Burns

Question 1

Skin

Answer 1

Largest organ of the body
Consists of 2 layers
- Epidermis
- Dermis

Question 2

Epidermis

Answer 2

Outermost layer is dead, yet it is a protective barrier

Inner cells are metabolically active

Question 3

Dermis

Answer 3

Connective tissue
Contains blood vessels, nerve ending which mediate pain and sweat glands
Helps maintain body temperature - controlling amount of water that evaporates

Question 4

First Degree burns

Answer 4

Superficial
Involves only the epidermis
Erythema, tissue damage and edema is minimal
Protective function are intact and systemic effects are rare
Usually resolves in 48-72h
Peeling in 5-10 days
Example - sunburn

Question 5

Second Degree burns

Answer 5

Partial thickness
Deeper
Involve the epidermis and some of the dermis
Systemic severity and healing of burn directly related to the amount of undamaged dermis
Pain, hypersensitive swollen, dry, mottled
May blister - Superficial burn
Deeper dermal partial thickness burns - reddish or layer of whitish, nonviable tissue

Question 6

Third Degree burns

Answer 6

Full thickness
White, dry, waxy appearance
Lack of sensation in burned skin
Lack of capillary refill
Leathery texture

Question 7

Second degree - superficial burn

Answer 7

Blister
Painful
Typically heal in 10-14 days with minimal scarring unless they become infected

Question 8

Second degree - Deeper dermal partial thickness burns

Answer 8

Reddish or layer of whitish
Nonvialble tisuse
Heals over 4-8 weeks
Severe hypertrophic scaring
High evaporative loss
May convert to full-thickness when complicated by bacterial infection
Skin grafting may be needed to improve healing and quality

Question 9

What type of burns progress and look worse on day 3 than day 1? Could these progress to full thickness?

Answer 9

Chemical and grease burns

Yes

Question 10

Severity

Answer 10

Illness and death are dependent upon
Size (surface area)
Depth
Age
Prior state of health
Location of burn
Associated injuries (lung)

Question 11

Percentage burned

Answer 11

Age-related charts

• Important b/c burns are often over/under estimated
• Relates to prognosis
• Determines who needs inpatient vs. outpatient tx

Question 12

Rule of 9’s

Answer 12

Head and Neck - 9%
Anterior Trunk - 18%
Posterior Trunk - 18%
Each arm - 9%
Each leg - 18%
Genitalia and perineum - 1%

Question 13

Who is a greatest risk after a burn?

Answer 13

Elderly (>60 yo)
Young (<2 yo)
Burns to the perineum, hands, face or feet
Respiratory, chemical and electrical burns

Question 14

The zones of pathophysiology

Answer 14

Coagulation
Injury or stasis
Hyperemia

Question 15

Pathophysiology - coagulation

Answer 15

Necrosis with irreversible cell death and no capillary blood flow

Question 16

Pathophysiology - injury or stasis

Answer 16

Sluggish capillary blood flow and injured cells (still viable)

Question 17

Pathophysiology - Hyperemia

Answer 17

Inflammatory response of healthy tissue to nonlethal injury

Vasodilation and increased capillary permeability

Question 18

Pathophysiology - general concerns

Answer 18

Volume loss
Inflammation (can be systemic)
Protein loss in the burn
Hemodynamic instability

Question 19

Metabolic response

Answer 19

Metabolic rate and oxygen consumption rise
Evaporative water loss
Heat loss
Secretion of hormones, catecholamines, cortisol, glucagon

Question 20

Immunologic Factors in burns

Answer 20

Immunologic abnormalities predispose to infection
Decreased serum IgA, IgM, IgG (reflects depressed B-cell function
Cell-mediated immunity or T-cell function depressed
PMN chemotactic activity suppressed

Question 21

Acute management - in general

Answer 21

Adequate airway
Intubate
Fluids
Debridement of loose skin and dirt once stable
Control pain with IV narcotics
Tetanus prophylaxis

Question 22

Acute management - adequate airway

Answer 22

Inhalation injury? (may have carbonious sputum)
If so ABG, arterial oxygen saturation of HgB and carboxyhemoglobin
Administer 100% O2

Question 23

Acute management - intubation

Answer 23

If pt is
- Semicomatose
- Deep burns to face / neck
- Otherwise critically injured
Do early (waiting pt may have swelling making it more difficult to intubate)

Question 24

Acute management - fluids

Answer 24

Severe burns characterized by large losses of intravascular fluid
Greatest loss is in the first 8-12h
Parkland formula
Lactated ringers is commonly used
Rate dictated by urine output, pulse, state of consciousness and BP

Question 25

Parkland Formula

Answer 25

4ml * 80kg * % body burned

Question 26

Post-resuscitation management

Answer 26

``` Control hypothermia, pain, anxiety Prevent hypovolemia by giving enough fluid to make up for losses Prevent pulmonary complications Nutritional support Supplement Vit. A, E, C and zinc Low-dose heparin ```

Question 27

Care of the burn wound - Superficial partial or second-degree burn

Answer 27

Aseptic environment Occlusive dressing If no infection, heals spontaneously

Question 28

Occlusive dressing

Answer 28

Minimize air exposure Increase rate of epithelializaiton Decrease pain (exception is the face)

Question 29

How are burns to the face dressed?

Answer 29

Tx ope with antibacterial ointment

Question 30

Care of the burn wound - third degree

Answer 30

Prevent infection Remove dead tissue Cover wound with skin or skin substitute ASAP Topical abx retard wound healing - use in deep second or third degree wounds (high-risk infection)

Question 31

Topical Antibacterial Agents

Answer 31

Silver containing products Superior antimicrobial properties Sulfa sulfadiazine Silver release dressings

Question 32

Sulfa sulfadiazine

Answer 32

Most common topical antibacterial silver containing product | Cream effective against Gram positive and Gram negative organisms

Question 33

Silver release dressings

Answer 33

Available in slow-release form that releases ions for several days Decreases dressing changes Improves pt comfort

Question 34

Exposure therapy

Answer 34

No dressings after application of agent 2-3 times daily Face and head Disadvantage - heat loss, increased risk of cross-contamination

Question 35

Closed method

Answer 35

Generally preferred Occlusive dressing over agent and changed BID Advantage - Less pain,, less heat, less cross-contamination Disadvantage - Increase in bacterial growth if dressing not changed

Question 36

Skin substitutes

Answer 36

``` Alternative to topical agents Partial thickness or clean excised wound Reepithelialization is accelerated Pain better controlled Homografts (human skin) or engineered skin substitutes ```

Question 37

Hydrotherapy

Answer 37

Use of immersion decreased risk of infection | On slant board - useful once wounds are ready for debridement

Question 38

Debridement and grafting

Answer 38

More aggressive than in the past More rapid debridement and closure of burn wounds Skin grafts and skin substitutes

Question 39

Function

Answer 39

Wound contracture occurs | Maintain motion and function of joints to avoid permanent function loss

Question 40

Complications - in general

Answer 40

Infection | Sepsis syndrome

Question 41

Complications - infection

Answer 41

``` Critical problem Pulmonary Wound - S.aureus - P. aeruginosa - C. albicans ```

Question 42

Complications - children

Answer 42

Seizures secondary to electrolyte imbalance Hypoxemia Infection Drugs

Question 43

Complications - sepsis syndrome

Answer 43

Occurs in all major burns Fever, hypermetabolism, catabolism, leukocytosis Can lead to death from multi-system organ failure Infection often not present, but bodies response to inflammation