Burn, part 5 (Schwartz)

Question 1

Remarks on nutrition in burn patients

Answer 1

1. “Nutritional support may be more important in patients with large burns than in any other patient population.”
2. The hypermetabolic response in burn injury may raise baseline metabolic rates by as much as 200%
3. Early enteral feeding shortens ICU stay, decreases wound infection rates, and prevents gastric ileus.

Question 2

Amino acid supplement that may decrease infectious complications in burn patietns

Answer 2

Glutamine
probably via prevention of T-cell suppression in mesenteric lymph nodes

Question 3

Two formulas for calculation of caloric needs

Answer 3

Harris-Benedict equation
Curreri formula

Question 4

Harris-Benedict equation

Answer 4

1. commonly used formula in non-burned patients
2. uses factors such as gender, age, height, and weight
3. Activity factor for burns: 2
   4 May be inaccurate in burns <40% TBSA

Question 5

Curreri formula

Answer 5

25 kcal/kg/day + 40 kcal/%tBSA/day
May be more appropriate for patients with <40% TBSA

Question 6

Hyperglycemia in burn

Answer 6

1. associated with increased mortality after burn injury
2. Intensive insulin therapy has shown benefit in critically ill patients
3. in burn patients, insulin has added metabolic benefit, with improvements in lean body mass and amelioration of inflammatory response

Question 7

Complications in burn care

Answer 7

1. VAP or post-injury pneumonia
2. Abdominal compartment syndrome
3. DVT

Question 8

DVT in Burn

Answer 8

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

Question 9

Abdominal compartment syndrome should be suspected when?

Answer 9

Decreased urine output
Increased ventilator airway pressures
Hypotension

Question 10

Remarks on escharotomies

Answer 10

1. Excharotomies are rarely needed within the first 8 hours following injury and should not be performed unless indicated because of the terrible aesthetic sequelae
2. When indicated, they are usually performed at the bedside, preferably with electrocautery to minimize blood loss

Question 11

Remarks on extremity escharotomy

Answer 11

1. Incisions are made on the lateral and medial aspects of the limbs and may extend onto thenar and hypothenar eminences of the hand
2. Digital escharotomies are NOT recommended as it does not result in any meaningful salvage of functional tissue
3. 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

Question 12

Thoracic escharotomy

Answer 12

1. Escharotomies should be placed along the anterior axillary lines with bilateral subcostal and subclavicular extensions
2. Extension of the anterior axillary incisions down the lateral abdomen typically will allow adequate release of abdominal eschar

Question 13

This has revolutionized survival outcomes in burn care

Answer 13

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.

Question 14

How is excision performed?

Answer 14

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

Question 15

This makes the most durable wound coverings

Answer 15

Split-thickness sheet autografts harvested with a power dermatome.

Question 16

Wound coverage for large burns

Answer 16

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

Question 17

Wound coverage for areas of cosmetic importance

Answer 17

Such as face, neck, hands.
Should be grafted with **nonmeshed sheet grafts* to ensure optimal appearnce and function

Question 18

Donor sites for grafting

Answer 18

1. **Thighs*
   - convenient anatomic donor site
   - thicker skin; especially useful in elderly
2. Buttocks
   - excellent donor site in infants and toddlers
   - silver sulfadiazine can be applied to the donor site with a diaper as coverage
3. Scalp
   Many hair follicles allow rapid healing
   - completely hidden once hair regrows

Question 19

Most affected site for contractures

Answer 19

Shoulders
Followed by elbow, wrist, ankle, and knee

Question 20

The 5 E’s for prevention of burn injuries

Answer 20

Engineering/environment
Enforcement
Education
Emergency response
Economic initiative

Question 21

Remarks on Burn Disasters

Answer 21

1. As per ABA, up to 30% of patients in MCI suffer from burn injury
2. Preparedness is paramount for reacting quickly, efficiently, and effectively to a burn disaster.

Question 22

General surgeon’s role in burn disasters

Answer 22

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

Question 23

Radiation burns syndrome

Answer 23

Hematologic (1-8 Sv exposure)
Gastrointestinal (8-30 Sv exposure)
Cardiovascular/neurologic (>30 Sv exposure)
With the latter two being nonsurvivable

Question 24

After initial evaluation and decontamination by removing clothing of radiation burn patients, a useful way to estimate exposure is

Answer 24

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

Question 25

Remarks on concomitant radiation exposure and burn injuries

Answer 25

Early closure of wounds before radiation depletes circulating lymphocytes may be needed for wound healing (which occurs within 48 hours)

Question 26

Agents used in warfare

Answer 26

White phosphorus
Sulfur mustard

Question 27

Remarks on white phosphorus

A shell that appears to be white phosphporus from Israeli artillery explodes over a house in al-Busta, a Lebanese border village on Oct 15, 2023

Answer 27

1. Absorption of even small amounts can result in hypocalcemia and hyperphosphatemia
2. 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

Question 28

remarks on sulfur mustard

Answer 28

1. a.k.a. “mustard gas”
2. the gas infiltrates the skin surface, causing degranulation of mast cells, leukocyte invasion and blistering of skin
3. Treatment
   a. scrubbing to relieve the remaining skinof sulfur mustard
   b. irrigation
   c. traditional burn therapy depending on the depth of lesion