Burns Flashcards
What are the causes of burn injuries?
Heat (hot objects, gases and flames) Chemicals Electricity Lightening Friction Radiation
What are the populations that are most at risk of burn death?
Ages 0-4
Ages >65
Rural populations
Populations with poor socio-economic statuses
What are the populations experiencing most burns?
Ages 0-4
Ages 20-24 and gradually decreases
The majority of burn injuries are minor injuries
What are the different types of burns?
Scalds: most common cause in under 5 year old
Flames: most common cause in older age groups
Electric
Much less common causes: contact and chemicals
What are the measures used to classify burns?
Degree (first degree, second degree, third degree, fourth degree)
Thickness-Superficial, Partial thickness (1st/2nd degree), Full thickness (third degree)
Percentage-total body surface area
What type of injury is hot water most likely to cause?
Partial thickness wounds
What type of injury are flames most likely to cause?
Full thickness burns
Describe Superficial-First degree burns.
Most cases of sunburn Epidermis only Erythematous and very painful Does not blister Peels off in 3-4 days and replaces by healed skin
Into which two categories are partial thickness-second degree burns divided into?
Superficial partial thickness
Deep partial thickness
Describe superficial partial thickness burns.
Extends into papillary dermis Blistering Wet, pink, hypersensitive to touch Very painful Blanches with pressure Usually heals within three weeks without scarring
Describe deep partial thickness burns.
Extends into the reticular dermis
Mottled pink and white
May have small areas of hemorrhage
Discomfort and pressure, rather than pain
Blanches with pressure, but slow capillary refill
Takes longer to heal, often causes scarring
Describe full thickness-third degree burns.
Extends through the entire dermis and into subcutaneous tissue Charred or leathery No pain Does not blanch Will not heal
Describe fourth degree burns.
Seldom seen in non-fatal injuries
Involvement of deeper structures=extends through the fascia
High voltage electrical injuries may have significant deep injuries that are not initially apparent
Describe partial thickness burns:
First or second degree burn which is red and painful and often with blisters
Describe full thickness burns:
Third degree burns which is charred, insensitive, deep and involving all layers of the skin
Describe mild burns according to the percentage of burn.
Partial thickness burns, <15% in adults or <10% in children
Full thickness burns less than 2%
Can be treated on an outpatient basis
Describe moderate burns according to the percentage of burn.
Second degree 15-25% burns, 10-20% in children
Third degree between 2-10%
Burns which are not involving the eyes, ears, face, hands and perineum
Describe severe burns according to the percentage of burn.
Second degree burns >25% in adults, children >20%
All third degree >10%
Burns involving eyes, ears, feet, hands and perineum
All inhalation and electrical burns
Burns with fractures or major mechanical trauma
List the burn management multidisciplinary team
Surgeons Intensive care OT and physio Dietician and speech therapists Social workers and play therapists Psychologists
What are the steps to the pathway to burn recovery?
Emergent Acute Psychosocial support-caregiver group Education/health promotion Theatre/Ward Rehabilitation Prevention of contractures Scar management Itch management Sun protection Return to school Psychological support and functional rehabilitation Functional and cosmetic reconstruction
What does TBSA stand for?
Total Body Surface Area
What is the Total Body Surface Area used for?
In the Parkland formula to calculate the resuscitation fluids for the first 24 hours
What is the Parkland formula
Fluid in 1st 24 hours=TBSA x weight x 4
How do you calculate the TBSA?
Using the “Rule of Nine” or Lund and Browder chart
What is the Lund&Browder Chart?
A chart marking the areas of the burns on the body and using the table to calculate the area.
What are the further aspects of initial management of burn injuries?
Treating polytrauma conditions, e.g MVA, electrical injury.
Management of inhalation injuries, airway maintenance, carbon monoxide poisoning.
Cooling of the wounds
Adequate cleaning and dressing of wounds
Escharotomies (removing the full-thickness burn to the subcutaneous fat)
Fasciotomies in electrical injuries.
Transfers to burn centers.
What influence does the estimation of burn depth play?
The burn depth determines whether a burn is likely to heal or need reconstruction.
Using objective tools, e.g. Laser doppler
Superficial partial wounds will usually heal
Deep partial wounds are most difficult to assess and may heal.
full thickness wounds will not heal
What is done once a burn patient is stabilized?
Wounds that are unlikely to heal need to be excised and reconstructed. Split skin graft is the mainstay of reconstruction. Other circumstances: excision and primary closure, flaps, full thickness grafts, skin cultures. When donor sites are insufficient->expansion techniques are used (meshing and Meek micrografting). Skin substitutes may be used to but time when donor sites are insufficient. Biological substitutes (allograft, xenograft), synthetic substitutes or mixed (Biobrane)
What are the three zones of injury in burn injuries?
coagulation (tissue destroyed at injury).
Stasis (inflammation and low perfusion).
Hyperemia (microvascular perfusion is not impaired but red due to inflammation.
Explain the local pathophysiology of burn injuries.
It is a local response.
Zone of coagulation: zone of maximum injury, irreversible tissue damage.
Zone of stasis: zone of reduced perfusion, potentially reversible damage.
Zone of hyperaemia: outermost area increased perfusion.
Explain the systematic response of burn injuries.
Respiratory response: release of inflammatory mediators (bronchoconstriction, pulmonary oedema and ARDS)
Metabolic response: increased basal metabolic rate (x3)
Immunological response: down regulation of immune system
Other responses: renal failure, GI bleeding, reduced get mobility, skeletal muscle influences.
What are the systemic complications of burn injuries?
Multisystem organ dysfunction (Multiple Organ Dysfunction Syndrome-MODS), Increases with >20% TBSA.
Sepsis
Hypoperfusion
Under resuscitation.
What are other complications with burn injuries?
Infections (especially in the first 21 days)
Respiratory complications
Contractures-hypertrophic scar (disturbance in collagen productions, modelling, resorptions.
Burn shock
Pulmonary complications due to inhalation injury
Acute renal failure
Infections and sepsis
Curlings ulcers >30% burns
Extensive and disabling scarring
psychological trauma
Cancer called Marjolins ulcer
What are the loss of function complications?
Deformities Fear of pain and/or discrimination Fear/lack of social integration Depression Psychological factors
Does a burn victim need increased energy input due to an increased energy requirement?
Yes.
Significant burn injuries induced a hypermetabolic state.
Which populations have a lower threshold in nutrition?
The young, the elderly, pregnant and lactating women and people with underlying disease.
In which cases are nutritional supplementation needed?
Wound healing To preserve lean body mass Address nutritional deficiencies Prevent starvation Prevent and manage infections Modulate stress responses.
What specific nutritional requirements should be considered?
Nutritional intake increases with wound size
Nutritional intake is higher in children
CHO: 60-70% total energy
Fats: 20-25% in children and 15-25% in adults
Protein: 2,5-4g/kg in children and 1-2g/kg in adults
Specific amino acids (glutamine and arginine) may improve immune function,
Micronutrient supplementation is advised (vitamins and trace elements)
What are some of the respiratory considerations in burn victims?
Inhalation injuries: bronchoconstriction, small airway closure, impaired ciliary clearance, increased dead space, intrapulmonary shunting, reduced lung and chest wall compliance, tracheobronchitis, pneumonia.
Upper airway oedema and patency.
Carbon monoxide exposure
Respiratory failure.
What other special considerations should be made when treating burn victims?
Electrical injuries.
High, intermediate and low voltage exposures.
High voltage exposures are associated with LOC, arrhythmias, myoglobinuria, compartment syndromes and blunt trauma.
Often having a mix of flame burns, flash burns and entry and exit wounds.
What is the initial management for burn victims and how long are they treated for?
Superficial partial thickness burns–10 to 14 days
Deep partial thickness burns–10 to 21 days
Full thickness burns–almost always requires grafting.
Any burn that is not healing in 21-28 days requires grafting.
What is the initial management for burn victims?
Airway, fluids, analgesia and sedation.
Wound management: cleaning-analgesia, Bioscrub/iodine, remove dead skin, leave blisters until burst.
NB sterility.
What are the benefits of pressure garments?
Applied to help with scar formation, application of constant pressure. Improve mobility Reduces oedema Reduce itchiness Accelerate healing
How do pressure garments work?
Should fit like a second skin. Worn 24 hours a day Seems are on the outside Checked for stretching every 4-5 weeks Worn until mature scar forms, 6-24 months.
What is the role of silicone in the management of burns and burn scarring?
Usually worn under pressure garments. Minimum of 12 hrs per day.
Theory: helps improve scar formation through hydration and occlusion.
What are some factors that have to be considered what considering surgical intervention for patients with burn injuries?
Not all burns require surgical management
The worse or more severe the burn the higher the chance of needing surgery/grafting.
If TBSA is too high, then there is an increased chance of death during surgery.
What is eschar?
Thick, leathery burn tissue.
Why perform an escharotomy?
The reduced elasticity of eschar can lead to further tissue death.
What is an escharotomy?
A surgical incision is made to reduce the pressure and improve compliance, essentially removing dead, leathery tissue.
What is a skin graft?
Skin or a skin substitute is placed over the damaged area.
What are the types of skin grafts?
Autograft-skin is taken from a different site of the same donor.
Allograft-skin is taken from a donor.
Xenograft-skin is taken from a different species (bovine)
Prosthetic-synthetic materials
What is the different classification of grafts?
Split thickness-includes the epidermis and part of the dermis
Full thickness-entire epidermis and dermis
Composite-small graft including some underlying tissue
What are the complications of skin grafting?
Excessive bleeding
Graft does not take
Hypertrophic scarring
