Burns Flashcards
Describe the 4 degrees of burn wounds
1st degree: To epidermis (sunburn)
2nd degree: To dermis: Superficial-papillary (blebs/blister-painful) & Deep-reticular (loss of hair follicles-loss of sensation)
3rd degree: To subcutaneous (leathery)
4th degree: Down to bone, adipose or muscle
How do 1st degree and 2nd degree (superficial) heal?
Epithelialization: primary site of epithelial cells are in the hair follicles. Loss of hair follicles such as in 2nd degree deep to 4th degree require skin graft
Describe initial volume resuscitation
Parkland Formula: 4cc/kg x% burn over 24 hours.
Give 1/2 in first 8 hrs, other 1/2 in the next 16hrs.
Use LR 1st 24hrs, then D5 1/2NS
When does Parkland formula resuscitation apply?
Only for greater or equal to 2nd degree that are greater than equal to 20% BSA
What risk increases with albumin resuscitation in severe burns?
PNA
Indication for escharotomy
- Circumferential deep burns with decreased temp, pulse, capillary refill, pain sensation.
- Trouble ventilating pt’s w/significant torso burns
When to initiate escharotomy?
within 4-6 hours to prevent myonecrosis
What are the types of escharotomy?
- Medial and lateral sides of limbs
- Dorsum of hands
- Fingers (avoid lateral incicisions due to nerves)
- Chest lateral, sub-clavicular and above costal margin
What electrolyte imbalance is due to Burns
HyperK released from dead tissue
What is the treatment for myoglobinuria?
volume resuscitation ad HCO3 to alkalinize urine
What specific initial blood test should be ordered when a burn patient is admitted?
carboxyhemoglobin
How to dress burns?
Silvadene, telfa and loosely wrapped gauze
How to dress burns over cartilaginous area?
Sulfamylon (mafenide) anti-microbial
When to excise burned area
within 48-72 hrs
How to excise burned areas for deep 2nd degree and 3rd degree
Use dermatome patterns
What determines residual skin viability?
color, texture, punctate bleeding
What is the best method of suspected burn wound infection?
Biopsy
When is auto-graft indicated?
if Cx pos for beta-hemolytic strep or bacteria greater than 10 to the 5th
What are the types of skin graft?
Auto-graft and Homograft
Types of auto graft
STSG and FTSG
What layers does STSG include?
epidermis and part of dermis
Advantages of STSG
- Better Survival: easier imbibition and re-vascularization
2. Can re-use donor site
Advantages of FTSG
- Less wound contraction
- Better skin color match: good for face, palms back of hands, genitals
(Not good for large areas, Not as many donor sites)
Donor sites for FTSG
- Behind the ear
- Above Clavicle
- Above groin
How to manage STSG donor site?
- Hemostasis w/epi soaked gauze
2. Op-site
How does STSG donor site heal
Epithelial appendages (epithelium migrates from hair follicles)
What is most common cause of skin graft failure
Seroma or hematoma
Skin needs to be compressed with xeroform and cotton balls
What parameters need to be followed for each burn wound excision session
- Less than 1L blood loss
- Less than 20% skin excised
- Less than 2 hours in the OR
Contraindication of homografts
Pregnant women: reported fetal deaths with HLA mismatch
Physiology of graft survival
- Imbibition: 0-3 days (osmotic nutrient and O2)
2. Neovascularization: 3+ days
Areas with high risk of skin graft failure
tendons, tendons, bone w/o periosteum, radiated skin
Reasons to delay auto-grafting
- Infection
- Not enough skin donor site
- septic or hemodynamically unstable
- wounds to face, palms, soles and genitals - deferred 1st week
Best source of calories for burn patients
Glucose
What is the caloric need of a burn patient?
25 kcal/kg/day + (30 kcal/day x %burn)
Don’t exceed 3000 kcal/day
What is the protein need of a burn patient?
1 g/kg/day + (3g/d x %burn)
What burn areas are treated at the 2nd week of management?
Hands, Feet, Face, Genital Areas
How to treat face burn?
topical abx for 1 week
FTSG (non-meshed) for unhealed areas
How to treat hand burn?
- immobilize in functional position
- abx for 1 week
- and immobilize in functional position for another week
- PT
- Wire fixation of joints if unstable or open
How to treat palm burn?
- Preserve specialized palmar aponeurosis (dorsal surface for escharotomy or fasciotomy)
- Splint hand in extension for 1 week
- FTSG in 2nd week
How to treat genital burn?
- Topical abx for 1 week
2. FTSG in 2nd week
Admission Criteria for 2nd and 3rd degree burns
- Greater than 10% BSA in pts aged less than 10yo or greater than 50yo
- Greater than 20% BSA in all other pts
- Significant portions of special areas (hands, face, feet, genitalia, perineum, or skin overliying major joints
Admission Criteria for 2nd and 3rd degree burns
- Greater than 10% BSA in pts aged less than 10yo or greater than 50yo
- Greater than 20% BSA in all other pts
- Significant portions of special areas (hands, face, feet, genitalia, perineum, or skin overliying major joints
Admission criteria for 3rd degree burns
> 5% BSA
Admission criteria for 3rd degree burns
> 5% BSA
Admission for electrical/chemical burn
Any
Admission for electrical/chemical burn
Any
Other justification for admission
- inhalation injury, mechanical trauma, or medical comorbidities
- Pts w/special needs
- Child abuse/neglect
Other justification for admission
- inhalation injury, mechanical trauma, or medical comorbidities
- Pts w/special needs
- Child abuse/neglect
How to assess % BSA burned
Rule of 9:
- Head = 9
- Arms = 18
- Chest = 18
- Back = 18
- Legs = 36
- Perineum = 1
- Palm = 1: Can be used to estimate BSA burned
How to assess % BSA burned
Rule of 9:
- Head = 9
- Arms = 18
- Chest = 18
- Back = 18
- Legs = 36
- Perineum = 1
- Palm = 1: Can be used to estimate BSA burned
Age group with highest death from burns
Children and elderly
Age group with highest death from burns
Children and elderly
Most common type of burn
Scald burn
Most common type of burn
Scald burn
Most common type of burn to be admitted
Flame burn
Most common type of burn to be admitted
Flame burn
What is the source of inhalation injury?
Carbonaceous material and smoke (Not heat)
What is the source of inhalation injury?
Carbonaceous material and smoke (Not heat)
What are risk factors for inhalation injuries?
EtOH, Trauma, Closed Space, Rapid Combustion, Age (50), Delayed extrication
What are risk factors for inhalation injuries?
EtOH, Trauma, Closed Space, Rapid Combustion, Age (50), Delayed extrication
What are Sx’s of delayed inhalation injury?
Stridor, facial burns, wheezing, carbonaceous sputum
What are Sx’s of delayed inhalation injury?
Stridor, facial burns, wheezing, carbonaceous sputum
What are possible complications of inhalation injury?
- Upper AIrway Obstruction: Can occur up to 24 hrs after burn. Worsened edema with Massive volume resuscitation.
- Bronchospasm
- Atelectasis
- CO poisoning
What are possible complications of inhalation injury?
- Upper AIrway Obstruction: Can occur up to 24 hrs after burn. Worsened edema with Massive volume resuscitation.
- Bronchospasm
- Atelectasis
- CO poisoning
Best diagnostic tool for inhalation injury
Fiberoptic bronchoscopy: lok for soot
Best diagnostic tool for inhalation injury
Fiberoptic bronchoscopy: lok for soot
Most common infection in pts w/ >30% BSA burn
PNA
Most common cause of death after significant burn
infection (PNA)
What PPX IV Abx used for burn wounds
None. No role
What are the Sx of burn wound infection?
- Rapid eschar separation
- Edema
- 2nd to 3rd degree conversion
- Hemorrhage in wound
- Erythema gangrenosum
- Green discoloration of fat
- Black Skin around the wound
- Pseudomonas smell
Most common organism in burn wound infection?
Pseudomonas
Most common cause of burn wound sepsis
Pseudomonas
Most common viral burn wound infection
HSV
How to prevent burn wound infections?
- Topical abx
- Silvadene: Limited eschar penetration. Bacteriostatic
- Silver nitrate: Limited eschar penetration
- Sulfamylon: Painful application, Good for pseudomonas, eschar penetration and cartilage penetration.
What is the risk of ppx topical abx?
Increase risk of candida infections
What is the side effect of Silvadene?
Neutropenia and Thrombocytopenia
What is the side effect of Silver Nitrate?
Electrolyte imbalance (Hypo Ca, CL, Na, K) and Methemoglobinemia (contraindicated with G6PD deficiency)
What is the side effect of sulfamylon?
Metabolic acidosis
Degrees of CO poisoning
Normal = 10%
In smokers = 20%
Coma = 50%
Death = 70%
What are common complications after burns
- Seizures
- Ectopia
- Eyes: fluorescin staining
- corneal abrasion
- symblepahron : eyelid stuck to underlying conjunctiva
- Fractures
- Curling’s ulcer: duo ulcer
- Marjolin’s ulcer: malignant, ulcerative squamous call cancer
- Acalculous Chole
- Hypertrophic scar
What is treatment of ectopia caused by burns?
Surgical eyelid release
What is treatment for fluorescin staining or corneal abrasion?
topical fluoroquinolone ointment
What is the physiology behind hypertrophic scars?
neovascularity
What type of burn causes liquefaction necrosis?
Alkali burn
What type of burn causes coagulation necrosis?
Acid burn
How to treat hydrofluoric acid burns?
Calcium over the burn (neutralizes)
How to treat Tar and Phenol burns?
cool, wipe off w/lipophyllic solvent (GLYCEROL)
How to improve burn scar hypopigmentation?
Dermal Abrasion or thin STSG
What is Staph Scalded Skin Syndrome?
Detachment of epidermis to dermis: Multiple etiologies include: Drugs(Phenytoin, Bactrim, PCN), Viruses
What is the treatment for SSSS?
- Remove offending drug
- Topical abx (No silvadene if sulfa is suspected cause)
- Topical allograft
- Wrap with telfa gauze
- Fluid Resuscitation
- Abx if due to S. Aureus
- NO STEROIDS
