17 Burns Flashcards
First degree burn
Epidermis
Sunburn
Superficial dermis burn (second degree)
Papillary dermis
Painful to touch, blebs and blisters, hair follicles intact, blanches
Does NOT need skin grafts
Deep dermis burn (second degree)
Reticular dermis
Decreased sensation, loss of follicles
Requires skin grafts
Third degree burn
Leathery (charred parchment)
Down to subcutaneous fat
Fourth degree burn
Down to bone
Into adjacent adipose or muscle tissue
Admission criteria for a burn center
Only relates to 2/3rd degree burns:
- >10% BSA (<10, >50yo)
- >20% BSA anyone
- Hands, face, feet, genitalia, perineum or major joints
3rd degree > 5%
Electrical and chemical burns
Concomitant inhalation injury, mechanical traumas, pre-existing medical conditions
Special social, emotional or long-term rehab needs
Suspected child abuse/neglect
Most common type of burn?
Scald
Most common type of burn to present to ED and be admitted?
Flame
Parkland formula
Burns >20%; only 2nd degree and greater
4cc x kg x % burn
Give 1/2 in first 8 hours, next 1/2 over 16 hours
Underestimates in patients with inhalation injury, ETOH, electrical injury, post-escharotomy
What fluid do you use in the first 24hrs after a burn?
Lactated ringers
Colloid (albumin) within the first 24 hours increases pulmonary/respiratory complicaitons
Indications for escharotomy
Perform within 4-6 hours
- Circumferential deep burns
- Low temp, weak pulse, decreased capillary refill, decreased pain sensation or decreased neurological functioning extremity
- Problems ventilating patient with significant chest torso burns
If concern for compartment syndrome after escharotomy - perform fasciotomy
Risk factors for burn injuries
Alcohol or dug use Age (very young/very old) Smoking Low SES Violence Epilepsy
What is the cause of lung injury in burn patients?
Carbonaceous materials and smoke NOT heat (protective closing)
Risk factors for airway injury in a burn patient?
ETOH Trauma Closed space Rapid combustion Extremes of age delayed extrication
Signs and symptoms of possible airway injury in burn patients?
Facial burns
Wheezing, stridor
Carbonaceous sputum
Indications for intubation in burn patients?
Upper airway stridor or obstruction
Worsening hypoxemia
Massive volume resuscitation can worsen symptoms
Most common infection in patients with >30% burns? Most common cause of death?
Pneumonia
Treatment of acid and alkali burns?
Water irrigation
Type of burn that causes liquefaction necrosis?
Alkali
Deeper burn
Type of burn that causes coagulation necrosis?
Acid
Treatment of hydrofluoric acid burns?
Spread calcium on the wound
Treatment of tar burns?
Cool
Wipe away with lipophilic solvent (adhesive remover)
Complications of electrical burns
Rhabdomyolysis Compartment syndrome Polyneuritis Quadriplegia Transverse myelitis Cataracts Liver necrosis Intestinal perforation Gallbladder perforation Pancreatic necrosis
Caloric need in first week of burn?
25kcal/kg/day + (30kcal x %burn)
Protein need in first week of burn?
1g/kg/day + (3g x %burn)
What is the best source of non-protein calories in burn patients?
Glucose
Burn wounds use glucose in an obligatory fashion
When do you excise burn wounds? Exceptions?
Within 72 hours, but AFTER appropriate fluid resuscitation
Used in deep 2nd, 3rd and 4th degree burns
Exception - face, palms, soles, genitals - defer for 1 week
Limitations/goals for burn surgery?
< 1L blood loss
< 20% of skin excised
< 2hrs in OR
When are skin grafts contraindicated?
Positive B-hem strep
Bacterial > 10^5
Benefits of Autografts
Decreased - infection, desiccation, protein loss, pan, water loss, heat loss and RBC loss
What are donor skin sites regenerated?
From hair follicles and skin edges
Imbibition
Osmotic nutrition
Blood supply to skin graft for days 0-3
Neovascularization
Starts around day 3
Where are skin grafts unlikely to do well?
Areas of poor vascularized beds
Tendons, bone without periostomy, radiation areas
How thick are split-thickeness grafts?
12-15mm
Includes epidermis and part of dermis
Homografts
Cadaveric skin
Temporizing material - last 2-4 weeks
They vascularize and are eventually rejected
Xenografts
Porcine
Last 2 weeks
Do NOT vascularize
Reasons to delay autografting
Infection
Not enough skin donor sites
Patient septic or unstable
Do not want to create any more donor sites with concomitant blood loss
Most common cause for skin graft loss?
SEroma/hematoma
STSGs are more likely to:
Survive
Easier for imbibition and revascularization due to being thinner
FTSGs have less:
Wound contraction
Good for palms and back of hands
Treatment of facial burns?
Topical antibiotics for 1 week
FTSG for unhealed areas (non-meshed)
Treatment of hand burns?
Superficial - ROM exercise, splint in extension if too much edema
Deep - Immobilize in extension for 7 days after FTSG, then physical therapy
Treatment of palm burns?
Try to preserve specialized palmar attachments
Splint hand in extension for 7 days after FTGS
Treatment of genital burns?
Use STSG (meshed)
Most common organisms in burn wound infections?
Pseudomonas*
Staph
E. coli
Enterobacter
Silvadene (silver sulfadiazine)
AE: neutropenia, thrombocytopenia CI: sulfa allergy Negative: - Limited eschar penetration - Can inhibit epithelialization - Ineffective against pseudomonas
Good for Candida
Silver nitrate
AE: electrolyte imbalance (hyponatremia, hypochloremia, hypocalcemia, hypokalemia), methemoglobinemia Negative: - Discoloration - Limited eschar penetration - Ineffecetive against pseudomonas, GPCs
Sulfamylon (mafenide sodium)
AE: painful application, metabolic acidosis Positives: - Good eschar penetration - Good for burns overlying cartilage - Broadest spectrum (peudomonas, GNRs)
Mupirocin
Good for MRSA
Very expensive
Signs of burn wound infection?
Peripheral edema 2-3rd degree burn conversion Hemorrhage into scare Erythema gangrenosum Green fat Black skin around wound Rapid eschar separation Focal discoloration
Most common cause of burn wound sepsis?
Pseudomonas
Most common viral infection in burn wound?
HSV
Best way to detect a burn wound infection (and differentiate from colonization)?
Biopsy of burn wound
<10^5 organisms - NOT an infection (just colonization)
Complications after burns:
Seizures
Iatrogenic - sodium concentrations
Complications after burns:
Peripheral neuropoathy
Secondary to small vessel injury and demyelination
Complications after burns:
Ectopia
From contraction of burned adnexa
Tx: Eyelid release
Complications after burns:
Corneal abrasions
Topical antibiotics
Complications after burns:
Symblepharon
Eyelids stuck to conjunctiva
Tx: Release with glass rod
Complications after burns:
Heterotopic ossification of tendons
Tx: Physical therapy, may need surgery
Complications after burns:
Fractures
Tx: external fixation to allow for treatment of burns
Complications after burns:
Curling’s ulcer
Gastric ulcer that occurs with burns
Complications after burns:
Marjolin’s ulcer
Squamous cell CA that occurs in chronic non-healing wounds or unstable scars
Complications after burns:
Hypertrophic scar
Occurs 3-4 months after injury
Secondary to neovascularity
Increased risk: deep thermal injurys that take >3wks to heal, heal by contraction and epithelial spread, heal across flexor surfaces
Tx: Steroid injection to lesion*, silicone, compression, wait 1-2 years before scar modification surgery
Erythema multiforme > Stevens-Johnson syndrome > Toxic epidermal necrolysis
EM - least severe, self-limited, target lesions
SJS - More serious, <10% BSA
TEN - most severe
Epidermal-dermal separation Caused by drugs/viruses Tx: - Fluid resuscitation and support - Prevent wound desiccation with homografts/xenograft wraps - Topical antibiotics - IV abx if Staph - NO steroids
Scalded skin syndrome
Caused by staph aureus
