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)
Physiology of Skin Graft Take
Graft take: incorporation of new graft into implanted site
- hemostasis
- normal response to prevent excess bleeding following grafting - plasmatic imbibition
- occurs around days 1-2
- initially fluid migrates into graft bed, becoming edematous but remains avascular - Inosculation
- occurs around days 2-3, vascular network slowly begins to be established - re-innervation
- begins 2-4wk after grafting, but sensation may require several months or years
Full Thickness Skin Graft
Full thickness of epidermis and dermis
- once graft is harvested, no epidermis left behind at donor site, thus must be closed using sutures
Used to cover areas w/optimal vascular availability (bc they have higher energy requirements)
Donor - recipient
postauricular skin - face
upper eyelid - contralateral eye defect
supraclavicular skin - face
flexure skin - hand surgery, flexion contractures
thigh/abd skin - palms of hands or soles of feet
Process:
- scalpel takes epidermis and dermis
- subcutaneous fat is removed (de-fatting)
- sutured into place at donor site
Split thickness skin graft (STSG)
Full epidermis w/variable thickness dermis
- dermal remnants at donor site to allow for re-epithelialization
Commonly used for skin defects that are too large for full thickness graft
MC donor site = thigh
- other: forearm, torso, lower leg
Harvested using a dermatome
- applied with downward and forward pressure to harvest
Skin flaps
Tissue is transferred from donor site to recipient site along with its corresponding blood supply
Provide better cosmetic results than skin grafting
- skin tone and texture usually better matched
- reduced chance of failure
Flap failure:
- issues with arterial supply: pallor, reduced perfusion [need to return to OR]
- issues with venous supply: venous congestion [often respond to conservative therapy]
Classification of Flaps
Tissue Type: composition - cutaneous, fasciocutaneous, musculocutaneous, muscle
Blood Supply:
- axial: designated fasciocutaneous artery runs beneath the flaps longitudinal axis
- random: no designated named artery providing blood supply to the flap; blood supply via subdermal plexus
- pedicled: tissue completely raised on named vessel from donor site and transferred to recipient site
Location:
Local: harvested from contiguous site, common for: facial defect, fingertip, defects of limb
- advancement: skin is moved directly forward
- rotation: skin rotated around a pivot point to cover adjacent defect
- transposition: lateral movement in relation to pedicle to cover adjacent defect
Regional (pedicled): harvested from same anatomical region but not directly adjacent
- attached skin tunneled under intact tissue or laid over intact skin forming a skin bridge, which can then detached from the donor site in a second procedure
Free (distant): harvested from a different anatomical region entirely
- tissue and named fasciocutaneous artery are separated from donor site before being reattached at recipient site using microsurgical techniques
Examples of free flaps
Deep inferior epigastric perforator (DIEP)
- donor: skin and subq tissue of lower abdomen, sparing the rectus abdominis
- vessel: deep inferior epigastric artery
Transverse rectus abdominis myocutaneous (TRAM)
- donor: skin, subq tissue, and part of rectus abdominus
- vessel: deep inferior epigastric artery
Latissimus dorsi myocutaneous flap (LDMF)
- donor: skin, subq tissue, and part of latissimus dorsi
- vessel: subscapular artery
Thoracodorsal artery perforator (TAP)
- donor: skin, subq tissue of lateral back, sparing latissimus dorsi
- vessel: thoracodorsal artery
Anterolateral thigh (ALT)
- donor: skin, subq tissue of anterolateral thigh (can include vastus lateralis muscle)
- vessel: descending branch of lateral circumflex artery
Skin functions physiology
Epidermis:
- temperature regulation
- protection from infection
- prevent fluid loss
Dermis:
- regulate temperature, fluid via blood flow
- elasticity for function
- presence of growth factors for repair
Superficial burn (epidermal)
Cause:
- UV exposure
- very short flash
dry, red
blanches w/pressure
painful sensation
3-6d to heal
Superficial partial-thickness
Cause:
- scald (spill or splash)
- short flash
blisters
moist, red, weeping
blanches w/pressure
painful to temperature and air
7-20d heal
deep partial thickness
Cause:
- scald (spill)
- flame
- oil
- grease
blisters (easily unroofed)
wet or waxy dry
variable color: patchy to cheesy, white to red
does not blanch w/pressure
painful, perceptive of pressure
heal >21d
full thickness burn
cause:
- scald (immersion)
- flame
- steam
- oil
- grease
- chemical
- electrical
waxy white to leathery gray to charred and black
dry and inelastic
no blanch w/pressure
sensation: deep pressure only
never totally heal
Burns pathophysiology
- local response
- tissue destruction
- zones of injury - systemic response
- damaged tissue releases cytokines and prostaglandins
- increased capillary permeability = third spacing - metabolic response
- increased catecholamines, glucagon, and cortisol leading to increased energy expenditure
Burns zones of injury
zone of coagulation
- central area, most direct contact w/heat source
- characterized by coagulation necrosis of cells
zone of stasis
- just peripheral to central area
- injured cells w/decreased blood flow
- most likely cells will necrose w/in 24-48hr
zone of hyperemia
- most peripheral
- minimal injury here and will likely recover w/in 7-10d
How does a partial thickness burn convert to a full thickness burn?
Wound conversion:
- excess inflammation
- uncontrolled bacterial colonization
- excess metalloproteinases
- excess surface exudate
Fluid resuscitation
Goal: adequate urine output
- adults: 0.5 cc/kg/hr (30-50cc/hr)
- child <30kg: 1 cc/kg/hr
Use parkland formula
Fluid: Lactated Ringer’s (crystalloid fluid)
- lactate may reduce hyperchloremic acidosis
Peds fluid: dextrose containing maintenance fluid in addition to parkland formula
Burn shock occurs w/in first 24-48hr
- hypovolemia, decreased CO, major fluid shifts can all lead to hypoperfusion
Goal: replace lost intravascular volume
Avoid fluid overload
- complication: pneumonia, MOF, compartment syndrome
Secondary survey burn management
history - what caused the burn
PE - complete head to toe, determine severity
AMPLE: allergies, meds, PMH, last meal, events prior
Special considerations: tetanus immunization history
Determine depth and severity
Depth = temperature, duration, thickness of dermis
Extent: rule of nines, Lund and Browder
Problem areas:
- hands
- feet
- genitals/perineum
- face
- major joints
Emergency department management of minor burns
- remove all clothing
- cover burns w/clean dry blanket
- maintain temp (loss of skin = loss of heat) - warm blankets, warming lights, warm IVF
- EDTC provide conscious sedation: ketamine
- supplies to debride wounds: gauze, chlorahexadine scrub, saline, scissors, burn dressing and outer dressing supplies
- apply dressing: silvadene, mepilex
Respiratory Injury (burn)
Cause: inhalation injury
- # 1 cause of death in adult burn victim
- inhalation, aspiration when unconscious, pneumonia, pulmonary edema
Findings:
- facial burns
- hoarseness
- singed eyebrows or eyelashes
- stridor
- decreased consciousness
- wheezing
- hypoxia or hypercapnia
Upper airway
- thermal injury causes tissue damage and potential obstruction d/t edema
- early intubation
Lower airway:
- chemicals found in smoke cause damage to epithelium of airway
- inflammation, impaired ciliary activity, hypersecretion
- monitor ABGs/CXRs for several days as condition may worsen
Carbon monoxide (burns)
Consider in all pt w/moderate-severe burns
Binds hemoglobin 200X > than oxygen
Result: tissue hypoxia (brain)
Findings:
- mild: HA, mild dyspnea, confusion
- moderate: irritable, diminished judgement, easy fatigue
- severe: hallucination, confusion, collapse, coma
Pulse ox not reliable
- recognizes hemoglobin is saturated
** need carboxyhemoglobin level
Electrical (burns)
Factors causing injury:
- direct effect of current on tissue
- electrical energy converting to thermal causing burn injury
- blunt injury from strike or fall secondary to strike
Tissue resistance
- high resistance: heat up and don’t transmit current (skin, bone, fat)
- low resistance: transmit current (nerves, blood vessels)
Patterns of injury:
- classic entry/exit wounds
- arrhythmias uncommon but may result in asystole
- rhabdo - kidney injury
- respiratory paralysis leading to hypoxia
- LOC or paralysis
Mgmt:
- parkland is not best guide (since you can only see the entrance site)
- goal = appropriate urine output
- avoid K+
- cardiac monitor, labs
- transfer to burn center
Chemical (burns)
3% of burn injuries, often work related
Alkali (base)
- liquefaction necrosis - deeper spread of chemical and more severe burn
- e.g. oven cleaner, drain cleaner, fertilizer
Acid
- coagulation necrosis - limits depth of tissue damage
- e.g. bathroom cleaner, rust remover, pool cleaner
Assessment:
- protect self
- remove chemical exposure
- irrigation
Refer, w/close monitoring
Pediatric burns
Scald > Flame > Electrical > Chemical
BSA
- greater surface area for their weight = greater fluid losses
- head/neck comprises 18% of body surface c/t 9% adults
Skin thickness: for same temperature, tissue destruction occurs at a faster rate
Child abuse*
- e.g. immersion burns, delay in treatment
Non-accidental burn RED FLAGS
- delayed treatment
- isolated scald or contact burns to hands, feet, genitalia
- buttocks-stock/glove distribution or well-demarcated without splash
- no clearly defined mechanism or inconsistent story
- premature or chronically ill children at higher risk
Frostbite
Literal freezing of the tissue
- severe, localized cold induced injury
RF:
- anything increasing heat loss OR decreasing heat prod
- use of inadequate clothing
- exhaustion, dehydration, alcohol abuse, PVD
Most susceptible areas:
- hands, feet, face
1st deg frostbite
epidermis
erythema, edema
minimal pain w/rewarming
2nd deg frostbite
epidermis, dermis
hard edema, clear blisters
mild-mod pain w/rewarming
3rd deg frostbite
hypodermis
hemorrhagic bullae, pale grey extremity
severe pain w/rewarming
4th deg frostbite
skin, muscles, tendons, bones
insensate, black/grey
painless during rewarming
Frostbite treatment
Pre-hospital
- warm environment, remove wet clothing
- walking or rubbing tissue can increase damage!!
In hospital
- rewarm w/warmed water (100F)
- TPA recommended for grade 3/4 w/demonstrated loss of perfusion and presenting w/in 24hr of injury
Wound care
- change wound w/aseptic technique
- dry, nonadherent, non occlusive dressing
- blisters: drain large blister; minor leave intact
Frostbite tx do NOT:
- rub frozen extremity
- warm by contact w/hot surface or exposure to fire
- thaw/rewarm if risk for refreezing
- amputate early (unless infected tissue)
- allow patient to smoke
Topical agents for burns
Sulfamylon
- antimicrobial solution applied once a day
- may be painful when applied
- necessary for deeper nose and ear burns
- goal: avoid infection (pseudo*, staph aureus, MRSA)
Silvadene (Silver sulfadiazine)
- bactericidal for many gram neg and pos bacteria, effective against yeast
- verify no sulfa allergy
- change daily
- not absorbed systemically
- will not penetrate eschar = not used on full thickness burn
- may cause leukopenia: decrease in mature neutrophils; self-limited that does not increase incidence of infectious complications nor final outcome
Indication for escharotomy
compartment syndrome
Burns hypermetabolic response
Hyperdynamic circulatory and immune response
Massive protein and lipid catabolism - total body protein loss w/muscle wasting and peripheral insulin resistance
Increased:
- energy expenditure
- body temperature
- infection risk (impaired immunity)
Metabolic rate increases proportionally to TBSA burn
- 15-25% burn initiates catabolic response
How do you alter the hypermetabolic response?
Early excision and grafting (w/in 2-3wk)
Oxandrolone
- anabolic steroid to improve muscle protein catabolism via enhanced protein synthesis efficiency, reduces weight loss, increases donor site wound healing
- improvements in metabolism w/out negative adverse events
- dose: 10mg PO bid q day (adults)
Propranolol
- blunts effect of elevated catecholamines to dec cardiac o2 demand and dec resting metabolism
- increased protein synthesis
- improved wound healing and decreased mortality
- considering admin for up to 1y post burn injury (10-20mg TID in adults)
Tx pain and anxiety
Nutrition
- > 20% TBSA or intubated = initiate nutrition supplement (enteral)
- enteral should start w/in 6hr of admission and advance to goal nutrition volume w/in 24hr
- high calorie, high protein
- multivitamin
Glycemic control
What to do with intact blisters?
<2cm and not impeding function - leave intact w/DRY dressing
Thick-walled blister - leave intact
Avoid applying ointment until ruptured - no benefit and may hasten rupture
When ruptured will need debridement and dressings
Do burns need prophylactic antibiotics?
No role for empiric abx administration
Reserve for positive cultures or other clinical evidence of infection
Topical antimicrobial dressings and early excision of full-thickness burns are the most useful methods to prevent invasive infection
Electrical (burns)
Factors causing injury:
- direct effect of current on tissue
- electrical energy converting to thermal causing burn injury
- blunt injury from strike or fall secondary to strike
Tissue resistance
- high resistance: heat up and don’t transmit current (skin, bone, fat)
- low resistance: transmit current (nerves, blood vessels)
Patterns of injury:
- classic entry/exit wounds
- arrhythmias uncommon but may result in asystole
- rhabdo - kidney injury
- respiratory paralysis leading to hypoxia
- LOC or paralysis
Mgmt:
- parkland is not best guide (since you can only see the entrance site)
- goal = appropriate urine output
- avoid K+
- cardiac monitor, labs
- transfer to burn center
Chemical (burns)
3% of burn injuries, often work related
Alkali (base)
- liquefaction necrosis - deeper spread of chemical and more severe burn
- e.g. oven cleaner, drain cleaner, fertilizer
Acid
- coagulation necrosis - limits depth of tissue damage
- e.g. bathroom cleaner, rust remover, pool cleaner
Assessment:
- protect self
- remove chemical exposure
- irrigation
Refer, w/close monitoring
Pediatric burns
Scald > Flame > Electrical > Chemical
BSA
- greater surface area for their weight = greater fluid losses
- head/neck comprises 18% of body surface c/t 9% adults
Skin thickness: for same temperature, tissue destruction occurs at a faster rate
Child abuse*
- e.g. immersion burns, delay in treatment
Non-accidental burn RED FLAGS
- delayed treatment
- isolated scald or contact burns to hands, feet, genitalia
- buttocks-stock/glove distribution or well-demarcated without splash
- no clearly defined mechanism or inconsistent story
- premature or chronically ill children at higher risk
Frostbite
Literal freezing of the tissue
- severe, localized cold induced injury
RF:
- anything increasing heat loss OR decreasing heat prod
- use of inadequate clothing
- exhaustion, dehydration, alcohol abuse, PVD
Most susceptible areas:
- hands, feet, face
1st deg frostbite
epidermis
erythema, edema
minimal pain w/rewarming
2nd deg frostbite
epidermis, dermis
hard edema, clear blisters
mild-mod pain w/rewarming
3rd deg frostbite
hypodermis
hemorrhagic bullae, pale grey extremity
severe pain w/rewarming
4th deg frostbite
skin, muscles, tendons, bones
insensate, black/grey
painless during rewarming
Frostbite treatment
Pre-hospital
- warm environment, remove wet clothing
- walking or rubbing tissue can increase damage!!
In hospital
- rewarm w/warmed water (100F)
- TPA recommended for grade 3/4 w/demonstrated loss of perfusion and presenting w/in 24hr of injury
Wound care
- change wound w/aseptic technique
- dry, nonadherent, non occlusive dressing
- blisters: drain large blister; minor leave intact
Frostbite tx do NOT:
- rub frozen extremity
- warm by contact w/hot surface or exposure to fire
- thaw/rewarm if risk for refreezing
- amputate early (unless infected tissue)
- allow patient to smoke
Topical agents for burns
Sulfamylon
- antimicrobial solution applied once a day
- may be painful when applied
- necessary for deeper nose and ear burns
- goal: avoid infection (pseudo*, staph aureus, MRSA)
Silvadene (Silver sulfadiazine)
- bactericidal for many gram neg and pos bacteria, effective against yeast
- verify no sulfa allergy
- change daily
- not absorbed systemically
- will not penetrate eschar = not used on full thickness burn
- may cause leukopenia: decrease in mature neutrophils; self-limited that does not increase incidence of infectious complications nor final outcome
Indication for escharotomy
compartment syndrome
Burns hypermetabolic response
Hyperdynamic circulatory and immune response
Massive protein and lipid catabolism - total body protein loss w/muscle wasting and peripheral insulin resistance
Increased:
- energy expenditure
- body temperature
- infection risk (impaired immunity)
Metabolic rate increases proportionally to TBSA burn
- 15-25% burn initiates catabolic response
How do you alter the hypermetabolic response?
Early excision and grafting (w/in 2-3wk)
Oxandrolone
- anabolic steroid to improve muscle protein catabolism via enhanced protein synthesis efficiency, reduces weight loss, increases donor site wound healing
- improvements in metabolism w/out negative adverse events
- dose: 10mg PO bid q day (adults)
Propranolol
- blunts effect of elevated catecholamines to dec cardiac o2 demand and dec resting metabolism
- increased protein synthesis
- improved wound healing and decreased mortality
- considering admin for up to 1y post burn injury (10-20mg TID in adults)
Tx pain and anxiety
Nutrition
- > 20% TBSA or intubated = initiate nutrition supplement (enteral)
- enteral should start w/in 6hr of admission and advance to goal nutrition volume w/in 24hr
- high calorie, high protein
- multivitamin
Glycemic control
What to do with intact blisters?
<2cm and not impeding function - leave intact w/DRY dressing
Thick-walled blister - leave intact
Avoid applying ointment until ruptured - no benefit and may hasten rupture
When ruptured will need debridement and dressings
Do burns need prophylactic antibiotics?
No role for empiric abx administration
Reserve for positive cultures or other clinical evidence of infection
Topical antimicrobial dressings and early excision of full-thickness burns are the most useful methods to prevent invasive infection
