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