Burns and Wound Management

Question 1

EM: Burn Management
Epidemiology
1. Mortality is highest in patients of what age?

2. Highest risk is what age and gender?
3. In children the highest incidence is what injury?

50% of burn patients are admitted to 130 burn centers in US

Answer 1

1. over 65
2. 18-35 years old and 2:1 male to female in both injury and death
3. scalding injuries from hot drinks or bath

Question 2

1. Skin is 2 layers?
   Various thickness
2. Thickness varies with what?
3. Skin is ____________ barrier for evaporative loss?
4. Skin also responsible for control of what?

Answer 2

1. Dermis and epidermis
2. age
3. semi-permeable
4. body temp

Question 3

1. Cellular changes seen in burns? 4

2. Burn shock is what? 2

Answer 3

1. Cellular changes seen in burns:
   - Intracellular influx of Na/H2O
   - Extracellular migration of K
   - Disruption of cell membrane function
   - Failure of “sodium pump”
2. Burn Shock with
   - depression of myocardium
   - metabolic acidosis

Question 4

EM: Burn Management
Pathophysiology

1. Hematologic changes? 3
2. Local progressive injuries? 3
3. Cell damage occurs at what temp?

Answer 4

1. Hematologic changes
   - Increase in hematocrit
   - Increase in blood viscosity
   - Anemia due to RBC destruction
2. Local progressive injury
   - Liberation of vasoactive substances
   - Disruption of cellular function
   - Edema formation
3. > 113F due to denaturation of protein

Question 5

What are the 3 zones of injury and what occurs in these zones?

Answer 5

1. Zone of coagulation
   -Irreversibly destroyed
2. Zone of stasis
   -Stagnation of microcirculation
   Can/will extend if not treated appropriately
3. Zone of hyperemia
   -Increase blood flow

Question 6

Clinical Features – Burn Size

1. Quantified as?
2. Rapid method is based on what?
3. Rule of 9s is?
4. Which diagrams are best?

Answer 6

1. Quantified as percentage of body surface area (BSA) burned
2. Rapid method is based on the area of the back of patient’s hand is approximately 1% of BSA
3. Rule of 9’s breaks portions of body into multiples of 9 with the perineum being 1%
4. Lund and Browder burn diagram is best

Question 7

EM: Burn Management
Clinical Features – Burn Depth

First degree? 3

Answer 7

First Degree

1. Erythema of skin
2. Possibly minimal surrounding edema
3. Minimal pain

Question 8

EM: Burn Management
Clinical Features – Burn Depth
Second degree? 4

Answer 8

1. Deeper than first degree
2. Involve partial thickness
3. Very deep sunburn, contact with hot liquids, flash burns from gasoline flames
4. Usually much more painful than third degree

Question 9

2nd degree burns appear how? 6

Answer 9

1. Red or mottled;
2. blisters with broken epidermis;
3. considerable swelling;
4. wet/weeping surfaces;
5. painful;
6. sensitive to the air

Question 10

EM: Burn Management
Clinical Features – Burn Depth
Third degree
1. Damage to which layers? 3
2. Skin appears how? 6

Answer 10

1. Damage to all
   - skin layers,
   - subcutaneous tissues, and
   - nerve endings
2. Skin appears:
   - Pale white or charred appearance,
   - leathery;
   - broken skin with fat exposed;
   - dry surface;
   - painless to pinprick;
   - edema.

Question 11

EM: Burn Management
Specific Issues: inhalation issues
6

Answer 11

Inhalation
1. Carbon around nose
2. Burns involving mouth
3. Significant Resp problems
4. Fires in enclosed areas
5. Remember CO exposure
CYANIDE!!!!!
6. Intubate early…a must!

Question 12

EM: Burn Management
Specific Issues

Chemical burns

1. Which types of chemicals? 2
2. Do not do what?
3. Managment?
4. Which are more serious?

Answer 12

1. Alkali or acids can cause
2. DO NOT TRY TO NEUTRALIZE
3. “The solution to pollution is dilution” - - IRRIGATE, IRRIGATE, IRRIGATE!
4. Alkali burns are more serious than acid burns because the alkalis penetrate deeper

Question 13

EM: Burn Management
Specific Issues

Electrical Burns

1. What to remember about these?
2. Why is this true?
3. Occult destruction of muscle can cause _________ which causes the release of myoglobin and can lead to _______________?

Answer 13

1. Always more serious than they appear
2. Skin has more resistance than bone, muscle, blood vessels or nerves; therefore deeper structures have more damage
3. rhabdomyolysis
   acute renal failure

Question 14

Electrical Burns

1. If urine is dark, assume what?
2. and increase fluids to achieve a urine output of ____ml/hr
3. If urine doesn’t clear…….________ to ensure continued diuresis?
4. Control metabolic acidosis by what? 2

Answer 14

1. myoglobin
2. 100
3. mannitol
4. • perfusion and
   • add sodium bicarbonate as needed to alkalinize urine to solubilize myoglobin

Question 15

By definition, major burn patients are multiple injury trauma patients: ABCDE
Check for evidence of airway involvement and if present; consider endotracheal intubation EARLY!
Start 2 large bore IVs as soon as possible
Place in non-burned areas if practical
Do secondary survey and
MAKE SURE TO LOOK CLOSELY AT?

Answer 15

1. look closely at eyes for evidence of corneal burns

Estimate depth and extent of burn and record

Question 16

ED management
1. Any patient with > 20% BSA partial-thickness burn needs what?

2. labs? 5
3. What on any suspected inhalation injury? 4
4. Urine for what? 2
5. Check what status and when in doubt, give?

Answer 16

1. NG tube placed as ileus is likely (yes, NG tube)
2. • CBC,
   • electrolytes,
   • BUN,
   • Creatinine,
   • Glucose (Chem 7) should be obtained
3. • ABGs,
   • carboxyhemaglobin level,
   • Chest XRay, and
   • EKG
4. • myoglobin
   • CPK
5. Tetanus

Question 17

EM: Burn Management
Emergency Department Management

1. Remove any jewelry Closely monitor distal pulses in extremities with what kind of burns?
2. What PRN?
3. Every patient with significant burns gets a what?!
4. Critical in monitoring what?
5. Until a swan or CVP line is placed, it is the only way to ensure what?
6. Pain control: Especially in patients with widespread what?

Answer 17

1. circumferential burns
2. escharotomy
3. foley!
4. resuscitation
5. adequate renal perfusion
6. second-degree burns

ABX………..?

Question 18

Fluid Resuscitation Requirements
1. Adults?

2. Children?

Answer 18

1. NS or RL 4ml x weight (kg) x %BSA for 1st 24hr

2. NS or RL 3ml x weight (kg) x %BSA (admin schedule same as adult)

Question 19

Minimal burns or burns that are being treated as an outpatient:

1. Use what?
2. Re-evaluate how often?
3. Dressing changes how often?

Answer 19

1. 1% silver sulfadiazine (silvadene)
2. Re-evaluate every 24 hours until full extent is known
3. Dressing changes BID until burn stops weeping

Question 20

EM: Burn Management
Emergency Department Management

Transfer Guidelines?
6

Answer 20

1. Partial thickness burns of > 10% BSA
2. Burns involving face, hands, feet, genitalia, perineum, or major joints
3. Third-degree burns in any age group
4. Electrical burns, especially lightening injuries
5. Burns with preexisting complicating medical disorders
6. Children with significant burns that are not in a children’s hospital

WHEN IN DOUBT CALL THE REFERRAL BURN CENTER

Question 21

Esophageal burns

1. Assess what?
2. Alkali worse in?
3. Stop at burn with what?
   - Whats this needed for?

Answer 21

1. Airway
2. Alkali worse than acid
3. Stop at burn with scope
   
   • needed to diagnose degree and length