Burn & Skin Flashcards
1
Q
what burns can heal by epithelialization (no graft needed)?
A
1st and superficial second
2
Q
admission criteria for burn
A
TBSA > 10% <10YO or >50YO
TBSA > 20% 10-50 YO
3rd degree > 5% in any age group
electrical, chemical, inhalational, trauma, comorbid, rehab needs, NAT suspected
3
Q
difference betweern superifical and deep second degree burn?
A
superficial PAPILLARY - pianful, blisters, hair follicles INTACT
deep RETICULAR - decreased sensation, loss of hair follicles
4
Q
Parklands formula - when to use?
A
for 20%+ TBSA of 2nd degree or 3rd degree
5
Q
Parklands formula
A
4 cc/kg x TBSA x kg; 1/2 in first 8 hrs other 1/2 in 16 hours LR.
6
Q
main risk factor for PNA in burn patient?
A
inhalational injury
7
Q
how to dx inhalational injury if suspected (facial burn, wheezing, carbonaceous sputum)
A
fiberoptic bronchoscopyt
8
Q
when to use albumin in resuscitation
A
only after 24 hours (decrease pulmonary complications)
9
Q
types of necrosis in alkali vs acid?
A
alkaline: liquefaction necrosis
acid: coagulation necrosis
10
Q
tx chemical spill?
A
water irrigation
11
Q
hydrofluoric acid burn?
A
CALCIUM-gluconate gel on wound.
12
Q
powder burn?
A
wipe away powder then irrigate
13
Q
tar burn?
A
cool then wipe with lipophilic solvent
14
Q
electrical burn
A
watch for polyneuritis demyelinixzation, quadriplegia, transverse myelitis, cataracts, liver necrosis, bowel perf, GB perf, necrotizing panc, posterior shoulder dislocation, vertebral body fracture… get CARDIAC MONITORING
15
Q
lightning cause of death
A
arrest 2/2 Vfib
16
Q
child abuse burn cases
A
15% of burn cases
17
Q
blood flow from graft to burn?
A
0-3 days: imbibition (osmotic) - inosculation
3+ day: neovascularization
18
Q
how long do homografts (cadaveric) last?
A
4 wks, then are rejected once vascularized
19
Q
xenografts last?
A
2 wks but do not vascularize
20
Q
what has less wound contraction? FTSG vs STSG?
A
FTSG; use for hands
21
Q
STSG dermatome thickness
A
0.12-0.15 mm
22
Q
how long to immobilize after FTSG?
A
7 days.
23
Q
infected burn wound
A
no ppx required but
cover PSEUDOMONAS > Staph, E.coli, enterobacter coverage if infected
24
Q
MC cause of viral infection
A
HSV
25
ectopia eye burn
release eyelid
26
corneal abrasion
can do fluorescin staining.
tx: topical fluoroquinolone or gentamicin
27
symblepharon
eyelid stuck to conjunctiva
release with glass rod
28
heterotopic ossification of tendons tx
physical therapy ... may need OR
29
silvadene SE?
silver sulfadiazine...
NEUTROPENIA, THROMBOCYTOPENIA
sulfa allergy
30
silvadene penetrate eschar?
no.... can inhibit epithelialization
31
pseudomonas coverage for silvadene?
none.
32
silver nitrate SE
electrolytes... hyponatremia, hypochloremia, hypoCa, hypoK
also methemoglobinemia esp with G6PD deficiency
33
silver MOA
ribosomal toxicity, intercalates into DNA, denatures proteins,disrupts bacterial cell membrane
34
eschar and silver nitrate?
no...
35
pseudomonas coverage by silver nitrate?
none
36
sulfamylon (mafenide sodium) SE
painful... METABOLIC acidosis (in renal)
37
eschar and sulfamylon?
great penetrance
38
pseudomonas coverage by sulfamylon?
great!
39
curling vs marjolin ulcer
curling: ulcer after/in the setting of burn
marjolin: highly malignant squamous cell cancer in scar/old burn
40
tetanus shot in burns and frostbite
don't forget
41
path in erythema multiform>SJS>TEN and SSSS
epidermal-dermal separation
42
SJS, TEN, multiforme, SSSS
no steroids
consider supportive, fluids and IVIF +/-
43
langerhans cells
dendritic cellsof skin
act as APCs (MHC class II)
originate from BONE MARROW
role in type IV hypersensitivity
44
pacinian corpuscle sensation
pressure
45
ruffinis endings sensation
warmth
46
krauses end bulbs sensation
cold
47
meissners corpuscle sensation
tactile sense
48
cause of flap necrosis
venous thrombosis mostly
49
TRAM flap vessels
superior epigastric vessels
50
viability of TRAM determined by what?
periumbilical muscle perforators
51
pressure sore stages I-IV
I. erythema and pain (tx: offload)
II. partial skin loss with yellow dermis showing (offload, local tx)
III. full thickness, fat showing (tx: sharp debride possible myocut flap)
IV. bone, muscle, adipose, tendon (tx: myocut/glut flap)
52
biggest risk factor for melanoma
large congenital nevi, >50 typical nevi, dysplastic or atypical nevi 10% lifetime risk
xeroderma pigmentosum
fair complexion, etc.
53
familial syndrome with melanomas?
BK mole syndrome (100% risk)
54
superficial parotidectomy
scalp and face melanomas anterior to tragus and above lower lip... 1+ mm deep including of the ear.
55
melanoma in situ or thin lentigo maligna (Hutchinsons freckle
0.4 cm margin is good
56
lentigo maligna melanoma
least aggressive... radial growth first and presents as elevated nodule
57
superficial spreading melanoma
MC type... originates from nevus/sun exposed
58
acral lentiginous
very aggressive... palms/soles black.. includes subungual
59
dacarbazine
1st line chemo for metastatic melanoma > IFN , immunotherapy /pembro/ipilimumab?, tumor vaccine
60
melanoma staining
S-100 and HMB-45
61
MC site for melanoma
men: back
women: legs
62
lido 1% dose
max 7 mg/kg;
5 mg/kg with epi
63
3 phases of skin grafting
1. imbibition (diffusion)
2. inosculation (anastomosis of new capillaries) 48 hrs
3. reinnervation vs neovascularization (starts day 7 organization by fibroblasts)
64
frostbite grades
I. superficial
II. blisters
III. necrosis
IV. gangrene
65
frostbite severity
mild >32
mod28-32
sev <28
66
frostbite sx severity
mild: shiver, mild AMS
mod: agitation, spasticity, dilated pupils, slow RR
sev: prolonged QRS, Osborn waves, flaccid, coma, ----> VFib
67
tPA in frostbite
if no improvement 15-20 min active bath
if absent dopplers
if limited perfusion on 99mTc bone scan
within 24hrs of initial rewarming
68
warm fluids
43C = 109F in microwave
69
hemangioma timecourse
F after birth > quickly grow > quiescence > involute
70
hemangioma tx
observe unless bleeds, ulcerates, visual obstruction, airway, CHF involvement
71
glomus tumor
AV malformations in subungual area
sx; Pain, cold intolerance, point tenderness of blue mass
72
Love and hildreth sign
Glomus tumor
love: extreme pain with pressure on glomus
hildreth: removal of pain with proximal tourniquet inflation
73
glomus dx and tx
MRI or US
excision
74
superficial inguinal LN dissection boundaries
femoral triangle = inguinal ligament above, sart laterally, adductus magnus medially, the intersection of both inferiorly
75
how to extend superficial inguinal LN dissection to deep LNs
extend to 3-4 cm medial to ASIS
or separate transplant incision
76
ifn a2b indication
melanoma IIB-III
77
melanoma TNM staging
T: breslow
b = ulceration
N: N1=1, N2=2-3, N3=4+
M1a: other skin, LNs
M1b: lung
M1c: other organs
78
mohs margin
5mm
79
melanoma in situ
5mm-10mm
80
MSLT-II trial for SLN mets
instead of completion LAD, just serial clinical exams and nodal basin US q4 mo x 2yrs > q6mo x 3 yrs > annual
81
ehlers danlos defect
collagen v
82
margin excision bcc and scc
LN adenectomy
bcc 4mm
scc 1cm
for clinically positive nodes
83
BCC pathology
peripheral palisading nuclei and stromal retraction
morpheaform: AGGRESSIVE has collagenase production
84
cloquets node
first of deep nodes to receive drainage from superficial inguinal nodes
85
histologic zones of a burn
hyperemia: recoverable increased perfusion
stasis: poor perfusion, questionable recovery
coagulation: max damage, permanent
86
target UOP
0.5 cc/kg/hr adult
1 cc/kg/hr child
2 cc/kg/hr for infant < 6 mos
87
carbon monoxide poisoning sx
sz, AMS, lactic acidosis, arrhythmia, MIA
88
CO poisoning dx and tx
COHg trend
tx: 100% O2 possible hyperbaric oxygen
89
cyanide poisoning
concurrent with CO... treat with cyanokit = hydroxocobalamin
90
SCIP surgical care improvement project 7 intiiatives
1. avoid hyperglycemia
2. normothermia
3. ppx abx iwthin 60 min of incision
4. select appropriate ppx
5. stop abx within 24 hour of surgery end time
6. clipper > razor
7. remove Foley within 2 postop days
91
MC bugs in NSTI
nec fasc: GAS
Nec myositis: GAS
nec cellulitis: C. perf or poly
92
types of NSTI
Type I: polymicrobial
2: mono MC GAS
3: GN-marine
93
pilonidal disease risk factors
M
BMI > 25
sitting
thick body hair
94
MC sarcoma
1. malignant fibrous histiosarcoma
2. liposarcoma
95
sarcoma workup
CXR (lung mets)
MRI (before bx for vascular/neuro/bone invasion)
CBx ...if fails? then excisional (<4 cm) or longitudinal incision > 4cm
96
sarcoma tx
1-3 cm margin and negative fascial plane ideally +/- radiation +/- neoadjuvant chemo
97
sarcoma px
overall poor....
chemo and XRT have NOT changed survival
98
5 yr survival rate with complete resection of sarcoma
40%
99
sarcoma radiation indication
high grade tumor
close margins <1-3 cm
or tumors > 5 cm
100
sarcoma chemo indication
DOXORUBICIN
tumor > 10 cm to allow for limb sparing procedure
101
MC site of sarcoma met
LUNG
102
dermatofibrosarcoma protuberans
MC young black pts
plaque/nodule > reddish
Tx: resection… and keep resecting with wide margins if recurs no LN staging required
103
dermatofibrosarcoma protuberans chromosomal dx
chromosomal translocation 11&22
104
Dermatofibrosarcoma protuberans histo
whorled spindle type cells
105
dermatofibrosarcoma mets
LUNG >>> fibrosarcomatous changes
106
dermatofirosarcoma tx
WLE 2-4 CENTIMETER margin
107
meckel cell carcinoma
rapid growing firm red purple nodule
108
meckel cell carcinoma dx
histo = neuroendocrine
PET scan prior to resection
109
meckel cell carcinoma tx
WLE 1-2 cm with SLNB
aduvant radiation for > 2cm or LN mets
110
subungual melanoma tx
mid proximal phalanx amputation if finger
toe amp to metatarsal head if toe
SLNB if >1mm
111
herpetic whitlow tc
just obs, avoid contact, no I&D
112
lymphangitis MC bug
GAS
113
MC erysipelas bug
GAS
114
lip lower ca
SQUAMOUS
115
lip upper ca
BASAL
116
timing of grafting (location)
within first week except for:
FACE (abx first then FTSG)
HANDS FTSG
PALMS FTSG
genitals: can use STSG
and change allografts to autografts after the first week!
117
kaposi sarcoma tx
HAART to shrink +/- XRT or intralesional vinblastine for local disease
if disseminated, use IFN-a (like for melanoma)
surgery if intestinal hemorrhage
118
dermoid cyst
midline, intraabdominal and sacral lesions
need resection due to malignancy risk
119
wart
viral...
tx: salicylic acid, liquid nitrogen
120
actinic keratosis tx
excisional bx and diclofenac sodium and liquid nitrogen
121
arsenical keratosis
associated with SCC
122
merkel cell biomarkers
neuron specific enolase
cytokeratin
neurofilament protein
123
merkel tx
SLNBx (all need) vs formal LN dissection
+ resection with 2-3 cm margins
