Burn, part 3 (Schwartz)

Question 1

4 crucial assessments in a burn patient

Answer 1

1. Airway management
2. Evaluation of other injuries
3. Estimation of burn size
4. Diagnosis of CO and cyanide poisoning

Question 2

Signs of impending respiratory compromise

Answer 2

1. hoarse voice
2. wheezing
3. stridor
4. subjective dyspnea

Question 3

Remarks on perioral burns

Answer 3

“Perioral burns and singed nasal hairs alone do not indicate an upper airway injury, but are signs that the oral cavity and pharynx should be further evaluated for mucosal injury.”

Question 4

two large-bore IV catheters are ideal when?

Answer 4

burn TBSA >40%
Central venous access and intraosseous access should be considered when peripheral access cannot be easily obtained.

Question 5

Remarks on x-rays in a burn patient

Answer 5

1. Urgent radiology studies, such as a chest x-ray, should be performed in the emergency department
2. But nonurgent skeletal evaluation (i.e., extremity X-rays) can be done in the ICU to avoid hypothermia and delayed resuscitation

Question 6

Remarks on hypothermia

Answer 6

1. Hypothermia is a common prehospital complication that contributes to resuscitation failure
2. Patients should be wrapped with clean blankets in transport

ª3. Cooling should be avoided in patients with moderate or large (>20% TBSA) burns

ªFor larger burns, sterile drapes are preferred because application of saline-soaked dressings to a large area can cause hypothermia (Tintinalli)

Question 7

Remarks on prophylactic antibiotics

Answer 7

Patients with acute burn injuries should NEVER receive prophylactic antibiotics.
This intervention has been clearly demonstrated to promote development of fungal infections and resistant organisms and was abandoned in the mid-1980s.

Question 8

“Rule of the palm”

Answer 8

For smaller or odd-shaped burns, the “rule of the palm” where the palmar surface of the hand, including the digits, is 1 % TBSA is useful

Question 9

This diagram gives a more accurate accounting of the true burn size in children and adults

Answer 9

Lund and Browder chart

Question 10

Remarks on burn size estimation

Answer 10

1. The importance of an accurate burn size assessment cannot be overemphasized.
2. Superficial or first-degree burns should not be included when calculating burn size
3. Thorough cleaning of soot and debris is mandatory to avoid confusing soiled skin with burns

Question 11

Remarks on high-voltage electrical injuries

Answer 11

1. > 1000 V
2. Long-term neurologic symptoms and cataract development is not uncommon

Question 12

Remarks on hydrofluoric acid chemical injury

Answer 12

1. causes liquefactive necrosis
2. causes hypocalcemia
3. mainstay treatment: topical application of calcium gluconate

Question 13

Remarks on formic acid chemical injury

Answer 13

may cause hemolysis and hemoglobinuria

Question 14

Remarks on the zone of stasis

Answer 14

1. With variable degrees of vasoconstriction and resultant ischemia, much like a second-degree burn
2. Appropriate resuscitation and wound care may prevent conversion to a deeper wound
3. But infection or suboptimal perfusion may result in an increase in burn depth
4. This is clinically relevant because many superficial partial-thickness burns will heal with nonoperative management, and the majority of deep partial-thickness burns benefit from excision and skin grafting

Question 15

Most robust indicators for burn mortality

Answer 15

Age, Burn size, and Inhalational injury
Accounted for by the Revised Baux Score

Question 16

Parkland or Baxter formula for fluid resuscitation

Answer 16

3-4 mL/kg per % burn of PLRS.
Half - first 8 horus
Half - next 16 hours

Question 17

ABA consensus formula for fluid resuscitation

Answer 17

2 mL/kg per % burn of PLRS.
Half - first 8 horus
Half - next 16 hours
(given the tendency toward excessive fluid administration with the traditional formulas)

Question 18

2 resuscitation endpoints in fluid resuscitation

Answer 18

MAP >60 mmHg
UO
- adults: 0.5-1 mL/kg/hour
- pedia: 1-1.5 mL/kg/hour

Question 19

fluid resuscitation in children

Answer 19

For children <20 kg, deliver a weight-based maintenance IV fluid with glucose supplementation in addition to the calculated resuscitation with pLRS

Question 20

Remarks on colloids

Answer 20

1. In late resuscitation when the capillary leak has closed, colloid administration may decrease overall fluid volumes and potentially decrease associated complications such as intra-abdoinal hypertension
2. A recent meta-analysis demonstrated a trend toward mortality benefit for patients receiving albumin
3. May use albumin as an adjunct during burn resuscitation

Question 21

Blood transfusion in burn patients

Answer 21

1. Blood transfusion are considered immunomodulatory and potentially immunosuppresive, which may lead to increased infection and higher mortality
2. Restrictive transfusion (Hgb threshold 7 g/dL) is recommended over the traditional transfusion trigger of 10 g/dL
3. Another approach is to perform blood transfusions only when there is an apparent physiologic need