7 - Burns Flashcards
Epithelialization
Starts within one day
Skin grows in from the wound edges and up from hair follicle
If full thickness - no hair follicles, no epithelialization
Calculating burn surface area (TBSA)
Patient’s palm is appx 1%
Rule of 9’s (picture on slide 4)
Superficial burns (aka 1st degree burns)
Injury limited to the dermis
Manage the pain with APAP/NSAIDs
Hydrating lotions (avoid alcohol-based lotions)
Rarely long-term sequelae
Partial thickness (aka 2nd degree)
Injury extends into the dermis
Initially cover and protect
Debride and clean with warm water an soap
UPDATE TETANUS
Painful - may need narcs
If small, heals from outside -> in
Topical ABX (silvadine)
If large (follicle destroyed) will need skin graft
What’s preferred for partial thickness - cream or ointment?
Cream is preferred - easier to remove
How long should you protect the skin from sunlight with a partial thickness?
A year
Also, keep moisturized with hydrating lotion
Avoid vigorous debridement - gentle debridement of devascularized tissue
Primary care responsibilities for partial thickness burns:
Clean it Debride blisters Cover with silvadine (ABX) cream Apply dressings Ensure tetanus is up to date Patient education (sunlight protection, dressing changes)
Full thickness (aka 3rd or 4th degree)
Extends into SQ fat, muscle, tendon, or bone
Nerves destroyed - mostly no sensation
What to do with full-thickness?
Admit to burn unit for:
IV ABX Fluids Pain control Serial debridements Escharotomy Skin grafting
Initial txt for full-thickness
Rinse with clean water
Dress
Elevate
ABX cream
Ensure bandaging between digits - do not impede circulation
Fluid resuscitation for full thickness?
Aggressive
2-4mL (TBSA)(body weight in Kg)
1/2 that volume in the first 8 hrs, the remainder of 16 hrs
Adjust UOP to 0.5ml/kg/hr (adult)
-if it goes over, decrease IVF rate
Airway considerations?
Full-thickness burn patients usually need ET-tube
Tale that airway before it closes up
Heat considerations for burn victims?
Room needs to be kept really warm
Loss of skin barrier leads to inability to thermoregulate, which can lead to metabolic acidosis
Ways to monitor fluid status
ABG
Lactate
Central venous pressure monitoring (Swan-Ganz catheters)(via central line)
Circumferential burns typically need:
Escharotomy
Prevents tourniquet effect
Pain out of proportion
Especially chest or limbs
Silver-impregnated dressing
Soak in water
Apply directly overtop of burned area
Apply moisture dressing over top silver dressing
Rinse off daily and can reuse bandage
Splinting
Splint extremity in position of function (not comfort)
Accomplished with specialized splints
If left in position of comfort, may result in wound contraction -> disability (may be amenable to z-plasty after healed)
Autograft
From self
Allograft
Same species
Xenograft
Another species
Full thickness (sheet graft)
Only skin (no fenestration like STSG)
Covers smaller area
Reserved for covering bone, tendon, vessels
Definitive skin graft comes from:
The patient (autograft)
Split thickness skin graft (STSG)
Covers other surfaces
Healthy skin grafted from donor site
Meshed to maximize surface area
Electrical burns
Often worse than they outwardly appear
Electricity traverses bones, nerves
Txt - admit to burn unit Cardiac monitoring 2/2 increased cellular damage and leaking K+ (worrisome for arrhythmias) Aggressive fluids (UOP 0.5-1mL/Kg/hr) CMP, CK Q14-6hs Serial evals of long bones
Cord biting
Normally no surgery or debridement needed immediately
Splint to avoid contracture
Reconstruction of the mouth after healed
Chemical burns
Acids - coagulation necrosis
Alkaline - liquefaction necrosis
Remove clothing from burned area
Irrigate with copious amounts of running water
Elevate and dress
Splint in position of function
Send em off to the specialists
Evacuate to burn unit if:
> 20% TBSA
Any exposed tendon, bone
Face, genitalia, hands, feet, mouth
Inhalation injury
Target UOP for burn victims
Around 0.5mL/Kg/hr (but no more than 1 - if above 1, back the fluid off)
Remember parkland - 2-4ml x TBSA x weight in kg)
Prevent hypothermia
Fluid for burn victimes
LR
If you use NS, you may create an acidosis
ADC-VAN-DISMAL
Slide 22 for explanations
Admit Diagnosis Condition Vitals Activity Nursing Diet IVF Special tests Meds Allergies Labs
Burn unit team
1:1 nursing Attending surgeons/intensivists/PAs Resp-therapy OT/dietician BHT Social workers Discharge planners
What lies at the bottom of the ocean and twitches?
A nervous wreck
