Burn wound management, infection control, and inhalation injury Flashcards
What are the zones of injury in a burn wound?
Zone of coagulation
Zone of stasis - edema, where inflammatory mediators are released, may progress.
Zone of hyperaemia - vasodilation
What occurs in zone of stasis?
- inflammation
- procoagulation/anti-fibrinolysis
What causes conversion of a wound? occurs in zone of stasis
and
What is the difference between conversion and progression
Conversion occurs due to an insult such as
- infection
- hypoperfusion (over resuscitation, underresuscitation)
- edema
- Progression is the timely development of the wound, but cannot be altered, not avoidable
- conversion is the change due to an additional insult and is avoidable.
What is your initial management of a burn injury
- ABC (life threatening)
- Escharotomy (limb threatening)
- Hx: mechanism, comorbidities
- PE: inhalational injury / burn depth estimation
- Determination: Severity of injury and need fo rtrasnfer/triage
- Irrigation and debridement of wounds
- burn wound dressing and infection control
- treatment planning: non-op vs op
What are 3 principles functions of burn dressings?
- Protective - barrier to microorganisms
- Metabolic - prevents heat evaporation, cold stress
- Comfort - prevents air currents, absorbs secretions
List skin substitutes
Temporary
- Biologic: allograft, xenograft, amnion
- Synthetic: Biobrane, trasncyte
Permanent
- Biologic: Autograft, cultured epidermal cell autograft
- Synthetic: Alloderm, Integra
What are optimal properties of a skin substitute?
- Protective: against heat/vapor loss, barrier to microrganisms
- Comfort: decrease pain
- non-immunogenic, non-toxic
- able to resist shear forces
- promotes healing and prepares wound bed for autograft (temporary substitutes)
What are operative indications for Excision and Grafting
- Full thickness burns { larger than 1cm2 in non-critical areas}
- deep partial burns which would take longer than 2-3wks to heal
What are reasons for early E&G?
- improved survival, decrease LOS in hospital
- for hand and foot, less resulting disability
How do you reduce intra-operative blood loss?
- Tumescent solution (1:1 000 000 - 1:500 000 epinephrine)
- Topical epinephrine (1:30 000)
- tourniquet
- staged operations (minimize operative time)
Describe how you would do escharotimies to all critical areas:
- chest/abdo
- neck
- Upper extremity
- Interossei
- Palm
- Digits/toes
- Leg
In general - beyond the margin of the burn, through to the hypodermis
- chest/abdo
- from clavicle, along anterior axillary line, trasnverse across costal margin
- neck
- from mastoid to sternal notch, along anterior border of SCM
- Upper extremity
- arm in anatomic position
- medial and lateral arm, anterior to medial epicondyle
- Interossei
- longitudinal incision over 2nd and 4th MC
- Palm
- along palm crease and at wrist cross ulnar to avoid palmar cut br
- Digits/toes
- posterior to mid lateral line on non-tactile surface of each digit
- Leg
- midlateral and midmedial incisioncs
What are risk factors for burn wound infection? and which microorganisms are likely to be responsible?
RISK FACTORS
- Large burn
- burn immunosuppression, hypermetabolism/malnutrition, ileus with altered gut permeability, loss of skin barrier, catheterization
- Dessicated wounds
- Pre-burn co-morbidities
- Age >60 or <16
ORGANISMS
- Early (within 24hr) endogenous Gr+
- Late (within 3-7days ) exogenous Gr-
- Delayed burn closure : yeast, fungi, drug resistant bugs
How do you diasnoe and treat a burn wound infection
- Dx: quantitative cultures and signs of infection
- Tx
- prevention: aseptic techqnieu w dressing change
- debriding dressing
How do you treatv pneumonia associated w burn injury/II?
- targeted abx Tx
- chest physio
- coughing
- turning
- pulmonary toileting
How do you manage blood stream/catheter infection
- cleanse site and dress with antmicrobial dressing
- avoid line in burn wound
- change line q3-7days if suspected infection (not prophylactic)
