Burn care Flashcards

1
Q

What is the first step in management of a burn victim?

A

Primary survey—maintain airway patency, breathing, circulation. (Just like the ABCs of any trauma.) Secondary survey—identify associated life-threatening injuries and remove burned clothing and jewelry.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What are the ABA criteria for transfer to a specialized burn center?

A
  1. Partial-thickness burns involving greater than 10% total body surface area (TBSA)
  2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints
  3. Third-degree burns in any age group
  4. Electrical burns, including lightning injury
  5. Chemical burns
  6. Inhalation injury
  7. Burn injury in patients with preexisting medical disorders that could complicate management
  8. Any patients with traumatic injury in which the burn injury poses the greatest risk of morbidity or mortality
  9. Any burned children if the hospital initially receiving the patient does not have qualified personnel or equipment for children
  10. Any patient with burns that require special social, emotional, or long-term rehabilitative intervention
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What methods are used to estimate burn size?

A

Lund and Brower chart—most accurate, accounts for body proportions by age group.
Wallace’s “Rule of Nines”—head and neck (9%), anterior torso, (18%), posterior torso (18%), each upper
extremity (9%), each lower extremity (18%), and perineum (1%).
“Patient’s Palm” method—the patient’s palm is roughly equivalent to 1% of the TBSA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

When should fluid resuscitation begin in a burn victim?

A

Fluid resuscitation should begin immediately. Resuscitation for burns >20% TBSA in an adult is based on the Parkland formula. Resuscitation requirements are calculated based on the time of injury, not the time of presentation.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is the Parkland formula?

A

4 cc × weight (kg) × %TBSA = Total volume of Lactated Ringer’s (LR) to be given over the first 24 hours.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

At what rate should fluid resuscitation begin for a 70-kg man with a 40% TBSA second- and third-degree
flame burn, now 3 hours postinjury?

A

4 cc × 70 kg × 40% = 11,200 cc of LR over first 24 hours.
Half of volume is given over the first 8 hours; the remainder is given over the next 16 hours
11,200 ÷ 2 = 5,600 cc needed within the first 8 hours.
5,600 ÷ 5 = 1,120 cc/hour (the total fluid requirements for the first 8 hours will be given within 5 hours since the
patient presented in a delayed fashion)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

For this patient, at what rate should fluid resuscitation continue over the next 16 hours?

A

5,600 ÷ 16 = 350 cc/hour

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

How are the resuscitation requirements determined for children?

A

Based on body surface area:
Galveston Shriners Burns Institute formula: 5,000 cc/m2/BSA burn + 2,000 cc/m2/Total BSA = total LR for first 24 hours.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is the single best monitor of fluid resuscitation?

A

Urine output (0.5 cc/kg/hour for adults; 1.0 cc/kg/hour for children).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

By what percent does inhalation injury increase fluid resuscitation requirements?

A

40% to 75% (∼2 cc/kg/%TBSA)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What is the fluid regimen for patients with myoglobinuria or hemoglobinuria?

A

Discontinue LR and begin normal saline with sodium bicarbonate.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What osmotic diuretic may be added to assist in clearing the urine of these pigments?

A

Mannitol.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Which burn patients should receive tetanus immunization?

A

10% TBSA burn injury should receive 0.5 cc of tetanus toxoid; if unknown immunization history or >10 years
since last booster, add 250 units of immunoglobulin.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What are the depth classifications of burn injury?

A

First degree—involves epidermis only.
Second degree—involves partial thickness of dermis.
Third degree—involves full thickness of dermis and all adnexal structures. Fourth degree—involves underlying muscle, bone, or tendon.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What is the clinical appearance of a partial-thickness versus full-thickness burn wound?

A

A partial-thickness wound bed usually will be pink and moist underneath blisters, with intact sensation. A full-thickness injury will appear dry and insensate, and may be white, leathery, or charred depending on the depth of involvement.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

In what order do different sensory modalities return in a healed burn wound?

A

Pain (first), light touch, temperature, vibration (last).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What are the three histologic zones of burn injury?

A

Zone of necrosis—area of tissue necrosis due to destruction from burn injury.
Zone of ischemia—surrounds zones of necrosis; can convert to zone of necrosis because of inadequate tissue
perfusion.
Zone of hyperemia—surrounds zone of ischemia; usually reversible injury (heals).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

When should escharotomies be performed?

A

For deep, circumferential extremity burns with decreased or absent pulses or deep burns involving the torso that
impair ventilation.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

How should escharotomy incisions be planned?

A

Release of eschar should occur immediately at the bedside using a Bovie electrocautery.
Midaxial incisions release eschar of extremities.
Axial incisions along the flanks that connect across the midline to release the chest/torso.
Unilateral midaxial incisions on the digits on the radial surface of the small finger and thumb; escharotomy
incisions on the index, long, and ring finger generally should be placed on the ulnar surface.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What is the cardiovascular response to a burn injury?

A

Cardiac output (CO) initially decreases and systemic vascular resistance (SVR) increases. After the first 24 to 48 hours, the heart rate and CO increase and SVR decreases.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

How are red blood cells affected by burn injury?

A

Their T1/2 is shortened.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What are some causes of early renal insufficiency in burned patients?

A

Hypovolemia, vasoconstriction due to catecholamine release, myoglobinuria, nephrotoxic medications.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Which muscle relaxant should be avoided in burned patients?

A

Succinylcholine—causes marked hyperkalemia.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What is the immunologic response to thermal injury?

A

Decreased lymphocytes, macrophages, immunoglobulins, and lysosomal enzymes.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

What is the hypermetabolic response?

A

After an early “ebb” phase, a more prolonged period of protein catabolism, lipolysis, tachycardia, increased urinary output, increased oxygen consumption, nitrogen loss, and elevated body temperature ensues.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

What are the hormonal manifestations of the hypermetabolic response?

A

Increased levels of cortisol, catecholamines, and glucagons; there is an overall increase in the blood glucose level.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

What are signs and symptoms of inhalation injury?

A

Facial burns, singed nasal hairs, carbonaceous sputum, hypoxemia with or without an elevated carbon monoxide
level, hoarseness, stridor.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

What is an accurate and practical test for diagnosing an inhalation injury?

A

Fiberoptic bronchoscopy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

How can parenchymal thermal lung injury be detected?

A

133Xenon lung scan.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

What is the T 1/2 of carbon monoxide at room air and on 100% oxygen?

A

∼4 hours on room air, ∼45 minutes on 100% oxygen (at sea level).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

What is the initial treatment of suspected inhalation injury?

A

100% oxygen via face mask or nasal cannula.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

What is a low-voltage versus a high-voltage electrical exposure?

A

Low-voltage—<1,000 volts, mostly cutaneous manifestations of burn injury.
High-voltage—>1,000 volts, extent of injury usually involves deeper structures (based on resistance of different
tissues to passage of current).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

How does a lightning injury differ from a high-voltage electrical accident?

A

Lightning injuries result in a “flashover” and do not tend to cause devastating internal thermal injuries.

34
Q

What is the most common cause of death in a lightning victim?

A

Cardiopulmonary arrest.

35
Q

Which tissue has the greatest amount of resistance and therefore produces the most heat?

A

Bone.

36
Q

Which tissues have the least resistance to electrical current?

A

Nerves, blood vessels, muscle.

37
Q

What are emergent management considerations for electrical injury?

A

Evaluate for associated injuries, including cervical spine or extremity fractures, pneumothorax, neurologic changes, cardiac arrhythmias.
Escharotomy or fasciotomy alone or in combination (for compartment syndrome) and nerve decompression (eg, release of Carpal tunnel, Guyon’s canal) may also be warranted emergently.

38
Q

What are long-term management considerations for a patient with an electrical injury?

A

Debridement of all nonviable tissue, especially muscle; involved extremities may require amputation. Cataracts may present with a slow and progressive onset years after the injury.

39
Q

How are low-voltage electrical oral commissure burns managed?

A

Conservative local wound and splinting with a mouth spreader to prevent microstomia.

40
Q

What is a known complication of the use of a mouth spreader splint?

A

Hemorrhage from the superficial labial artery with sloughing of the eschar (5–7 days).

41
Q

What are the first steps in management of a chemical burn?

A

Disrobe patient, early irrigation of affected area with copious amounts of plain water, identify offending agent,
identify and treat systemic toxicity.

42
Q

Why should a chemical burn NOT be treated with a neutralizing agent?

A

The heat generated can induce a thermal injury.

43
Q

Which causes a deeper burn: acids or alkalis?

A

Alkalis.

44
Q

What are some commonly encountered alkali agents?

A

Lime, bleach, sodium hydroxide, potassium hydroxide (usually agents found in household cleaning products).

45
Q

What are the mechanisms by which alkali chemicals induce tissue injury?

A
  1. Fat saponification.
  2. Water extraction from cells.
  3. Formation of hydroxide ion-containing alkaline proteinates, leading to deeper tissue penetration.
46
Q

What are examples of some commonly encountered acidic agents?

A

Acetic acid, hydrochloric acid, hydrofluoric acid, trichloroacetic acid.

47
Q

By what mechanisms do acid chemicals induce tissue injury?

A

Hydrolysis of proteins, generation of heat in contact with skin

48
Q

How does hydrofluoric acid (HF) differ in its mechanism of injury?

A

Free fluoride ions complex with bivalent cations (Ca++, Mg++) to form insoluble salts, thereby depleting the available Ca++ and Mg++ in circulation.

49
Q

What can be applied topically to chelate fluoride ions and reduce pain?

A

2.5% calcium gluconate in a water-soluble gel.

50
Q

If pain relief is refractory to topical calcium gluconate, what is the next step in management?

A

Subcutaneous injection of 10% calcium gluconate.

51
Q

How are phosphorous and phosphoric acid similar to hydrofluoric acid?

A

They bind calcium ions.

52
Q

What can be applied topically to impede oxidation and burn injury from phosphorous compounds?

A

0.5% copper sulfate solution—on contact, copper sulfate forms a black film that delineates the area of phosphorus
injury.

53
Q

What is the basic tenet of surgical treatment for burn wounds?

A

Wounds that will not heal within 2 weeks should be excised and skin grafted.

54
Q

Which wounds tend to require excision and autografting?

A

Deep partial-thickness and full-thickness burn wounds.

55
Q

What is the “overlay” grafting method?

A

The use of widely expanded (4:1 meshed) split-thickness autograft with a meshed, unexpanded homograft overlay
(used for patients with large burns and minimal donor sites).

56
Q

What is the most common side effect of silver sulfadiazine (Silvadene)?

A

Transient leukopenia.

57
Q

What is the most common side effect of mafenide acetate (Sulfamylon)?

A

Carbonic anhydrase inhibition or hyperchloremic metabolic acidosis.

58
Q

What are the side effects of silver nitrate solution?

A

Electrolyte leaching, methemoglobinemia, silver discoloration of tissues.

59
Q

What is Acticoat?

A

Antimicrobial silver-coated barrier dressing.

60
Q

What is Biobrane?

A

Knitted nylon mesh bonded to a thin silicone membrane with a porcine collagen matrix.

61
Q

How does TransCyte compare to Biobrane?

A

Both are temporary skin replacement products—TransCyte has a polymer membrane with newborn human fibroblasts cultured onto a porcine collagen nylon mesh.

62
Q

What is Integra?

A

Bilaminate membrane—outer silicone layer and inner dermal layer made up of bovine type I collagen that is
cross-linked with shark glycosaminoglycans and chondroitin-6-sulfate.

63
Q

What are some advantages and disadvantages of using Integra for wound closure or contracture release?

A

The disadvantages are the need for a second surgery to remove the outer silicone layer, the risk of collecting fluid under the Integra, and infection.
The advantage is the creation of a “neodermis” and the ability to take a very thin (∼0.005 inch) split-thickness skin graft.

64
Q

When should the outer silicone layer be removed?

A

Approximately 21 days.

65
Q

How does AlloDerm differ from allograft?

A

AlloDerm is acellular cadaver skin that incorporates as a neodermis and can also be grafted with a much thinner skin graft.
Allograft is cadaveric homograft. It is not acellular so an eventual immune response is to be expected.

66
Q

What is CEA?

A

Cultured epithelial autograft—keratinocytes cultured in a laboratory setting over 3 to 4 weeks from a single punch biopsy of patient’s normal skin.
Utilized for near total 100% TBSA burns that require excision and grafting.

67
Q

How is a skin graft perfused within the first 24 to 48 hours?

A

By plasmatic imbibition; the graft becomes vascularized by inosculation over a period of 3 to 4 days.

68
Q

How is a skin graft perfused within the first 24 to 48 hours?

A

By plasmatic imbibition; the graft becomes vascularized by inosculation over a period of 3 to 4 days.

69
Q

What is plasmatic imbibition?

A

Plasmatic imbibition is the passive transport of nutrients from the wound bed to the graft.

70
Q

What is inosculation?

A

Inosculation is the establishment of anastomoses between graft and recipient blood vessels. Revascularization is complete by 7 days.

71
Q

What is neovascularization?

A

The ingrowth of durable, new vessels into the skin graft.

72
Q

What is primary versus secondary contraction?

A

Primary contraction is the passive immediate recoil of a skin graft after graft harvest.
Secondary contraction is the shrinkage of the graft that occurs during the healing process due to the action of
myofibroblasts. Increasing amounts of deep dermis included in thicker grafts are comparatively more resistant to secondary contraction than a graft that includes less dermis.

73
Q

In what order do skin grafts undergo increasing amounts of primary contraction?

A

Full-thickness, thick split-thickness, thin split-thickness, meshed split-thickness. How do you remember this?
MORE DERMIS=MORE ELASTIN=MORE PRIMARY CONTRACTION.

74
Q

What is the depth of harvest for each type of split-thickness skin graft?

A

Thin split-thickness skin graft: ≈0.005 to 0.012 inches thick
Medium split-thickness skin graft: ≈0.012 to 0.018 inches thick Thick split-thickness skin graft: ≈0.018 to 0.030 inches thick

75
Q

What quality of the skin graft determines the degree of primary contraction?

A

Elastin present in increasing amounts with the thickness of the dermal component provides a greater potential for
primary contraction.

76
Q

What is an important aspect of burn rehabilitation/reconstruction that begins during the acute phase of the injury?

A

Early range of motion, mobilization, and proper positioning/splinting.

77
Q

How should burned areas be splinted?

A

Neck in slight extension, shoulder abducted, elbow in full extension, hand in intrinsic plus position, hips in
extension/abduction, knees in full extension, and foot in neutral position/90◦ of dorsiflexion.

78
Q

What is the best way to preserve the most normal appearance in facial burn coverage?

A

Using medium- or full-thickness skin grafts and grafting within facial aesthetic units. Full-thickness skin grafts require closure at the donor site (either primary or with split-thickness skin grafting), and tend not to be used in the acute phase of burn coverage.

79
Q

How can the reconstruction of burn alopecia be managed?

A

Excision and primary closure (for small, concentrated defects).
Tissue expansion (defects up to 50% of the scalp).
Scalp rotational flaps (larger defects, with or without tissue expansion).

80
Q

What is the approach to operative management of an anterior neck contracture with lower lip and lower
eyelid ectropion?

A

Usually, the neck undergoes surgical release first, followed by the lower lip and lower eyelids. Lower lip and lower eyelid ectropion may improve or resolve after release of the anterior neck.

81
Q

What is the preferred skin graft technique for upper versus lower eyelid ectropion reconstruction?

A

The upper eyelid is released with a split-thickness skin graft (for mobility), whereas the lower eyelid is released with
a full-thickness skin graft (for support).

82
Q

What are examples of flaps commonly used in burn reconstruction?

A

Z-plasty, V-to-Y, 5 flap plasty (also known as, “Jumping Man”).
Scalp rotational flaps.
Advancement of neck and facial flaps after tissue expansion
Pedicled or free tissue transfer for release of burn scar contracture (scapular/parascapular, thoracoepigastric,
anterolateral thigh, latissimus dorsi).