BURNS Flashcards
- The affinity of carbon monoxide for hemoglobin is
A. 2-5 times greater than oxygen
B. 20-50 times greater than oxygen
C. 200-250 times greater than oxygen
D. 2000-2500 times greater than oxygen
C. 200-250 times greater than oxygen
Another important contributor to early mortality in burns is carbon monoxide (CO) poisoning resulting from smoke inhalation. The affinity of CO for hemoglobin is approximately 200–250 times more than that of oxygen, which decreases the levels of normal oxygenated hemoglobin and can quickly lead to anoxia and death. Unexpected neurologic symptoms should raise the level of suspicion, and an arterial carboxyhemoglobin level must be obtained because pulse oximetry is falsely elevated. (See Schwartz 9th ed., p 198.)
- A 100-kg patient with a 50% TBSA full thickness burn receives 10 L of 0.9% NaCl solution in transit to the hospital. His laboratory values 6 hours after the injury are likely to reflect which of the following:
A. Acidosis
B. Alkalosis
C. Hypoxia
D. Dilutional anemia
A. Acidosis
The most commonly used formula, the Parkland or Baxter formula, consists of 3 to 4 ml/kg per percent burned of Lactated Ringer’s, of which half is given during the first 8 hours postburn, and the remaining half over the subsequent 16 hours. Given these large volumes of intravenous resuscitation fluid, Lactated Ringer’s solution is preferred, because 0.9% NaCl results in hypernatremia and more importantly a hyperchloremic acidosis. (See Schwartz 9th ed., p 200.)
- The topical antimicrobial agent mafenide acetate is most likely to cause which of the following complications:
A. Methemoglobinemia
B. Neutropenia
C. Metabolic acidosis
D. Nephrotoxicity
C. Metabolic acidosis
Mafenide acetate, either in cream or solution form, is an effective topical antimicrobial. It is effective even in the presence of eschar and can be used in both treating and preventing wound infections, and the solution form is an excellent antimicrobial for fresh skin grafts. The use of mafenide acetate may be limited by pain with application to partial-thickness burns. Mafenide is absorbed systemically and a major side effect is metabolic acidosis resulting from carbonic anhydrase inhibition. (See Schwartz 9th ed., p 202.)
- Which of the following patients should be immediately referred to a burn center?
A. A 20-year-old with a 12% partial thickness burn
B. A 30-year-old with a major liver injury and a 15% partial thickness burn
C. A 2% TBSA partial thickness burn to the anterior leg, crossing the knee
D. A 10-year-old with a 7% partial thickness burn
B. A 30-year-old with a major liver injury and a 15% partial thickness burn
All patients with a partial thickness burn >10% TBSA should be transferred to a burn center. A patient with a burn and other major trauma can be treated and stabilized in the trauma center first. Burns that involve the entire joint should be transferred to a burn center, but a small burn to the anterior surface of the knee would not necessarily mandate transfer. Children should be transferred if there are no personnel able to care for them, but for a child with a 7% TBSA burn, this would not be mandatory. (See Schwartz 9th ed., p 198; See Table 8-1.)
- Which of the following should prompt immediate, elective intubation in a patient with a major burn?
A. Subjective dyspnea
B. Singed nasal hair
C. Perioral burns
D. Oxygen saturation 96%
A. Subjective dyspnea
Perioral burns and singed nasal hairs are signs that the oral cavity and pharynx should be further evaluated for mucosal injury, but in themselves these physical findings do not indicate an upper airway injury. Signs of impending respiratory compromise may include a hoarse voice, wheezing, or stridor; subjective dyspnea is a particularly concerning symptom, and should trigger prompt elective endotracheal intubation. (See Schwartz 9th ed., p 197.)
- Which of the following is indicated in a 46-year-old patient with a 22% TBSA partial thickness burn?
A. Prophylactic 1st generation cephalosporin
B. Prophylactic clindamycin
C. Tetanus booster
D. Tetanus toxoid
C. Tetanus booster
Patients with acute burn injuries should never receive prophylactic antibiotics. This intervention has been clearly demonstrated to promote development of fungal infections and resistant organisms and was abandoned in the mid-1980s. A tetanus booster should be administered in the emergency room. (See Schwartz 9th ed., p 198.)
- A 4-year-old patient presents with a diffuse scald wound after being held in a hot tub of water. There are circumferential blisters present over the right leg (from hip to toes) and circumferential blistering over the lower left leg (from knee to toes). The right thigh, abdomen and back below the umbilicus, as well as the buttocks and perineum are red but without blisters. What is the total BSA burn?
A. 25%
B. 36%
C. 46%
D. 54%
A. 25%
Right leg (circumferential): 14%
Lower left leg (circumferential, knee to toes): 7%
The ‘rule of nines’ is a crude but quick and effective method of estimating burn size (Fig. 8-1). In adults, the anterior and posterior trunk each account for 18%, each lower extremity is 18%, each upper extremity is 9%, and the head is 9%. In children younger than 3 years old, the head accounts for a larger relative surface area and should be taken into account when estimating burn size. Diagrams such as the Lund and Browder chart give a more accurate accounting of the true burn size in children. The importance of an accurate burn size assessment cannot be overemphasized. Superficial or first-degree burns should not be included when calculating the percent of TBSA, and thorough cleaning of soot and debris is mandatory to avoid confusing areas of soiling with burns. Examination of referral data suggests that physicians inexperienced with burns tend to overestimate the size of small burns and underestimate the size of large burns, with potentially detrimental effects on pretransfer resuscitation.
If patient in question is over the age of 3; the adult estimates can be used. Only the areas of partial thickness (in this case, blistering) are used to calculate the burn area. The left leg is 18%, and the lower right leg should be slightly less than half of 18% (i.e., approximately 7-8%). (See Schwartz 9th ed., p 198.)
- 100% inhaled oxygen decreases the half-life of carbon monoxide from 250
minutes to approximately
A. 200 minutes
B. 150 minutes
C. 100 minutes
D. 50 minutes
D. 50 minutes
Administration of 100% oxygen is the gold standard for treatment of CO poisoning, and reduces the half-life of CO from 250 minutes in room air to 40 to 60 minutes. (See Schwartz 9th ed., p 198.)
- Which of the following is used to treat severe hydrogen cyanide poisoning?
A. Hydroxocobalamin
B. Methylene blue
C. Dialysis
D. None of the above-there is no effective treatment
A. Hydroxocobalamin
Hydrogen cyanide toxicity may also be a component of smoke inhalation injury. Afflicted patients may have a persistent lactic acidosis or S-T elevation on electrocardiogram (ECG). Cyanide inhibits cytochrome oxidase, which in turn inhibits cellular oxygenation. Treatment consists of sodium thiosulfate, hydroxocobalamin, and 100% oxygen. Sodium thiosulfate works by transforming cyanide into a nontoxic thiocyanate derivative; however, it works slowly and is not effective for acute therapy. Hydroxocobalamin quickly complexes with cyanide and is excreted by the kidney, and is recommended for immediate therapy. In the majority of patients, the lactic acidosis will resolve with ventilation and sodium thiosulfate treatment becomes unnecessary. (See Schwartz 9th ed., p 198.)
- Most chemical burns require large volumes of water to remove the chemical.
Which of the following chemical burns should be treated by careful wiping or sweeping of the skin, rather than water?
A. Powdered form of lye
B. Formic acid
C. Hydrofluoric acid
D. Acetic acid
A. Powdered form of lye
Chemical burns are less common, but potentially are severe burns. The most important components of initial therapy are careful removal of the toxic substance from the patient and irrigation of the affected area with water for a minimum of 30 minutes. An exception to this is in cases of concrete powder or powdered forms of lye, which should be swept from the patient to avoid activating the aluminum hydroxide with water. (See Schwartz 9th ed., p 199.)
- Formic acid burns are associated with
A. Hemoglobinuria
B. Rhabdomyolosis
C. Hypocalemia
D. Hypokalemia
A. Hemoglobinuria
The offending agents in chemical burns can be systemically absorbed and may cause specific metabolic derangements. Formic acid has been known to cause hemolysis and hemoglobinuria. (See Schwartz 9thed., p 199.)
- The agent most effective in treating hydrofluoric acid burns is
A. Calcium
B. Magnesium
C. Vitamin K
D. Vitamin A
A. Calcium
Hydrofluoric acid is a particularly common offender due to its widespread industrial uses. Calcium-based therapies are the mainstay of treating hydrofluoric acid burns, with topical calcium gluconate applied to wounds, and subcutaneous or IV infiltration of calcium gluconate for systemic symptoms. Intra-arterial infusion of calcium gluconate may be effective in the most severe cases. Patients undergoing intra-arterial therapy need continuous cardiac monitoring. Persistent electrocardiac abnormalities or refractory hypocalcemia may signal the need for emergent excision of the burned areas. (See Schwartz 9th ed., p 199.)
- The major improvement in burn survival in the 20th century can be attributed to the introduction of which of the following therapies:
A. Antibiotics
B. Central venous fluid resuscitation
C. Nutritional support
D. Early excision of the burn wound
D. Early excision of the burn wound
The strategy of early excision and grafting in burned patients revolutionized survival outcomes in burn care. Not only did it improve mortality, but early excision decreased reconstruction surgery, improved hospital length of stay, and reduced costs of care. After the initial resuscitation is complete and the patient is hemodynamically stable, attention should be turned to excising the burn wound. Burn excision and wound coverage should ideally start within the first several days, and in larger burns, serial excisions can be performed as the patient’s condition allows. (See Schwartz 9th ed., p 204.)
- A 22-year-old man is brought to the emergency room after a house fire. He has burns around his mouth and his voice is hoarse, but breathing is unlabored. What most appropriate next step in management?
A. Immediate endotracheal intubation.
B. Examination of oral cavity and pharynx, with fiberoptic laryngoscope if available.
C. Place on supplemental oxygen.
D. Placement of two large-bore intravenous (IV) catheters with fluid resuscitation.
B. Examination of oral cavity and pharynx, with fiberoptic laryngoscope if available.
- What percentage burn does a patient have who has suffered burns to one leg (circumferential), one arm (circum-ferential), and the anterior trunk?
A. 18%
B. 27%
C. 36%
D. 45%
D. 45%
To calculate the percentage of burns using the Rule of Nines for an adult, let’s consider the areas mentioned:
One leg (circumferential): Since each leg is 18% of the body’s surface area (9% anterior and 9% posterior), a circumferential burn to one leg accounts for 18%.
One arm (circumferential): Each arm is 9% of the body’s surface area (4.5% anterior and 4.5% posterior), so a circumferential burn to one arm accounts for 9%.
Anterior trunk: The trunk can be divided into the anterior and posterior trunk, each accounting for 18% of the body’s surface area. Therefore, burns to the anterior trunk account for 18%.
Adding these percentages together:
Leg: 18%
Arm: 9%
Anterior trunk: 18%
Total = 18% + 9% + 18% = 45%
Therefore, the correct answer is D. 45%.
- A 40-year-old woman is admitted to the burn unit after an industrial fire at a plastics manufacturing plant with burns to the face and arms. Her electrocardiogram (ECG) shows
S-T elevation, and initial chemistry panel and arterial blood gas reveal an anion gap metabolic acidosis with normal arterial carboxyhemoglobin. What is the most appropriate next step?
A. Correction of acidosis by adding sodium bicarbonate to IV fluids.
B. Administration of 100% oxygen and hydroxocobalamin.
C. Transthoracic echocardiogram.
D. Blood culture with IV antibiotics.
B. Administration of 100% oxygen and hydroxocobalamin.
- Which of the following is a common sequelae of electrical injury?
A. Cardiac arrhythmias
B. Paralysis
C. Brain damage
D. Cataracts
D. Cataracts
- An 8-year-old boy is brought to the emergency room after accidentally touching a hot iron with his forearm. On examination, the burned area has weeping blisters and is very tender to the touch. What is the burn depth?
A. First degree
B. Second degree
C. Third degree
D. Fourth degree
B. Second degree
- Three hours after a burn injury that consisted of circum-ferential, third-degree burns at the wrist and elbow of the right arm, a patient loses sensation to light touch in his fin-gers. Motor function of his digits, however, remains intact.
The most appropriate treatment for this patient now would consist of:
A. Elevation of the extremity, Doppler ultrasonography every 4 hours, and if distal pulses are absent 8 hours later, immediate escharotomy.
B. Palpation for distal pulses and immediate escharotomy if pulses are absent.
C. Doppler ultrasonography for assessment of peripheral flow and immediate escharotomy if flow is decreased.
D. Immediate escharotomy under general anesthesia from above the elbow to below the wrist on both medial and lateral aspects of the arm.
C. Doppler ultrasonography for assessment of peripheral flow and immediate escharotomy if flow is decreased.
- What is the fluid requirement of a 50-kg man with first-degree burns to his left arm and leg, circumferential second-degree burn to his right arm, and third-degree burns to his torso and right leg. What is the rate of initial fluid resuscitation?
A. 4.5 L over 8 hours, followed by 4.5 Lover 16 hours
B. 4.5 L over 8 hours, followed by 6 L over 16 hours
C. 6 L over 8 hours, followed by 6 Lover 16 hours
D. 6 L over 8 hours, followed by 9 Lover 16 hours
A. 4.5 L over 8 hours, followed by 4.5 Lover 16 hours
A patient with a 90% burn encompassing the entire torso develops an increasing co, and peak inspiratory pressure.
Which of the following is most likely to resolve this problem?
A. Increase the delivered tidal volume.
B. Increase the respiratory rate.
C. Increase the Fio,*
D. Perform a thoracic escharotomy.
D. Perform a thoracic escharotomy.
The adequacy of respiration must be monitored continuously throughout the resuscitation period. Early respiratory distress may be due to the compromise of ventilation caused by chest wall inelasticity related to a deep circumferential burn wound of the thorax. Pressures required for ventilation increase and arterial Pco, rises. Inhalation injury, pneumothorax, or other causes can also result in respiratory distress and should be appropriately treated.
Thoracic escharotomy is seldom required, even with a circumferential chest wall burn. When required, escharotomies are performed bilaterally in the anterior axillary lines. If there is significant extension of the burn onto the adjacent abdominal wall, the escharotomy incisions should be extended to this area by a transverse incision along the costal margins. (See
Schwartz 10th ed., p. 230.)
- Which of the following is FALSE regarding silver sulfadiazine?
A. Used as prophylaxis against burn wound infections with a wide range of antimicrobial activity.
B. Safe to use on full and partial thickness burn wounds, as well as skin grafts.
C. Has limited systemic absorption.
D. May inhibit epithelial migration in partial thickness wound healing
B. Safe to use on full and partial thickness burn wounds, as well as skin grafts.
- Successful antibiotic penetration of a burn eschar can be
achieved with
A. Mafenide acetate
B. Neomycin
C. Silver nitrate
D. Silver sulfadiazine
A. Mafenide acetate
- Which of the following is true regarding nutritional needs of burn patients?
A. The hypermetabolic response to burn wounds typically raises the basic metabolic rate by 120%.
B. Oxandrolone, an anabolic steroid, can improve lean body mass but can be associated with hyperglycemia and clinically significant rise in hepatic transaminitis.
C. Early enteral feeding is safe when burns are less than 20% TBSA, otherwise enteral feeding should await return of bowel function to avoid feeding a patient with gastric ileus.
D. For patients with greater than 40% TBSA, caloric needs are estimated to be 25 kcal/kg/day plus 40 kcal/%TBSA/day.
D. For patients with greater than 40% TBSA, caloric needs are estimated to be 25 kcal/kg/day plus 40 kcal/%TBSA/day.
- A 14-year-old girl sustains a steam burn measuring 6 by 7 inches over the ulnar aspect of her right forearm. Blisters develop over the entire area of the burn wound, and by the time the patient is seen 6 hours after the injury, some of the blisters have ruptured spontaneously. All of the following therapeutic regimens might be considered appropriate for this patient EXCEPT
A. Application of silver sulfadiazine cream (Silvadene) and daily washes, but no dressing.
B. Application of mafenide acetate cream (Sulfamylon), but no daily washes or dressing.
C. Homograft application without sutures to secure it in place, but no daily washes or dressing.
D. Heterograft (pigskin) application with sutures to secure it in place and daily washes, but no dressing.
D. Heterograft (pigskin) application with sutures to secure it in place and daily washes, but no dressing.
- Which is FALSE concerning surgical treatment of burn wounds?
A. Tangential excision consists of tangential slices of burn tissue until bleeding tissue is encountered. Thus, excision can be associated with potentially significant blood loss.
B. Human cadaveric allograft is a permanent alternative to split-thickness skin grafts when there are insuficient donor sites.
C. Bleeding from tangential excision can be helped with injection of epinephrine tumescence solution, pneumatic tourniquets, epinephrine soaked compresses, and fibrinogen and thrombin spray sealant.
D. Meshed split thickness skin grafts allow serosangui-nous drainage to prevent graft loss and provide a greater area of wound coverage.
B. Human cadaveric allograft is a permanent alternative to split-thickness skin grafts when there are insuficient donor sites.
- A 45-year-old woman is admitted to a hospital because of a third-degree burn injury to 40% of her TBSA, and her wounds are treated with topical silver sulfadiazine cream (Silvadene). Three days after admission, a burn wound biopsy semiquantitative culture shows 104 Pseudomonas organisms per gram of tissue. T e patient’s condition is stable at this time. The most appropriate management for this patient would be to
A. Repeat the biopsy and culture in 24 hours.
B. Start subeschar clysis with antibiotics.
C. Administer systemic antibiotics.
D. Surgically excise the burn wounds.
B. Start subeschar clysis with antibiotics.
- Fourteen days after admission to the hospital for a 30% partial thickness burn and hemodynamic instability requiring central venous access, a patient develops a spiking temperature curve. On physical examination, the central venous catheter insertion site was red, tender, and warm. The best treatment for this complication is to
A. Exchange of central venous catheter over guidewire, culture tip of previous catheter.
B. Treat patient with IV antibiotics until blood cultures drawn from catheter are negative.
C. Removal of central venous catheter, culture tip, and placement of new catheter on contralateral site.
D. Removal of catheter and treat patient with oral antibiotics and pain medication as needed.
C. Removal of central venous catheter, culture tip, and placement of new catheter on contralateral site.
- What percentage burn does a patient have who has suffered partial-
thickness burns to their anterior right leg and anterior chest and
abdomen as well as superficial burns to their right arm?
A. 18%
B. 27%
C. 36%
D. 45%
C. 36%
The distribution for an adult is approximately as follows:
Head and neck: 9%
Each arm: 9%
Each leg: 18% (anterior 9% + posterior 9%)
Anterior trunk (chest and abdomen): 18%
Posterior trunk (back and buttocks): 18%
Perineum: 1%
Given the patient has suffered:
Partial-thickness burns to their anterior right leg (9%)
Anterior chest and abdomen (18%)
Superficial burns to their right arm
- In order to assess the special concerns associated with electrical burns:
A. All extremity compartments should be evaluated and a baseline ECG
should be obtained.
B. A full neurologic assessment including ophthalmologic is required to evaluate acute intraocular pathology.
C. A Foley catheter should be placed to allow for titration of fluid administration.
D. Workup should include an echocardiogram to evaluate ventricular
wall motion.
A. All extremity compartments should be evaluated and a baseline ECG
should be obtained.
Electrical burns make up 3% of US hospital admissions but have special concerns, including cardiac arrhythmia and compartment syndrome with concurrent rhabdomyolysis. A baseline ECG is recommended in all patients with an electrical injury, and a normal ECG in a low-voltage injury (<1000
V) may preclude hospital admission. Because compartment syndrome and rhabdomyolysis are common in high-voltage electrical injuries, vigilance must be maintained for neurologic or vascular compromise, and fasciotomies should be performed even in cases of moderate clinical
suspicion. For patients with rhabdomyolysis, a Foley catheter and monitoring of electrolytes may be aid in renal function monitoring, but fluid administration and urine output is not prioritized as highly in electrical when compared to external burns. Long-term neurologic symptoms and cataract development are not uncommon with high-voltage electrical injuries, and neurologic and ophthalmologic consultation should be obtained to define baseline patient function. However, acute intraocular pathology is unlikely to be uncovered. (See Schwartz 11th ed., p. 252.)
- What is the zone of coagulation and what is the appropriate treatment?
A. The most severely burned portion is typically in the center of the wound, which will require excision and grafting.
B. The most severely burned portion is typically in the center of the wound, which will likely heal without surgical intervention if adequate perfusion is maintained and infection is prevented.
C. It has variable degrees of vasoconstriction and resultant ischemia, which will require excision and grafting.
D. It is hyperemic and extremely painful to touch, but will not require surgical excision or grafting.
A. The most severely burned portion is typically in the center of the wound, which will require excision and grafting.
- Which of the following describes a partial-thickness, second-degree burn?
A. Leathery, painless, and nonblanching
B. Painful but do not blister
C. Dermal involvement and are extremely painful with weeping and
blisters
D. Will need excision and grafting
C. Dermal involvement and are extremely painful with weeping and
blisters
- What is the fluid requirement of a 50-kg man with first-degree burns to his left arm and leg, circumferential second-degree burn to his right arm, and third-degree burns to his torso and right leg. What is the rate of initial fluid resuscitation?
A. 4.5 L over 8 hours, followed by 4.5 L over 16 hours
B. 4.5 L over 8 hours, followed by 6 L over 16 hours
C. 6 L over 8 hours, followed by 6 L over 16 hours
D. 6 L over 8 hours, followed by 9 L over 16 hours
A. 4.5 L over 8 hours, followed by 4.5 L over 16 hours
The most commonly used formula, the Parkland or Baxter formula, consists of 3 to 4 mL/kg per % burn of Lactated Ringer’s, of which half is given during the first 8 hours after burn and the remaining half is given over the subsequent 16 hours. The most recent American Burn Association
consensus formula recommends 2 mL/kg per % burn of Lactated Ringers given the tendency toward excessive fluid administration with the traditional formulas. The concept behind continuous fluid requirements is simple. The burn (and/or inhalation injury) drives an inflammatory response that leads to capillary leak; as plasma leaks into the extravascular space, crystalloid administration maintains the intravascular volume. Therefore, if a patient receives a large fluid bolus in a prehospital setting or emergency department, the fluid has likely leaked into the interstitium, and the patient still requires ongoing burn resuscitation according to the estimates.
Continuation of fluid volumes should depend on the time since injury, urine output, and mean arterial pressure (MAP). As the capillary leak closes, the patient will require less volume to maintain these two resuscitation endpoints. Children under 20 kg have the additional requirement that they do not have sufficient glycogen stores to maintain an adequate glucose level in response to the inflammatory response. Specific pediatric formulas have been described, but the simplest approach is to deliver a weight-based maintenance IV fluid with glucose supplementation in addition to the calculated resuscitation with lactated Ringer’s. (See Schwartz 11th ed., p.
254.)
- A patient with partial- and full-thickness burns to their torso was intubated emergently and has become increasingly difficult to ventilate demonstrating rising PCOz and peak inspiratory pressure. The most important treatment includes:
A. Low tidal volume (6 cc/kg) for lung-protection ventilation.
B. High-frequency percussive ventilation (HFPV).
C. Increase the F102 and decrease in positive end-expiratory pressure
(PEEP).
D. Eschar release along the anterior axillary lines with bilateral subcostal and subclavicular extensions.
D. Eschar release along the anterior axillary lines with bilateral subcostal and subclavicular extensions.
Hypoventilation, increased airway pressures, and hypotension may also characterize thoracic compartment syndrome. Escharotomies are rarely needed within the first 8 hours following injury and should not be performed unless indicated because of the terrible aesthetic sequelae. When
indicated, they are usually performed at the bedside, preferably with electrocutery to minimize blood loss. Extremity incisions are made on the lateral and medial aspects of the limbs in an anatomic position and may extend onto thenar and hypothenar eminences of the hand. Digital escharotomies do not usually result in any meaningful salvage of functional tissue and are not recommended. Inadequate perfusion despite proper escharotomies may indicate the need for fasciotomy, but this procedure should not be routinely performed as part of the eschar release. Thoracic escharotomies should be placed along the anterior axillary lines with bilateral subcostal and subclavicular extensions. Extension of the anterior axillary incisions down the lateral abdomen typically will allow adequate release of abdominal eschar. (See Schwartz 11th ed., p. 259.)
- What is the indication for the topical therapy which can cause neutropenia when applied to burns?
A. Primarily as prophylaxis against burn wound infections with a wide range of antimicrobial activity
B. Primarily as antimicrobial prophylaxis against eschar and newly
grafted areas
C. MRSA culture-positive burn wound infections
D. To improve patient comfort while reducing the need for daily dressing changes
A. Primarily as prophylaxis against burn wound infections with a wide range of antimicrobial activity
- Successful antibiotic penetration of a burn eschar can be achieved with:
A. Mafenide acetate.
B. Neomycin.
C. Silver nitrate.
D. Silver sulfadiazine.
A. Mafenide acetate.
- A 42-year-old man with burns of >40% TBSA was required a high volume of intravenous fluids over the first 3 days of his ICU admission to maintain his urine output, which had finally stabilized. However, he has become increasingly difficult to ventilate, with high peak pressures, and his urine output is now declining without response to additional crystalloid. What treatment is now required for this patient?
A. Discontinuation of crystalloid administration, favoring vasopressor initiation for hemodynamic support, if required
B. Transitioning from crystalloid to colloid
C. Torso escharotomies
D. Decompressive laparotomy
D. Decompressive laparotomy
- Which of the following statements is FALSE concerning surgical treatment of burn wounds?
A. Tangential excision consists of tangential slices of burn tissue until bleeding tissue is encountered. Thus, excision can be associated with potentially significant blood loss.
B. Xenographs are a permanent alternative to split thickness skin grafts when there is insufficient donor sites.
C. Bleeding from tangential excision can be helped with injection of epinephrine tumescence solution, pneumatic tourniquets, epinephrine-soaked compresses, and fibrinogen and thrombin spray sealant.
D. Meshed split-thickness skin grafts allow serosanguinous drainage to prevent graft loss and provide a greater area of wound coverage.
B. Xenographs are a permanent alternative to split thickness skin grafts when there is insufficient donor sites.
- Which of the following late complications of an acute burn has the appropriately described treatment?
A. Hypertrophic burn scars should be excised and revised to minimize the increasing inflammatory response.
B. The most common type of contracture is that of the hand which rarely requires surgical excision.
C. Heterotopic ossification (HO) associated pain can be often successfully treated with oral pain control, physiotherapy, and radiation therapy.
D. HO requires surgical excision to prevent malignant transformation of pathologic lamellar bone.
C. Heterotopic ossification (HO) associated pain can be often successfully treated with oral pain control, physiotherapy, and radiation therapy.
- Which of the following descriptions of a burn disaster is TRUE?
A. Do not include exposure to radioactive materials.
B. Should be coordinated by local hospital systems, regionalization and national plans inappropriately allocate resources.
C. Thirty percent of patients in mass casualty incidents suffer from burn injury.
D. Globally, they occur most commonly in the United States.
C. Thirty percent of patients in mass casualty incidents suffer from burn injury.
- Why does carbon monoxide (CO) poisoning lead to anoxia and potentially death in burn patients?
A) CO increases the levels of oxygenated hemoglobin.
B) CO has a lower affinity for hemoglobin than oxygen.
C) CO has a significantly higher affinity for hemoglobin than oxygen, decreasing oxygenated hemoglobin levels.
D) CO directly damages the respiratory center in the brain.
C) CO has a significantly higher affinity for hemoglobin than oxygen, decreasing oxygenated hemoglobin levels.
Rationale: Carbon monoxide has a 200–250 times greater affinity for hemoglobin than oxygen does. This high affinity leads to a decrease in the levels of oxygenated hemoglobin, resulting in anoxia (lack of oxygen) and can lead to death if not treated promptly.
- Why are pulse oximetry readings misleading in the diagnosis of CO poisoning in burn patients?
A) Pulse oximetry can accurately measure carboxyhemoglobin levels.
B) CO poisoning does not affect pulse oximetry readings.
C) Pulse oximetry readings can be misleadingly high due to CO’s higher affinity for hemoglobin than oxygen.
D) Pulse oximetry readings are unaffected by hemoglobin levels.
C) Pulse oximetry readings can be misleadingly high due to CO’s higher affinity for hemoglobin than oxygen.
Rationale: Pulse oximetry measures oxygen saturation levels in the blood. However, because CO binds more readily to hemoglobin than oxygen does, the device may show falsely high oxygen saturation levels in the presence of CO poisoning. This is why measuring arterial carboxyhemoglobin levels is crucial for accurate diagnosis.
- What is the primary use of mafenide acetate in burn treatment?
A) To increase oxygenation in burn areas.
B) As an effective topical antimicrobial agent for burns.
C) To reduce the affinity of CO for hemoglobin.
D) As a pain reliever for burn patients.
B) As an effective topical antimicrobial agent for burns.
Rationale: Mafenide acetate is used in burn treatment due to its effectiveness as an antimicrobial agent. It can be applied in both cream and solution forms and remains effective even in the presence of eschar, helping to treat and prevent wound infections.
- What significant side effect can occur with the systemic absorption of mafenide acetate?
A) Increased oxygenation of hemoglobin.
B) Decreased risk of CO poisoning.
C) Metabolic acidosis due to inhibition of carbonic anhydrase.
D) Improved wound healing without complications.
C) Metabolic acidosis due to inhibition of carbonic anhydrase.
Rationale: While mafenide acetate is beneficial for treating burns and fresh skin grafts, its systemic absorption can lead to metabolic acidosis. This is because mafenide acetate inhibits carbonic anhydrase, an enzyme important for maintaining acid-base balance in the body.
- What criterion necessitates the transfer of a burn patient to a specialized burn center?
A) Partial-thickness burns covering less than 5% of Total Body Surface Area (TBSA).
B) Burns involving an entire joint.
C) First-degree burns regardless of TBSA.
D) All burns, irrespective of severity and TBSA.
B) Burns involving an entire joint.
Rationale: Burns involving an entire joint require specialized care due to the complexity of treatment needed for such injuries. This highlights the importance of transferring patients with such burns to a specialized burn center where they can receive the appropriate care.
- Under which condition should children with burns be transferred to a specialized burn center?
A) If the burn covers more than 5% TBSA.
B) If the initial facility lacks the expertise to care for pediatric burn patients.
C) Only if the child has burns on the face, regardless of TBSA.
D) All children with any size burn should be transferred.
B) If the initial facility lacks the expertise to care for pediatric burn patients.
Rationale: The decision to transfer a child with burns to a specialized burn center depends on the initial facility’s capability to provide the necessary care for pediatric patients. A child with a 7% TBSA burn might not require transfer if the facility is equipped to handle such cases.
