Burns, C39 P246-254 Flashcards
Define:
TBSA
P246
Total Body Surface Area
Define:
STSG
P246
Split Thickness Skin Graft
Are acid or alkali chemical burns are more burns more serious?
P246
In general, ALKALI burns are more serious because the body cannot buffer
the alkali, thus allowing them to burn for
much longer
Why are electrical burns so dangerous?
P246
Most of the destruction from electrical burns is internal because the route of least electrical resistance follows nerves, blood vessels, and fascia; injury is usually worse than external burns at entrance and exit sites would indicate; cardiac dysrhythmias, myoglobinuria, acidosis, and renal failure are common
How is myoglobinuria treated?
P247
To avoid renal injury, think “HAM”:
Hydration with IV fluids
Alkalization of urine with IV
bicarbonate
Mannitol diuresisDefine level of burn injury:
First-degree burns
P247
Epidermis only
Define level of burn injury:
Second-degree burns
P247
Epidermis and varying levels of
dermis
Define level of burn injury:
Third-degree burns
P247
A.k.a. “full thickness”; all layers of the
skin including the entire dermis (Think:
“getting the third degree”)
Define level of burn injury:
Fourth-degree burns
P247
Burn injury into bone or muscle
How do first-degree burns present?
P247
Painful, dry, red areas that do not form blisters (think of sunburn)
How do second-degree burns present?
P247
Painful, hypersensitive, swollen, mottled
areas with blisters and open weeping surfaces
How do third-degree burns present?
P247
Painless, insensate, swollen, dry, mottled
white, and charred areas; often described
as dried leather
What is the major clinical difference between second- and third-degree burns?
P247
Third-degree burns are painless, and
second-degree burns are painful
By which measure is burn
severity determined?
P247
Depth of burn and TBSA affected by
second- and third-degree burns
TBSA is calculated by the “rule of
nines” in adults and by a modified
rule in children to account for the
disproportionate size of the head and
trunkWhat is the “rule of nines”?
P248 (picture)
In an adult, the total body surface area that is burned can be estimated by the following: Each upper limb = 9% Each lower limb = 18% Anterior and posterior trunk = 18% each Head and neck = 9% Perineum and genitalia = 1%
What is the “rule of the palm”?
P248
Surface area of the patient’s palm is 1%
of the TBSA used for estimating size of
small burns
What is the burn center referral criteria for the following?
Second-degree burns
P248
>20% TBSA
What is the burn center referral criteria for the following?
Third-degree burns
>5% TBSA
Second degree >10% TBSA in children
and the elderly
Any burns involving the face, hands, feet,
or perineum
Any burns with inhalation injury
Any burns with associated trauma
Any electrical burnsWhat is the treatment of first-degree burns?
P249
Keep clean, ± Neosporin®, pain meds
What is the treatment of
second-degree burns?
P249
Remove blisters; apply antibiotic
ointment (usually Silvadene®) and
dressing; pain meds
Most second-degree burns do not require
skin grafting (epidermis grows from
hair follicles and from margins)What are some newer
options for treating a
second-degree burn?
P249
- Biobrane® (silicone artificial
epidermis—temporary) - Silverlon® (silver ion dressings)
What is the treatment of
third-degree burns?
P249
Early excision of eschar (within first week
postburn) and STSG
How can you decrease
bleeding during excision?
P249
Tourniquets as possible, topical
epinephrine, topical thrombin
What is an autograft STSG?
P249
STSG from the patient’s own skin
What is an allograft STSG?
P249
STSG from a cadaver (temporary
coverage)
What thickness is the STSG?
P249
10/1000 to 15/1000 of an inch (down to
the dermal layer)
What prophylaxis should the
burn patient get in the ER?
P249
Tetanus
What is used to evaluate the
eyes after a third-degree burn?
P249
Fluorescein
What principles guide the
initial assessment and
resuscitation of the burn patient?
P249
ABCDEs, then urine output; check for
eschar and compartment syndromes
What are the signs of
smoke inhalation?
P249
Smoke and soot in sputum/mouth/nose,
nasal/facial hair burns, carboxyhemoglobin,
throat/mouth erythema, history of loss of
consciousness/explosion/fire in small
enclosed area, dyspnea, low O(2) saturation,
confusion, headache, coma
What diagnostic imaging is
used for smoke inhalation?
P250
Bronchoscopy
What lab value assesses
smoke inhalation?
P250
Carboxyhemoglobin level (a carboxysmoke-
hemoglobin level of >60% is associated
with a 50% mortality); treat with 100%
O(2) and time
How should the airway be
managed in the burn patient
with an inhalational injury?
P250
With a low threshold for intubation; oropharyngeal swelling may occlude the airway so that intubation is impossible; 100% oxygen should be administered immediately and continued until significant carboxyhemoglobin is ruled out
What is “burn shock”?
P250
Burn shock describes the loss of fluid from the intravascular space as a result of burn injury, which causes “leaking capillaries” that require crystalloid infusion
What is the “Parkland formula”?
P250
V = TBSA Burn (%) x Weight (kg) x 4
Formula widely used to estimate the
volume (V) of crystalloid necessary for
the initial resuscitation of the burn
patient; half of the calculated volume
is given in the first 8 hours, the rest
in the next 16 hours
What burns qualify for the
Parkland formula?
P250
≥20% TBSA second- and third-degree
burns only
What is the Brooke formula
for burn resuscitation?
P250
Replace 2 cc for the 4 cc in the Parkland
formula
How is the crystalloid given?
P250
Through two large-bore peripheral
venous catheters
Can you place an IV or central
line through burned skin?
P250
YES
What is the adult urine output goal?
P250
30–50 cc (titrate IVF)
Why is glucose-containing IVF contraindicated in burn patients in the first 24 hours postburn? P251
Patient’s serum glucose will be elevated
on its own because of the stress response
What fluid is used after the
first 24 hours postburn?
Colloid; use D5W and 5% albumin at
0.5 cc/kg/% burn surface area
Why should D5W IV be
administered after 24 hours
postburn?
P251
Because of the massive sodium load in the first 24 hrs of LR infusion and because of the massive evaporation of H(2)O from the burn injury, the patient will need free water; after 24 hours, the capillaries begin to work and then the patient can usually benefit from albumin and D5W
What is the minimal urine
output for burn patients?
P251
Adults 30 cc; children 1–2 cc/kg/hr
How is volume status
monitored in the burn
patient?
P251
Urine output, blood pressure, heart rate, peripheral perfusion, and mental status; Foley catheter is mandatory and may be supplemented by central venous pressure and pulmonary capillary wedge pressure monitoring
Why do most severely
burned patients require
nasogastric decompression?
P251
Patients with greater than 20% TBSA
burns usually develop a paralytic ileus →
vomiting → aspiration risk → pneumonia
What stress prophylaxis must
be given to the burn patient?
P251
H2 blocker to prevent burn stress ulcer
Curling’s ulcer
What are the signs of burn
wound infection?
P251
Increased WBC with left shift, discoloration of burn eschar (most common sign), green pigment, necrotic skin lesion in unburned skin, edema, ecchymosis tissue below eschar, seconddegree burns that turn into third-degree burns, hypotension
Is fever a good sign of
infection in burn patients?
P251
NO
What are the common
organisms found in burn
wound infections?
P252
Staphylococcus aureus, Pseudomonas,
Streptococcus, Candida albicans
How is a burn wound
infection diagnosed?
P252
Send burned tissue in question to the laboratory for quantitative burn wound bacterial count; if the count is >105/gram, infection is present and IV antibiotics should be administered
How are minor burns dressed?
P252
Gentle cleaning with nonionic detergent and débridement of loose skin and broken blisters; the burn is dressed with a topical antibacterial (e.g., neomycin) and covered with a sterile dressing
How are major burns dressed?
P252
Cleansing and application of topical
antibacterial agent
Why are systemic IV antibi-otics contraindicated in fresh burns?
P252
Bacteria live in the eschar, which is
avascular (the systemic antibiotic will
not be delivered to the eschar); thus,
apply topical antimicrobial agents
Note some advantages and disadvantages of the following topical antibiotic agents: Silver sulfadiazine (Silvadene®)
P252
Painless, but little eschar penetration,
misses Pseudomonas, and has idiosyncratic
neutropenia; sulfa allergy is contraindication
Note some advantages and disadvantages of the following topical antibiotic agents:
Mafenide acetate (Sulfamylon®)
P252
Penetrates eschars, broad spectrum (but misses Staphylococcus), causes pain on application; triggers allergic reaction in 7% of patients; may cause acid-base imbalances (Think: Mafenide ACetate Metabolic ACidosis); agent of choice in already-contaminated burn wounds
Note some advantages and disadvantages of the following topical antibiotic agents:
Polysporin®
P252
Polymyxin B sulfate; painless, clear, used
for facial burns; does not have a wide
antimicrobial spectrum
Are prophylactic systemic
antibiotics administered to
burn patients?
P253
No—prophylactic antibiotics have not been shown to reduce the incidence of sepsis, but rather have been shown to select for resistant organisms; IV antibiotics are reserved for established wound infections, pneumonia, urinary tract infections, etc.
Are prophylactic antibiotics
administered for inhalational
injury?
P253
No
Circumferential, full-thickness burns to the
extremities are at risk forwhat complication?
P253
Distal neurovascular impairment
How is it treated?
P253
Escharotomy: full-thickness longitudinal
incision through the eschar with scalpel
or electrocautery
What is the major infection complication (other than wound infection) in burn patients? P253
Pneumonia, central line infection (change
central lines prophylactically every 3 to
4 days)
Is tetanus prophylaxis
required in the burn patient?
P253
Yes, it is mandatory in all patients except
those actively immunized within the past
12 months (with incomplete immunization:
toxoid x 3)
From which burn wound is
water evaporation highest?
P253
Third degree
Can infection convert a
partial-thickness injury into
a full-thickness injury?
P253
Yes!
How is carbon monoxide
inhalation overdose treated?
P253
100% O(2) ( ± hyperbaric O(2))
Which electrolyte must be
closely followed acutely after a burn?
P253
Na⁺ (sodium)
When should central lines be
changed in the burn patient?
P254
Most burn centers change them every
3 to 4 days
What is the name of the
gastric/duodenal ulcer
associated with burn injury?
P254
Curling’s ulcer (Think: CURLING iron
burn = CURLING’s burn ulcer)
How are STSGs nourished
in the first 24 hours?
P254
IMBIBITION (fed from wound bed
exudate)
