Burns and Wound Management Flashcards
EM: Burn Management
Epidemiology
1. Mortality is highest in patients of what age?
- Highest risk is what age and gender?
- In children the highest incidence is what injury?
50% of burn patients are admitted to 130 burn centers in US
- over 65
- 18-35 years old and 2:1 male to female in both injury and death
- scalding injuries from hot drinks or bath
- Skin is 2 layers?
Various thickness - Thickness varies with what?
- Skin is ____________ barrier for evaporative loss?
- Skin also responsible for control of what?
- Dermis and epidermis
- age
- semi-permeable
- body temp
- Cellular changes seen in burns? 4
2. Burn shock is what? 2
- Cellular changes seen in burns:
- Intracellular influx of Na/H2O
- Extracellular migration of K
- Disruption of cell membrane function
- Failure of “sodium pump” - Burn Shock with
- depression of myocardium
- metabolic acidosis
EM: Burn Management
Pathophysiology
- Hematologic changes? 3
- Local progressive injuries? 3
- Cell damage occurs at what temp?
- Hematologic changes
- Increase in hematocrit
- Increase in blood viscosity
- Anemia due to RBC destruction - Local progressive injury
- Liberation of vasoactive substances
- Disruption of cellular function
- Edema formation - > 113F due to denaturation of protein
What are the 3 zones of injury and what occurs in these zones?
- Zone of coagulation
-Irreversibly destroyed - Zone of stasis
-Stagnation of microcirculation
Can/will extend if not treated appropriately - Zone of hyperemia
-Increase blood flow
Clinical Features – Burn Size
- Quantified as?
- Rapid method is based on what?
- Rule of 9s is?
- Which diagrams are best?
- Quantified as percentage of body surface area (BSA) burned
- Rapid method is based on the area of the back of patient’s hand is approximately 1% of BSA
- Rule of 9’s breaks portions of body into multiples of 9 with the perineum being 1%
- Lund and Browder burn diagram is best
EM: Burn Management
Clinical Features – Burn Depth
First degree? 3
First Degree
- Erythema of skin
- Possibly minimal surrounding edema
- Minimal pain
EM: Burn Management
Clinical Features – Burn Depth
Second degree? 4
- Deeper than first degree
- Involve partial thickness
- Very deep sunburn, contact with hot liquids, flash burns from gasoline flames
- Usually much more painful than third degree
2nd degree burns appear how? 6
- Red or mottled;
- blisters with broken epidermis;
- considerable swelling;
- wet/weeping surfaces;
- painful;
- sensitive to the air
EM: Burn Management Clinical Features – Burn Depth Third degree 1. Damage to which layers? 3 2. Skin appears how? 6
- Damage to all
- skin layers,
- subcutaneous tissues, and
- nerve endings - Skin appears:
- Pale white or charred appearance,
- leathery;
- broken skin with fat exposed;
- dry surface;
- painless to pinprick;
- edema.
EM: Burn Management
Specific Issues: inhalation issues
6
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!
EM: Burn Management
Specific Issues
Chemical burns
- Which types of chemicals? 2
- Do not do what?
- Managment?
- Which are more serious?
- Alkali or acids can cause
- DO NOT TRY TO NEUTRALIZE
- “The solution to pollution is dilution” - - IRRIGATE, IRRIGATE, IRRIGATE!
- Alkali burns are more serious than acid burns because the alkalis penetrate deeper
EM: Burn Management
Specific Issues
Electrical Burns
- What to remember about these?
- Why is this true?
- Occult destruction of muscle can cause _________ which causes the release of myoglobin and can lead to _______________?
- Always more serious than they appear
- Skin has more resistance than bone, muscle, blood vessels or nerves; therefore deeper structures have more damage
- rhabdomyolysis
acute renal failure
Electrical Burns
- If urine is dark, assume what?
- and increase fluids to achieve a urine output of ____ml/hr
- If urine doesn’t clear…….________ to ensure continued diuresis?
- Control metabolic acidosis by what? 2
- myoglobin
- 100
- mannitol
- perfusion and
- add sodium bicarbonate as needed to alkalinize urine to solubilize myoglobin
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?
- look closely at eyes for evidence of corneal burns
Estimate depth and extent of burn and record
ED management
1. Any patient with > 20% BSA partial-thickness burn needs what?
- labs? 5
- What on any suspected inhalation injury? 4
- Urine for what? 2
- Check what status and when in doubt, give?
- NG tube placed as ileus is likely (yes, NG tube)
- CBC,
- electrolytes,
- BUN,
- Creatinine,
- Glucose (Chem 7) should be obtained
- ABGs,
- carboxyhemaglobin level,
- Chest XRay, and
- EKG
- myoglobin
- CPK
- Tetanus
EM: Burn Management
Emergency Department Management
- Remove any jewelry Closely monitor distal pulses in extremities with what kind of burns?
- What PRN?
- Every patient with significant burns gets a what?!
- Critical in monitoring what?
- Until a swan or CVP line is placed, it is the only way to ensure what?
- Pain control: Especially in patients with widespread what?
- circumferential burns
- escharotomy
- foley!
- resuscitation
- adequate renal perfusion
- second-degree burns
ABX………..?
Fluid Resuscitation Requirements
1. Adults?
- Children?
- 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)
Minimal burns or burns that are being treated as an outpatient:
- Use what?
- Re-evaluate how often?
- Dressing changes how often?
- 1% silver sulfadiazine (silvadene)
- Re-evaluate every 24 hours until full extent is known
- Dressing changes BID until burn stops weeping
EM: Burn Management
Emergency Department Management
Transfer Guidelines?
6
- Partial thickness burns of > 10% BSA
- Burns involving face, hands, feet, genitalia, perineum, or major joints
- Third-degree burns in any age group
- Electrical burns, especially lightening injuries
- Burns with preexisting complicating medical disorders
- Children with significant burns that are not in a children’s hospital
WHEN IN DOUBT CALL THE REFERRAL BURN CENTER
Esophageal burns
- Assess what?
- Alkali worse in?
- Stop at burn with what?
- Whats this needed for?
- Airway
- Alkali worse than acid
- Stop at burn with scope
- needed to diagnose degree and length
