Burns Flashcards
Simple lac or surgical wound mgmt
Primary closure - then clean and dress
“sealed” = after 48hr, further dressings not required
Systematic assessment of wound - TIMES
T: tissue involved (viable vs. nonviable) I: infection, inflammation M: moisture level E: edge of wound S: surrounding skin
Negative-pressure wound therapy [Wound VAC]
May aid in healing wounds or temporize them pending formal reconstruction
Encourages blood supply to wound site
Reduces wound edema
Removes need for multiple dressing changes
Encourages cell activity and wound perfusion
Stimulates granulation tissue formation
Sealed dressing must be applied over wound
Device set to negative pressure (75-150 mmHg) - acts to remove exudate through its pump into a collecting canister
C.I.
- active exposure over vessel or bowel
- ongoing infection
- significant tissue necrosis requiring further debridement
Reconstructive Ladder
- Secondary intention
- Primary closure
- Delayed primary closure
- Split thickness graft
- Full thickness skin graft
- Tissue expansion
- Random flap
- Pedicled flap
- Free flap
Skin grafting
Surgical operation in which piece of skin is transplanted to a new site
Necessary when wound cannot be closed primarily and delayed healing is not appropriate
Skin graft has no blood supply, thus depends on vascularised bed where it is placed
Types of Skin Grafts
- Split-skin thickness skin graft: does not contain whole dermis
- leaves dermal remnants to allow re-epithelization of donor site
- used for larger areas requiring cover (burn surgery)
- meshed = increase size
- harvested with a dermatome or using a specialist blade (Humby knife) - Full-thickness skin graft: contains the whole dermis (also transplanting hair follicles)
- donor site must be closed directly
- only relatively small areas can be taken from regions with surplus skin (supraclavicular fossa, pre-auricular, post-auricular, groin, medial upper arm)
- tend to be used for smaller areas (face) - better cosmesis
Skin Flaps
Flaps - bring their own blood supply
Described by:
- circulation/blood supply
- composition
- location/movement
Process: taking composite block of tissue along w/its blood supply and moving it from one place to another
Local = area of tissue is taken from an area adjacent to the defect
Regional = tissue is raised from nearby area and moved into the defect
“Free flaps” = tissue is raised w/its blood supply, then completely detached and reattched (anastomosed) to a new vessel at the donor site
Thermal burns
Scald: hot liquid/steam, common in children and elderly
Flame: direct exposure to fire, a/w concomitant inhalation injury
Flash: indirect exposure to flame
Contact burns
Exposure to very hot stimulus for short amount of time (e.g. industrial accidents) or exposure to a hot surface for an abnormally long amount of time (e.g. radiator)
Chemical burns
Acid: coagulation necrosis to affected tissue
Base: liquefaction necrosis to affected tissue
- deeper and more severe burn, d/t protein denaturation and fat saponification
Electrical burns
Direct contact: current from an electrical source passes directly through the body, resulting in entry and exit wound and can cause significant internal damage
- complications: cardiac arrhythmia, rhabdomyolysis
Electrical arc: flash thermal burn occurs d/t an electrical arc coming briefly into contact w/skin
Inhalation injury
Damage to airway secondary to inhalation of hot air
- suspect whenever injury is from a flame or smoke exposure in enclosed in environment
- increased mortality 20%
Features of airway compromise = definitive airway placement (e.g. intubation)
- stridor
- hoarse voice
- respiratory compromise
Subtle features
- singed nasal hairs
- facial burns
- soot deposits around nose
Nasoendoscopy - may show erythema or edema of airway on direct visualization
Initial general management
Assess patient once stable - for mechanism of burn
Major burn = >20% BSA (>10% children) of parital or full thickness burns
- result in profound inflammatory response and large fluid shifts
Aggressive fluid resuscitation is required to mitigate burn shock
Remove source of burning and non-adherent clothing
Initial assessment
Airway
- eval signs of inhalation injry
- pre-emptive intubation if high-risk
- protect C-spine until clinically cleared
Breathing
- admin 100% o2 via non-rebreather reservoir mask
- obtain ABG and check carboxyhemaglobin levels
Circulation
- site two wide bore IV cannulas (avoid inserting in burned tissue)
- routine blood labs
- aggressive IV therapy is indicated
- insert urinary catheter for monitoring fluid balance
Disability
- eval neurological status (GCS)
- check temperature - increased r/o hypothermia
Exposure
- full exposure to get accurate estimation of % TBSA and check for concomitant injuries
- ensure utd tetanus booster
Other mgmt strategies
IV morphine for analgesia
ECG/CXR
Fluid balance chart
Wound dressings
- if pt is transferred to higher-level burn care, initially dress the wound with Clingfilm to allow full evaluation of burn depth, while maintaining fluid losses from affected wounds
Hypothermia d/t extensive heat and fluid loss from burn sites
- perform assessment in warmed room, give warm fluids if possible
- reduce wound exposure time
Minor burns
Rapid, thorough first aid
Remove source of burn
Non-adherent clothing removed
Wound is cooled under running water for 20min to promote re-epitheliazation
Burn Area (% TBSA)
Rule of Nines
- Head/neck =9%
- Each arm = 9%
- Anterior trunk = 18%
- Posterior trunk = 18%
- genitalia = 1%
- Each leg = 18%
Lund & Browder Chart (most used w/peds)
Superficial Burn (First degree)
Epidermis
Appearance: dry, blanching, erythematous
Painful
Heals without scarring, 5-10d
Superficial partial-thickness (Second degree)
Upper dermis
Blisters, wet, blanching, erythema
Painful
Heals without scarring, <3wk
Deep partial-thickness (Second degree)
Lower dermis
Yellow or white, dry, non-blanching
Decreased sensation
Heals in 3-8 weeks, likely to scar if >3wk healing
Full thickness (Third degree)
Subcutaneous tissue
Leathery, waxy white, non-blanching, dry
Painless
Heals by contracture >8wk, will scar
Fluid resuscitation
Allows for adequate intravascular volume to limit hypovolemia, maintain organ perfusion, and minimize tissue ischemia
Calculate from time of burn (not hospital arrival)
Correct clinical shock prior to resuscitation
Modified Parkland Formula: volume of crystalloid fluid (ideally Hartmann’s solution) to be administered in the first 24hr post-burn
Adults: 4mL x Wt (kg) x % TBSA
Peds: 3mL x Wt (kg) x % TBSA
50% of calculated volume w/in 8hr, remaining 50% in remaining 16hr
This formula has been shown to underestimate fluid requirements in pt w/large full thickness burns, inhalation injury, or electrical burn
Monitor urine output**
- Adults should be maintained >0.5mL/kg/hr
Who is indicated for Burn Unit
TBSA: 10-39%
Depth: deep partial or full-thickness
Site: specialized areas (hands, feet, face, perineum, genitals, major joints) or non-blanching circumferential burns
Etiology: chemical, electrical, friction, cold injury
Other: non-accidental injury, pregnant, concomitant trauma
Who is indicated for Burn Center
> 40% TBSA or >25% w/inhalation injury
Concomitant major trauma w/burn injury
Severe co-morbidity and pt >65yo w/ >25% TBSA
Systemic complications (general)
Typically manifest in pt >25% TBSA
Arise secondary to large inflammatory response
SIRS - exaggerated and dysregulated inflammatory response may lead to third space losses, hypotension and organ dysfunction
May progress to MODS - leads to end-organ failure
- inc risk w/the degree and severity of the burn, and pt age
- Supportive treatment by ensuring adequate and careful fluid resuscitation
Systemic complications - specific organ injuries
Acute lung injury
- burn/smoke inhalation, may lead to ARDS
AKI
- combination of SIRS, hypotension, myoglobinuria, and iatrogenic nephrotoxic agents
- tx: supportive w/fluid mgmt; mannitol in severe cases especially w/myoglobinuria
Endocrine
- electrolyte imbalances: initial hyperNa then subsequent hypoK, hypoMg, hypoCa, hypoP
- due to fluid loss, third space losses, and kidney injury
GI
- paralytic ileus, ulcer, bacterial translocation
- early enteral feeding mitigates complications - aimed to maintain body weight and endocrine homeostasis
- Curling’s ulcer: gastric ulcer following severe burns d/t reduced plasma volume causing gastric mucosa ischemia and ulcer formation [start on PPI]
Local complications
Adverse scarring: hypertrophy, keloid growth
Contractures: abnormal stiffening of tissues resulting in decreased movement and range of motion
- intrinsic: scarring w/in affected area
- extrinsic: scarring outside affected area
Burn reconstruction
Early excision and grafting in the initial phase to prevent post-burn hypertrophic scarring/contracture
- Thick sheet grafts can be used for important areas (face, hands, neck)
- Pressure garments are applied as soon as scars are stable
Formed scars/contractures
- do not attempt surgery until scars have matured (unless evolving complications such as eyelid contractures or contractures causing nerve compression)
- techniques: excision and grafting* (other - scar release and joint release, local/regional flaps, skin substitutes, tissue expansion)
Non-surgical techniques:
- intralesional corticosteroid injection
- cryotherapy
- laser treatment
- radiotherapy
- 5-FU
Physiotherapy - maintain ROM
Nutritional support
Chemical burn
Cause continuous tissue destruction through oxidation, reduction, desiccation… until the chemical is neutralized
Initial mgmt:
- thorough and immediate irrigation of affected area using warm water for at least 30min (longer for alkaline or eye exposure)
- clothes must be removed
- buffer or neutralizing agents not recommended
Electrical burn
Large electrical burn: lightning strikes or contact w/high-voltage power lines
- low voltage: <1000V (household supply)
- high voltage: >1000V (industrial)
Entry and exit wounds
Damage caused is more serious than it visually appears
Risks:
- arrhythmia: travels through conduction system
- rhabdo: travels through soft tissue
- seizure/resp arrest: travels through brain
Dx:
- ECG
- Labs: renal function, CK levels
Cold injury
Freezing: frostbite
- injury d/t cellular and microvascular damage secondary to ice crystal formation w/in cells and extracellular space
Non-freezing: trench foot
- near-freezing environment + wet + gravitational stasis + constriction = superficial liquefactive necrosis
tx: wash, airdry, rewarm, elevate and rest feet - may take up to 6mo to recover
Mgmt:
- remove wet clothing and replace w/dry blanks
- do not massage or rub affected area
- rewarming needs to be gradual in order to avoid reperfusion injury
- place affected extremity in circulating water bath until tissues soften and become red/purple
Hypothermia - pt needs systemic rewarming
- <32deg: warm IV fluids
Admin IV analgesia during reperfusion period
Affected area should be demarcated to determine injury progression
- dead tissue may require surgical debridement
- tetanus prophylaxis
Toxic Epidermal Necrolysis (TENS)
- immune-mediated process results in sheet-like loss of skin and mucosa
- a/w drugs: allopurinol, anticonvulsants, abx, NSAIDs
- other: mycoplasma infection, vaccination
Immediate phase: detachment of skin at epidermal/dermal junction w/mild shearing force
Later: full epidermal and mucosal detachment involving >35% TBSA
Mgmt: stop causative agent
- dressings, supportive care
Staphylococcal Scalded Skin Syndrome (SSSS)
Affects young children, particularly neonates
Skin becomes erythematous and blistered, like a scald, d/t exfoliateive staphylococcal exotoxins affecting protein complexes that bind epidermal cells
Mgmt: anti-staph abx and supportive care
Stevens-Johnson is milder - 10-35% TBSA
General skin graft/skin flap
Graft: receives blood from recipient site
Flap: brings its blood supply from donor site
Indications: sizeable defect
CI:
- infection
- known skin cancer
- previous radiotherapy at recipient site
- comorbidity: immunosuppression, current smoker, poorly controlled DM
Skin graft
Mgmt of:
- extensive skin damage - deep burn, large skin excision procedures, poorly healing ulcerated lesions
Types:
- Split-skin thickness graft: does not contain whole dermis
- Full-thickness skin graft: whole dermis (including hair follicles)
Must heal by developing new blood supply
Failure
- hematoma or seroma formation under graft
- infection (commonly strep)
- shearing forces
- unsuitable bed
- technical error
Signs of failure:
- pallor or discoloration at graft site
- evidence of localized infection
- systemic features: malaise, lethargy
- full-thickness necrosis - occurs 1-2wk after grafting
Primary contraction: immediate contraction or recoil of freshly harvested skin (more pronounced in FTSG)
Secondary contracture: process of contraction onces the graft has been applied to its bed and healing is underway (more pronounced in SSGs)
