Burns Flashcards
What type of cells is the Epidermis made of?
Squamous epithelial cells
What layer of the skin does keratinzation happen in?
Epidermis
—Begins at the stratum basale and ends at the stratum corneum)
What is the stratum corneum
The outer most layer of the epidermis. Made of layers of dead keratinocytes
What is the stratum lucidum
Layer only found in thick skin which is hairless (palms of hands, soles of feet)
What is stratum granulosum
Layers of keratinocytes with slow degeneration of organelles
What is the stratum spinosum?
Tightly packed layer of keratinocytes. Dendritic cells live here
What is the stratum basale?
The base layer of the epidermis. Where keratinocytes are actively proliferating. The beginning of keratinization.
—There is some blood supply in this layer
—Melanocytes live here
Where are blood vessels and blood supply of the skin?
In the Dermis
What skin layer provides most of the skins thickness?
The dermis
What is the papillary layer of the dermis?
The dermal papillae connect the dermis to the epidermis
What is the reticular layer of the dermis?
Dense layer composed of connective tissue fibers. Overlays the hypodermis
What is the Hypodermis?
The deepest layer of skin under the dermis. The subcutaneous layer overlying the muscle. Adipose cells, blood vessels
What are first degree burns?
Painful, erythematous, blanch with palpation, **No Bullae*
Sunburn, flash burn of the skin that hasn’t peeled yet
What is a superficial second degree burn?
Pink, moist, bullae which may need to be derided. Painful
Also called a partial thickness burn
What is a deep second degree burn?
Typically a lighter pink than superficial second degree burn, remains moist, but may also be slightly drier than superficial second degree. Blanches but may have slightly prolonged refill time, painful, Bullae
Third degree burn
Full thickness burn. All the way down into subcutaneous fat. Not painful. Do not blanch/no capillary refill, may be covered with eschar, dry, leathery feel, white in color
Burns exist on a ____
Continuum.
They can convert (worsen)
One of the biggest burn character differentiators?
Pain
What is the rule of nines?
A way to estimate burn size to determine fluid resuscitation.
Everything on the front is labeled and everything on the back is labeled
What is the Palmar method?
The patients palm makes up 1%. Tends to be easier to use for cases of scattered burns
Why do you not include the 1st degree burns in TBSA?
You can over resuscitate your pt and cause pulmonary edema or compartment syndrome
What are flashburns?
Intense heat for a short period of time
Examples: explosions, accelerant applied to fires inappropriately.
Protective factors— clothing, distance from combustion
—May encompass larger TBSA and involve the upper airway
What are flame burns?
Intense heat for a larger amount of time
Examples: flash that caught clothing on fire, house fires, careless smoking, MVCs with fire, bon fires.
Typically deeper (deep dermal/full thickness) burns requiring surgical intervention
What does scarring over joints put pts at risk for?
Contracture
What are scald burns?
Depth on injury dependent on skin thickness, water temp, and duration of contact.
Examples: spilled soup, boiling water spills, diabetics soaking their feet, grease burns.
Mixed depth
Contact burns
Depth is determined by the duration of contact and temperature of material.
Typically full thickness, may extend beyond hypodermis, often require several surgeries to correct
—molten metal spill, pinned under car in MVC, child touches iron
Chemical burns
Depth is determined by type of chemical and duration of contact.
Key to stopping the burn is decontamination
—Copious irrigation for 15-20 minutes
**exception= powders MUST be brushed off as much as possible to avoid activating with irrigation
**we do not try to neutralize an acid with a base (and vice versa) because this will result in an exothermic reaction causing a thermal injury superimposed on a chemical burn
Acids tend to ____ the skin and alkalis continue to ______.
Acids tend to “tan” the skin and alkalis continue to dissolve the tissue
*exception hydrofluoric acid
Electric burns
Thermal burns from very high intensity heat and require trauma evaluation d/t fall or myoclonic contractures
**3 general patterns: arc, direct, and flame
Depth depends on voltage
Low= <440
High=>1000 volts
Low voltage burns
Deep cutaneous burns at contact points—usually small and may be able to be non op
High voltage burns
Deep tissue destruction— typically requires surgery
Indications for operative intervention prior to wound declaration (3-5 days):
—Acidosis or myoglobinuria refractory to resuscitation
—Compartment syndrome
What are the Burn Resuscitation Guidelines
Advanced Burn Life Support ABLS
Initial fluid rates are based on age, Adjusted fluid rates are based on injury, age, and weight
What are the initial fluid rates for 5 years and younger?
125mL LR/hr
Initial fluid rates for 6-13 yr olds
250mL LR/hr
Initial fluid rates for 14yo and older
500mL LR/hr
What is the adjusted fluid rate for Adults and Children >14yo
2mL LR x kg x %TBSA
What is the adjusted fluid rate for Children <14 yrs old?
3mL LR x kg x %TBSA
What’s the adjusted fluid rate for infants and younger children (<30kg)?
3mL LR x kg x %TBSA + D5LR at maintenance rate
What is the adjusted fluid rate for all ages when they have an electrical injury?
4mL LR x kg x %TBSA + D5LR @ maintenance rate for infants and young children
What is the Parkland formula for resuscitation
Volume of LR in 24 hours= 4mL x %TBSA x kg
Divide in half and give 1st half in the first 8 hours and give the second half over the next 16 hours
What is the Modified Brooke Formula for Resuscitation
Volume of LR in 24 hours = 2mL x kg x %TBSA
Divided in half and the first half is given in the first 8 hours and the 2nd half is given in the following 16 hours
Fluids are titrated according to ________
Patient response and UOP
Burn shock
Hypovolemia and shifting of fluid from the intravascular space to the interstitial space + cardiac depression from humoral factors and loss of preload + increased SVR
Cellular shifts in burn shock
Na enters and K exits
Autografts
A graft that comes from the patient. Has a donor site and a graft site
—Full thickness burns and deeper
—Split thickness vs full thickness
Xenograft AKA heterograft
A biological dressing placed over wounds
—ex: pig skin, tilapia skin
—May be used as a scab to cover painful burns (partial thickness)
—May be used to cover excised tissues to prevent trauma during dressing changes and decrease pain (called “staging” the wound)
Allografts AKA Homograft
A graft that comes from a cadaver
—not a skin transplant
—same concept as xenograft but far more expensive
Goal of wound dressings
To provide optimal healing environment for wound healing while maintaining comfort, allowing mobility, and providing ease for the patient
The inner layer of wound dressing
Inner layer= non adherent layer
—Its purpose is to prevent tissue from sticking to the absorbent layer, may be antibiotic infused or bare
—If bare will often combine with antibacterial cream (Bactrian, polysporin, Silvadene)
The outer layer of wound dressing
Absorbs and secures
Wound vacs
Encourage granulation and healing of wounds— great for deep wounds that need to granulate or for patients with comorbidities
—often used over autografts to avoid graft becoming displaced and to assist with integration of the graft to the wound bed
Applied both intraoperatively and outside of the OR
Hydrotherapy
The tank room where pt is brought and wounds are cleansed with running soap and water
—Optimal environment for cleansing and evaluation
—Clean, not sterile
Who is eligible for hydrotherapy ?
—Immobile, unable to shower —Chrnoically colonized —Exudative drainage, excessive drainage —Requiring more controlled environment for dressing change —Requiring further debridement —Large surface area burn
Appropriateness determined by APP/MD team
