7 Burn, part 1 (Tintinalli)

Question 1

Remarks on Burn situation in the US

Answer 1

“The vast majority of burn patients are treated in the acute setting by emergency physicians and discharged with outpatient follow-up.”

Question 2

Cardiovascular consequence of burn

Answer 2

In patients with burns >60% TBSA, depression of cardiac output results in a lack of response to aggressive volume resuscitation, likely due to circulating myocardial depressants

Question 3

Zones of burn tissue injury

Answer 3

“Jackson zones”
1. Zone of coagulation
- tissue is irreversibly destroyed with thrombosis of blood vessels
2. Zone of stasis
- stagnation of the microciculation
3. Zone of hyperemia
- increased blood flow
- minimal damage to the cells and spontanous recovery is likely

Question 4

Remaks on zone of stasis

Answer 4

can become progressively more hypoxemic and ischemi if resuscitation is not adequate

Question 5

Describe the Rule of Nines

Answer 5

18% - Front torso
18% - back torso
18% - R LE
18% - L LE
9% - R UE
9% - L LE
9% - head
1% - perineum

Question 6

“area of the hand”

Answer 6

area of the hand of the patient, including the digits, represent 1%

Question 7

More precise and accurate representation of TBSA

Answer 7

Lund-Browder burn diagram

Question 8

remarks on determining burn depth

Answer 8

1. Requires clinician judgment using commonly observed wound features
2. There is no objective method of measuring burn depth
3. Burn wound biopsy is not routine practice

Question 9

Superficial burn

Answer 9

1. only the epidermal layer
2. red, painful, and tender without blister
3. require only symptomatic treatment
4. usually heal in about 7 days without scarring

Question 10

Superficial partial-thickness burn

Answer 10

1. epidermis and superficial dermis (papillary layer), with sparing of hair follicles and sweat and sebaceous glands
2. often caused by hot water scalding
3. blistered, and the exposed dermis is red, moist , and very tender*
4. dermis is well-perfused with intact capillary refill
5. healing typically occurs in 14 to 21 days, scarring is usually minimal, with full return of function

Question 11

Deep partial thickness burn

Answer 11

1. extend into the deep dermis (reticular layer), with damage of hair folllicles and sweat and sebaceous glands
2. usually from hot oil/grease, steawm, or flame
3. exposed dermis is pale white to yellow, with absent pain sensation
4. burned area does NOT blanch; with absent capillary refill,
5. Healing takes 3 weeks to 2 months; scarring is common; and surgical debridement and skin grafting may be necessary to obtain maximum function

Question 12

Full thickness burn

Answer 12

1. skin is charred, pale, painless, and leathery
2. Because all dermal elements are destroyed, these injuries do not heal spontaneously
3. Surgical repair and skin grafting are necessary
4. significant scarring is the norm

Question 13

4th degree burns

Answer 13

those that extend throught the skin, to the subcutaneous fat, muscle, and even bone
these are devastating, life-threatening injuries

Question 14

Major burn characteristics

Answer 14

1. Partial-thickness >25% BSA, age 10-50y
2. Partial-thickness >20% BSA, age <10y or >50y
3. Full-thickness >10% BSA in anyone
4. Burns involving hands, face, feet, or perineum
5. Burns crossing major joints
6. Circumferential burns of an extremity
7. Burns complicated by inhalation injury
8. Electrical burns
9. Burns complicated by fracture or other trauma
10. Burns in high-risk patients
    Disposition: Burn center treatment

Question 15

Moderate burn characteristics

Answer 15

1. Partial-thickness 15%-25% BSA, age 10-50 y
2. Partial-thickness 10%-20% BSA, age <10 y or >50 y
3. Full-thickness ≤10% BSA in enyone
4. No major burn characteristics
   Disposition: hospitalization

Question 16

Minor burn characteristics

Answer 16

1. Partial-thickness <15% BSA, age 10-50 y
2. Partial thickness <10% BSA, age <10 y or >50 y
3. Full-thickness <2% in anyone
4. No major burn characteristics present
   Disposition: outpatient treatment

Question 17

Inhalation injury is associated with the following situations/conditions

Answer 17

1. closed-space fires
2. conditions that decresease mentation
   - overdose
   - alchol intoxiation
   - drug abuse
   - head injury

Question 18

the 2 major tissue asphyxiants

Answer 18

carbon monoxide
hydrogen cyanide`

Question 19

Carbon monoxide poisoning

Answer 19

All patients should receive 100% oxygen by NRM

Question 20

Hydrogen cyanide poisoning

Answer 20

1. Formed by the combustion of nitrogen-containing polymers such as wool, silk, polyurethane, and vinyl
2. cyanide binds to cytochrome oxidase and uncouples mitochondrial oxidative phosphorylation –> profound tissue hypoxia
3. Traditionally taught but rare presentation: bitter almond breath and cherry red skin

Question 21

Mechanisms of injury of inhalation injury in burn

Answer 21

1. Inhalation injury damages endothelial cells, produces mucosal edema of the small airways, and decreases alveolar surfactant activity, resulting in bronchospasm, airflow obstructoin, and atelectasis
2. Approx half of intubated burn patients develop ARDS
3. Prophylactic antiobiotics and corticosteroids are NOT recommended

Question 22

Can help avoid pulmonary edema and ARDS

Answer 22

careful fluid resuscitation guided by hemodynamic monitoring

Question 23

upper vs lower airway edema

Answer 23

Upper airway edema can occur rapidly,
whereas lower airway edema may not be clinically evident for up to 6 hours