5. Burns Flashcards
Are burns bad?
Yes, don’t get them.
Why do doors open out?
Fire code - no stampedes
Who played in the football game where everyone died?
BC and Holy Cross - 1942
Where’s a bad place in the USA to get a burn due to no burn centers?
Wyoming, Montana, Idaho, the Dakotas (e.g. Fargo)
Why have deaths and %TBSA decreased?
Better prevention efforts
Where does Maine rank of death rates from fire?
Below national average, but only as of late. Used to be WAY above. Oil Embargo of ‘74 (‘Nam) made it all worse.
Most prevalent type of burn?
42% - fire/flame
31% - scald 9% - contact 4% - electrical 3% - chemical 11% - other (e.g. radiation)
Where are most healing factors in the skin?
In the dermis. This is bad if it is injured
Which layer only heals by scar tissue?
Subcutaneous layer
What are the functions of the skin?
Protection, fluid balance, thermo-regulation, neurosensation, social interaction, metabolism (vitamin D)
What are the 3 zones of Thermal Injury?
Zone of Hyperemia
Zone of Stasis
Zone of Coagulation
What is the Zone of Coagulation?
Trace tissue necrosis
- Where it was hit
- Black, white, or brown
What is the Zone of Hyperemia?
pink/red surrounding edges due to inflammation
What is the Zone of Stasis?
Main focus of burn care!
- edema, slow capillary refill
- ALL efforts should be towards Zone of Stasis
- Change the zone, change the overall appearance
What are the different types of burn depths?
Partial Superficial = Top of Dermis
Partial Deep = bottom of Dermis
Full - through the dermis –> skin graft needed
What are the characteristics of superficial partial thickness burns?
Color red-pink Wet, weeping fluid \+ cap refill \+/- blisters \+hair (HAIR IS INTACT) \+ sensation / pain (ask about sensation) \+soft compliant texture Recovery time = 5-10 days
What are the characteristics of Deep Partial Thickness burns?
Color = pale red - pink (SALMON color) -More pale = more deep Wet-dry (deeper = more dry) \+/- hair (some intact, some not) Sluggish cap refill Pain not so intense (not acute) -Do sensation test for LIGHT TOUCH Texture more firm, like leather.
What are the characteristics of a full thickness burn?
Color = white (char may be present) Dry appearing, like leather. NO cap refill NO intact hair NO pain -Increased pressure detection
But can still be red. Do not go by color alone
Adults vs Kids?
Kids under 1 have thin skin. More susecptible to burns (same w/ old people)
Time vs Temp in Heat Tolerance?
Big increase at 130 degrees. This is why hot water heaters are set to 125 degrees.
When should you suspect neglect or abuse?
Burn should be a V pattern going down (less severe at bottom). Likely will NOT be symmetrical.
Abuse will produce clear immersion lines. Be cautious if someone other than caregiver brings the pt in, or if there is a delay in treatment.
When do you refer to a burn center? (WILL BE ON THE QUIZ PER RIJO RAJAN)
Partial thickness burn > 10% TBSA Burn of face, hands, feet, genitals, perineum, or major joints Full thickness Electrical burns Inhalation injury w/ burn Pre-existing medical conditions Children if qualified personnel are not there Special emotional or social needs Long term follow-up
What are the 3 phases of burn injury?
- Emergent Phase (0-72 hours)
- Perfuse all major organs (resuscitation) - Acute Phase (lasts until wounds are healed - longest phase)
- Provide for wound healing, prevent complications - Rehab phase (begins on admission)
- Return to pre-burn level of function
Who is on the burn team?
Lots of people. Dietitians, mental health, and social workers included. Make sure they ask about inhalation injury!
What happens immediately post-burn?
Fluid shifts and evaporative losses
- Interruption of thermo-regulation
- Hypermetabolic response (body goes into overdrive)
- Loss of protective barrier (must manually protect patient from infection)
Lots of swelling in the 1st 24 hours - 40% humidity and keep the room hot!
What is the rule of 9’s?
Chest = 18% Back = 18 Leg = 18 (9% front, 9% back) Leg #2 = 18% (9% front, 9% back) Arm = 9% (4.5% front, 4.5% back) Arm #2 = 9% (4.5% front, 4.5% back) Head = 9% Groin = 1%
1% = size of patient’s hands
In babies, Legs are 14% each and head is 18%
When is fluid resuscitation indicated?
For burns > 15% TBSA
-Obtain venous access early (2 lg IV’s)
How much fluid do you give?
(Given over 24 hours) Initial volume:
2-4mL x kg x %TBSA (usually 4 mL)
- Give 1/2 of the amount in first 8 hours since burn
- Give other 1/2 over the next 16 hours
*Only a guide, adjust according to patient response
You should avoid frequent fluid bolus except in?
Marked hypotension (not low u/o)
Aim for u/o of 30-50 mL in the adult, 1cc/kg/hr in the child
Hct will normalize as patient is resuscitated
What are some CV effects after a burn?
Increased CO
Increased HR (120 bpm is normal)
Watch for perfusion problems due to edema
Escharotomies? (getting rid of dead tissue after full thickness burns)
Increased temperatures
Is BP an adeqaute indicator of volume status?
No, it is not.
What are the metabolic considerations with all patients??
Core temperature elevated
Limited glycogen stores in children
Temp is raised 2-3 degrees higher than normal, can last 3-4 months
How do you Minimized metabolic expenditures?
Warm the patient (don't let them waste calories on staying warm) Close wounds early Minimize stressors (pain, hypothermia) Feed early 20% enteral feeds Minimize pain
When does Fluid Re-Mobilization occur?
3 days post-burn
What are the evaporative water loses?
4L/m^2 of burn
Greater in children and greater with pulmonary injury and high air loss beds
What injury accounts for most fatalities at the scene?
Smoke inhalation (70%)
- CO poisoning
- Injury above or below glottis
What causes an inhalation injury in the lower airway
Caused by inhaled steam, toxic substances (fumes, gases or mists), or gas under pressure
Results in physiological changes (ciliary activity, bronchi-spasm, impaired immune defenses, increased airway resistances, hypoxia, possible respiratory failure requiring mechanical ventilation)
What does heat alone damage?
Heat alone usually only damages the upper airways and may cause edema and possible obstruction if severe enough
Get a good history:
- enclosed space
- unconscious?
- suspect inhaled noxious fumes?
Look for lots of stuff in physical assessment
What is bad about CO?
CO has 250 times the affinity for hemoglobin than oxygen (O2), binds to all the O2 receptor sites decreasing the ability of hemoglobin to carry O2 to the tissues
What is falsely elevated with CO?
Measurements of arterial O2 levels and pulse ox DO NOT REFLECT the amount of carboxyhemoglobin (COHb) present in the blood may be normal despite LETHAL COHb levels
What is a normal COHb level?
0-15% 15-20 = headache and confusion 20-40 40-60 - real bad stuff Mortally is > 50 = damage to lungs
CAn you determine severity of smoke inhalation during initial eval?
no
CXR normal
Pulse ox nomral
Must follow fluid resusictation
How to treat smoke inhalation?
Hyperbaric chamber et al
When does a person get reverse isolation?
> 15% TBSA
Should you remove a blister or no?
No one knows. Mixed results
If blister still there after 1-2 weeks, just pop it.
- But leave them intact on palms and soles
- MUST SHAVE HAIR AROUND THE SITE
What to use for burn blister?
Silvadene - requires debridement with dressing change
It is a broad spectrum antimicrobial
*Be sure to separate fingers with gauze
What is the “creamy layer”
Psuedo-eschar
GET IT OFF
Should you disrupt epithelial budding?
no
What is Xeroform?
Yellow greasy gauze
PROTECTS EPIDERMIS AND ALLOWS EPITHELIUM TO GROW (used for protection only)
No antimicrobial properties
*Cannot use over necrotic tissue
Can be uncomfortable when dry and limit ROM
What is Gentamicin?
Broad spectrum
Easy to use
Cleanse wounds and reapply 3-4 times per day
Most commonly used on facial burns
(stay away from triple, many people allergic)
What is Sulfamylon?
Available as a cream of 5% topical solution
Broad spectrum, effective against pseudomonas
Penetrates eschar, most commonly used on ears
SE: pain, metabolic acidosis
What are silver dressings?
Silver Nitrate Solution
Apply moist and keep moist!!!
Change Q8-12H
Watch for electrolyte imbalances
What is Aquacel AG
Composed of 1.2% ionic silver
Creates a gel as it absorbs wound drainage
Change Q3-14 days
Partial: leave for up to 14 days - inspect after first 48 hrs
Full: change 3-7 days
-May be covered with other dressings; can leave yellow film on
What are hydrocolloids?
Wafers, paste, or powders composed of gelatin, pectin, or carboxymethyl -cellulose
-Minimal to moderate absorption
Autolytic debridement
Good for small deep partial or full thickness burns
As dressing absorbs exudate, forms viscous gel (must be cleansed with dsg changes) Impermeable to bacteria Reduces pain Change Q3-5 days Foul odor may be confused with infection
Duoderm Signal Dressing?
If the bubble goes past the green line, change it.
DO NOT CUT THE DRESSING
Works best if left in place for several days
Tan gelatinous drainage is not “pus” - it’s normal
BioBrane?
Silocone / nylon membrane bonded with collagen
-Closes the wound, reducing water loss, infection, and pain
-Used on superficial partial thickness burns
Allows visualization and ROM
What type of burn is sunburn?
Partial thickness burn
What is Integra?
Approved for use on large or complex burns in 1996
- Approved for burn reconstruction in 2001
- Dermal regeneration template
Artificial dermis; silocone layer fit by surgeon, very expensive. Must avoid shearing due to regrowing blood vessels (PT will be limited) - better than a mesh skin graft
Reduces scar, makes skin less rigid due to dermal elements
How do you manage pain?
Cover wounds as quickly as possible, medications
Elevate extremities
Keep warm
What is Xeroform?
Inexpensive and easy to use Remove outer dsg at 24 hours Air dry Wrap posterior sites with bulky DSD daily Healed in 10-14 days
Trim to fit then apply lotion to skin
What is Op-Site?
Inexpensive Reduces pain Need intact skin at periphery to use Fluid may build-up under dsg Heals in 7-10 days (FASTER!)
What are the two most common causes of death in wound infections?
Sepsis and pneumonia
What are risk factors for burn wound infection?
> 30% TBSA
Wound dryness
Depth
Age of pt
What are local signs of wound infections?
Color or texture changes PPeri-wound erythema Wound conversion (from partial to full thickness) Ulcerations Dx by Quantitative Cultures! (not swab!)
What is a HSV Infection?
Re-activation of the virus Usually facial burns present Intubated Crater-like wounds, serrated edges (irregualr) High fever, other cultures negative Wounds at a standstill
Must use topical systemic anti-virus
DEEP!
Nutrition?
Protein repletion, limit weight loss to 15-20% TBSA burn
Other nutrition considerations?
Encourage family to bring in favorite foods
Offer burn frappes and snacks between meals
Avoid activities at meal time
Treat nausea
Caloric counts and weekly weights
D/C: eat high calorie / high protein while healing, instant breakfast, etc
Every 8oz of burn is 26g of protein?
Should you dilute chemicals with water in cases of burns?
yes, unless it is Hydrochloric acid (must use calcum gluconate gel)
Where will electrical burns travel
Thru path of least resistance (nerves, blood, mucous membranes, muscles)
NOT thru bones, fat and tendons
Skin has intermediate resistance, unless wet
Can result in indirect injury due to severe muscle contraction
No organ is safe
- CNS may show symptoms much later
- Bones may break
How to treat electrical burns?
Increase IV fluids to main u/o of 100 mL/hr until urine is clear
- May need bicard to make urine alkaline
- Use Mannitol 12.5g/L if urine does not clean with fluids alone
- Fascioectomy, ophthalmologic eval, telemetry
What are two Exfoliative Diseases?
Stephen’s Johnson’s Syndrome (SJS) 30%TBSA
Eryhtemia Multiforme Minor
(Staph Scalded Skin Syndrome)
What causes SJS and TEN
Immunologic reactions to certain agents (usually drugs)
Skin biopsy needed for diagnosis
+Nikolsky’s sign
2 or more areas of mucosal involvement typical (precedes skin lesions by 1-3 days)
How to treat SJS and TEN?
Remove cause and protect dermal surface - early closure
(use antibiotics with SSSS)
Protect eyes
Nutrition and fluid
Corticosteroid therapy
Maintain thermal reguation and prevent pressure injury
What are the degrees of frost bite?
Mild (red, slightly cyanotic, burning)
Moderate (waxy white, serous fld, blisters, intense pain, hard eschar may form)
Severe (hard, not able to depress, cold, mottled, blisters)
How to treat frostbite?
Rapid rewarming (100-110 F bath, 30-60 mins) Doppler Tetanus Medications Protect areas Wait it out!!!!!!!!!!!!!!!!!
