic gas inhalation

Carbon Monoxide Poisoning

CO combines w/ Hgb Carboxyhemoglobin (COHb) 200 xs more affinity for Hgb Direct myocardial depression S&S Headache, irritibility Respiratory failure, myocardial ischemia Seizures, coma, death

Treatment = 100% O2 (reduces CO half-life from 4hrs to 40min) SpO2 will read falsely high ABGs must have co-oximetry to determine true O2 saturation

Frostbite
Local freezing of tissue
Ice formation in the extracellular space Appears waxy / white Extent of damage may be hidden for days to weeks

Numbness & Pain (upon thawing) Upon thawing

Severe hyperemia, edema, blistering RBC & Platelet dumping = circulatory stasis / ischemia (gangrene)

Treatment
Rapid re-warming decreases extent of the damage
Emersion in warm water

Stages of Thermal Injuries

1st Stage Edema 2nd Stage Diuresis

1st Stage: Edema

First 24 hours Fluid leak: vascular space interstitial space
osmotic pressure capillary permeability Vasoactive substances released

interstitial edema and intravascular hypovolemia occurs

1st Stage Cont

Burns >30% BSA cause capillary changes in both burned and non-burned tissue
Burned tissue edema
Direct thermal injury to endothelial cells and burn tissue osmolarity

Non-burn tissue edema

Severe hypoproteinemia

Small wound
Edema greatest 8-12 hrs post injury

Large wound
Edema greatest 18-24 hrs post injury

2nd Stage: Diuresis

24-36 hours after burn, fluid and electrolytes begin to remobilize back into intravascular space Capillary seal reestablishes

Diuresis occurs due to GFR in response to intravascular volume

May see hypernatremia and hypokalemia Cardiac output may 200-300% normal O2 consumption

Impact on Systems
Immune System
Alters immune cells ability to function killing power of neutrophils Macrophages and lymphocytes do not work well

Hematologic System
Destruction of RBCs Hemoglobinuria Hgb level viscosity WBC level Coagulation altered

Impact on Systems
Cellular Response
tissue oxygen tension Na and H2O shift into cell intracellular swelling Possible cell death K+ level intravascularly O2 level Anaerobic metabolism begins Lactic acid levels Metabolic acidosis occurs

Impact on Systems
Endocrine System
Massive release of catecholamines, glucagon, ACTH, ADH, Renin, Angiotensin, & Aldosterone
Hyperglycemia

Neurological System
cerebral perfusion Cerebral edema occurs from Na shifts Carbon monoxide or associated head injury may cause neuro changes

Impact on Systems
GI System
Slow peristalsis and possible ileus HCL acid secretion from stress response Narcotics for pain management further slow peristalsis

Hepatic System
Decreased hepatic synthesis Decreased metabolic function

Impact on Systems
Renal System
RBF & GFR Activation of RAS
Release of ADH
retain water & Na lose of K, Ca, & Mg

ARF Acute Tubular Necrosis 2o hemoglobinuria & myoglobinuria d/t hemolysis & tissue necrosis
Maintain high u/o (2ml/kg/hr) w/ fluids / osmotic diuretics

Impact on Systems
CV 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 decreased venous return:

preload cardiac filling pressure CVP and PCWP

After 24hrs = increased blood flow to tissues, HTN

Impact on Systems
Respiratory System
Upper airway injury
Involves all of airway to level of true vocal cords Initially due to inflammation from heat of inspired smoke Exacerbated by accumulation of excess interstitial fluid

Major airway injuries

Involves trachea and bronchi

Parenchymal injury
Involves entire respiratory tract down to, and including, alveolar membrane Commonly lethal within first few hours after injury due to profound bronchospasms and hypoxia

Impact on Systems
Respiratory System Cont
0-24hrs Edema Obstruction Carbon Monoxide Poisoning
2-5 Days May develop ARDS Signs & Symptoms Stridor / Hoarseness / Facial burns / Singed nasal hairs / Carbonaceous sputum / Impaired level of consciousness
S/S of deteriorating ABGs & increasing respiratory distress

Estimation of Burned Area

Rule of 9s
Head and neck9% Each arm..9% Each leg..18% Anterior trunk..18% Posterior trunk18% Perineum...1%

Lund and Browder

Designed for children Larger heads Adjustments based on growth

Pharmacology

Induction Medications
Hemodynamics Stable Questionable Unstable Medication Propofol / STP Ketamine Etomidate

Remember medications may be more potent and have a prolonged effect in the burn patient.

Muscle Relaxants
Anectine safe in the 1st 24hrs (afterwhich hyperkalemia may be a problem up to a year or the burn is healed) Non-depolarizers burn patients tend to be resistant to the effects of nondepolarizing muscle relaxants
May need 2-5 xs the normal dose!!!

Anesthetic Technique & Management

Preoperative Evaluation & Testing

Initial evaluation of the burn patient
Time of the injury* Type (electrical / chemical), depth, & extent of burn Airway / pulmonary damage Age, allergies, medications Associated trauma Co-existing medical conditions Anesthetic history

Preoperative Testing
Diagnostic Testing
ABG (w/ co-oximetry) acid-base balance Electrolytes imbalances (hyperkalemia) Serial Hct ongoing blood loss or erythrocyte destruction / volume status Coagulation Profile rule out a bleeding diathesis Urine Myoglobin (electrical injuries or pigmented u/o) CXR

Anesthetic Technique & Management

Preop Meds
Provide adequate analgesia Fluids

Establish Adequate Vascular Access

Consider Invasive Monitoring

Airway Management
Consider Alternatives to Direct Laryngoscopy
Awake FOB

Anesthetic Technique & Management

Ventilation
Increased minute ventilation
increased metabolic rate

Fluids & Blood

Anticipate rapid, large blood loss Evaluate coagulation status

Temperature Regulation
Increase ambient temperature Warm IV fluids

Anesthetic Technique & Management

Anesthetic Drugs
Include opioids Consider effects of increased circulating catecholamines

Muscle Relaxants
Avoid Anectine Anticipate resistance to nondepolarizing muscle relaxants

Postoperative
Anticipate increased analgesic requirements

Management of Complications

General Concerns
Compromised Airway Hypovolemia Compromised Vascular Access Interaction of Anesthetic Agents Pain

Thermal Injuries
General Management
Stop the burning Supportive care Oxygen (intubation) Fluid replacement Electrolyte management Escharotomies / Fasciotomies Wear isolation materials with patient contact Do NOT institute broad spectrum antibiotics

Inhalation Injury
Supportive Care
Maintain oxygenation Manage bronchospasms Fluid replacement Pulmonary toilet Intubation / tracheostomy
Low volume, high PEEP

Fluid Resuscitation
Parkland formula
4cc X weight X % burn
volume in first 8 hours

Second over last 16 hours

Brooke formula
2cc X weight X % burn
volume in first 8 hours

Second over last 16 hours

Daily maintenance fluids

Common Operations
Decompression procedures
escharotomies & fasciotomies

Burn excision & skin grafting Reconstruction operations Supportive procedures

tracheostomy, gastrostomy, vascular access

Escharotomy
A surgical incision of the eschar and superficial fascia in order to permit the cut edges to separate and restore blood flow to unburned tissue distal to the eschar.
Circumferential burns (impede ventilation) Compartment syndrome (impede perfusion)

Can be performed at the bedside / ED.

Fasciotomy
The fascia is thin connective tissue covering, or separating, the muscles and internal organs of the body. Usually done by a surgeon under general or regional anesthesia. An incision is made in the skin, and a small area of fascia is removed where it will best relieve pressure. Then the incision is closed.

Review Anesthetic Management

Preop Meds
Provide adequate analgesia Fluids

Temperature Regulation
Increase ambient temperature Warm IV fluids

Establish Adequate Vascular Access

Consider Invasive Monitoring

Anesthetic Drugs
Include opioids Consider effects of increased circulating catecholamines

Airway Management
Consider Alternatives to Direct Laryngoscopy
Awake FOB

Muscle Relaxants
Avoid Anectine Anticipate resistance to nondepolarizing muscle relaxants

Ventilation
Increased minute ventilation
increased metabolic rate

Postoperative
Anticipate increased analgesic requirements

Fluids & Blood

Anticipate rapid, large blood loss Parkland Formula

Case Presentation
30 y/o male coming back to O.R. the day following initial injury for debridement of 2nd and 3rd degree burns of chest, arms, and face.
History Patient was outdoors lighting barbeque. Coals were not lighting as anticipated so patient was spraying them with lighter fluid. Flames flashed back up stream of lighter fluid and in a panic the patient sprayed himself. He has been maintaining his own airway, however you notice that he is having stridor and oxygen saturations have slowly decreased over last 4 hours. Additional medical history include mild hypertension - for which patient was on metoprolol 100 mg daily, borderline diabetes, obesity 125 kg, daily ETOH consumption of a 6 pack of beer.

Case Presentation
Anesthetic considerations
Health concerns Potential problems Fluid replacement Areas burned

Case Presentation
Anesthetic concerns
New respiratory concern how should we manage this?
Awake FOB

What drugs should we use potential problems?

No succs consider Roc/Nimbex at 2-5xs normal dose Avoid Des more irritating to airway Possibly use TIVA technique drugs?

Case Presentation
Health issues
Fluid replacement
Parkland formula 4 mL x 125 kg x 45% burned
22,500 mLs replace 1st half over 8 hours, 2nd half over next 16 hours

Comorbidities
Hypertension Diabetes Etoh consumption

Questions?

Questions for quiz

1. What is the percentage of burned area for a 7 y/o with burns on the left side of the body, front and back? A) 34% B) 43% C) 29% D) 51% How much fluid should you give the first 8 hours to a 70 kg person burned over 25% of their body? A) 3000 mL B) 4000 mL C) 7000 mL D) 3500 mL Which relaxant should be avoided 24 hours following burn injury and why? Succinocholine, severe hyperkalemia What are the four types of burns a patient can receive? Thermal, Chemical, Electrical, Inhalation What is the major concern with anyone with facial burns? Damage to airway structures creating a difficult intubation scenario

2.

3.

4.

5.