Basic Principles in Burn Management Flashcards
What layer of the skin is involved in the 1st & 2nd degree burns?
Epidermis
What layer of the skin has bulk of structures for pain sensitization?
The skin
What is the rules of nines?
Estimation of burn size by dividing the body into regions to which total body surface area is dividide in multiples of nine
What are the rule of nines in adult?
Anterior trunk: 18% TBSA
Posterior trunk: 18% off TBSA
Each lower extremity: 18% TBSA
Each upper extremities: 9% TBSA
Head: 9% TBSA (4.5% front, 4.5% back)
Palm: 1% TBSA
What accounts for rule of nines in the children <3 y/o?
Head has larger relative surface area & taken into account when estimating burn size
What is the rule of the palm?
Used for smaller, odd-shaped burns where palmar surface of the hand including digits is 1% TBSA
What is a diagram that gives a more accurate account of the burn size in children & adults?
Lung & Browder chart
What is an important use for Lung & Browder chart?
Basis of how a px will be resuscitated = so make sure to accurately assess burn size
What type of burn should not be included in calculating burn size?
SUperficial or 1st degree burns
Why shouldn’t u include 1st degree burns in assessing burn size? What should be done instead?
Because it can lead to over-resuscitation
Clean off soot & debris to avoid confusing soiled skin with burns
WHat are the 3 classifications or causes of burns?
Thermal burns
Electrical burns
Chemical burns
What are the 3 types of thermal burns?
Flame burns
COntact burns
Scald burns
What type of thermal burn is the most common cause of hospital admission of burns & has the highest mortality rate?
Flame burns
What type of thermal burn is due to contact with hot solids
Contact burns
What type of thermal burns is from a large amt of heat delivered in liquid form like boiling water?
Scald burns
What usually comes out of scalded burns?
Bullae and skin slough
What assoc conditions occur with electrical burns?
Cardiac arrhythmia
Compartment syndrome
COncurrent rhabdomyolsysi
What is a special typ eof burn injury that is important to take note of in electrical burns?
Entrance & exit points
What is the appearance of electrical burns?
Soft, pliable & doughy
What should immediately be done in cases of electrical burns?
check for baseline ECG to see if cardiac tissue is affected
In high voltage electrical burns >1,000V, what are the common injuries?
COmpartment syndrome
Rhabdomyolysis
What long-term symptoms can develop as cause of the electrical burn?
Neurological symptoms and Cataract devt
- so check check
What are the most common high-voltage electrical injuries?
COmpartment syndrome
Rhabdomyolysis
What procedure is done in high voltage electrical burns to relieve the compartment of the hands so blood flow is less compromised?
Fasciotomies
What is another type of burn resulting from acid/alkali chemicals?
Chemical burns
What is the result of an acid chemical burn?
Coagulation necrosis
What is the result of an alkali chemical burn?
Liquefactive necrosis
What are the effects of hydrofluoric acid burn?
LIquifactive necrosis
Hypocalcemia —> Cardiac arrhythmias
Common offender -> industrial use
What are the mainstays of tx of Hydrogluoric acid?
Ca based therapies:
- Topical application of Ca gluconate on wounds
- IV Ca gluconate = systemic hypocalcemia symptoms
- Intra-arterial Ca gluconate infusion = effective tx of progressive tissue injury & intense pain
What chemical causes very corrosive & severe burns + tissue damage? In what products is this seen?
Na hydroxide/Iye
Products: Drain cleaners, Oven cleaners, Dishwasher detergent, soaps
What is the effect of burning yourself w/ Formic acid?
Hemolysis & Hemogloburia
What is formic acid used for?
Preservative & antibacterial agent
What is the most importnat component of initial therapy?
- Careful removal of toxic substance from the px
- Irrigation of the affected area w. H2O for a min of 30mins
What is done in cases where there is exposure to dry chemicals?
- Do not attempt to irrigate affected area
- Substance should be swept from the px to avoid thermal rxn w/ H2O
What are the 2 types of second deg burns?
Superficial partial thickness
Deep partial thickness
What layers of the skin are affected in superfiical partial and deep partial thickness?
SUperifical = red, painful, w/ blisters, min scarring, 2wks healing
Deep = less painful, white, mottled, 3-6wks healing w/ hypertrophic scarring
What layers of the skin are affected in 3rd degree burn and what does it look like?
Epidermis & Dermis
No pain, white, leathery
What are the 2 ways 3rd degree burns can heal?
Tangential excision
Split-thickness skin graft tangential excision
What layers are affected in the 4th, 5th & 6th degree burns?
4th degree = undelrying tissue
5th degree = bone
6th deg = charred bone
WHat are the zones described in Jackson Zone of injury of burns?
Zone of coagulation
Zone of stasis
Zone of hyeperemia
What zone of injury is the most severely burned portioned & has frank necrosis whih needs to be excisioned & grafted (full thickness typically)?
Zone of coagulation
What is the zone of injury where there is peripheral to zone of coagulaltion w/ var degrees of vascoonstriction & ischemia like a 2nd deg burn?
Zone of stasis
What zone of injury is found at the outermost zone and will heal w/ minimal or no scarrinl?
Zone of hyperemia
Upon burn evaluation, what should be done during primary survey?
Insert large-bore peripheral IV catheres
Initiate fluid resucitation
In px with burns larger than 40% total TBSA, what type of catheter should be inserted?
2 large-bore IVs
What should be done if peripheral access is not obtaned of burn px?
Central venous access & intraosseous access
What should you do if the burn is smaller than 15%?
Hydrate orallyt
What should be done if pedia px have burns >15%?
IO access in emergent situations
What % of burn is considered as a big burn?
20% in adults
What should u do upon initial assessment of burnt patient?
Airway management
Eval of other injuries
Estimation of burn size
Eval of CO & cyanide posioning
When should u administer IV resuscitation?
> 20% TBSA for adults
15% pedia px
What is the px’s TBSA is >40%, what should u do?
Administer 2 large bore IV catheters for resuscitation
How do you evaluate a px for CO poisoning?
Administer 100% normobaric O2 via nasal cannua or mask to reduce 1/2 life of CO from 250 mins to 40-60mins
What are the guidelines for referral to burn center?
- Partial thickness burns >10% TBSA
- Burns involving the face, hands, feet, genitalia, perineum or major joints
- 3rd degree burn in any age grp
- Electrical burns
- Chemical burns
- Inhalation injury
What should u do if the px’s greatest risk is their burn lesions?
Px should be stabilized in a trauma center before being transferred to a burn center
Which of the 2 is more accurate in assessing burn px: rule of nines or Lund & Browder chart?
Lund & Browder chart
What is the Parkland formula?
4 x %TBSA x kg = 24hr fluid ntake
- half given during 1st 8 hrs post burn
- half given during next 16hrs post burn
What is the concensus formula for?
This formula is meant to be a guide in resuscitation
What are end parameters of Concesus formula in critically ill px?
Mean Arterial Pressure (MAP) of 60mmHg to ensure organ perfusion
What are the conventional goals of Consensus formula?
30mL/hr in adults
1-1.5mL/kg/hr in pedia px
What is the formula for Consensus formula?
2mL x %TBSA x kg = 24hrs fluid intake
What are the rx for burn wounds? There are 6
- Silver sulfadiazine dressing
- Mafenide acetate
- Silver nitrate
- Dakin’s solution
- Antibacterials
- Other dressings: Ag containing dressings, Hydrocolloid dressings
What is the 1st line of tx & most widely used in clin practice of treating burn wounds?
Silver sulfadiazine dressing
Why is Ag SUlfadiazine dressing used as a propylaxis against burn wound infections?
It has a wide range of antimicrobial activity
What are side effects of Ag Sulfadiazine dressing?
Leukopenia/Neutropenia
Alleviation: cessation of usage
- rashes of delayed HSN
- destroys skin grafts
- retards epithelial migration in healing partial thickness wounds
What tx of burn wounds is goon on eschar penetraiton & an excellent antimicrobial for fresh skin grafts?
Mafenide acetate
What is a SE of Mafenide acetate?
Metabolic acidosis since it is a Carbonic anhydrase inhibitor
What is a tx of burn wounds that has a broad spectrum atnumicrobial activity as topical soln?
Ag Nitrate
If u administer Ag nitrate for a long time, what is the SE?
Electrolyte exxtravation & hyponatremia
What is a rare complication of Ag nitrate?
Methemoglobinemia
WHat is an inexpensive burn dressing that combines saline w/ Na hypochlorite, an alternative topcial antimicrobial?
Dakin’s soln
What are antimicrobials used in txing smaller burn wounds?
Bacitracin
Neomycin
Polymyxin B
What is a SE of Antibacterials in txing burn wounds?
Nephrotoxicity
For what are Ag containing dressings & HYdrocolloid dressing used for?
- Ag containing dressings = antibacterial; for donor sites, skin grafts, partial thickness burns to avoid daily dressing changes
- Hydrocolloid dessings = stable burns; occlude wounds while healing as long as it’s not affected
What are the 2 formulas used for nutrition of burn wounds?
Harrison Benedict Formula
Curreri formula
What formula for nutrition is used to calculate caloric needs using factors like gender, age, ht & weight
Harrison BEnedict formula
What are precautions/guidelines in using Harrison Benedict formula?
Inaccurate in burns <40% TBSA
Basa energy expenditure is multiplied by 2
What is the most appropriate nutritional formula for px w/ <40% TBSA?
Curreri formula - may overestimte nutritional reqs
What is the Curreri formula?
Estimated daily caloric needs:
[25 x body wt (kg)] + [40 x %BSA burned]
When do u use early enteral feeding in burn px?
1.Those w/ burns >20% TBSA
2. Loss of lean body mass
3. Slow hypermetabolic response
4. More efficient protein metabolism
What are the 4 types of burn surgeries done?
Fasciotomy
Skin grafting
Contact burn reconstruction
Release of contracture & flaps
WHat type of surgery is done to relieve swelling and pressure in a compartment of the body?
Fasciotomy
What is the diff betw Fasciotomy & Escharotomy?
Escharotomy = skin is cut (tough & crunchy)
Fasciotomy = skin is still flreshy
What is a net-like skin that is uses mesh to put holes in order for surface area of the skin to INC & have a bigger surface area of granulation of tissue?
Split thickness skin grafting
What type of surgery is done where the zone of coagulation is replaced and reconstructed?
Contact burn re=construction
In contact burn reconstruction, when is the initial placement of skin graft?
1 week after the inj=ury
What do you do in contact burn recnstruction?
- Remove devitalized tisssue
- Perform Debridement
- Good granulation tissue
- Inital placement of skin graft
- Healing, good color match
what happens if a burn px suffers from full thickness burns?
Since there are no more pliable & viable area of the skin => contacting the tissue since there’s no skin => closes the skin with contracture
What are the 2 main complications of burns?
- Contactures
- Malignancy transformation
What happens if contracture is in the joint area?
The body wiol try to close that area
What is the ave time of malignant transformation in burn wounds?
30-40yrs
