99 - Burns Flashcards
Two independent systems of describing the depth of burn injury exist
- Degrees
2. Thickness
Involve only the epidermis
Painful, dry burn with no blisters or eschar formation, blanching
First-degree burn (superficial)
Involves epidermis and papillary dermis
Exquisitely painful, wet, weeping burn, blanching
Second-degree burn (superficial partial thickness)
Involves epidermis, papillary dermis, and reticular dermis
Less painful, pale, nonblanching
Second-degree burn (deep partial thickness)
Penetrate to the subcutaneous tissue and beyond
Insensate, dry, waxy, nonblanching with eschar formation
Third-degree burn (full thickness)
Self-limited with sloughing within 7-14 days
No risk of scarring
First-degree burn (superficial)
Heals in 2 weeks with proper wound care
Low risk of scarring
Second-degree burn (superficial partial thickness)
> 3 weeks to heal
Debridement and grafting may be necessary
High risk for scarring and pigmentary changes
Second-degree burn (deep partial thickness)
Surgical excision with skin grafting necessary for healing
Contractures, hypertrophic scars are common
Third-degree burn (full thickness)
Burns of this degree are the most painful
Partial-thickness burn
The transition to full-thickness from adjacent partial-thickness burn is clear by the lack of
Tissue edema
Has been used to refer to burn injuries that penetrate to and/or expose deep structures (eg, bone, muscle, tendon)
“Fourth-degree burn”
Breadth of injury is described as
A percentage of total body surface area
Zones of injury according to Jackson’s thermal wound theory
Zone of hyperemia
Zone of stasis
Zone of coagulation
Zone: cell death
Coagulation
Zone: cell injury that can either recover to or transform into zone of coagulation
Stasis
Zone: cells that will recover from injury
Hyperemia
Third-degree burns should be debrided within _____ to avoid cellulitis and wound infections
3 to 5 days
Burns sustained in structural fires have a high incidence of _____, wherein the pulmonary epithelium sustains direct thermal injury with ensuing edema and airway obstruction
Smoke inhalation injury
Highly suspicious for smoke inhalation injury
Perioral burns
Presence of ashes and soot around or within the mouth and oropharynx
Circumferential burns of the extremities are at risk for the development of
Compartment syndrome
Excess resuscitation can cause abdominal compartment syndrome, which is defined as a bladder pressure over
30 mmHg
Patients with abdominal compartment syndrome often present with
Oliguria
Abdominal distension
May develop in the gastric or duodenal mucosa as a result of intravascular volume depletion
Acute stress gastritis (Curling ulcer)
May occur following inadequate resuscitation or thermal injury to muscle as a consequence of massive myoglobulinuria, particularly in electrical burns
Acute renal failure
May develop in patients with large TBSA burns
Most commonly occurs in the elbow
More frequent if the burn injury includes the upper extremity
Ectopic bone formation
Most common cause of death in burn patients
Infection and sepsis
The pathophysiology of burn injury can be appreciated by considering 2 paradigms
- Loss of skin organ function
2. Production of an inflammatory response
In burns greater than _____% TBSA, the initial insult from inflammatory mediator release triggers a systemic inflammatory response
20
In burns greater than _____% TBSA, bacterial load becomes so large that without intervention, sepsis and death are imminent
40
Most common burn etiology
Thermal injuries, caused by fire or flames
Associated with the highest risk of death and complications compared to all other burn etiologies
Thermal injuries, caused by fire or flames
Flame burns most commonly occur
At home
Second leading cause of burn injuries
Scald burn
Most common mechanism of burns in the pediatric population
Scald burn
Third leading cause of burns in children
Contact burns
Scalp burns then to cause a (lesser/greater) inflammatory response than flame burns
Greater
Pose the greatest diagnostic, therapeutic, and prognostic challenge among burn mechansims
Electrical burn
Electrocution injuries are classified as
Low voltage (<1000 V) High voltage (>1000 V)
It is the _____ of the electricity and its direction of travel that ultimately determine ensuing tissue damage and lethality
Current (amperage)
_____ milliamperes (mA) are required to paralyze respiratory muscles
20
_____ milliamperes (mA) are required to induce ventricular fibrillation
100
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
No let-go
Primary electrical injury is greatest in areas with
The least cross-sectional area, such as digits, wrist, and toes
Has the greatest resistance of all body tissues, and therefore generates the most heat as current flows through it
Bone
If compartment pressures are greater than _____ mmHg, then fasciotomies should be performed
30
Long-term complications of high-voltage electrical injury also includes _____, and these patients should followup with ophthalmology as an outpatient
Cataracts
(Alkalis/Acids) induce burn damage through binding of hydrogen ions to proteins, inducing coagulation
Acids
(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
Alkali
_____ burns are unique in that they will continue to progress after the initial insult until the offending agent is eliminated
Chemical
It is advisable for _____ to be removed by brushes or dusting, as wetting with irrigation may provoke injuries in some cases
Solids or powders
Y/N: Attempts at neutralizing pH with a complementary chemical should be undertaken
No - should not be
Hydrofluoric acid is toxic because of the fluoride ion that binds calcium, but can be neutralized with
Topical calcium gel (1 ampule of calcium gluconate in 100g of lubricating jelly)
Treatment of phenol exposure includes copious water irrigation and cleansing with
Polyethylene glycol or ethyl alcohol
Can be considered if there are no other burns oustide of the inhalation injury
Systemic steroids
Symptoms of carbon monoxide poisoning typically begin with _____ at levels of approximately 10%
Headaches
CO in the blood becomes toxic at levels of approximately
50% to 70%
Half-life of CO
4 hours
Delivery of _____ reduces the half-life of CO to 30 to 90 minutes
100% O2
Most important initial step in the management of a burn patient
Prompt and aggressive evaluation and maintenance of the airway
For superficial burns, treatment of the burn wound oftentimes requires
Topical antimicrobial agents and corticosteroids
Totaled to calculate the TBSA
Partial-thickness and full-thickness burns
Regions on the adult that constitutes 9% of the TBSA
Head
Each arm
Regions on the adult that constitutes 18% of the TBSA
Each leg
Anterior trunk
Posterior trunk
Regions on children that constitutes 9% of the TBSA
Each arm
Regions on children that constitutes 14% of the TBSA
Each leg
Regions on children that constitutes 18% of the TBSA
Head and neck
Anterior trunk
Posterior trunk
Patients who have burns of more than _____% TBSA commonly require IV fluid resuscitation
20
Most commonly used to calculate fluid requirements within the first 24 hours of burn injury
Parkland formula
Parkland formula
4mL x %TBSA x weight (kg)
Half of the volume is administered in the first _____ after the injury and the second half is administered over the next _____
8 hours
16 hours
Recommended fluid resuscitation to avoid complications associated with metabolic acidosis with normal saline or abnormal fluid shifts with colloid fluids
Lactated Ringer solution
Commonly used as maintenance fluids
Dextrose 5% in lactated Ringer solution
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
0.5
1
Aggressive hydration also accounts for potential _____, leading to acute kidney injury
Rhabdomyolysis
If the organs are perfused, _____ should be observed
Decreases in lactate and base deficit
Increases in central venous O2
Normalization of pH
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
Silvadene
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
Suflamylon
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
Silver nitrate
Commonly used for facial burns
Bacitracin
Often used for partial-thickness skin graft donor sites
Xenograft
Consists of silver-impregnated sheets
Mainly used in partial-thickness injuries
Only needs to be changed every 5 days
Acticoat
Acticoat is activated with
Water
Not normal saline as the sodium can leech out with the silver
Early intubation is recommended for patients with
Severe airway involvement or
Patients with large TBSA burns (>20% deep partial or full thickness) that will require Parkland large fluid resuscitation
A _____ vaccine should be given to all burn patients with partial-thickness or full-thickness burns
Tetanus toxoid
Tetanus immunoglobulin should also be administered in
Very young children
Persons with high-risk tetanus wound (ie, burn older than 6 hours at presentation, immunodeficiency, or soil contamination in wound)
Tetanus should not be given in
Children younger than age 4 years
First-line medications for the management of outpatient burn pain
Scheduled narcotics
Analgesics that should play a secondary role in management
Acetaminophen
Nonsteroidal antiinflammatory drugs
Pulsing or throbbing pain accompanied by warmth at the wound site may be associated with
Inflammatory progression
Inflammatory progression may be managed with
Nonsteroidal antiinflammatory drugs
The infection rate of burns managed in the outpatient setting is _____%, which increases to _____% in diabetic patients
5
11 to 15
Usual culprits in infections developing in the first 7 to 10 days
Normal flora organisms, such as Staphylococcus
Infections developing in the first 7 to 10 days have good response to
First-generation cephalosporins
Infections occurring after the first 10 days are more likely caused by
Gram-negative rods
Patients with infections occurring after the first 10 days benefit from
Wound culture
Empiric coverage with ciprofloxacin
Risk factors for developing chronic pruritus
Female gender Young age Skin grafting Raised or thick scars Dry skin
Evidence of treatment of burn pruritus is limited to 3 categories
Topicals
Antihistamines
Neuropathic agents
Y/N: Cetirizine, a selective H1-blocker, is more effective than general antihistamines such as diphenhydramine
Yes
Risk factors that contribute to the development of hypertrophic scarring
Localization of the burn injury
Burn depth
Time to heal
Skin color
Steps that can optimize a burn scar:
Wound closure of a burn that is likely not to heal on its own in
3 weeks
Steps that can optimize a burn scar:
Avoidance of sun contact of the scar during the first
6 months
Steps that can optimize a burn scar:
Compression garments for those who can tolerate treatment for up to
1 year
Steps that can optimize a burn scar:
Keeping the scar
Moist
The most important step in rejuvenating the scar
Release of tension
Traditional treatment for hypertrophic scarring
Surgical manipulation to remove the excess skin
