How do you classify the burn injury?
How do you express the extent of the burn injury?
Should the “rule of nines” be used in children?
What is the definition and etiologies of a major burn according to the American Burn Association?
What functions does the skin perform?
What pathophysiologic changes accompany major thermal injury?
Name some of the known mediators released with thermal injury. What are the responses to those mediators?
What is the prognosis for this patient? What major factors affect his prognosis?
What are the most common causes of death?
Does this patient have a smoke inhalation burn? How do you make the diagnosis?
What is carbon monoxide poisoning? How do you diagnose and treat carbon monoxide poisoning?
What resuscitative measure would you institute immediately in this patient with 40% burns?
What fluid formula would you use?
What cardiovascular changes typify the burn injury?
What hematologic changes occur in burn injury?
What changes occur in liver function? What are the anesthetic implications of such changes?
What are Curling ulcers? How can they be prevented?
What complications are associated with electrical burns?
What preoperative preparations would you order? What are particular concerns in this patient?
What are the various operative and management options available for severely burned patients?
What are the advantages and disadvantages of early tangential excision splitthickness skin grafting (TE/STSG)?
What is this patient’s mean arterial blood pressure? How do you calculate it?
Are you concerned about this patient’s blood pressure? What treatment would you institute?
This patient was ventilated with respirator settings of tidal volume, 800 mL; respiratory rate, 20 breaths per minute; FIO2, 60%; and positive end-expiratory pressure, 10 cm H2O. Arterial blood gas analyses showed the following: pH, 7.24; PO2, 56 mm Hg; PCO2, 60 mm Hg; and O2 saturation, 80%. How would you interpret these arterial blood gas analysis results? What are the possible causes of high PCO2 and low PO2?
How do you calculate oxygen content and oxygen delivery? What factors govern the oxygen delivery to the tissues?
What are the symptoms and signs of alcohol withdrawal? Are you concerned that this patient could develop delirium tremens?
How would you prevent the adverse effects of alcohol withdrawal?
What monitors would you use in the operating room?
What information can be obtained from an arterial line and a pulmonary artery catheter? How are these calculations performed?
If the patient had not been intubated, how would you proceed with the anesthetic induction?
Why is awake intubation considered the safest?
What anesthetic agents would you use? Discuss inhalation versus intravenous agents.
Why are you concerned about the patient’s body temperature? What is normothermia for a burned patient?
How is temperature best maintained?
What derangements occur with hypothermia?
What muscle relaxant would you use?
Why is succinylcholine contraindicated in burned patients? For how long should it be avoided?
What other adverse effects are associated with succinylcholine?
How are the doses of nondepolarizing muscle relaxants affected by burn injury?
How are the muscle relaxants such as succinylcholine, atracurium, cisatracurium, vecuronium, pancuronium, rocuronium, and curare metabolized and eliminated? Which of them has significant histamine release?
What is the difference between metabolism and elimination of drugs?
How would you monitor this patient during transport?
What is meant by diffusion hypoxia? How do you prevent it?
Why do patients often shiver in the recovery room on emergence from anesthesia?
Discuss the causes of oliguria in the recovery room.
and deep dermal burns. Third-degree burns are full-thickness and characterized by irreversible destruction of all dermal and epidermal elements. Fourth-degree burns involve injury to underlying tissue structures—muscle, fascia, tendon, and bone (Table 56.1).
TABLE 56.1 Classification of Burn Depth
Full-thickness burns more than 10% TBSA
Partial-thickness burns more than 25% in adults or 20% at extremes of age
Burns involving face, hands, feet, or perineum
FIGURE 56.1 The rule of nines for determining the percentage of body surface area burned in adults. (Adapted from MacLennan N, Heimbach DM, Cullen BF. Anesthesia for major thermal injury. Anesthesiology. 1998;89:749-770.)
Flame—from superheated oxidized air
Scaled—from hot liquid
Contact—from hot or cold solid materials
Chemicals—from noxious chemicals
Electricity—conduction of current through tissues
FIGURE 56.2 Diagram and table for determining the percentage of body surface area burned in children. (Adapted from MacLennan N, Heimbach DM, Cullen BF. Anesthesia for major thermal injury. Anesthesiology. 1998;89:749-770.)
FIGURE 56.3 Mediators released with thermal injury and the response to their release. TNF, tumor necrosis factor. (From MacLennan N, Heimbach DM, Cullen BF. Anesthesia for major thermal injury. Anesthesiology. 1998;89: 749-770, with permission.)
injury include burned nasal mucosa/lips/mouth, singed nasal hair, hoarseness, wheezing, and soot in the sputum. The posterior pharynx may appear red, and the larynx may appear edematous. Radiographic findings are usually negative immediately after injury. Laboratory tests include blood gas analysis, carboxyhemoglobin concentration, xenon scans, and fiberoptic bronchoscopy.