Burns Flashcards
First degree histology ?
epidermis
First degree anatomy ?
no blisters
painful
First degree durn depth ?
Superficial thickness
- *1 = does not blanch
- *
Superficial second degree or superficial partial thickness burn depth ?
Superficial partial
Superficial second degree or superficial partial thickness anatomy ?
Blisters
very painful
Superficial second degree or superficial partial thickness histology ?
Epidermis and superficial dermis
Deep second degree or deep partial thickness burn depth ?
Deep partial
Deep second degree or deep partial thickness Histology ?
Epidermis and deep dermis
sweat glands
hair follicles
Deep second degree or deep partial thickness anatomy?
Blisters
very painful
Third degree burn depth ?
full thickness
Third degree Histology/anatomy ?
Entire epidermis and dermis charred
pale
leathery
no pain
** 3 - epi and dermis are toast , no pain = worse in severity **
Fourth degree histology/anatomy ?
Entire epidermis and dermis
bone
fat
muscle
Rule of 9’s: entire head ?
9 = front and back
front = 4.5 back= 4.5
Rule of 9’s: entire arm ?
9 front and back
front = 4.5 back = 4.5
Rule of 9’s: entire trunk ?
36
front = 18 back = 18
Rule of 9’s: entire leg ?
18
posterior = 9 anterior = 9
Rule of 9’s: genital s?
1
First degree clinical presentation ?
Damage to the epidermal later only
painful, erythematous
heals spontaneously within several days
no scarring
Second degree clinical presentation ?
Damage to the dermis
erythematous, painful
blisters
pink/red/shiny to pale/mottled
heals by reepithelization from structures within dermis
may lead to sign. scarring based on level of dermal involvement
Third degree/full thickness clinical presentation ?
Damage through the dermis
hard, dry eschar
painless
heals by skin grafting surgery
significant scarring
Fourth degree clinical presentation ?
Damage to structures and tissue below the skin
charred the bone
Burns DS minor ?
none
Burns DS severe ?
CBC
electrolytes
BUN/Cr
Glucose
**severe - 10% plus **
Burns DS if inhalation injury ?
ABG
carboxyhemoglobin level
CXR
EKG ( also for electric burn)
Complications related to ?
age and % burned
Complications of smoke inhalation ?
ARDS
Complication of circumferential burn?
Compartment syndrome
** this tissue cant stretch anymore + inflammatory response ( CS from the inside out)**
Burns Tx: wound care ?
Debridement as appropriate
Topical antibiotics (silver sulfadiazine)
Burns Tx: severe burns?
Fluid resuscitation
Skin grafts
Burns Tx: CS ?
Escharotomy
Burns Tx: Hydrofluoric acid ?
Topical calcium gluconate
Consider IV calcium gluconate
Burns Tx: Lye ?
brush off before irrigating - powder brush it off first ,
if water first then you just spread it and activated it
Burns Tx: Major burns?
ABCA
airway
breathing
circulation
adjuncts
Minor burn tx plan ?
Provide appropriate analgesics before burn care and for outpatient use
Cleanse burn with mild soap and water or dilute antiseptic solution
Debride wound as needed
Apply topical antimicrobial
**pour bedaine on it = NO! cause it stops growth ? **
Burns debridement ?
Remove tissue that is open
Decreases wound infections
Burns topical ABS ?
Silver sulfadiazine
Why Silver sulfadiazine ?
Great for infection prophylaxis
Also has soothing effect
Silver sulfadiazine concerns ?
Destroys skin graft sites
May slow partial thickness wound healing
Topical antibiotics other options ?
Bacitracin
Neomycin
Polymixin B
Silver dressings
Burns IV fluid resuscitation formula ?
Parkland formula is a general guideline
Burns IV fluid resuscitation effective resuscitation has ?
MAP >60 mmHg
Urinary output
** no urine production then they are so dehydrated that the kidney is absorbing everything **
What is the parkland formula ?
Helps determine the volume of LR solution:
4ml x BSA(%) x weight (kg)
For the parkland formula you want to give half of the determined solution for the first ___ hours ?
8
** 8,400 ml ( liter back times 8) and in first 8 hours they need 4.2 L**
For the parkland formula you want to give the other half of the solution over the next ___ hours
16
Burns tx: transfusion ?
Debated among literature
Concensus is to treat for physiologic need– significant blood loss
- -Do not transfuse for all burns
- –Have higher risk of infection and mortality
Guidelines for referral to burn center ?
partial thickness > 10% TBSA
involving face, hands, feet, genitailia, perineum, major joints
3rd degree at any age
electrical burns (lightning)
chemical
inhalation injury
pre-existing medical disorders
if current location does not have qualified personnel
if tx requires social, emotional or rehab intervention
Crystalloids examples ?
ECF
LR
0.9 Nacl
D5 = 0.45 NaCL
D5w
3% NaCL
ECF electrolyte composition ?
Na - 142
CL - 103
K - 4
Bicarb - 27
Ca - 5
Mg - 3
mOsm - 280-310
LR electrolyte composition ?
Na - 130
CL - 109
K - 4
Bicarb - 28
Ca - 3
mOsm - 273
volume depleted and low Na then no LR
0.9% NaCL electrolyte composition ?
Na - 154
CL - 154
mOsm - 308
D5 0.45% NaCL electrolyte composition ?
Na - 77
CL - 77
mOsm - 407
D5w electrolyte composition ?
mOsm - 253
3% NaCL electrolyte composition ?
Na - 513
CL - 513
LR indications ?
Volume replacement
post surgical and burns
NL saline indications ?
Volume replacement
Hyponatremia
Hypochloremia
metabolic alkalosis
D5 Half normal (Dextrose 5%, 0.45% sodium chloride)
indications ?
Postoperative maintenance
Hypertonic saline (3% sodium chloride) indications ?
Severe hyponatremia ( Na at 120 )
Cerebral edema
Volume deficit: generalized hx. ?
weight loss
decreased skin turgor
Volume deficit: cardiac hx. ?
Tachy
Orthostasis/hypoTN
Collapsed neck veins
Volume deficit: Renal hx. ?
Oliguria
Azotemia
Volume deficit: GI hx. ?
Ileus
Volume deficit: Pulm hx. ?
N/A
Volume excess: Generalized hx. ?
weight gain
peripheral edema
Volume excess: cardiac hx. ?
increased CO
increased central venous pressure
Distended neck veins
Murmur
Volume excess: Renal hx. ?
N/A
Volume excess: GI hx. ?
Bowel edema
Volume excess: Pulm hx. ?
Pulmonary edema
Complications: LR ?
Lactate may initiate inflammatory response and induce apoptosis
Complications: NL saline ?
No significant
Complications: D5 half NL saline ?
Cerebral edema
Complications: Hypertonic saline 3% ?
Hemorrhage
Fluid management monitoring ?
Blood pressure
Pulse
Electrolytes
Hyperkalemia tx ?
Kayexalate
oral/rectal sorbitol
Dialysis
glucose D50 & insulin
Bicarb.
calcium glutinate - cardiac
albuterol
Hyperkalemia monitoring ?
Interventions are temporary, lasting 1-4 hours
Continue to check potassium levels
Hypokalemia tx. Asymptomatic, tolerating enteral nutrition ?
KCl 40 mEq per enteral access × 1 dose
Hypokalemia tx. Asymptomatic, not tolerating enteral nutrition ?
KCl 20 mEq IV q2h × 2 doses
Hypokalemia tx. Symptomatic ?
KCl 20 mEq IV q1h × 4 doses
Hypokalemia monitoring ?
Check potassium levels 2 hours after infusion
Caution should be exercised when oliguria or impaired renal function is coexistent
Hypernatremia tx. ?
Volume correction (Normal saline)
Electrolyte correction (Hypotonic solutions) -if they are not volume depleted
Hypernatremia monitoring ?
Hypotonic solutions can induce cerebral edema
Correct no more than 1 mEq/hr or 12 mEq/ day
Hyponatremia tx. hypervolemic ?
Fluid restriction
CHF folks
Hyponatremia tx. hypovolemic ?
NL saline
Hyponatremia tx. Neurologic sxs. ?
Hypertonic saline
Hyponatremia monitoring ?
Correct no more than 0.5 mEq/hr (12 mEq/ day)
Hyponatremia, rapid correction can cause ?
pontine myelinolysis which includes ?
Seizures Weakness Paresis akinetic movements Unresponsiveness permanent brain damage death
**sheds axonal sheaths and radioopaqueness in the PONS
they are there but they cannot do anything - Locked in syndrome **
Skin graft types ?
Split thickness
Full thickness
Composite tissue
Split thickness description thin ?
Thiersch-Ollier
Split thickness description intermediate ?
Blair-Brown
Split thickness description thick ?
Padgett
Full thickness description ?
Entire dermis (Wolfe-Krause)
Composite tissue description ?
Full-thickness skin with additional tissue
SubQ, fat, cartilage, muscle
Split thickness benefits ?
Better take
More availability
Split thickness negatives ?
Less durability
hypopigmentation
Full thickness benefits ?
Lower take
Full thickness negatives ?
Higher durability
Better cosmesis
Composite benefits ?
Used only for special cases
Composite negatives ?
N/A
Split thickness may be ____________ to increase surface area x1.5-1.6
meshed (or fenestrated)
Graft take phases ?
- Imbibition
- Inosculation
- Revascularization
Imbibition ?
thin film of fibrin separate wound from graft (24-48 hours)
Inosculation ?
fine vascular network begins in fibrin film (about 48 hours)
Revascularization ?
vessels invade dermis creating vascular channels–
pink hue develops (2-6 days)
Skin grafts indications ?
Burns
Large wounds
**DM folks with large infections and debridement **
Skin grafts complications ?
infections
Skin grafts procedure ?
Clean site
Place graft
Apply nonadherent dressing
-petroleum type things so it doesn’t move
Skin grafts procedure- Large burn ?
Fenestrated grafts best for high surface area
May not need to suture (decrease general anesthesia time)
Skin grafts monitoring ?
General wound care (see Patient Evaluation)
Burn thermal types ?
Flame
Contact
Scalding
Flame burn ?
Most common for hospital admission
Highest mortality
Risk of smoke inhalation injury and carbon monoxide poisoning
Burn types ?
thermal
electrical
chemical
Electrical burns are high risk of ?
Cardiac arrhythmia
Rhabdomyolysis
Neurologic dysfunction
- Look for entry and exit on exam
- Only 4% of hospital admissions
**heart spine and nerves use electricity and it can coarse down these areas
looking for entry and exit ( and it toasted things in between) - if exit would it can cause arrhythmias, and rhadbo - over stimulation of the muscles and to much contraction(tetany) over use and yeah rhabdo
it is better if there is no exit wound**
Chemical acid burns ?
Hydrofluoric acid - common industrial cleaning agent
Formic acid - preservative
Chemical basic burns ?
Lye- used to make soap and oven cleaner
What burn can cause hypocalcemia ?
Hydrofluoric acid
**Absorption of HF may cause hypocalcemia due to HF’s fixation of blood calcium.
HFA can bind the calcium - hypo calcium = seizures ( we treat the burn in this case but also give them calcium supplementation)
**
What burn can cause hemolysis and hemoglobinuria ?
Formic acid
