Burns Flashcards
Parkland Forumla
2-4ml/kg x kg x TBSA% = 1st 24hr fluid requirement
1/2 vol 1st 8hrs
1/2 vol over the next 16 hrs
monitor UOP
0.5cc/kg/hr adults, 1cc/kg/hr peds
if not responding to fluid after 8hrs start albumin or FFP
Zone of coagulation
point of max damage, irreversible tissue loss
Zone of stasis
decreased perfusion, reversible damage dependent on resus
Zone of hyperemia
INCREASED perfusion, inflamed, outer most from center of burn
Lund and Browder Chart
TBSA chart used in billing
2nd degree - superficial partial thickness
epidermis and papillary dermis
blister/weep 12-24hrs
painful, blanching
re-epithelialization in 1-3 weeks
if healing takes >3wks = full thickness
improved result with grafting
3rd degree - full thickness
through dermis
white, leathery, non-blanching
insensate
min-no re-ep due to loss of adnexal structures
without grafting will heal by contraction from wound edge
Compartment pressure when escharotomy is needed
> 30 mmHg
- increased vent pressures
fasciotomies for electric burns
Tangential excision
Weck/Watson blade excises layers until healthy bleeding tissue exposed, use a tourniquet
fascial excision used in large surface area full thickness
- lower risk of blood loss
limit blood loss
Epi, tourniquet, elevation
Burn Multicenter Trial Group
TBS >20%
found that mortality is proportional to units transfused
risk of infection 11%/transfusion
temporary skin subs for early large excision of burns
integra, biobrane, alloderm, apligraf, surgisis
cadaveric split thickness for temp coverage awaiting CEA
biobrane
bilaminate membrane
type 1 porcine collagen
outer silicone film and nylon fabric matrix
apligraf
bilayered
cultured neonatal foreskin keratinocytes and fibroblasts
bovine collagen matrix
integra
bilaminate membrane
cross linked bovine tendon collagen
shark derived glycosaminoglycans
outer silicone sheet
alloderm
cadaveric acellular dermis
surgisis
porcine small intestines
mesh ratios for STSG
increases surface area
1:1 2:1 3:1
4:1 w/ overlying allograft (Alexander technique)
Incubation period for Cultured Epidermal Autograft
3 weeks
CEA when donor sites are limited - 10,000 fold expansion of keratinocytes
$13,000 / 1% TBSA
Epidermis only
very susceptible to shear
What can silver sulfadiazine cause?
leukopenia
- dont d/c unless WBC <2,000
- worse in sulfa allergy
silver sulfa
- has poor pentration (used in ppx only)
- causes yellow/grey pseudoeschar
where is mafenide (sulfamylon) used?
Ears
- dont excise early
- can cause met acid (carbonic anhydrase inhibitor)
- painful
- good penetration
Silver nitrate may cause what electrolyte abnormalities?
hyponatremia and hypochloremia due to being hypotonic
can also cause methemoglobinemia
- requires frequent application to keep moist
- stains black
What is Acticoat antimicrobial against?
gram + and - in addition to fungal
- silver coated mesh dressing
- moisten w/ sterile water
change q2-3 days + moisten outer dressing daily - painful and can stain
When is xeroform/baci best used in burns?
initial dressing for 2nd degree burns
what is the gold standard evaluation for inhalation injuries?
bronchoscopy
- shows carbonaceous deposits and mucosal sloughing below vocal cords
carbon monoxide poisoning when carboxyhgb >15%
- smokers can be up to 10% at baseline
Intubate: stridor, hypoexmia, massive fluid resus
what is the major determinant of tissue damage in electrical burns?
VOLTAGE
alternating current (AC) is more dangerous then direct which is unidirectional
ohms law: current (I) = voltage (E)/resistance (R)
jules: power (P) = voltage (E)/current(I)
What current causes v-fib/resp effects?
50-100mA
1mA = perceptible
10-15 = tetany
1000 = mycardial tetany
High voltage = >1000 volts
- throws patients
- can cause deep tissue burn w/o evidence of external burn
What type of necrosis does alkali burns cause?
liquifactive
- cement, lime, lye
alkali worse than acid burns
Acids cause coagulation necrosis (except for hydrofluoric acid - neutralize with calcium or mag)
- irrigate until skin pH normalizes
what is the antidote to phenol burns?
polyethylene glycol
- phenol causes cardiac and CNS issues
what is the antidote to phosphorus burns?
copper sulfate
- phos causes cardiac arrythmias
what are the 2 frostbite mechanism of injury?
<-2 celcius
direct cellular damage:
- extracellular crystals
- osmotic gradient
- mechanical cell destruction
progressive dermal ischemia:
- like reperfusion injury
- inflam
- microvasc emboli
- arachidonic acid metabolities
first degree frostbite
numb white plaque w/ surround erythema
2nd degree frostbite injury
soft fluid filled blister w/ surround erythema and edema
3rd degree frostbite
hemorrhagic blisters over non-perfused skin
4th degree frostbite
insensate, woody, mottled/gray skin
irreversible
initial treatment for frostbite
rapid rewarming 100-104 bath w/ circulating water
- cont until thawing complete
- NO radiant heat
image with tech 99 triple phase bone scan
- not useful in 1st degree
- hypo uptake in 2nd degree
- absent uptake 3rd/4th degree
post thawing tx of frostbite
thrombolytic therapy
NSAIDS
tetnus
wound care, splint, elevate
- wait for demarcation prior to surgery
- if blisters are clear okay to debride (dont if hemorrhagic)
what is the most frequent complication of burns?
pneumonia
- no abx ppx
- > 4 days on vent increases mortality
treatment of hydrofluroic acid?
calcium gluconate
can also cause liquifactive necrosis like alkali due to dissociation of fluoride ions into subQ -> causes hyperK -> pain out of perportion
Why are compression garments used for management of burn scars?
when compression is applied perpendicular to area of highest wound tension there is a reduced differentiation of fibroblasts to myofibroblasts decreasing scar contracture and collagen deposition (similarly used in keloid scar)
scar strength was improved with pressure garment by 34% in ultimate tensile strength
causes smaller more densely packed collagen fibers
what is the mechanism of steroids in scar healing?
increased tissue proteinases
