Burns

Question 1

Layers of dermis?

Layers of epidermis?

Answer 1

Reticular - deep dermis contains skin appendages (sweat glands, hair follicles, sebaceous glands). Give strength and elasticity

Papillary - superficial dermis. Contains capillaries and nerves for touch.

Epidermis:
-stratum basale ->spinosum->granulosum->lucidum->corneum

Question 2

Concentric burn zones?

Answer 2

Coagulation - area of most damage, tissue necrosis, capillaries are destroyed

Stasis - decreased perfusion but may be salvaged with adequate tissue O2 delivery

Hyperemia- vasodilation from cytokines release, typically heals without intervention.

Question 3

Phases of burn/wound healing?

Answer 3

Inflammatory 2-5 days

Proliferative 2.5 weeks

Remodeling up to 1 year

Question 4

Burn depth classification?

Answer 4

Superficial thickness - hyperemia, pain WITHOUT blisters. Injury to epidermis only. *do not include in resuscitation formula

Partial thickness: Skin appendages in tact
*Superficial partial - blisters appear at 24 hrs, hyperemia blanchable, painful. Heal spontaneously

    *Deep partial - deep layer of dermis is      destroyed (reticular dermis). Mottled red/white, thick blisters. May lose sensation. - recommend excision if possible. 

Full thickness - all layers of dermis with destruction of appendages. Loss of sensation. Appears leathery. Requires excision and grafting.

Fourth degree - involves underlying tissues.

Question 5

Indications for intubation with burns?

Answer 5

> 40% TBSA burn
Facial or oral burns
Signs of inhalation injury

Question 6

Organized trauma response for burn:

Answer 6

• Intubate in inicated
• Give 100%O2 if suspected CO intoxiacation
• Greater than 20% TBSA should have calculated resuscitation. Avoid bolus fluids unless hypotensive to minimize edema.
• Cover burns with non-adherent dressing to avoid hypothermia

Question 7

Estimation of TBSA?

Answer 7

Rule of 9’s if over ten years:
Head/arms 9%. Legs 18%, trunk 18% front and back.

Palm = 1%

Question 8

When to suspect CO poisoning?

Answer 8

Burning coal, wood, oil, kerosene, propane or natural gas.

Symptoms: headache, dyspnea, dizziness, altered GCS

Confirm with ABG

Question 9

Parkland formula?

Answer 9

4cc x kg x TBSA given in addition to maintenance.

50% of volume in first 8 hours then give the rest over 16 hours.

Transition to urine output based approach after 24 hours.

Give D5NS maintenance for young children.

Question 10

Principles of burn wound management?

Answer 10

Debride necrotic tissue and keep wound base clean.

Partial thickness burns can be treated with salves and soaks changed daily - Silvadene and bacitracin (cause leukopenia)
- Sulfamylon gives pseudomonas coverage (causes metabolic acidosis)

Question 11

Debridement and escharotomy principles?

Answer 11

• Removal of all devitalized tissue
• indeterminate burns can be observed and will declare after 2-3 days
• excision of full thickness burns should be done in the first week to reduce hyper metabolic state.

Eschartomies of the extremities run longitudinally
The thorax runs bilaterally along anteroaxillary line

Question 12

Two types of chemical burns?

Answer 12

Alkali and acidic

Question 13

Concerns with alkali burns and management ?

Answer 13

Penetrate and injure deep tissues- causes sapinifcation of fat resulting in large fluid loss.

Prolonged copious irrigation with water - do not apply acid to neutralize (can worsen burn).

Question 14

Most common acidic household product and management?

Answer 14

Hydrofluoric acid
*beware of acute calcium depletion and cardiac arythmias

Apply topical calcium gluconate to bind fluoride ion

Question 15

Recognition and treatment of ingestion injuries?

Answer 15

Vomiting, chest pain, dysphagia
Mucosal edema, erythema and ulcers.

If symptomatic patients are admitted for serial xrays, scopes and swallow studies.

Do not induce vomiting

Start PPI

Contrast study at 3 weeks to assess stricture

Question 16

How are electrical injuries classified?

Answer 16

Low voltage < 1000 volts
High voltage > 1000 volts
Lighting injuries > 1000000 volts

Household injuries are low

Direct contact with power line is high

Question 17

4 Mechanisms of electrical injury?

Answer 17

1) Thermal injury : heat= resistance squared x current x time. - Damage to underlying muscle may be more significant than surface burns.
* beware arc injuries - cause temps of > 5000 degrees

2) Direct effects of current :
Cause cardiac arythmias and neurologic sequelae
AC current causes tetany

3) electroporation: causes microperforations of cell membrane and apoptosis (important for Rhabdo)
4) indirect injuries: associated falls, compartment syndrome, anoxia etc.

Question 18

Treatment for low voltage injuries?

Answer 18

Usually require minimal treatment to local wounds unless contacted with water.

ECG should be done and if abnormal patient should be monitored x 24 hours.

Question 19

Treatment for high voltage injuries?

Answer 19

ECG and cardiac monitor

Monitor for compartment syndrome with pressures prn
(Pain out of proportion, parasthesias, pulsless, paralyisis)

Lytes, CK, and urine myoglobin should be monitored.

Maintain urine output of 2/kg/hr
Give mannitol at 0.5/kg/hr

Treat as per burn for tissue necrosis.

Question 20

Hard signs for inhalation injury and management?

Answer 20

Facial burns
Signed nasal hairs
Carbonaceous sputum
Trapped in house with smoke

*Intubate if these signs are present with respiratory distress or confusion.

Confirm with bronchoscopy

Question 21

Treatment of inhalation injury includes?

Answer 21

Intubation
Bronchodilator
Racemic epi to decrease edema
Pulmonary toilet

Mucomyst and heparin?

If carboxyhemoglobin levels are >15% on ABG start 100% O2.

Question 22

How do the fluid resuscitation change with Inhalation injury?

Answer 22

Add an additional 2 cc/kg/TBSA% to parkland formula.