99 - Burns

Question 1

Two independent systems of describing the depth of burn injury exist

Answer 1

1. Degrees

2. Thickness

Question 2

Involve only the epidermis

Painful, dry burn with no blisters or eschar formation, blanching

Answer 2

First-degree burn (superficial)

Question 3

Involves epidermis and papillary dermis

Exquisitely painful, wet, weeping burn, blanching

Answer 3

Second-degree burn (superficial partial thickness)

Question 4

Involves epidermis, papillary dermis, and reticular dermis

Less painful, pale, nonblanching

Answer 4

Second-degree burn (deep partial thickness)

Question 5

Penetrate to the subcutaneous tissue and beyond

Insensate, dry, waxy, nonblanching with eschar formation

Answer 5

Third-degree burn (full thickness)

Question 6

Self-limited with sloughing within 7-14 days

No risk of scarring

Answer 6

First-degree burn (superficial)

Question 7

Heals in 2 weeks with proper wound care

Low risk of scarring

Answer 7

Second-degree burn (superficial partial thickness)

Question 8

> 3 weeks to heal
Debridement and grafting may be necessary
High risk for scarring and pigmentary changes

Answer 8

Second-degree burn (deep partial thickness)

Question 9

Surgical excision with skin grafting necessary for healing

Contractures, hypertrophic scars are common

Answer 9

Third-degree burn (full thickness)

Question 10

Burns of this degree are the most painful

Answer 10

Partial-thickness burn

Question 11

The transition to full-thickness from adjacent partial-thickness burn is clear by the lack of

Answer 11

Tissue edema

Question 12

Has been used to refer to burn injuries that penetrate to and/or expose deep structures (eg, bone, muscle, tendon)

Answer 12

“Fourth-degree burn”

Question 13

Breadth of injury is described as

Answer 13

A percentage of total body surface area

Question 14

Zones of injury according to Jackson’s thermal wound theory

Answer 14

Zone of hyperemia
Zone of stasis
Zone of coagulation

Question 15

Zone: cell death

Answer 15

Coagulation

Question 16

Zone: cell injury that can either recover to or transform into zone of coagulation

Answer 16

Stasis

Question 17

Zone: cells that will recover from injury

Answer 17

Hyperemia

Question 18

Third-degree burns should be debrided within _____ to avoid cellulitis and wound infections

Answer 18

3 to 5 days

Question 19

Burns sustained in structural fires have a high incidence of _____, wherein the pulmonary epithelium sustains direct thermal injury with ensuing edema and airway obstruction

Answer 19

Smoke inhalation injury

Question 20

Highly suspicious for smoke inhalation injury

Answer 20

Perioral burns

Presence of ashes and soot around or within the mouth and oropharynx

Question 21

Circumferential burns of the extremities are at risk for the development of

Answer 21

Compartment syndrome

Question 22

Excess resuscitation can cause abdominal compartment syndrome, which is defined as a bladder pressure over

Answer 22

30 mmHg

Question 23

Patients with abdominal compartment syndrome often present with

Answer 23

Oliguria

Abdominal distension

Question 24

May develop in the gastric or duodenal mucosa as a result of intravascular volume depletion

Answer 24

Acute stress gastritis (Curling ulcer)

Question 25

May occur following inadequate resuscitation or thermal injury to muscle as a consequence of massive myoglobulinuria, particularly in electrical burns

Answer 25

Acute renal failure

Question 26

May develop in patients with large TBSA burns Most commonly occurs in the elbow More frequent if the burn injury includes the upper extremity

Answer 26

Ectopic bone formation

Question 27

Most common cause of death in burn patients

Answer 27

Infection and sepsis

Question 28

The pathophysiology of burn injury can be appreciated by considering 2 paradigms

Answer 28

1. Loss of skin organ function | 2. Production of an inflammatory response

Question 29

In burns greater than _____% TBSA, the initial insult from inflammatory mediator release triggers a systemic inflammatory response

Answer 29

20

Question 30

In burns greater than _____% TBSA, bacterial load becomes so large that without intervention, sepsis and death are imminent

Answer 30

40

Question 31

Most common burn etiology

Answer 31

Thermal injuries, caused by fire or flames

Question 32

Associated with the highest risk of death and complications compared to all other burn etiologies

Answer 32

Thermal injuries, caused by fire or flames

Question 33

Flame burns most commonly occur

Answer 33

At home

Question 34

Second leading cause of burn injuries

Answer 34

Scald burn

Question 35

Most common mechanism of burns in the pediatric population

Answer 35

Scald burn

Question 36

Third leading cause of burns in children

Answer 36

Contact burns

Question 37

Scalp burns then to cause a (lesser/greater) inflammatory response than flame burns

Answer 37

Greater

Question 38

Pose the greatest diagnostic, therapeutic, and prognostic challenge among burn mechansims

Answer 38

Electrical burn

Question 39

Electrocution injuries are classified as

Answer 39

``` Low voltage (<1000 V) High voltage (>1000 V) ```

Question 40

It is the _____ of the electricity and its direction of travel that ultimately determine ensuing tissue damage and lethality

Answer 40

Current (amperage)

Question 41

_____ milliamperes (mA) are required to paralyze respiratory muscles

Answer 41

20

Question 42

_____ milliamperes (mA) are required to induce ventricular fibrillation

Answer 42

100

Question 43

During electric shock by alternating current, both flexor and extensor muscles are stimulated, by the strength of the flexors is greater than that of extensors, causing the "_____" phenomenon

Answer 43

No let-go

Question 44

Primary electrical injury is greatest in areas with

Answer 44

The least cross-sectional area, such as digits, wrist, and toes

Question 45

Has the greatest resistance of all body tissues, and therefore generates the most heat as current flows through it

Answer 45

Bone

Question 46

If compartment pressures are greater than _____ mmHg, then fasciotomies should be performed

Answer 46

30

Question 47

Long-term complications of high-voltage electrical injury also includes _____, and these patients should followup with ophthalmology as an outpatient

Answer 47

Cataracts

Question 48

(Alkalis/Acids) induce burn damage through binding of hydrogen ions to proteins, inducing coagulation

Answer 48

Acids

Question 49

(Alkali/Acid) burns are typically deeper and more serious as hydroxide ion saponification of fats induces liquefactive necrosis and permits further depth of chemical penetration

Answer 49

Alkali

Question 50

_____ burns are unique in that they will continue to progress after the initial insult until the offending agent is eliminated

Answer 50

Chemical

Question 51

It is advisable for _____ to be removed by brushes or dusting, as wetting with irrigation may provoke injuries in some cases

Answer 51

Solids or powders

Question 52

Y/N: Attempts at neutralizing pH with a complementary chemical should be undertaken

Answer 52

No - should not be

Question 53

Hydrofluoric acid is toxic because of the fluoride ion that binds calcium, but can be neutralized with

Answer 53

Topical calcium gel (1 ampule of calcium gluconate in 100g of lubricating jelly)

Question 54

Treatment of phenol exposure includes copious water irrigation and cleansing with

Answer 54

Polyethylene glycol or ethyl alcohol

Question 55

Can be considered if there are no other burns oustide of the inhalation injury

Answer 55

Systemic steroids

Question 56

Symptoms of carbon monoxide poisoning typically begin with _____ at levels of approximately 10%

Answer 56

Headaches

Question 57

CO in the blood becomes toxic at levels of approximately

Answer 57

50% to 70%

Question 58

Half-life of CO

Answer 58

4 hours

Question 59

Delivery of _____ reduces the half-life of CO to 30 to 90 minutes

Answer 59

100% O2

Question 60

Most important initial step in the management of a burn patient

Answer 60

Prompt and aggressive evaluation and maintenance of the airway

Question 61

For superficial burns, treatment of the burn wound oftentimes requires

Answer 61

Topical antimicrobial agents and corticosteroids

Question 62

Totaled to calculate the TBSA

Answer 62

Partial-thickness and full-thickness burns

Question 63

Regions on the adult that constitutes 9% of the TBSA

Answer 63

Head | Each arm

Question 64

Regions on the adult that constitutes 18% of the TBSA

Answer 64

Each leg Anterior trunk Posterior trunk

Question 65

Regions on children that constitutes 9% of the TBSA

Answer 65

Each arm

Question 66

Regions on children that constitutes 14% of the TBSA

Answer 66

Each leg

Question 67

Regions on children that constitutes 18% of the TBSA

Answer 67

Head and neck Anterior trunk Posterior trunk

Question 68

Patients who have burns of more than _____% TBSA commonly require IV fluid resuscitation

Answer 68

20

Question 69

Most commonly used to calculate fluid requirements within the first 24 hours of burn injury

Answer 69

Parkland formula

Question 70

Parkland formula

Answer 70

4mL x %TBSA x weight (kg)

Question 71

Half of the volume is administered in the first _____ after the injury and the second half is administered over the next _____

Answer 71

8 hours | 16 hours

Question 72

Recommended fluid resuscitation to avoid complications associated with metabolic acidosis with normal saline or abnormal fluid shifts with colloid fluids

Answer 72

Lactated Ringer solution

Question 73

Commonly used as maintenance fluids

Answer 73

Dextrose 5% in lactated Ringer solution

Question 74

Proper resuscitation is based on overall fluid status as represented by urine output with the goal of _____ mL/kg/h in adults and _____ mL/kg/h in children

Answer 74

0.5 | 1

Question 75

Aggressive hydration also accounts for potential _____, leading to acute kidney injury

Answer 75

Rhabdomyolysis

Question 76

If the organs are perfused, _____ should be observed

Answer 76

Decreases in lactate and base deficit Increases in central venous O2 Normalization of pH

Question 77

Silver-containing cream that has broad-spectrum coverage against both Gram-negative and Gram-positive bacteria Contraindicated in patients with sulfa allergies and over wounds near the eyes Possible leukopenia in the acute phase

Answer 77

Silvadene

Question 78

Used over cartilaginous areas such as the nose or ear because of increased penetration of the dressing over these areas Can be used without dressings Associated with increased pain; risk for hyperchloremic metabolic acidosis; chronic use at risk for fungal infection

Answer 78

Suflamylon

Question 79

Typically applied as soak dressings 2 to 3 times a day Covers fungal species Can cause leaching of cations causing hyponatremia; stains the skin as well as anything it comes in contact with

Answer 79

Silver nitrate

Question 80

Commonly used for facial burns

Answer 80

Bacitracin

Question 81

Often used for partial-thickness skin graft donor sites

Answer 81

Xenograft

Question 82

Consists of silver-impregnated sheets Mainly used in partial-thickness injuries Only needs to be changed every 5 days

Answer 82

Acticoat

Question 83

Acticoat is activated with

Answer 83

Water Not normal saline as the sodium can leech out with the silver

Question 84

Early intubation is recommended for patients with

Answer 84

Severe airway involvement or Patients with large TBSA burns (>20% deep partial or full thickness) that will require Parkland large fluid resuscitation

Question 85

A _____ vaccine should be given to all burn patients with partial-thickness or full-thickness burns

Answer 85

Tetanus toxoid

Question 86

Tetanus immunoglobulin should also be administered in

Answer 86

Very young children Persons with high-risk tetanus wound (ie, burn older than 6 hours at presentation, immunodeficiency, or soil contamination in wound)

Question 87

Tetanus should not be given in

Answer 87

Children younger than age 4 years

Question 88

First-line medications for the management of outpatient burn pain

Answer 88

Scheduled narcotics

Question 89

Analgesics that should play a secondary role in management

Answer 89

Acetaminophen | Nonsteroidal antiinflammatory drugs

Question 90

Pulsing or throbbing pain accompanied by warmth at the wound site may be associated with

Answer 90

Inflammatory progression

Question 91

Inflammatory progression may be managed with

Answer 91

Nonsteroidal antiinflammatory drugs

Question 92

The infection rate of burns managed in the outpatient setting is _____%, which increases to _____% in diabetic patients

Answer 92

5 | 11 to 15

Question 93

Usual culprits in infections developing in the first 7 to 10 days

Answer 93

Normal flora organisms, such as Staphylococcus

Question 94

Infections developing in the first 7 to 10 days have good response to

Answer 94

First-generation cephalosporins

Question 95

Infections occurring after the first 10 days are more likely caused by

Answer 95

Gram-negative rods

Question 96

Patients with infections occurring after the first 10 days benefit from

Answer 96

Wound culture | Empiric coverage with ciprofloxacin

Question 97

Risk factors for developing chronic pruritus

Answer 97

``` Female gender Young age Skin grafting Raised or thick scars Dry skin ```

Question 98

Evidence of treatment of burn pruritus is limited to 3 categories

Answer 98

Topicals Antihistamines Neuropathic agents

Question 99

Y/N: Cetirizine, a selective H1-blocker, is more effective than general antihistamines such as diphenhydramine

Answer 99

Yes

Question 100

Risk factors that contribute to the development of hypertrophic scarring

Answer 100

Localization of the burn injury Burn depth Time to heal Skin color

Question 101

Steps that can optimize a burn scar: | Wound closure of a burn that is likely not to heal on its own in

Answer 101

3 weeks

Question 102

Steps that can optimize a burn scar: | Avoidance of sun contact of the scar during the first

Answer 102

6 months

Question 103

Steps that can optimize a burn scar: | Compression garments for those who can tolerate treatment for up to

Answer 103

1 year

Question 104

Steps that can optimize a burn scar: | Keeping the scar

Answer 104

Moist

Question 105

The most important step in rejuvenating the scar

Answer 105

Release of tension

Question 106

Traditional treatment for hypertrophic scarring

Answer 106

Surgical manipulation to remove the excess skin