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Fall 2014 - CM Dermatology > Burns > Flashcards

Burns Flashcards

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Dermatology Board Prep flashcards
1
Q

Burns

A

-occur when cells in the skin or deeper tissues are damaged due to heat, cold, electricity, radiation, caustic chemicals

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2
Q

Types of Burns (6)

A
  • thermal/heat
  • cold/frostbite
  • electrical
  • chemical
  • inhalation
  • radiation
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3
Q

Lund-Browder Chart

A
  • most accurate for determining TBSA
  • accounts for body variation and shape with age
  • most accurate for kids
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4
Q

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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5
Q

Palm Method

A
  • the palm of the patient’s hand (excluding fingers) is approx .5-.8% of TBSA
  • palmar surface with fingers 1%
  • 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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6
Q

What 4 things determine the depth of tissue damage from a burn?

A
  • temperature of burning object
  • duration of contact
  • thickness of the dermis
  • blood supply

-young and old have much thinner skin –> burn deeper

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7
Q

How are burns classified?

A
  1. First degree: superficial
  2. Second degree: partial thickness (superficial or deep)
  3. Third degree: full thickness (down to SQ tissue)
  4. Fourth degree: goes to tendon, bone, muscle
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8
Q

Superficial (1st degree) Burn Characteristics

A
  • epidermis only
  • painful, erythematous skin
  • dry, no oozing or weeping
  • blanch with pressure
  • heal quickly: over 2-3 days, pain and redness subside
  • epithelial cells peel away at day 4
  • healed in about 6 days
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9
Q

Partial Thickness (2nd degree) Superficial Burn Characteristics

A
  • entire epidermis and a variable portion of dermis
  • forms blister w/in 24 hours
  • painful, red, weeping
  • heal in 7-21 days
  • scarring unusual
  • pigment changes may occur
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10
Q

Partial Thickness (2nd degree) Deep Burn Characteristics

A
  • extend deeper into dermis; damage hair follicles and glandular tissue
  • painful only to pressure (nerves affected)
  • blistered (usually unroofed)
  • mottled color from white to red
  • do not blanch (blood vessels have coagulated)
  • heal 3-9 weeks
  • hypertrophic scarring
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11
Q

Full Thickness (3rd degree) Burn Characteristics

A
  • entire thickness of epidermis and dermis, into subQ tissue
  • whitish to black in color (charred)
  • little or no pain (nerves damaged)
  • no blisters
  • coagulated vessels, no capillary refill
  • these burns heal with contractures and severe scars
  • surgery needed
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12
Q

Full Thickness (4th degree) Burn Characteristics

A
  • involves fat, fascia, muscle or bone

- these are potentially life threatening

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13
Q

Minor Burns - Characteristics

A
  • partial thickness burn 50 y.o
  • full thickness burns <2% w/o other injury

-AND isolated injury; may not involve the hands, face, perineum or feet; may not cross major joints; may not be circumferential

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14
Q

Minor Burns - Cooling Treatment

A
  • remove any hot or burned clothing, jewelry, debris
  • burned areas soaked immediately with saline or cool water
  • do not use ice (hypothermia)
  • monitor core temp to prevent hypothermia esp when burns >10% TBSA
  • keep body temp above 95F (35C)
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15
Q

Minor Burns - Cleaning/Debridement

A
  • clean with gentle soap and water
  • debride loose epidermis and blisters > 2 cm
  • use saline and gauze
  • use surgical scrub brushes
  • enzymatic debriding agents (Collagenase)
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16
Q

Minor Burns - Blisters??

A
  • if ruptured, debride the tissue

- if intact, there is controversy regarding management

17
Q

Minor Burns - Topical Treatments

A
  • topical antimicrobials and dressings are best choice
  • silver sulfadiazine: thick white topical agent; can’t be used in pregnant or BF moms or infants; antibacterial activity
  • bacitracin and polymyxin: easier to apply and remove w/ dressing changes; may be used on perineum and face
  • fine mesh gauze
  • hydrocolloid dressings
  • silver containing dressings: silver = antimicrobial
  • biosynthetic dressings: fewer dressing changes; semi-biologic skin substitute
18
Q

Scarring from Burns

A
  • excessive scarring in form of keloid scars and contractures
  • both types may be uncomfortable and can interfere with ROM
19
Q

Major Burns - Characteristics

A
  • 25% TBSA in 10-40 y.o
  • 20%+ TBSA in kids 40
  • 10% TBSA full thicknes burns
  • all burns involving eyes, ears, face, hands, feet, perineum
  • burns across a major joint
  • all high voltage electrical burns, chemical or inhalation
  • all burns complicated by major trauma (eg broken bone)
  • all patients w/ burns and serious co-morbidity (DM, renal failure)
  • your facility is not equipped to care for peds
20
Q

Major Burns - Airway Assessment

A
  • important to assess airway early; large % of smoke inhalation patients develop airway obstruction
  • common signs of smoke inhalation: persistent cough, stridor or wheezing; hoarse; deep facial burns; nares with inflammation or singed hair; blistering/edema of oropharynx; depressed mental status; respiratory distress; hypoxia or hypercapnia
21
Q

Major Burns - Circulation Assessment

A
  • normal heart rates for burn patients 100-120 bpm

- tachycardia is expected: pain, anxiety, hypovolemia, inadequate oxygenation

22
Q

Fluid Resuscitation

A
  • burn shock during initial 24-48 hours = large fluid shifts and depletion of intravascular volumes
  • rapid, aggressive fluids needed
  • protect end organ damage
  • any patient w/ > 15% TBSA should receive fluids
  • lactated ringers preferred
23
Q

Parkland Formula

A
  • fluids given during the initial 24 hours: 4 mL/kg for each % TBSA/24 hours
  • 1/2 of fluids given over first 8 hours; other half given over 16 hours
  • in infants and kids, 3 mL/kg for each %TBSA/24 hours (add dextrose)
24
Q

A 25 y.o male with TBSA of 30% weighs 70 kg.

How much fluid is needed in the first 24 hours?
How much should be given per hour in the first 8 hours?
In the next 16 hours?

A
  1. 4 x 70 x 30 = 8400 mL for 24 hours
  2. 4200 mL over 8 hours = 525/hour
  3. 4200 mL over 16 hours = 262.5/hour
25
Q

ABLS Guidelines for Fluid Resuscitation

A
  • adults: 2 mL LR x kg x TBSA
  • kids: 3 mL LR x kg x TBSA
  • electrical: 4 mL x kg x TBSA
26
Q

Subsequent Fluid Resuscitation

A
  • urinary output is most reliable guide (foley cath, depends on normal renal function)
  • expected urine output for adults (0.5 mL/kg/hr) and for kids (1 mL/kg/hr)
27
Q

What happens in the case of excessive or inadequate volume during fluid resuscitation?

A
  • excessive: exaggerates edema, compromises blood flow, exacerbates laryngeal swelling
  • inadequate: may cause shock and organ failure
28
Q

Pediatric Fluid Resuscitation

A
  • greater surface area per unit body mass
  • require relatively greater amounts of resuscitation fluid
  • BUT are more susceptible to fluid overload
29
Q

Skin Grafting

A
  • skin grafts are a biologic dressing
  • consist of skin taken from a donor site and grafted onto a wound
  • autograft: from same patient
  • allograft: from non-self source
30
Q

Full Thickness Skin Graft

A
  • contain epidermis and dermis
  • retain more of the characteristics of the normal skin
  • skin is taken from groin, lateral thigh, lower abdomen or lateral chest
31
Q

Split Thickness Skin Graft

A
  • contains epidermis and small amount of dermiss
  • tolerate a less than ideal wound bed and have broader range of applications
  • can be meshed to provide greater surface area coverage
  • tend to be abnormally pigmented (pale/white or hyperpigmented)
32
Q

Escharotomy

A
  • eschar: stiff and unyielding tissue associated with a full thickness burn
  • will compress the underlying tissue and cause compression and ischemia
  • if circumferential around the chest, it will not allow chest expansion for respiration
33
Q

Infection Control for Burns

A
  • wounds should be cleaned with a mild soap and water
  • topical antibiotics applied to all burns covered by a clean dry dressing
  • systemic antibiotics generally not needed
  • debridement
  • tetanus vaccine given for any burns greater than superficial
  • tetanus immune globulin should be given if patient has not completed primary immunization series
34
Q

What are the most common pathogens for a localized burn infection?

A
  • pseudomonas aeruginosa
  • staph aureus
  • MRSA
  • enterococcus
  • localized infections can become a generalized cellulitis or sepsis
35
Q

Pain Management of Burns

A
  • partial thickness can be especially painful
  • IV morphine is common for pain management, other opioids also acceptable
  • reasonable to give benzodiazepines to help with anxiety
36
Q

Mortality Risk Factors for Burns

A
  • age greater than 60
  • non-superficial burns over 40% TBSA
  • inhalation injury

-risk increases with each risk factor a patient has

37
Q

Burns in the Pregnant Female

A
  • outcome of pregnancy determined largely by outcome of woman
  • consider pregnancy loss in woman with >60% TBSA
  • pregnancy itself does not seem to alter maternal outcome
  • evaluate and treat the same as non-pregnant female
  • prevention of hypoxia and hypotension especially important to not limit blood flow to fetus
  • fluid resuscitation needs may be higher
  • fetal monitoring: OB consult
38
Q

Burns and Child Abuse

A
  • common burns of abuse are contact (cigarettes, iron) and scald burns
  • history of injury should mesh with physical exam findings
  • symmetrical burns are suggestive of abuse (eg lower legs from being lowered into hot water)
  • index of suspicion may be higher with other physical exam findings of injury (bruises, etc)

Fall 2014 - CM Dermatology (11 decks)

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