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Z Dermatology Clin Med > Burns > Flashcards

Burns Flashcards

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1
Q

When can burns occur

A

When cells in the skin and/or deeper tissues are damaged due to: Heat Cold Electricity Radiation Caustic chemicals

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2
Q

Types of Burns

A

Thermal Cold Chemical Electrical Inhalation Radiation

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3
Q

What does Burn severity depend on

A

Total body surface area (TBSA) Depth of burn Co-morbidities

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4
Q

What are the tools for body surface estimates

A

Lund-Browder Chart

Rule of Nines

Palm Method

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5
Q

What are benefits of using the lund-browder chart

A
  • If used correctly this is the most accurate method.
  • It accounts for body variation and shape with age.
  • Most accurate with kids.
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6
Q

Why use the rule of nines

A
  • Quick and easy way to estimate TBSA
  • Not always the most accurate.
  • Only include 2nd and 3rd degree burns.
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7
Q

What is the palm method

A
  • The palm of the patient’s hand, excluding fingers is approx. 0.5 – 0.8% of total body surface area.
  • The palmar surface with fingers is 1%.
  • This can be used to estimate small burns < 15% TBSA or large burns >8% TBSA.
  • Not as accurate for medium sized burns
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8
Q

What determines the depth of tissue damage

A
  1. Temperature
  2. Duration of contact
  3. Thickness of the dermis
  4. Blood supply
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9
Q

What is the burn classification

A
  1. Superficial
  2. Partial Thickness
    a) Superficial
    b) Deep
  3. Full Thickness
  4. Fourth Degree
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10
Q

What does a superficial (first degree) burn indicate

A
  1. Epidermis only
  2. Painful & erythematous skin
  3. Dry
  4. Blanch with pressure
  5. Heals quickly
    a) Over 2-3 days the pain and redness subsides
  6. Epithelial cells peel away
    a) About day 4
  7. Healed in about 6 days
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11
Q

What does a partial thickness burn (second degree) indicate in general

A

Entire epidermis and a variable portion of dermis

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12
Q

What does a partial thickness burn - superficial (second degree) indicate

A

▫Forms a blister within 24 hours
▫Painful, red, weeping
▫Heal in 7-21 days
▫Scarring is unusual
▫Pigment changes may occur

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13
Q

What does a partial thickness burn - deep (second degree) indicate

A

▫Extend deeper into the dermis
▫Damage hair follicles and glandular tissue
▫Painful only to pressure
▫Blistered (usually unroofed)
▫Mottled colorization from white to red
▫Do not blanch with pressure
▫Heal in 3-9 weeks
▫Cause hypertrophic scarring
▫Difficult to differentiate from a full thickness burn

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14
Q

What does a full thickness burn (third degree) indicate

A
  • Entire thickness of epidermis and dermis and into the subcutaneous tissue
  • Whitish to black in color (charred)
  • Little or no pain
  • No blisters
  • Coagulated vessels
  • No capillary refill
  • These burns heal with contracture and severe scars.
  • Surgery is needed
  • Involves fat, fascia, muscle or bone.
  • These are potentially life threatening injuries.
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15
Q

What type of Burn is this

A

Minor Burn

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16
Q

When do minor burns get treated outside of the burn center

A

•Partial thickness burns <10% TBSA in patients 10-50 years old
•Partial thickness burns <5% TBSA in patients <10 or >50 years old
•Full thickness burns <2% in any patient without any other injury
AND
•Isolated injury
•May not involve the face, hands, perineum, or feet
•May not cross major joints
•May not be circumferential

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17
Q

How to treat minor burns

A
  • Cool the skin
  • Debridement
  • Blisters?
  • Topical therapies
  • Types of dressings
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18
Q

Key points of minor burn treatment - cooling

A

▫Remove any hot or burned clothing, jewelry, and obvious debris (Take care to protect yourself here).
▫Burned areas should be soaked immediately using cool water or saline soaked gauze.
▫Ice and freezing should be avoided to prevent frostbite and hypothermia.
▫Monitoring core temperature continuously to prevent hypothermia especially when burns are >10% TBSA.
▫Keep body temperature above 95°F (35°C)

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19
Q

Key points of minor burn treatment - debridement

A

•Clean with a gentle soap and water.
•Debride loose epidermis and blisters > 2 cm.
▫Use saline and gauze
▫Use surgical scrub brushes
▫Enzymatic debriding agents (Collagenase, Bromelain)

20
Q

Key points of minor burn treatment - blisters

A

▫If the blister has ruptured, debride the devitalized tissue
▫If the blister is intact, there is controversy regarding management and no accepted standard

21
Q

Key points of minor burn treatment - topical therapies

A

•Topical antimicrobials and dressings are the best choice for wound coverage.
▫There is no consensus on the best topical antimicrobial.
•Commonly used agents are:
▫Silver Sulfadiazine
▫Topical antibiotic ointment
▫Petroleum gauze
▫Mafenide

22
Q

Key points of minor burn treatment - types of dressing

A

•Fine Mesh Gauze
•Hydrocolloid dressings
▫Forms a gel when the inner layer gets wet.
•Silver Containing Dressings
▫Silver has a broad spectrum antimicrobial activity.
•Biosynthetic dressings
▫Semi biologic skin substitutes
▫Allows for fewer dressing changes.

23
Q

How often should burns be checked

A

Every day

24
Q

What type of burn is this

A

Major Burn

25
Q

When do major burn victims get sent to a burn center

A

•25% TBSA or greater 10 – 40 y/o
•20% TBSA or greater in children <10 or adults > 40
•10% TBSA full thickness burns
•All burns involving the eyes, ears, face, hands, feet, or perineum.
•Burns across a major joint.
•All high-voltage electric burns, chemical or inhalation burns.
•All burns complicated by major trauma.
•All patients with burns and serious
co-morbidities.
•Need for physical or mental rehabilitation.
•Your facility is not equipped to care for peds.

26
Q

Are major burns trauma

A

yes

27
Q

What is the initial assessment for major burns

A
  • Primary and Secondary Survey
  • “Rule of nines”
  • Fluid Resuscitation
  • List necessary lab tests
  • Manage other co-morbidities
28
Q

What occurs in the primary survey for major burns

A
  1. ABC’s
    a) Manage airway, breathing, & circulation.
  2. Remove hot and burned clothing
  3. Begin cooling
29
Q

What are common signs of smoke inhalation injury

A

▫Persistent cough, stridor, wheezing
▫Hoarseness
▫Deep facial burns or circumferential neck burns
▫Nares with inflammation or singed hair
▫Carbonaceous sputum or burnt matter in the mouth or nose
▫Blistering or edema of the oropharynx
▫Depressed mental status
▫Respiratory distress
▫Hypoxia or hypercapnia
▫Elevated carbon monoxide and/or cyanide levels

30
Q

How should circulation be affected in major burn victims

A

•Normal heart rates for burn patients should be in range of 100 – 120 bpm
•Tachycardia is expected
▫Pain, anxiety, hypovolemia, inadequate oxygenation
•< 100 bpm (relative bradycardia)

31
Q

What occurs in fluid resuscitation

A
  • Burn shock during the initial 24-48 hours after a major burn results in large fluid shifts and depletion of the intravascular volume.
  • Rapid, aggressive fluid resuscitation to maintain an adequate intravascular volume is critical.
  • This protects from end organ damage.
  • Inadequate fluid resuscitation are associated with increased mortality.
  • Any patient with >15% TBSA should receive fluid resuscitation.
  • Lactated Ringer’s solution (LR) is preferred.
32
Q

What is the parkland formula for adults?

A

Adults

▫Fluids given during the initial 24 hours:
–4ml/kg for each % TBSA/24 hours
–
▫½ of the calculated fluids are given in the first 8 hours and the remaining given over the next 16 hours.

▫Give at as steady of a rate as possible. Do not give fluid boluses.

33
Q

What is the parkland formula for infants and children

A

Infants and children ( < 14 years old, < 40 kg )
▫3 ml / kg for each % TBSA/24 hours
▫Consider adding dextrose in this age group due to increased risk of hypoglycemia

34
Q

What are the ABLS guidelines for fluid resuscitation

A

▫Adults
–2 ml LR x kg x TBSA

▫Children
–3 ml LR x kg x TBSA
–< 10 kg use D5LR
–
▫Electrical
–4 ml x kg x TBSA

35
Q

How to measure fluid resuscitation

A

•Urinary output most reliable guide
▫Foley catheter
▫Dependent upon normal renal function
•Expected urine output for:
▫Adults and older children:
–0.5 ml/kg/hour
▫Children
–1 ml/kg/hour

36
Q

What are complications with fluid resuscitation

A

•Excessive volume:
▫Exaggerates edema
▫Compromises blood flow
▫Exacerbate laryngeal swelling

•Inadequate volume:
▫May cause shock and organ failure

•Confirming the adequacy of resuscitation is more important than strict adherence to the Parkland formula.

•Associated with morbidities including:
▫ARDS
▫Pneumonia
▫Multiorgan failure
▫Abdominal, extremity, and orbital compartment syndromes.

37
Q

What is important to know with fluid resuscitation in pediatrics

A
  1. Greater surface area per unit body mass
  2. Require relatively greater amounts of resuscitation fluids.
  3. More susceptible to fluid overload.
  4. When less than 1 year old, have limited glycogen stores – monitor blood glucose.
38
Q

What are initial lab studies associated with burns

A
  • CBC
  • Serum chemistries / electrolytes
  • BUN
  • Glucose
  • Urinalysis
  • Chest X-Rays
39
Q

What are additional labs associated with burn victims

A
  • ABG with carboxyhemoglobin
  • ECG
  • Type and screen (associated trauma)
  • X-Rays for associated trauma injuries
  • X-Rays for suspected child abuse
40
Q

What are skin grafts

A

•Skin grafts are a biologic dressing and consist of skin taken from a donor site and grafted onto a wound on the same patient.

  • Autograft: from same patient
  • Allograft: from a non-self source
41
Q

What are the types of skin grafts

A
  1. Full thickness grafts
    a) epidermis and dermis
  2. split thickness grafts
    a) epidermis with a little dermis
42
Q

What is escharotomy

A
  • Eschar= Stiff and unyielding tissue associated with a full thickness burn.
  • This will compress the underlying tissue causing compression and ischemia.
  • If it is circumferential around the chest, it will not allow chest expansion for respiration.
  • Incision is to the subcutaneous tissue, from non-burned skin to non-burned skin.
43
Q

How are infections controlled with burn victims

A

•Wounds should be cleaned with a mild soap and water. The use of Hibiclens or Betadine can inhibit the healing process
•Topical Antibiotics are applied to all burns covered by a clean dry dressing.
•Systemic antibiotics are generally not needed.
•Debridement helps to prevent infection
•Tetanus vaccination is given, if patient is due, for any burns greater than superficial thickness.
▫Tetanus is considered current if given within last 5 years
•Tetanus immune globulin should be given if the patient has not completed a primary immunization series.

44
Q

What are the most common pathogens associated with burns

A

•The most common pathogens for a localized burn infection includes:
▫Pseudomonas aeruginosa
▫Staph aureus
▫MRSA
▫Enterococcus

•Localized infections can become a generalized cellulitis or sepsis.

45
Q

What is pain management for burn victims

A
  • Partial thickness burns in particular can be excruciatingly painful.
  • IV morphine is the mainstay of pain management, other opioids are acceptable.
  • It is reasonable to give benzodiazepines in addition to help with anxiety.
46
Q

What are special considerations involved with pregnant females

A
  1. Airway: Prevention of hypoxia in the mother is important. Hypoxia of the mother causes increased uterine vascular resistance and decreased blood flow to the fetus.
  2. Circulation: Prevention of hypotension: Maternal hypotension may decrease fetal oxygenation by 45%.
  3. Fluid Resuscitation: In pregnancy there is an increase in maternal intravascular volume. Fluid resuscitation needs may be higher. Need to monitor output carefully.
    ▫Electrolyte imbalances are also important to monitor in the pregnant female.
  4. Fetal Monitoring:
    ▫OB consult
    ▫Fetal heart rate monitoring
    ▫Transfer to a burn center
47
Q

Child abuse and burns

A
  • Common burns of abuse are contact and scald burns.
  • The history of the injury should mesh with the physical exam findings.
  • Symmetrical burns are suggestive of abuse

•The index of suspicion may be greater with other physical exam findings of injury.
▫Bruises, cuts

Z Dermatology Clin Med (18 decks)

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