Burns and Bites

Question 1

Discuss the features of a superficial burn

Answer 1

Involved tissue
- Epidermis
Appearance
- Dry, red
- blanches with pressure
Sensation
- Painful
Healing Time
- 3-6 days
Common Exposure
- UV exposure

Question 2

Discuss the features of a superficial/partial thickness burn

Answer 2

Involved tissue
- Epidermis and part of dermis
Appearance
- Blisters
- Blanches with pressure
- moist, red, weeping
Sensation
- Painful to temperature and ir
Healing Time
- 7-20 days
Common Exposure
- Scald

Question 3

Discuss the features of deep partial thickness burn

Answer 3

Involved tissue
- Epidermis and part of dermis
Appearance
- blisters that are easily unroofed
- wet or waxy
- does not blanch with pressure
Sensation
- perceptive of pressure only
Healing Time
- >21 days
Common Exposure
- Scald
- flame
- oil, grease

Question 4

Discuss the features of full thickness burns

Answer 4

Involved tissue
- epidermis and all of dermis
Appearance
- waxy white to leathery gray to charred and black
- dry and inelastic
- no blancing
Sensation
- only to deep pressure
Healing time
- Never heals if >2% of total surface area
Common Exposure
- scald
- flame
- steam
- oil, grease
- electrical

Question 5

Discuss the features of fourth degree burn

Answer 5

Involved Tissue
- Down to muscle and fascia
Appearance
- underlying tissue visualized
Sensation
- deep pressure only
Healing Time
- never heals
Common Exposure
- Same as full thickness

Question 6

Discuss the rule of 9’s for patients >9 for estimating %total body surface area involved for burns

Answer 6

9%
- head
- chest
- abdomen
- upper back
- lower back
- left arm
- right arm
- anterior left leg
- posterior left leg
1%
- palm with fingers
0.5%
- palm without fingers

Question 7

Discuss the severity of burns

Answer 7

Minor
- <=15% of TBSA with <=2% full thickness
Moderate
- 15-25% TBSA with <=10% full thickness
Major
- >25% TBSA or >10% full thickness
- Burn that involve face/hands/feet/perineum

Question 8

Discuss the airway management for those with burns

Answer 8

- inhalation injuries cause progressive airway edema
Presentation
- hoarseness
- persistent cough
- stridor
- deep facial or circumferential neck burns
- carbonaceous sputum
- blistering or edema of oropharynx
- hypoxia/hypercapnia
- depressed mental status
Investigations
- O2 saturation
- ABG
- serial peak expiratory flow rate
- CXR
- capnography to monitor end-tidal CO2
- serum lactate
- serum cyanide
- blood carboxyhemoglobin (CO poisoning)
Management
- supplemental oxygen with early intubation
- CO poisoning reversed with 
- Cyanide poisoning reversed with hydroxocobalamin 5mg over 15 min
- bronchodilator

Question 9

Discuss the fluid resuscitation with burn patients

Answer 9

Parkland Formula

• 4mL/kg for each %TBSA burned over course of 24 hrs where 1/2 delivered in first 8hrs and rest over remaining 16hrs
• target urine output of 0.5mL/kg/hr

Question 10

Discuss the burn care

Answer 10

Immediate
- burned area should be cooled immediately using cool water or saline soaked gauze for 15-30 minutes
- watch for signs of hypothermia
Prevention of Infection
- Tetanus
- topical antibiotics Silver Sulfadiazine
Wound Management
- pain management with local or regional anesthesia
- clean and irrigate
- debride necrotic tissue
- dress with 1st layer being non-adherent mesh gauze, 2nd layer fluffed dry gauze and 3rd layer of elastic gauze

Question 11

Discuss the risk factors for bite wounds and most common bacteria

Answer 11

Risks
- deeps wounds: puncture or involve bone/joint
- crush injury
- wounds >12hrs without treatment
- wounds over poorly vascularized area
- cat or human bites
Bacteria
- Pasteurella found in dog and cat mouth
- Eikenella corrodens in human mouth
- Oral anaerobes and skin pathogens

Question 12

Discuss the wound care and closure for bite wounds

Answer 12

Wound Care
- explore to remove foreign bodies
- wash with anti-septic
- pressure irrigation
- debride necrotic or devascularized tissue
Wound Closure Criteria
- low risk for infection 
    - bite <12hrs
    - bite involving vascularized tissue
    - dog bites 
- closure usually done for wounds for cosmesis
- require prophylactic antibiotics
Wound Closure Not
- infected
- high risk for infection
     - bite >12hrs
     - bites involving poorly vascularized tissue
     - human and cat bites
     - puncture wounds
     - bites involving crush injury
     - immune compromised

Question 13

Discuss antibiotics for wounds

Answer 13

Infected Wounds
- Pip-Tazo 4.5g IV Q8H
- Ceftriazone 1g IV Q24H and Flagyl 500mg IV Q8H
- Meropenem 1g Q8H
- can change once have culture
High Risk Infection
- Amox-clav 500mg PO TID for 3-5d

Question 14

Discuss rabies prophylaxis

Answer 14

High Risk Features
- mammal appears unwell, wild or stray
- high risk mammal (bat, racoon, skunk, fox, coyote, bobcat, woodchuck)
- geographical area with high prevalance
- dog, cat, or ferret that is either unavailable for 10-day quarantine or have symptoms of rabies
Post-Exposure Prophylaxis
- includes rabies immunoglobulin
- rabies vaccine IM on day 0,3,7,14