Burn, part 5 (Schwartz) Flashcards
Remarks on nutrition in burn patients
- “Nutritional support may be more important in patients with large burns than in any other patient population.”
- The hypermetabolic response in burn injury may raise baseline metabolic rates by as much as 200%
- Early enteral feeding shortens ICU stay, decreases wound infection rates, and prevents gastric ileus.
Amino acid supplement that may decrease infectious complications in burn patietns
Glutamine
probably via prevention of T-cell suppression in mesenteric lymph nodes
Two formulas for calculation of caloric needs
Harris-Benedict equation
Curreri formula
Harris-Benedict equation
- commonly used formula in non-burned patients
- uses factors such as gender, age, height, and weight
- Activity factor for burns: 2
4 May be inaccurate in burns <40% TBSA
Curreri formula
25 kcal/kg/day + 40 kcal/%tBSA/day
May be more appropriate for patients with <40% TBSA
Hyperglycemia in burn
- associated with increased mortality after burn injury
- Intensive insulin therapy has shown benefit in critically ill patients
- in burn patients, insulin has added metabolic benefit, with improvements in lean body mass and amelioration of inflammatory response
Complications in burn care
- VAP or post-injury pneumonia
- Abdominal compartment syndrome
- DVT
DVT in Burn
1.) 8% incidence in patients with 30-60% TBSA
2) heparin prophylaxis is safe in burn patients
3) High index of suspicion for HIT particularly if the platelet count drops at hospital days 7 to 10
Abdominal compartment syndrome should be suspected when?
Decreased urine output
Increased ventilator airway pressures
Hypotension
Remarks on escharotomies
- Excharotomies are rarely needed within the first 8 hours following injury and should not be performed unless indicated because of the terrible aesthetic sequelae
- When indicated, they are usually performed at the bedside, preferably with electrocautery to minimize blood loss
Remarks on extremity escharotomy
- Incisions are made on the lateral and medial aspects of the limbs and may extend onto thenar and hypothenar eminences of the hand
- Digital escharotomies are NOT recommended as it does not result in any meaningful salvage of functional tissue
- Inadequate perfusion despite proper escharotomies may indicate the need for fasciotomy, but this procedure should NOT be routinely performed as part of the eschar release
Thoracic escharotomy
- Escharotomies should be placed along the anterior axillary lines with bilateral subcostal and subclavicular extensions
- Extension of the anterior axillary incisions down the lateral abdomen typically will allow adequate release of abdominal eschar
This has revolutionized survival outcomes in burn care
The strategy of early excision and grafting in burned patients
- improves mortality
- decreased reconstruction surgery
- decreased hospital length of stay
Once the initial resuscitation is complete and the patient is hemodynamically stable, attention should be turned to excising the burn wound.
How is excision performed?
With repeated tangential slices using a Watson or Goulian blade until viable, diffusely bleeding tissue remains.
It is appropriate to leave healthy dermis, which will appear white with punctate ares of bleeding
This makes the most durable wound coverings
Split-thickness sheet autografts harvested with a power dermatome.
Wound coverage for large burns
In larger burns, meshed autografted skin provides a larger area of wound coverage
- allows drainage of blood and serous fluid to prevent accumulation under the skin graft with subsequent graft loss
Wound coverage for areas of cosmetic importance
Such as face, neck, hands.
Should be grafted with **nonmeshed sheet grafts* to ensure optimal appearnce and function
Donor sites for grafting
- **Thighs*
- convenient anatomic donor site
- thicker skin; especially useful in elderly -
Buttocks
- excellent donor site in infants and toddlers
- silver sulfadiazine can be applied to the donor site with a diaper as coverage -
Scalp
Many hair follicles allow rapid healing
- completely hidden once hair regrows
Most affected site for contractures
Shoulders
Followed by elbow, wrist, ankle, and knee
The 5 E’s for prevention of burn injuries
Engineering/environment
Enforcement
Education
Emergency response
Economic initiative
Remarks on Burn Disasters
- As per ABA, up to 30% of patients in MCI suffer from burn injury
- Preparedness is paramount for reacting quickly, efficiently, and effectively to a burn disaster.
General surgeon’s role in burn disasters
Due to resource limitations, they should be prepared to care for burn patients for the first 72 hours of resuscitation or until the patients can be transferred to a center that specializes in burn care.
This will involve initial evaluation, resuscitation, and potential interventions including central line placement, intubation, and escharotomies
Radiation burns syndrome
Hematologic (1-8 Sv exposure)
Gastrointestinal (8-30 Sv exposure)
Cardiovascular/neurologic (>30 Sv exposure)
With the latter two being nonsurvivable
After initial evaluation and decontamination by removing clothing of radiation burn patients, a useful way to estimate exposure is
by determining the time to emesis
No emesis within 4 hours of exposure: unlikely to have severe clinical effects
Emesis within 2 hours : at least 3 Sv exposure
Emesis within 1 hour at least 4 Sv
Remarks on concomitant radiation exposure and burn injuries
Early closure of wounds before radiation depletes circulating lymphocytes may be needed for wound healing (which occurs within 48 hours)
Agents used in warfare
White phosphorus
Sulfur mustard
Remarks on white phosphorus
- Absorption of even small amounts can result in hypocalcemia and hyperphosphatemia
- Treatment:
a. irrigation with cool liquid (as phosphorus pentoxide liquidizes above 44C)
b. application of saline soaked gauze to prevent drying out and reignition
c. potential surgical excision
remarks on sulfur mustard
- a.k.a. “mustard gas”
- the gas infiltrates the skin surface, causing degranulation of mast cells, leukocyte invasion and blistering of skin
- Treatment
a. scrubbing to relieve the remaining skinof sulfur mustard
b. irrigation
c. traditional burn therapy depending on the depth of lesion
