burns Flashcards
first degree burns
epidermal burns; only involve the epidermis
s/sx of epidermal burns
within min the dermal capillaries dilate so burns appear red/erythemic (usually resolves within few hrs), pain, areas that blanch w direct pressure; blistering is absent
tx epidermal burns
supportive care w pain control (oral analgesics), adequate oral fluids, and application of a soothing topical compound such as neomycin sulfate ointment to prevent infx
healing and scaring of epidermal burns
healing occurs w/in few days as injured epidermis peels off revealing a new skin beneath; and no scar because it does not involve the dermis
second degree burns
partial thickness burns; extend into but not through the dermis; vary in appearance and significance
presentation superficial partial thickness burns
reddened skin that forms distended blisters comprised of epidermis and filled w proteinaceous fluid that escapes from damaged capillaries; underlying dermis is moist, blanches on direct pressure, very painful
how do deep partial thickness burns present
coagulation necrosis of the upper dermis often give these wounds a dry , thickened texture; variety of colors but most often waxy white; pain varies
tx deep partial thickness burns
excision of the burned tissue and skin grafting (heal that is often rigid, tender, and friable)
what happens during the first 24-48hr post partial burns
wound dev coating of dead tissue, coagulated serum, and debris called eschar
superficial partial thickness burns demonstrate eschar separation when
within 10-14d, revealing punctate areas of new epidermal growth called skin buds, which dev from epidermal linings of hair follicles and sweat glands
third degree burns
full thickness burns occur when all layers of skin are destroyed; usually covered w dry, avascular coagulum which is relatively insensate due to destruction of nerve endings
presentation of full thickness burns
any color; full thickness scald burns are often dark red color but surface is dry and does not blanch with pressure; tight, tourniquet like constriction which can cause circulatory compromise in the extremities
tx inhalation injury
supportive, endotracheal intubation to secure the swelling airway is mandatory; ventilator support w PEEP is most helpful in combating the airway collapse
pts exposed to large amounts of toxic smoke frequently present with
carbon monoxide poisoning from incomplete combustion of normal household items such as wood and cotton; carboxyhemoglobin cannot transport oxygen
s/sx of carbon monoxide poisoning
initially experience headache, progressing to dizziness, weakness, and syncope; later include coma, seizures and death
dx CO poisoning
arterial blood gas w direct measure of hemoglobin saturation
tx CO poisoning
ventilation with 100% oxygen; +/- endotracheal intubation; if need a more rapid dec then hyperbaric oxygen therapy
upper airway injury
produced by heat; rash burns and explosions may produce instantaneous deep burns of the face and oropharynx which lead to rapid, life threatening airway edema; endotracheal intubation is essential
lower airway injuries
“true” inhalation injury; pt inhales sig amy of smoke; large amounts of CO, formaldehyde, formic acid, and hydrochloric acid
what happens during lower airway injuries
severe damage to mucosal cells of the airway; as dead/damaged cells slough, they produce plugging, segmental collapse, and bronchiectasis
what can patients dev w lower airway injuries
pneumonia; takes several days to dev
rule of 9s
adult- head 9, ant torso 18, post torso 18, each arm 9, each leg 18, perineum 1
infants- head 18, ant torso 18, post torso 18, each arm 9, each leg 14
when can burn wounds be tx
after secondary surgery has been complete and burns have been evaluated
criteria for referral to burn center
- Partial-thickness burns >10% total body surface area (%TBSA)
- Burns the involve the face, hand, feet, genitalia, perineum, or major joints
- Third-degree burns in any age group
- Electrical burns, including lightning injury
- Chemical burns
- Inhalation Injury
- Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality
- Any patient with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality. In such cases, if the trauma poses the greater immediate risk, the patient’s condition may be stabilized initially in a trauma center before transfer to a burn center. Physician judgment will be necessary in such situations and should be in concert with the regional medical control plan and triage protocols.
- Burned children in hospitals without qualified personnel or equipment for the care of children
- Burn injury in patients who will require special social, emotional, or rehabilitative intervention
3 periods of burn care
resuscitation, wound closure, and rehabilitation
how long does the resuscitation period last
24-48hrs following injury; most important goal after being evaluated
burn shock
w large injuries, capillary leakage becomes systemic producing total body edema and severely depleting circulating volume
what % of TBSA of burns requires fluid resuscitation
10-15 or greater with isotonic crystalloid solution
consensus formula
2-4ml lactated ringers x body wt (kg) x %tbsa burns= total fluid for first 24 hrs; 1/2 during first 8hr, 1/4 during second 8 and last 1/4 during last 8 hrs
fluid resuscitation leads to fluid accumulation beneath eschar which compromises circulation creates pain and leads to
compartment syndrome
tx of compartment syndrome related to burns
escharotomy
dx of inhalation injury
positive broncoscopic
what is common w severe inhalation injury
adult respiratory distress (ARDS); can be worsened by overresuscitation
dx ARDS
ground glass appearance on cxr
tx ARDS
aggressive ventilator supports, PEEP, APRV, PRVC
when does wound coverage begin
immediately following fluid resuscitation
complications of burn eschar
infx, loss of skin integrity which causes inc evaporative fluid losses, severe pain, and intense inflammatory response that can lead to organ failure and death
early excision
burned skin is cut off the underlying tissue
fascial excision
skin and sub cut tissue are removed to the level of the fascia not much bleeding; permits good skin graft take but is disfiguring and removal of sub cut fat leads to joint stiffness and poor mobility
tangential excision
only burned tissue is removed w a dermatome, leaving viable dermis and subcutaneous tissue behind; a lot of bleeding and requires skill; better cosmetic and functional results
what is usually performed at the same time as excision
skin grafting
autograft- full or split thickness
graft that consists of the patients own tissue
most widely used skin substitute for graft
cadaver allograft; obtained from tissue banks
how long is the skin surface sterile after a burn
24-48hrs
burn wound sepsis
bacteria may colonize burn eschar harmlessly, or, by penetrating through the burn wound, invade intact tissues and overwhelm local defenses, producing invasive infection
abx for staph and strep
silver nitrate solution
abx gram neg
mafenide acetate (sulfamylon) and silver sulfadiazine (silvadene, thermazene, SSD)
most effective technique in the battle against burn wound infection
early burn excision and skin grafting
how many times should dressing and such be changed
bid
causes wasting of respiratory muscles and immune compromise w resulting pulmonary infx and death
protein malnutrition= enternal feeding of protein liquid diet
if unopposed what can burn scar contractors lead to
immobilize extremities completely and produce significant disfigurement
when if rehab therapy best
most effective if begun quickly, while scar tissue is still pliable and before it can set into sig contractors
3 classes of chemicals that produce skin injuries
alkalis, acids, organic compounds
alkali chemical burns
dissolve and combine with the proteins of the tissues to form alkaline proteinates, which contain hydroxide ions. These ions induce further chemical reactions, penetrating deeper into the tissue
acid chemical burns
induce protein breakdown by hydrolysis, which results in an eschar that does not penetrate as deeply as the alkalis. These agents also induce thermal injury by heat generation with contact of the skin, further causing tissue damage
organic compound chemical burns
petroleum products, phenols, and others injure tissue by their fat solvent action, which dissolves cell membranes
tx burn related anxiety
lorazepam, diazepam, and midazolam
tx itching burn
topical drugs (tricyclic histamine rec blockers, doxepin), gabapentin, depsone, ondansetron and h1/2 blocker; coolng; transcutaneous electrical nerve stimulation, massage
A 63-year-old man with chronic obstructive pulmonary disease (COPD) caught his home on fire while smoking in bed. He was trapped in the house for an unknown time period before firefighters extricated him. He presents to the Emergency Center with severe facial blistering, singed nasal hairs, black intraoral mucosa, a swollen tongue, and carbonaceous sputum. His pulse oximetry reads 85% on room air, and he is obtunded. What is the next best step in management?
A. Administer racemic epinephrine and steroids.
B. Draw an arterial blood gas for carboxyhemoglobin levels.
C. Secure his airway by endotracheal intubation.
D. Place him on 10 L oxygen by humidified facemask.
E. Transfer him to the hyperbaric oxygen chamber.
Answer: C
This man presents with every manifestation of inhalation injury, which is the most frequent cause of death in victims of structural fires. Oxygen therapy is essential, but this man likely does not have an adequate airway. Securing his airway is the first principle of treatment.
A 25-year-old man suffers burns to 40% total body surface area (TBSA) in an explosion at a natural gas drilling site. He requires emergent intubation and fluid resuscitation. During his first week of hospitalization, he undergoes a major operative procedure for excision and skin grafting, By the end of the third week in the hospital, his weight (which originally increased with resuscitation) has come back down, and he weighs 12 pounds less than before the injury. What is the most likely cause for his weight loss?
A. Decreased nitrogen excretion and resulting catabolism
B. Increased nitrogen excretion and resulting catabolism
C. Protein malnutrition with respiratory muscle building
D. Immune system building with increased risk of pneumonia and bacteremia
E. Indirect calorimetry readings to support positive nitrogen balance
Answer: B
In response to the increased metabolic demands of a major burn, skeletal muscle is broken down to provide an available energy substrate. This results in increased nitrogen excretion, and loss of lean body mass, which can exceed a half pound per day. Cardiac muscle and respiratory muscles are not immune from these effects, and as muscle wasting continues, both heart failure and respiratoryfailure can occur. Loss of as little as 15% lean body mass can lead to a fatal degree of inanition within a few weeks of injury
A 27-year-old man is sprayed with concentrated sulfuric acid while working in an oil refinery, sustaining burns to his face, hands, and forearms. He is brought immediately to the emergency room. On initial exam, he is awake and in pain. His clothes are soaked with acid. In addition to providing appropriate protection for all health care workers, the first step in management should be to
A. debride his burns and complete a Lund and Browder chart.
B. immediately place the patient in a decontamination shower.
C. perform a secondary survey.
D. begin fluid resuscitation.
E. contact the local burn center for referral.
Answer: B
The patient illustrates the danger that health care workers face when dealing with hazardous material spills. Unwary physicians and nurses who attempt to help this man could suffer serious burns from the acid on his clothing, which is continuing to burn the patient as well.
This chemical must be neutralized before a primary survey can be conducted safely. All of the other answers are appropriate steps in treatment but should not be performed until after the patient is decontaminated
A 6-year-old girl was burned in a house fire and unable to escape. She was found unconscious by firefighters, who intubated her at the scene. On arrival in the burn center, she is found to have carbonaceous sputum, elevated carboxyhemoglobin levels, and burns to 30% TBSA. You should inform her parents that inhalation injury significantly increases the mortality rate of patients with major burns mostly due to
A. increased metabolic rate and protein–calorie malnutrition.
B. persistent pulmonary infection and eventual development of multiple organ failure.
C. hypoxia.
D. airway obstruction.
E. increased fluid requirements for resuscitation.
Answer: B
Though inhalation injury can produce immediate death from carbon monoxide poisoning and hypoxia, patients who survive the initial event should survive this problem. Similarly, airway obstruction is usually a treatable problem with limited time course. Pneumonia is the most worrisome complication of smoke inhalation, because it is often persistent/recurrent, and difficult to treat. Persistent infection—including pneumonia—often leads to development of the multiple organ failure syndrome, which is usually fatal.
A 19-year-old man is seen in the emergency department 20 minutes after a high-speed head-on collision with a tree, in which his car caught fire. He was not wearing a seat belt and was ejected from the vehicle. In the emergency department, he is alert, but he does not remember what happened. He admits to drinking a few beers earlier. Blood pressure is 75/40 mm Hg and heart rate 140. His airway is patent. Breath sounds are equal bilaterally. Arterial blood gases reveal a PaO2 of 140, SaO2 of 98%, PaCO2 of 34, and pH of 7.33. He has burns to 15% TBSA, involving his anterior trunk and legs. His abdomen is covered with burns but appears distended; tenderness is hard to determine because of painful burn wounds. What is the most likely cause of his hypotension?
A. Smoke inhalation injury
B. Burn shock
C. Intra-abdominal hemorrhage
D. Ethanol intoxication
E. Closed head injury
Answer: C
This patient illustrates the importance of the secondary survey in victims of burn injury. This man’s burns are too limited in extent to cause severe shock, especially so soon after injury. Smoke inhalation is doubtful, especially with good blood gases. There is no evidence for ethanol intoxication or closed head injury. Unless a second injury (i.e., abdominal trauma) is considered, it will not be diagnosed.
