Burns Flashcards
Why does partial/full thickness burns result in disruption of the barrier function and contribute to free water deficits?
because the skin provides the semipermeable barrier to prevent evaporate water loss
Fluid and electrolyte abnormalities seen in burn shock are result of alterations of _________________
cell membrane potentials.
-intracellular influx water and sodium
-extracellular migration of potassium
Burns >60% body surface area (BSA) is associated with decreased _____________ > lack of response to aggressive fluid resuscitation
cardiac output
The rule of 9’s (look at pic on slide 8)
quantified as the percentage of BSA. All of the numbers add to nine or are all divisble by 9
________ degree burn involves the epidermal layer ONLY. The skin is red, painful, tender, NO _______ formation. E.g. sunburn. It heals within ______ days with no scarring, requires only symptomatic tx
First
blister
7
________ degree burns extend into the dermis. What are the two types?
second
1. superficial partial thickness
2. deep partial thickness
In a superficial partial thickness burn, the __________ and ______________ are damaged. It heals in _____________ scarring minimal, full return of function.
epidermis
superficial dermis (papillary layer)
14-21 days
Blistering of skin, exposed dermis is red and moist at blister base. Very painful to the touch, good profusion best describes which type of burn?
superficial partial thickness burn
A deep partial thickness burn extends deep into the ____________. Damage is done to the ________, ____________ and ________ glands.
dermis(reticular layer)
hair follicles, sweat, sebaceous glands
Skin is blistered, exposed dermis is pale white to yellow color, burned area does not blanch, absent cap refill, absent pain sensation best describes which type of burn?
deep partial thickness burn
A deep partial thickness burn may be hard to distinguish from a _______ degree burn
3rd
A deep partial thickness burn heals in _________ and scarring is common. May need surgical debridement, skin graft to return to normal function.
3weeks to 2 months
What are the common causes of deep partial thickness burns?
hot liquid, steam, grease, flame
Third degree burns are also called _______________. All ___________ and _________ structures are destroyed.
full thickness burns.
epidermal, dermal
Skin is charred, pale, painless, and leathery best describes which type of burn?
3rd degree akak full thickness burn
What are the causes of a third degree burn?
flame, hot oil, contact with hot objects
What is the treatment for third degree burns?
they will NOT spontaneously heal. need surgical repair, grafting, significant scarring.
Fourth degree burns extend through the skin to the ___________, __________ and even __________. These are life threatening injuries and you need amputation, extensive reconstruction.
subq fat, muscle, bone
How do you care for minor burn: 1st degree and superficial 2nd degree burn
- analgesics
- clean with soap and water
- debride as needed
- topical antimicrobial (bacitracin ointment, triple antibiotic ointment)
- synthethetic occlusive dressing
- tetanus
__________ can be covered with moist saline soaked dressing while ___________ can use sterile drapes
small wounds
large wounds (application of saline soaked could cause hypothermia, avoid sterile dressing in ED > they have to undress to eval wound)
Airway
re-evaluation of airway
early intubation
-signs of airway burn (mouth, nose) swelling, inhalation injury
Breathing
continuous pulse ox monitor with supplemental O2
determine carboxyhemoglobin level
-carbon monoxide
bronchoscopy if inhalation injury is concern
Circulation
BP, HR, cap refill, UO, mental status
establish TWO large bore access lines in UNBURNED skin if possible
cardiac monitoring
IV administration of lactaid ringers (LRs) solution using parkland formula
Fluid resuscitation: Parkland Formula
Adults
LR4ml x weight (kg) x BSA burned over initial 24 hrs
Half= over first 8 hrs from time of burn
Example: 154 lb, 40% 2nd and 3rd degree burns
4mL x 70kg x 40 = 11,200 mL over 24 hours
5600mL in the first 8 hours
What labs do you want to run as part of the secondary exam?
- routine: CBC, BMP
- If inhalation suspected: ABG, carboxyhemoglobin, CXR, EKG, bronchoscopy
You want to take pulses in all patients especially in those with …..
circumferential/deep burns of the limbs. Compartment syndrome!!
What is an escharotomy?
you cut through damaged skin to relieve the pressure and swelling.
for compromise of circulation
incised to the level of fat
not to level of fascia= fasciotomy
_____________ is the main cause of mortality in burn patients
inhalation injury.
carbon monoxide poisoning, edematous airways
Thermal injuries below vocal cords only due to __________ inhalation
steam
Smoke inhalation will cause mucosal edema. What are the signs/symptoms of this?
hoarseness, singed nasal hair, soot in mouth, nose
What are the indications for ET (endotracheal) intubation
- full thickness burns of face or peri oral region
- circumferential neck burns
- acute respiratory distress
- progressive hoarseness
- respiratory depression
- altered mental status
- supraglottic edema and inflammation on bronchoscopy
During emergent treatment for pain control, the preferred route is _________. Examples of meds are ________ and __________. ___________ agents are used along with pain meds.
IV
morphine, fentanyl
anxiolytic
What are ongoing treatment options for pain control?
codeine, hydrocodone, oxycodone, NSAIDs
You want to transfer these types of patients to the burn unit
- full thickness burn >10% any age
- electrical burns
- chemical burns
- inhalation injury
- burn in pts with preexisting conditions
- burns with trauma
- circumferential limb burns
- burns in pts needing social, emotional, long term rehab needs
- burns of hands, face, feet, perineum
- > 20% partial thickness (>50 yo <10 yo)
- > 25% partial thickness (ages 10-50)
Dispo: hospitalization
- partial thickness: 15-25% age 10-50
- partial thickness 10-20% age <10/ >50
- full thickness <10% anyone
Dispo: outpatient
partial thickness <15% age 10-50
partial thickness <10% age <10/>50
full thickness <2% anyone
What is the method of action for an acid burn?
coagulation necrosis
What is the method of action for an alkali burn?
liquefaction necrosis
- _________ burn has less tissue damage
- __________ burn has deep penetration of substance
- ________ burn: lethargy escahr forms which prevents deep penetration of substance
- acid
- alkali
- acid
What causes acid burns?
What causes alkali burns?
hydrochloric acid, sulphuric acid, nitric acid
bleach, sodium hydroxide, calcium hydroxide, ammonium hydroxide
In the general treatment for chemical burns, you want to immediately remove any particles/solution/saturated clothing. Contact time with the skin is the most important chemical burn feature that healthcare professionals can alter. The amount of time it takes to initiate _______/________ of chemical agent directly related to the _______ of the injury.
dilution, removal
severity
What is the treatment for chemical burns?
topical abx, tetanus, morgan lens
What are tar burns?
roofing, asphalt, heated tempts 500F(burns tend to be more thermal than chemical)
use emulsifying agent to remove tar from skin
What is MSDS (material safety data sheet)
contains info on the potential hazards of chemical products
During blast injuries, it is important to remember that _________ injuries do not correlate with ____________ injuries.
external, internal
What are primary-quaternary blast injuries?
- primary- affects air filled structures (lungs, ears, GI tract)- air is a poor conductor of blast wave energy
- secondary- collateral damage from flying objects
- tertiary- victim propelled in air and hits stationary object
- quaternary- burns, smoke inhalation, chemical agent release
What is the most common fatal primary blast injury secondary to pressure differentials across the alveolar capillary interface?
pulmonary
(more on slides 59-60)
What is a crush inury?
when a body part is subjected to a high degree of force or pressure, usually squeezed between two heavy or immobile objects
When crush injury produces an ongoing ischemia of fascia muscle compartment =
compartment syndrome
What is compartment syndrome?
increased pressure within a confined space that leads to microvascular compromise and cell death as a result of oxygen starvation
Crush injuries are clinically seen in 2 different scenarios
- single patient scenarios
- diasters of varying magnitude
e.g. earthquakes, tsunamis
Normal muscle compartment pressure is ___________. ___________ produces ischemia. Greater than ______ to ______ hours = irreversible damage
<10mmHg, >30mmHg, 4-6
What are the 5 P’s to diagnose a crush injury? How is the pressure measured?
- pain
- paresthesias
- passive stretch
- pressure
- pulseless
Saline filled needle connected to an intravascular pressure system to record pressure
How is a crush injury treated?
- fasciotomy
-lots of complications
-only indicated: loss of distal pulses, debride necrotic tissue, compartment pressures >30mmHg - Hyperbaric oxygen therapy to supplement O2 to hypoxic tissues
What are examples of types of chemical agents
- asphyxiates e.g. methane
- irritants e.g. ammonia
- agents that interrupt delivery of O2 to tissues e.g. CO
- agents that interfere with O2 utilization in the mitochondria e.g. cyanide
- nerve agents e.g. sarin
- incapacitating agents e.g. mace
- vesicants e.g. sulfur gas
ED recognition of a bioterrorism
- patient presents with obvious indicators (small pox rash)
- symptoms are nonspecific but enough historical/clinical data is obtained to make a dx
- not diagnosed, pt dc home and gets worse
- multiple pts presenting with same sx in the same area
What are accidental vs intentional radiation injuries?
accidental- transport, storage, working with radioactive materials
intentional- nuclear weapons, dirty boms
Radiation injuries have cutaneous involvement. Explain the presentation of a pt from weeks 1-4
week 1: transient symptoms
week 2: erythema progresses to hair los
week 3: tenderness, swelling, puritus
week 4: wound will form
Radiation injuries may be clinically indistinguishable from a thermal burn. In this case, _______________ is key.
delayed onset
What is the tx for radiation injuries?
local injury: traditional wound care, topical steroid (betamethasone)
acute radiation syndrome: support and recovery of hematologic system
