Burns

Question 1

Parkland Forumla

Answer 1

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

Question 2

Zone of coagulation

Answer 2

point of max damage, irreversible tissue loss

Question 3

Zone of stasis

Answer 3

decreased perfusion, reversible damage dependent on resus

Question 4

Zone of hyperemia

Answer 4

INCREASED perfusion, inflamed, outer most from center of burn

Question 5

Lund and Browder Chart

Answer 5

TBSA chart used in billing

Question 6

2nd degree - superficial partial thickness

Answer 6

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

Question 7

3rd degree - full thickness

Answer 7

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

Question 8

Compartment pressure when escharotomy is needed

Answer 8

> 30 mmHg
- increased vent pressures

fasciotomies for electric burns

Question 9

Tangential excision

Answer 9

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

Question 10

limit blood loss

Answer 10

Epi, tourniquet, elevation

Burn Multicenter Trial Group
TBS >20%
found that mortality is proportional to units transfused
risk of infection 11%/transfusion

Question 11

temporary skin subs for early large excision of burns

Answer 11

integra, biobrane, alloderm, apligraf, surgisis
cadaveric split thickness for temp coverage awaiting CEA

Question 12

biobrane

Answer 12

bilaminate membrane
type 1 porcine collagen
outer silicone film and nylon fabric matrix

Question 13

apligraf

Answer 13

bilayered
cultured neonatal foreskin keratinocytes and fibroblasts
bovine collagen matrix

Question 14

integra

Answer 14

bilaminate membrane
cross linked bovine tendon collagen
shark derived glycosaminoglycans
outer silicone sheet

Question 15

alloderm

Answer 15

cadaveric acellular dermis

Question 16

surgisis

Answer 16

porcine small intestines

Question 17

mesh ratios for STSG

Answer 17

increases surface area
1:1 2:1 3:1
4:1 w/ overlying allograft (Alexander technique)

Question 18

Incubation period for Cultured Epidermal Autograft

Answer 18

3 weeks

CEA when donor sites are limited - 10,000 fold expansion of keratinocytes

$13,000 / 1% TBSA
Epidermis only
very susceptible to shear

Question 19

What can silver sulfadiazine cause?

Answer 19

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

Question 20

where is mafenide (sulfamylon) used?

Answer 20

Ears

• dont excise early
• can cause met acid (carbonic anhydrase inhibitor)
• painful
• good penetration

Question 21

Silver nitrate may cause what electrolyte abnormalities?

Answer 21

hyponatremia and hypochloremia due to being hypotonic

can also cause methemoglobinemia

• requires frequent application to keep moist
• stains black

Question 22

What is Acticoat antimicrobial against?

Answer 22

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

Question 23

When is xeroform/baci best used in burns?

Answer 23

initial dressing for 2nd degree burns

Question 24

what is the gold standard evaluation for inhalation injuries?

Answer 24

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

Question 25

what is the major determinant of tissue damage in electrical burns?

Answer 25

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)

Question 26

What current causes v-fib/resp effects?

Answer 26

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

Question 27

What type of necrosis does alkali burns cause?

Answer 27

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

Question 28

what is the antidote to phenol burns?

Answer 28

polyethylene glycol - phenol causes cardiac and CNS issues

Question 29

what is the antidote to phosphorus burns?

Answer 29

copper sulfate - phos causes cardiac arrythmias

Question 30

what are the 2 frostbite mechanism of injury?

Answer 30

<-2 celcius direct cellular damage: - extracellular crystals - osmotic gradient - mechanical cell destruction progressive dermal ischemia: - like reperfusion injury - inflam - microvasc emboli - arachidonic acid metabolities

Question 31

first degree frostbite

Answer 31

numb white plaque w/ surround erythema

Question 32

2nd degree frostbite injury

Answer 32

soft fluid filled blister w/ surround erythema and edema

Question 33

3rd degree frostbite

Answer 33

hemorrhagic blisters over non-perfused skin

Question 34

4th degree frostbite

Answer 34

insensate, woody, mottled/gray skin irreversible

Question 35

initial treatment for frostbite

Answer 35

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

Question 36

post thawing tx of frostbite

Answer 36

thrombolytic therapy NSAIDS tetnus wound care, splint, elevate - wait for demarcation prior to surgery - if blisters are clear okay to debride (dont if hemorrhagic)

Question 37

what is the most frequent complication of burns?

Answer 37

pneumonia - no abx ppx - >4 days on vent increases mortality

Question 38

treatment of hydrofluroic acid?

Answer 38

calcium gluconate can also cause liquifactive necrosis like alkali due to dissociation of fluoride ions into subQ -> causes hyperK -> pain out of perportion

Question 39

Why are compression garments used for management of burn scars?

Answer 39

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

Question 40

what is the mechanism of steroids in scar healing?

Answer 40

increased tissue proteinases