burns Flashcards
what does burn severity and survival depend on?
patient age, comorbidites, inhalation injuries, burn size
what are the 4 zones of full thickness burns?
coagulation, stasis, hyperemia
what is the coagulation zone of full thickness burns?
dead or dying tissue d/t coagulation necrosis and absent blood flow
what is the stasis zone of full thickness burns?
red and may blanch with pressure, becomes avascular and necrotic by day 3
what is hyperemia zone of full thickness burns?
blanches with pressure and heals by day 7
when does systemic inflammatory response syndrome occur with burns?
burns affecting >30% of TBSA
what’s a superficial aka first degree burn? example?
minor epithelial damage to epidermis
redness, tenderness to pain, no blistering
healing occurs over several days w/out scarring
no infection
Ex: sunburn or flashburn
what is the appearance, sensation, and healing time of superficial partial-thickness burns?
appearance: blisters, moist, red, weeping, blanches with pressure
sensation: painful to temperature and air
healing time: 7-21 days
what is the appearance, sensation, healing time of deep partial-thickness burns?
appearance: blisters (easily unroofed), wet or waxy dry, variable color, doesn’t blanch with pressure
sensation: perceptive of pressure only
healing time: >21 days - usually needs surgery
what is the appearance, sensation, healing time of full-thickness/3rd degree burns?
appearance: waxy white to leathery gray to charred and black, dry and inelastic, no blanching with pressure
sensation: deep pressure only
healing time: rare, unless surgically treated
what is the appearance, sensation, healing time of fourth degree burns?
appearance: extends into fascia and/or muscle
sensation: deep pressure
healing time: never, unless surgically treated
what is the mantra for treating thermal burns?
ABCs and stabilization of the pt
what are 2 complications of thermal burns?
infection (major cause of death)
burn shock
what is the major cause of death in thermal burns?
infection
what are low voltage electrical burns?
<1000 V
what are high voltage electrical burns?
> 1000 V
how are low voltage electrical burns usually caused?
hand/mouth d/t contact with exposed wire
what’s the initial tx of low voltage electrical burns?
clean and dress with topical abx
splint, elevate and reassess in 2-3 days
what’s the surgical tx of low voltage burns? (skin loss only vs deeper injury)
skin loss only -> skin graft
deeper injury -> amp or flap coverage
an oral electrical injury is initially…
painless
what’s the tx for oral electrical injury?
clean and apply petroleum based abx ointment QID
treat with immediate dental prosthetic splinting to reduce need for oral reconstruction surgery in future
what is the most commonly devastating thermal burns?
high voltage electrical burns
LOC is more common in what electrical burns, low voltage or high voltage?
low voltage
baseline EKG for what burns?
electrical burns
when do you admit patient with electrical burn?
abnormal EKG, CP, transthoracic conduction, or h/o cardiac disease -> admit for 1-2 days for monitoring
what bx for electrical burn?
muscle bx
what fluid for electrical burn tx?
IVF resuscitation and foley cath
referral to who for high-voltage electrical injuries?
to burn specialist
who with electrical burn can be sent home?
anyone with mild sx’s and normal CPK/EKG can be sent home after obs in ER
when do you transfer patient to burn center?
high-voltage burn, significant burn, oral burns
what are s/s of frostbite?
coldness, stinging, burning, throbbing
numbness and complete loss of sensation
loss of muscle dexterity (clumsy fingers)
loss of large muscle dexterity (trouble walking)
if have soft palpable skin, what type of frostbite?
superficial frostbite
if have pitting edema or hard to touch, what type of frostbite?
deeper frostbite
what is first degree frostbite?
- epidermal involvement
- central white plaque with ring of hyperemia
- poor sensation, mild edema
- dequamation over several weeks
what is second degree frostbite?
- full thickness freezing
- clear blister with surrounding erythema
- hard outer skin, resilient tissue underneath
what is third degree frostbite?
- subdermal plexus freezing
- blue grey skin discoloration with hemorrhagic blister formation
- thick gangrenous eschar w/in 2 weeks
- deep burning pain on rewarnming (Can last 5 weeks)
what is 4th degree frostbite?
- involvement of muscle, bone, and tendons
- frozen, hard, avascular skin and tissue
- relatively little pain or edema on rewarming
- demarcation b/w viable and nonviable tissue takes 1 month
what are 3 subtypes of frostbite?
frostnip, trench foot, pernio
what is frostnip?
transient numbness and paresthesias that resolve with rewarming
no ice crystal formation in tissues or tissue loss
what is trench foot?
peripheral neuromuscular damage w/o crystal formation (reversible if treated early)
-pain, paresthesias, pallor, pulselessness, paralysis
what is permio?
painful, inflammation lesions from chronic exposure to damp, non-freezing cold (12 hrs post injury)
damage to capillary beds
resolves in 7-14 days
what must you do as quickly as possible in treatment of frostbite?
rewarm as quickly as possible
-40-42 C water for 15-30 mins or until signs of flush, soft, pliable tissue
avoid what after rewarming in frostbite?
refreezing
how long can healing of frostbite take?
6-12 months
favorable prognosis of frostbite is?
clear blister over hemorrhagic blister
poor prognosis of frostbite is?
absence of edema, hemorrhagic blebs that don’t extend to phalanges
what is hypothermia?
mechanism of temperature regulation is overwhelmed by cold stressor
causes of hypothermia?
- decreased heat produced
- increased heat loss
- impaired thermoregulation
- infection, cardiac arrest, drugs
what is mild hypothermia degrees?
32-35 C (89-95 F)
what is moderate hypothermia degrees?
28-32 C (68-89 F)
what is severe hypothermia?
<28 C (<68 F)
what is seen on EKG for hypothermia at 30 C (86F)?
J or Osborne waves
atrial and ventricular arrhythmias
brain death on EEG at what temp?
19-20C
what are s/s of hypothermia?
mood changes, confusion, irritability
slurred speech, ataxia
rhythmic movements
shivering stops at <31 C (87.8F)
what’s the ABG like for hypothermia?
falsely high O2/CO2
what’s the CBC like for hypothermia?
high HCT
what’s the K like for hypothermia?
K>10 = cell necrosis
need what temp of pt to determine degree of hypothermia?
core temp
how do you slowly rewarm hypothermic pt?
warmed IV fluids, heated humidified O2 by mask, warmed blankets
how do you moderately rewarm hypothermic pt?
warmed IVF, warmed gastric lavage, peritoneal lavage w/45 C fluid
how do you rapidly rewarm hypothermic pt?
thoracic lavage, cardiopulmonary bypass, ECMO, AV dialysis, warm water immersion
what are complications of hypothermia?
rewarming shock, cardiac arrhythmias at <32 C
pt is not pronounced dead until what?
until rewarmed to 32 C/89.6 F or above
what is hyperthermia elevated core temp? catastrophic?
elevated core temp >38.5C (101.3F)
catastrophic: >41.1C (106F)
what are the 2 types of hyperthermia?
heat exhaustion and heat stroke
what is heat exhaustion?
normal-slightly increased core temp
s/s of heat exhaustion?
intact MS, fatigue, dehydration
what is heat stroke?
temp >40.5C (104.9)
2 subtypes of heat stroke?
exertion heat stroke, nonexertional heat stroke
s/s of heat stroke?
AMS, anhidrosis
GI findings for hyperthermia?
GIB and hepatic injury
vitals for hyperthermia?
temp >40.5, HR >130, hypotension
CNS findings for hyperthermia?
AMS, seizures, posturing
eye findings for hyperthermia?
nystagmus, oculogyric
CV findings for hyperthermia?
hyperdynamic
Pulm findings for hyperthermia?
Tachypnea and hypoxia
renal findings for hyperthermia?
AKI (hypovolemia, low CO, rhabdomyolysis)
ABG findings for hyperthermia?
respiratory alkalosis or metabolic acidosis
lactate for hyperthermia?
> 4mmol/L (acidosis)
CMP for hyperthermia?
- hypernatremia
- hypoglycemia
- hypocalcemia
- hypomagnesemia
- hypokalemia (early phase -> hyperkalemia (late phase)
elevated CK in hyperthermia means what?
rhabdomyolysis
avoid what in tx of hyperthermia?
avoid overhydration
what’s the tx for heat exhaustion?
non-invasive cooling techniques
electrolyte/hydration management
what’s the tx for heat stroke?
decrease core temp to <40C (104F)
admin dantrolene if you suspect NMA and malignant hyperthermia
what are non-invasive external cooling methods for hyperthermia?
ice packs (remove at 39 C)
spray bottle and fan - quickest
cooling blanket
bath at 0-14C: decrease temp <39 C in 20-40 min
-best for extertional, Benzes for shivering
cooled IVF
what are invasive cooling methods for hyperthermia?
ice water gastric lavage
peritoneal lavage w/cooled NS
Dantrolene, Benzos for shivering, barbs for seizures, dobutamine for hypotension w/poor CO, IVF (but avoid overhydration d/t pulmonary edema)
never use what meds to treat hyperthermia?
antipyretics, phenytoin, neuroleptics, alpha-adrenergic w/poor CO
what’s the most common complication of burns?
neurologic complication
what are neurologic complication of burns?
central, peripheral, spinal cord
can get LOC, confusion, stroke like symptoms, damage to peripheral nerves (sensory problems), degernative disease of spine cord
what are cardiac complications of burns?
rhythm and conduction disturbances
fib with high voltage
ST-T changes are more common
what pulmonary complications from burns?
pleural damage -> effusions, local lobular pneumonitis
what abdominal organ is the most common to be injured electrically?
bowel
when do you do cardiac monitoring after electrical injuries?
If ANY are true:
documented arrhythmia or evidence of ischemia, LOC, high voltage (>1000V)
when do you not have to do cardiac monitoring after electrical injuries?
If ALL are true:
normal ECG, no LOC, low voltage (= 1000V)
who do you admit for electrical burns?
anything beyond minor low-voltage injury
those with mild sx’s, mild burns, normal CPK and EKG can be d/c’d after several hour observation
when do you transfer electrical burn to burn center?
- high-voltage burn
- significant burns
- oral burns
when are you at 2x the risk of frostbite/
pervious cold injury
what are signs of post-rewarming injury?
edema w/in 3 hours and lasts 1 weeks
large clear blebs within 6-24hrs
small hemorrhagic blebs after 24hrs if deep
eschar in 9-15 days
what are 2 big complications of frost-bite?
permanent sensory loss and wound infection
what’s the best tx for frostbite?
circulating water 40-42Cfor 15-30
aloe vera for what tx?
for minor frost-bite injury; used every 6 hours
what burns must be sent to the burn center?
major burns
what is classified as major burn?
- partial thickness burns >25% in adults
- partial thickness burns >20% in <10 y/o or >50 y/o
- full thickness >10%
- burns to face, eyes, ears, nose, hand, feet, perineum
- caustic burns, high voltage burns, high-risk pts, inhalation injury
what burns are hospitalized?
moderate burns
what is classified as moderate burns?
- partial thickness 15-25% in adults, 10-20% in child or older adult
- full-thickness 2-10% that don’t fit major burn critiera
what burns are treated at home?
minor burns
what is classified as minor burns?
- partial thickness <15% adults, <10% child or older adult
- full-thickness burns <2%
