17: Burns

Question 1

What is the treatment for the following types of burns?

• Alkali burn
• Acidic burn
• Hydrofluoric acid burns
• Powder burns
• Tar burns
• Electrical burns

Answer 1

• Alkali burn: Copious water irrigation
• Acidic burn: Copious water irrigation
• Hydrofluoric acid burns: Spread calcium on the wound
• Powder burns: Wipe away prior to irrigation
• Tar burns: Cool, then wipe away with a lipophilic solvent (adhesive remover)
• Electrical burns:Need cardiac monitoring

Question 2

What is both the most common infection and the most common cause of death after > 30% body surface area burns?

Answer 2

Pneumonia

Question 3

Skin grafts are contraindicated for a burn wound growing which bacteria or a burn wound with what bacterial burden?

Answer 3

• Beta-hemolytic strep
• Bacteria > 10⁵ (< 10⁵ organisms is not a burn wound infection)

Question 4

What are 8 circumstances for which burn patients should be admitted to the hospital?

Answer 4

1. 2nd and 3rd degree burns > 20% body surface area
2. 2nd and 3rd degree burns > 10% body surface area in kids < 10 years old or adults > 50 years old
3. 2nd and 3rd degree burns to significant portions of hands, face, feet, genitalia, perineum, or skin overlying major joints
4. 3rd degree burns > 5% body surface area
5. Electrical and chemical burns
6. Burns with concomitant inhalation injury, mechanical traumas, or in patients with pre-existing medical conditions
7. Bruns in patients with special social, emotional, or long-term rehabilitation needs
8. Suspected child abuse or neglect

Question 5

Which type of fluid should be used to resuscitate a burn patient in the first 24 hours?

Answer 5

Lactated ringer’s solution

[Colloid (albumin) in the 1st 24 hours causes increased pulmonary/respiratory complications. Colloid can be used after 24 hours.]

Question 6

When should burn wounds be excised?

Answer 6

Within the first 72 hours but after appropriate fluid resuscitation

[Wounds to the face, palms, soles, and genitals are deferred for the 1st week. For each burn wound excision, the goal should be < 1 L blood loss, < 20% of skin excised, and < 2 hours in the OR. Patients can get very sick iftoo much time is spent in the OR.]

Question 7

Which topical agent is good for use in burns overlying cartilage?

Answer 7

Sulfamylon (mafenide sodium)

[Good eschar penetration and good coverage against pseudomonas and gram negative rods.]

Question 8

What is the most common reason for skin graft loss?

Answer 8

Seroma or hematoma formation under the graft

[Need to apply pressure dressing (cotton balls) to the skin graft to prevent seroma and hematoma buildup underneath the graft.]

Question 9

What are the timing and indications of perfoming an escharotomy in a burn patient?

Answer 9

• Timing: Perform within 4-6 hours
• Indications: Circumferential deep burns, signs of compartment syndrome (low temperature, weak pulse, decreased capillary refill, decreased pain sensation, or decreased function in extremity), problems ventilating a patient with significant chest torso burns

[May need a fasciotomy if compartment syndrome is suspected after escharotomy.]

Question 10

What are the descriptions of the following ulcers?

• Curling’s ulcer
• Marjolin’s ulcer

Answer 10

• Curling’s ulcer: A gastric ulcer that occurs with burns
• Marjolin’s ulcer: Highly malignant squamous cell cancer that arises in chronic non-healing burn wounds or unstable scars

Question 11

What does an early skin graft rely on for blood supply and how long does it take for neovascularization?

Answer 11

• Plasmatic imbibition (osmotic)
• Neovascularization begins around day 3

[Poorly vascularized beds (tendon, bone without periosteum, XRT areas) are unlikely to support skin grafting.]

Question 12

What is the rule of 9s as it pertains to the following regions of the body?

• Head
• Arms
• Chest
• Back
• Legs
• Perineum

Answer 12

• Head: 9%
• Arms: 18% (9% per arm)
• Chest: 18%
• Back: 18%
• Legs: 36% (18% per leg)
• Perineum: 1%

[The head is 18% and the legs are each 14% in a child. The other way to estimate an injury is with the palm technique (palm = 1%).]

Question 13

Which of the following topical agents used for burns can penetrate an eschar and which is effective against pseudomonas?

• Silvadene (Silver sulfadiazine)
• Silver nitrate
• Sulfamylon (Mafenide sodium)

Answer 13

• Silvadene (Silver sulfadiazine): Limited eschar penetration, ineffective against pseudomonas
• Silver nitrate: Limited eschar penetration, ineffective against pseudomonas
• Sulfamylon (Mafenide sodium): Good eschar penetration, good coverage against pseudomonas

Question 14

What is the most common viral infection in burn wounds?

Answer 14

HSV

Question 15

What are the 4 most common organism in burn wound infections?

Answer 15

1. Pseudomonas is #1
2. Staph
3. E. Coli
4. Enterobacter

[Some texts says staph is #1 but Pseudomonas is the classic answer. Burn wound infections are more common in burns > 30% BSA.]

Question 16

What are the potential side effects of the following topical agents used for burns?

• Silvadene (Silver sulfadiazine)
• Silver nitrate
• Sulfamylon (Mafenide sodium)

Answer 16

• Silvadene (Silver sulfadiazine): Neutropenia and thrombocytopenia, also do not use in patients with sulfa allergy
• Silver nitrate: Electrolyte imbalances (hyponatremia, hypochloremia, hypocalcemia, hypokalemia), methemoglobinemia (contraindicated in patients with G6PD deficiency)
• Sulfamylon (Mafenide sodium): Metabolic acidosis due to carbonic anhydrase inhibition (decreased renal conversion of H₂CO₃ to H₂O + CO₂)

Question 17

What is the treatment for burns to the following areas?

• Face
• Hands (Superficial)
• Hands (Deep)
• Palms
• Genitals

Answer 17

• Face: Topical antibiotics for the 1st week, then full thickness skin graft to unhealed areas
• Hands (Superficial): Range of motion exercises, splint in extension if too much edema
• Hands (Deep): Immobilize in extension for 7 days after full thickness skin graft, then physical therapy (may need wire fixation of joints if unstable or open)
• Palms: Try to preserve specialized palmar attachments, splint hand in extension for 7 days after full thickness skin graft
• Genitals: Can use split thickness skin graft (meshed)

Question 18

Between acid and alkali burns, which causes liquefactive necrosis and which causes coagulation necrosis?

Answer 18

• Alkali burns cause liquefactive necrosis
• Acidic burns cause coagulative necrosis

Question 19

What is a skin homograft (allograft) used for and how does it differ from a xenograft?

Answer 19

Homografts are good temporizing material (lasting 2-4 weeks)

Xenografts are not as good as homografts (last 2 weeks)

[Allografts vascularize and are eventually rejected, at which time they must be replaced. Xenografts do not vascularize.]

Question 20

What are the descriptions of the following burns?

• 1st degree burn
• Superficial 2nd degree burn
• Deep 2nd degree burn
• 3rd degree burn
• 4th degree burn

Answer 20

• 1st degree burn: Sunburn
• Superficial 2nd degree burn: Down to dermis, painful to touch, blebs and blisters, blanches to touch, hair follicles are intact, no need for skin graft
• Deep 2nd degree burn: Decreased sensation, loss of hair follicles, skin graft needed
• 3rd degree burn: Down to subcutaneous fat, leathery (charred parchment)
• 4th degree burn: Down to bone, into adjacent adipose or muscle tissue

[1st and superficial 2nd-degree burns heal by epithelialization (primarily from hair follicles). Extremely deep burns, electrical burns, or compartment syndrome can cause rhabdomyolysis with myoglobinuria (Tx: hydration, alkalinize urine).]

Question 21

What is the treatment for all of the following: Erythema multiforme, Stevens-Johnson syndrome, Toxic epidermal necrolysis (TEN), and Scalded skin syndrome?

Answer 21

• Fluid resuscitation and supportive measures
• Need to prevent wound desiccation with homofrafts/xenografts
• Topical antibiotics
• IV antibiotics if due to staph (Scalded skin syndrome)

[Do not give steroids!]

Question 22

What should be applied to a burn immediately after it occurs?

Answer 22

Bacitracin or neosporin

[No role for prophylactic IV antibiotics.]

Question 23

Which topical agent is good for use in burns growing MRSA?

Answer 23

Mupirocin

[Very expensive.]

Question 24

What are the advantages of the below skin grafts?

• Split thickness skin graft
• Full thickness skin graft

Answer 24

• Split thickness skin graft: More likely to survive since graft is not as thick, making it easier for imbibition and subsequent revascularization to occur
• Full thickness skin graft: Have less wound contraction, making it good for areas such as the palms and back of hands

Question 25

What is the Parkland formula and when should it be used?

Answer 25

Formula for fluid resuscitation in a burn patient (4 cc/kg x % of BSA burned)

Use for burns > 20% BSA only

[Half of the calculated fluid should be administered in the first 8 hours and the second half should be administered over the following 16 hours. Parkland formula can grossly underestimate volume requirements in patients with inhalation injury, intoxication, electrical injury, or post-escharotomy. Urine output is the best measure of resuscitation (0.5-1.0 cc/kg/hr in adults, 2-4 cc/kg/hr in children <6 m/o).]