Burn Wounds Flashcards
What type of burn can cause direct injury to cell membranes in addition to heat transfer?
chemical/electrical
What are the different causes of burns?
flames, scald, contact, chemical, electrical
What does the depth of the burn depend on?
temperature
time exposed
specific heat
In what ways do burns cause a severe inflammatory reaction?
capillary leak intravascular fluid loss high fevers organ malperfusion MSOF
Where do we get edema from a burn?
in burned and unburned skin
In the characteristic ebb and flow model what is ebb and what is flow?
ebb- low metabolism/cardiac output, decreaseed temp
flow- hypermetabolism, high cardiac output, hyperglycemia, increased heat production
What are the burn classifications?
1st degree- superficial
2nd degree- superficial-partial thickness AND deep-partial thickness
3rd degree- full thickness
4th degree
What layer of skin does a 1st degree burn go to?
epidermis
Describe a 1st degree burn:
over 2-3 days the erythema and pain subside. By the fourth day, the injured epithelium peels
Dry, minor blisters, erythema, brisk capillary return
What is an example of a 1st degree burn?
sunburn
How do we treat a 1st degree burn?
no need for skin grafting, treat with topical antibiotics/supportive
What layer of skin does each second degree burn go to?
Superficial-partial- papillary dermis
Deep-partial- reticular dermis
Describe a 2nd degree burn (superficial-partial):
Specifically it shows as a blister with fluid collected at interface of the epidermis and dermis. Tissue is pink and wet; hair follicles intact. It is red and painful
Describe a 2nd degree burn (deep-partial):
Burn has gotten to some nervous tissue, it blisters and the tissue is molted, dry and decreased in sensation.
Moist, reddened with broken blisters, brisk capillary return
How does a 2nd degree superficial partial heal?
heals spontaneously in less than 3 weeks and does so with out functional impairment. They rarely cause hypertrophic scarring, but in pigmented individuals the healed burn may never completely match the color of the surrounding normal skin.
How does a 2nd degree deep partial heal?
Heals in 3-9 weeks but invariably does so with considerable scar formation. Unless active physical therapy is continued through outh the healing process, joint function can be impaired and hypertrophic scarring is common
What is the treatment for a 2nd degree superficial-partial?
Silvadene cream or Xenograft
What is a Xenograft?
Implementation of pig skin in the healing process that is not incorporated in to the new skin but just lays over the skin helping it to scab.
What is the treatment for a 2nd degree deep-partial?
skin grafting
What layer of skin does a 3rd degree burn get to?
the dermis; full thickness
Describe a 3rd degree burn:
Leathery, firm skin that does not blanch under pressure. It is insensate, white and not painful. This has burned all the layers of the dermis
Moist white slough, red mottled, sluggish capillary return
How does a 3rd degree burn heal?
Develops a classic burn eschar. It can only heal by wound contracture, epithelialization from the wound margin or skin graft
What is an eschar?
A structurally intact but dead and denatured dermis that if you left in situ over days and weeks, separates from underlying viable tissue
How do you treat a 3rd degree burn?
Skin graft- have to take the skin off because of the risk of infection
What layer of skin does a 4th degree burn go to?
subcutaneous fat, muscle and/or bone
How does a 4th degree burn heal?
will not heal if left alone
How do we treat a 4th degree burn?
reconstructive surgery, tissue flaps
CANNOT skin graft over bone or fat; need a better blood supply
What is the break down of the rules of Nine’s?
Head- 9% Arm (each 9%) Torso (anterior- 18%, posterior- 18%) Genitalia- 1% Legs- (each 18%)
What is another method we can use for determining the TBSA?
The palm of the hand is 1%
What is the basis of fluid resuscitation and care plans?
the size and the depth of the burn
How long does it take for a burn to fully evolve? What does this mean?
72 hours, our initial calculation may be off
What are the criteria for a burn center referral?
- partial thickness >10% in people 50
- partial thickness >20%
- involving the face, hands, feet, genitals or joints
- full thickness >5%
- electrical injury
- chemical burn
- inhalational injury
- comorbidities (CHF)
- concomitant trauma
- children
- special emotional, social or rehab needs
What is significant about a burn center?
Usually the only place that does skin grafts, people there are trained in burns
What is the most common type of burn?
scald burn
What do we need to look for with an electrical burn?
an entry and exit wound, also do heart monitoring
What are we looking for while heart monitoring an electrical burn victim?
rhabdo/compartmental syndrome
What do we and dont we use on an acid or alkali burn?
USE water, DO NOT TRY TO NEUTRALIZE
With an HCl burn what do we use?
Calcium
What goes into the initial assessment of a burn victim?
ABCDE airway breathing circulation disability exposure
Why do we look at airway?
can be an issue with severe burns or inhalation injury from heated air or smoke; especially from and indoor fire
What do we do if we are worried about a burn patients air way?
intubate
What are possible signs of an issue with an airway in a burn patient?
facial burns singed nose hairs wheezing carbaceous sputum tachypnea
What is a sign of impending airway obstruction?
progressive hoarseness
What do we do along with intubating a patient with suspected airway issues?
do a bronchoscopy to help diagnose inhalation injury and see its extent
What do we check when we look at breathing?
breath sounds
chest rise
ET CO2
What do we check when we look at circulation?
HR and BP, palpate or doppler extremity signals w/ circumferential extremity burns to assess damage
What do we start burn resuscitation with?
LR
What is the rule for intubating when we are looking at the patients disability?
GCS <8, intubate
What is involved in checking for exposure?
Remove all clothing, make sure all dry powder is off
What should we be thinking if the patient was in an explosion? In regards to their lungs.
pneumothorax
What is an escharotomy?
Cut burn tissues along sides and that removes tension and makes it easier to breathe
What is the airway at a secondary risk to?
direct trauma/injury
fluid resuscitation
edema from inflammatory response
Why should we not do nasotracheal intubation?
risk of sinusitis or erosion of nasal columella
What angle should the patients head be at during intubation?
45 to reduce swelling and to prevent aspiration
What are possible inhalation injuries?
CO poisoning
Upper airway thermal injury
Lower airway thermal injury
How do we treat CO poisoning?
give 100% O2, it rapidly accelerates CO dissociation from hemeglobin
How do we diagnose an upper airway thermal injury?
Direct visualization of the posterior pharynx
How do we diagnose CO poisoning?
Look at the carboxyhemaglobin level
What is the least likely inhalation injury to sustain and why?
Lower airway burn injury- rare due to heat absorptive capacity of the oropharynx
What causes an upper airway thermal injury?
hot air or chemical burn
What is the parkland formula?
4 x Weight(kg) x %TBSA = mg to give in one day
1/2 over 1st 8 hours, other 1/2 over the next 16
BUT FIRST FIGURE OUT WHAT THE EMS GAVE THEM. subtract that first then calculate.
What do you not give to a burn victim in the first 24 hours?
a colloid (albumin, blood prod)
Which burns can compromise circulation?
2nd degree deep - 4th
What are the 6 p’s of burn wound management?
pallor pulselessness paresthesias paralysis poikilothemia pain
What is poikilothemia?
coldness
How do we treat compartment syndrome?
escharotomy, deep burn so no pain, cut skin to relieve pressure
What is the last thing to go on a burn victim?
pulse
What are the indications for an escharotomy?
circumferential burns
cool extremity, weak pulse, decreased cap refill, decreased pain
difficulty with ventilation and chest burns
What does overresuscitation cause?
poor tissue perfusion, abdominal or extremity compartment syndrome, pulmonary edema and pleural effusion
How often should you evaluated burned extremities?
hourly
What must you do with the arm before you make the cuts for an escharotomy?
put it in anatomical position
Why are burn patients susceptible to infection?
immunological insult of large burns and b/c dead tissue is easily compromised
How do you aid in decreasing their susceptibility to infection?
Initially clean/debride and cover with topical antimicrobial
What are the types of autograft?
a full thickness skin graft
split thickness skin graft
meshed vs sheet
What is an allograft?
a temporary graft replaced after two weeks
What are dermal substitutes? Do we use them?
Integra, not often because its very expensive
What is a meshed graft?
uses less skin for a large area, has holes to prevent hematoma
What are topical antibiotics for wound management?
Mafenide acetate- (sulfaylon)
Bacitracin
Silver sulfadiazine (silvadene)
Mafenide acetate- (sulfaylon)
Used for cartilage
Good at penetrating eschar but its painful
broad spectrum
Side effect: metabolic acidosis via carbonic anhydrase inhibition
Bacitracin
used for the face
gram + bacteria
Silver sulfadiazine (silvadene)
used for the trunk and extremities broad spectrum does not penetrate the eschar well AVOID IF SULFA ALLERGY Side effects: neutropenia/thrombocytopenia
Why dont oral medications work?
The burned tissue is not highly vascularized
What drugs are good at preventing pseudomonas?
Mafenide acetate- (sulfaylon) Silver sulfadiazine (silvadene)
With electrical burns what is the most significant injury?
deep tissue
What do we have to follow with electrical burns?
serial CPK and urine myoglobin due to possibility of rhabdomyolysis
What type of chemical burn is the worst typically?
Alkalis
When assessing a burn using our ABCs what do we need to remember with A?
While starting A, don’t forget to “quench” burns by cooling affected tissues before starting oxygen
When do you include burns in the TBSA determination for burn fluid replacement?
Only second-degree burns or greater should be included in the TBSA determination for burn fluid calculations
What types of burns can compromise circulation?
Circumferential deep 2nd or 3rd degree extremity burn can compromise circulation
How do you assess for pulselessness?
check doppler
