17 Burns Flashcards by Ryan Bird

First degree burn

Epidermis

Sunburn

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Superficial dermis burn (second degree)

Papillary dermis
Painful to touch, blebs and blisters, hair follicles intact, blanches
Does NOT need skin grafts

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Deep dermis burn (second degree)

Reticular dermis
Decreased sensation, loss of follicles
Requires skin grafts

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Third degree burn

Leathery (charred parchment)

Down to subcutaneous fat

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Fourth degree burn

Down to bone

Into adjacent adipose or muscle tissue

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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

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Most common type of burn?

Scald

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Most common type of burn to present to ED and be admitted?

Flame

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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

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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

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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

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Risk factors for burn injuries

Alcohol or dug use
Age (very young/very old)
Smoking
Low SES
Violence
Epilepsy

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What is the cause of lung injury in burn patients?

Carbonaceous materials and smoke
NOT heat (protective closing)

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Risk factors for airway injury in a burn patient?

ETOH
Trauma
Closed space
Rapid combustion
Extremes of age
delayed extrication

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Signs and symptoms of possible airway injury in burn patients?

Facial burns
Wheezing, stridor
Carbonaceous sputum

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Indications for intubation in burn patients?

Upper airway stridor or obstruction
Worsening hypoxemia
Massive volume resuscitation can worsen symptoms

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Most common infection in patients with >30% burns? Most common cause of death?

Pneumonia

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Treatment of acid and alkali burns?

Water irrigation

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Type of burn that causes liquefaction necrosis?

Alkali

Deeper burn

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Type of burn that causes coagulation necrosis?

Acid

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Treatment of hydrofluoric acid burns?

Spread calcium on the wound

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Treatment of tar burns?

Cool

Wipe away with lipophilic solvent (adhesive remover)

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Complications of electrical burns

Rhabdomyolysis
Compartment syndrome
Polyneuritis
Quadriplegia
Transverse myelitis
Cataracts
Liver necrosis
Intestinal perforation
Gallbladder perforation
Pancreatic necrosis

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Caloric need in first week of burn?

25kcal/kg/day + (30kcal x %burn)

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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