17: Burns Flashcards
What is the treatment for the following types of burns?
- Alkali burn
- Acidic burn
- Hydrofluoric acid burns
- Powder burns
- Tar burns
- Electrical burns
- 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
What is both the most common infection and the most common cause of death after > 30% body surface area burns?
Pneumonia
Skin grafts are contraindicated for a burn wound growing which bacteria or a burn wound with what bacterial burden?
- Beta-hemolytic strep
- Bacteria > 105 (< 105 organisms is not a burn wound infection)
What are 8 circumstances for which burn patients should be admitted to the hospital?
- 2nd and 3rd degree burns > 20% body surface area
- 2nd and 3rd degree burns > 10% body surface area in kids < 10 years old or adults > 50 years old
- 2nd and 3rd degree burns to significant portions of hands, face, feet, genitalia, perineum, or skin overlying major joints
- 3rd degree burns > 5% body surface area
- Electrical and chemical burns
- Burns with concomitant inhalation injury, mechanical traumas, or in patients with pre-existing medical conditions
- Bruns in patients with special social, emotional, or long-term rehabilitation needs
- Suspected child abuse or neglect
Which type of fluid should be used to resuscitate a burn patient in the first 24 hours?
Lactated ringer’s solution
[Colloid (albumin) in the 1st 24 hours causes increased pulmonary/respiratory complications. Colloid can be used after 24 hours.]
When should burn wounds be excised?
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.]
Which topical agent is good for use in burns overlying cartilage?
Sulfamylon (mafenide sodium)
[Good eschar penetration and good coverage against pseudomonas and gram negative rods.]
What is the most common reason for skin graft loss?
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.]
What are the timing and indications of perfoming an escharotomy in a burn patient?
- 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.]
What are the descriptions of the following ulcers?
- Curling’s ulcer
- Marjolin’s ulcer
- 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
What does an early skin graft rely on for blood supply and how long does it take for neovascularization?
- Plasmatic imbibition (osmotic)
- Neovascularization begins around day 3
[Poorly vascularized beds (tendon, bone without periosteum, XRT areas) are unlikely to support skin grafting.]
What is the rule of 9s as it pertains to the following regions of the body?
- Head
- Arms
- Chest
- Back
- Legs
- Perineum
- 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%).]
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)
- 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
What is the most common viral infection in burn wounds?
HSV
What are the 4 most common organism in burn wound infections?
- Pseudomonas is #1
- Staph
- E. Coli
- Enterobacter
[Some texts says staph is #1 but Pseudomonas is the classic answer. Burn wound infections are more common in burns > 30% BSA.]
What are the potential side effects of the following topical agents used for burns?
- Silvadene (Silver sulfadiazine)
- Silver nitrate
- Sulfamylon (Mafenide sodium)
- 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)
What is the treatment for burns to the following areas?
- Face
- Hands (Superficial)
- Hands (Deep)
- Palms
- Genitals
- 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)
Between acid and alkali burns, which causes liquefactive necrosis and which causes coagulation necrosis?
- Alkali burns cause liquefactive necrosis
- Acidic burns cause coagulative necrosis
What is a skin homograft (allograft) used for and how does it differ from a xenograft?
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.]
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
- 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).]
What is the treatment for all of the following: Erythema multiforme, Stevens-Johnson syndrome, Toxic epidermal necrolysis (TEN), and Scalded skin syndrome?
- 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!]
What should be applied to a burn immediately after it occurs?
Bacitracin or neosporin
[No role for prophylactic IV antibiotics.]
Which topical agent is good for use in burns growing MRSA?
Mupirocin
[Very expensive.]
What are the advantages of the below skin grafts?
- Split thickness skin graft
- Full thickness skin graft
- 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
