8 Burn, part 2 (Tintinalli)

Question 1

the initial diagnosis of smoke inhalation is made from

Answer 1

1. history of exposure to fire in an enclosed space
2. physical signs:
   - facial burns
   - singed nasal hair
   - soot in the mouth or nose
   - hoarseness
   - carbonaceous sputum
   - expiratory wheeze

Question 2

Treatment of suspected inhalation injury

Answer 2

Treat supsected inhalation injury PRIOR to definitive diagnosis
1. humidified 100% oxygen
2. prompt intubation and ventilation
3. lung-protective vent settings
4. bronchodilators
5. aggressive pulmonary toilet

Question 3

Indications for intubation

Answer 3

1. full-thickness burns of the face or perioral region
2. circumferential neck burns
3. acute respiratory distress
4. progressive hoarseness or air hunger
5. respiratory depression or altered mental status
6. supraglottic edema and inflammation on bronchoscopy

Question 4

prehospital treatment of burn

Answer 4

1. stop the burning process
2. assess and, if necessary, secure the airway
3. initiate fluid resuscitation
4. relieve pain
5. protect the burn wound with clean sheets
6. transport to an appropriate facility

Question 5

heart rate in burn patients

Answer 5

HR 100-120 is considered within normal limits for adults, due to the catecholamine response with burn injury

Question 6

ileus

Answer 6

In patients with partial-thickness burns of >20% of BSA, NGT insertion is routinely required due to frequent development of ileus

Question 7

In patients with moderate or severe burns or suspected inhalation injury, added diagnostics include

Answer 7

1. ABG
2. CO
3. serum creatine kinase
4. urinalysis for myoglobin
5. CXR
6. ECG

Question 8

Remarks on fluid resuscitation

Answer 8

1. Resuscitation should be guided by monitoring cardiorespiratory status and urine output rather than strict adherence to a formula
2. Clear documentation of fluid resuscitation should accompany all patients transferred to burn centers

Question 9

urine output should be

Answer 9

0.5 to 1.0 mL/kg/hour

Question 10

remarks on fluid resuscitation in children

Answer 10

Add 5% dextrose to maintenance fluids for children weighing <20 kg due to smaller glycogen stores

Question 11

Wound care of burn patients

Answer 11

1. Initially, wounds are best covered with a clean, dry sheet.
2. Later, small burns can be covered with a moist saline-soaked dressing while the patient is awaiting admission or transfer
3. ªFor larger burns, sterile drapes are preferred because application of saline-soaked dressings to a large area can cause hypothermia
4. Avoid the use of antiseptic dressings in the ED, because the admitting service will need to assess the wound
5. Wound care for transferred patients should be discussed with the accepting burn center
6. Do not delay transfer for wound debridement

ªCooling shoud be avoided in patients with moderate or large (>20% TBSA) burns (Schwartz)

Question 12

Remarks on cooling

Answer 12

stabilizes mast cells
reduces histamine release
reduces kinin formation
reduces thromboxane B2 production

Question 13

Remarks on hypothermia

Answer 13

1. While early cooling can reduce the depth of burn and reduce pain, uncontrolled cooling may result in hypothermia (Tintinalli)
2. Cooling should be AVOIDED patients with moderate or large (>20% TBSA) burns (Schwartz)
3. For larger burns, sterile drapes are preferred because application of saline-soaked dressings to a large area can cause hypothermia (Tintinalli)

Question 14

indication of escharotomy

Answer 14

1. vascular compromise
2. ventilation compromise (circumferential burns of the chest and neck)

Question 15

how to perform escharotomy of the limb

Answer 15

1. The eschar is incised with a scalpel to the level of the fat on the mid-lateral portion of the limb, using care to avoid incising the vascia (i.e., fasciotomy
2. The incision may be extended to the hand and fingers
3. Escharotomy may provoke substantial soft tissue bleeding
4. Consider consultation by phone with a burn surgeon

Question 16

how to perform circumferential escharotomy of the chest

Answer 16

1. Incisions are made at the anterior axillary line from the level of the 2nd rib to the level of the 12th rib
2. These two incisions should be joined transversely so the chest wall can expand

Question 17

Most painful burn depth

Answer 17

superficial partial thickness burns

Question 18

Pain control in burn patients

Answer 18

1. Opioids are mainstay, and relatively large doses may be required
2. Anxiolytic agents ay also be given
3. Achieving adequate pain control is required for patients being considered for discharged

Question 19

ED care of minor burns

Answer 19

1. Provide appropriate analgesics before burn care and for outpatient use
2. Cleanse burn with mild soap and water or dilute antiseptic solution
3. Debride wound as needed
4. Apply topical antimicrobial or dressing
5. consider use of synthetic, solid, or biological dressings
6. provide tetanus immunization as needed
7. Provide detailed burn care instructions with follow-up in 24-48 hours

Question 20

Remarks on burn wound debridement

Answer 20

1. Debride ruptured blisters
2. Also debride large intact blisters or those over very mobile joints
3. Small bliseters on nonmobile areas should be left intact

Question 21

Examples of topical antimicrobials

Answer 21

1. 1% silver sulfadiazine
2. bacitracin
3. triple-antibiotic:
4. 8.5% mafenide acetate cream
5. 0.2% nitrofurazone ointment

Question 22

Remarks on silver sulfadiazine

Answer 22

1. easy application and minimal toxicity
2. delayed healing compared with newer dressings
   - May retard epithelial migration in healing partial-thickness wounds (Schwartz)
3. do NOT use on face because it can stain the skin gray
4. do NOT use in infants <2 months

Question 23

Remarks on bacitracin and triple antibiotic

Answer 23

1. recommended for the face or other small minor burns
2. triple-antibiotic: neomycin, polymyxin
   B, bacitracin zinc

SCHWARTZ:
- also useful in large burns that are mearly healed
- also useful for _superficial_ partial-thickness facial burns as they can be applied and left open to air without dressing coverage

Question 24

remarks on mafenide acetate cream

Answer 24

1. Penetrates the eschar well and is useful in treating patients with invasive infections
2. But is a carbonic anyhydrase inhibitor and can cause metabolic acidosis
3. not good choice for treatment of large burns in an outpatient setting

Question 25

Remarks on nitrofurazone

Answer 25

1. supplied in a polyethylene glycol vehicle that can be toxic if absorbed in patients with compromised renal function
2. mafenide and nitrofurazone have little utility in the ED management of the acutely burn-injured patients

Question 26

Remarks on change of dressing for the aforementioned topical antimicrobials

Answer 26

Dressings should ideally be changed twice daily, gently removing residual ointment, for as long as the wounds continue to weep, then daily until healing is complete

Question 27

Remarks on synthetic occlusive, solid, or biologic dressings

Answer 27

1. These are alternatives methods for managing partial-thickness burns in outpatients
2. The goal is for the dressing to act as artificial skin
3. Wound should be evaluated at 24 to 48 hours
4. These dressings are well tolerated by patients, require few dressing changes, and heal with good appearance

Question 28

Examples of synthetic occlusive, solid, or biologic dressings

Answer 28

Clear occlussive synthetics
Foam or hydro-fiber dressings impregnated with antiseptics
Treated biologic membranes

Consider contacting the director of the local or regional burn center to identify the center’s preferred topical antibicrobial agent and/or specific burn dressing to intergrate local and tertiary burn care

Question 29

Discharge instructions should include

Answer 29

1. Home burn care
2. Pain control
3. Symptoms and signs of infection
4. Elevation of burned extremities for 24-48 hours to prevent edema
5. Prompt follow-up

Question 30

Referral to plastic surgeon:

Answer 30

Patients with deep partial-thickness, full thickness, and mixed-thickness burns not requiring admission should be referred to a plastic surgeon or burn care specialist in 2-4 days for reevaluation and consideration for skin grafting