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EMED Unit 3 > Burns In The ED > Flashcards

Burns In The ED Flashcards

1
Q

What are the different categories of burns?

A

Scalds (liquids, grease, steam)

Contact (hot or cold)

Thermal (fire or flames)

Radiation

Chemical

Electrical

Friction

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2
Q

Risk factors for burns

A

Inadequate or faulty electrical wiring

Lack of or non functioning smoke detectors (63% of residential fires)

Arson

Water heater temps set too high

Carelessness with cigarettes

Young children and older adults

Workplace exposure to chemicals, electricity, or irradiation

EtOH or other substances that alter function/mental status

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3
Q

Superficial burns are also called…

A

First degree burns

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4
Q

Superficial burns involve the _____ layer only

A

Epidermal

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5
Q

Characteristics of first degree/superficial burns

A

Red, painful, dry

Blanch with pressure

No blisters

Heal within 7 days

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6
Q

Examples of superficial/first degree burns

A

Sunburn

Mild scalds

Mild electrical burns

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7
Q

How to treat superficial/first degree burns

A

Remove clothing and debris

Cool with water that is cool but not ice cold (not longer than 5 min)

Gentle cleansing

Topical calamine or aloe vera

Topical polysporin

Dressing usually not needed

OTC acetaminophen or NSAID for pain if needed

Consider tetanus booster

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8
Q

How do you prevent superficial burns?

A

Reduce sun exposure
Protective clothing
SPF >30

Specifically for little kids:
SUPERVISE THEM!
Unplug appliances
Plugs for outlets
Do not leave stove when cooking
Avoid hot liquids near kids
Use back burners so kids can’t reach
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9
Q

Partial thickness burns are also called…

A

2nd degree burns

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10
Q

Partial thickness/second degree burns extend ______

A

Into the dermis

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11
Q

Do partial thickness/second degree burns scar?

A

Can cause minimal to severe scarring

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12
Q

What are the two categories of partial thickness burns?

A

Superficial

Deep

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13
Q

What type of burn:

Pink, moist blisters

PAIN

Most heal in 7-21 days

A

Superficial partial thickness (superficial 2nd degree)

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14
Q

What type of burn:

Pale paint to white

Decreased cap refill

Pain with pressure

Most heal in 3-12 weeks

A

Deep partial thickness (deep 2nd degree)

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15
Q

What are the goals in treating partial thickness/second degree burns?

A

Keep wound moist

If blister is intact, LEAVE IT ALONE

If blister is already broken, debride wound - goal is re-epitheliazation

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16
Q

How do you treat superficial partial thickness burns?

A

Petroleum based moisturizer vs bacitracin

Occlusive dressing such as xeroform

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17
Q

How do you treat deep partial thickness burns?

A

Same as superficial unless eschar present

If eschar - silver sulfadiazine cream on 4x4, covered with roll gauze

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18
Q

How often should dressing changes occur for partial thickness burns?

A

1-2 times/day

May need opioids for pain management

Wash wound with each dressing change with mild soap and water

Consider tetanus booster

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19
Q

Full thickness burns are also called…

A

3rd degree burns

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20
Q

Full thickness burns involve…

A

Epidermis and full thickness dermis —> skin charring

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21
Q

What do full thickness burns look like?

A

Hard, leathery, PAINLESS (b/c no nerve endings)

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22
Q

Will full thickness burns heal spontaneously?

A

NO - requires surgical repair and skin grafting

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23
Q

What does wound care for full thickness wounds involve?

A

Wash with mild soap and water

Debride wound (surgical)

Silver sulfadiazine cream

Change dressing twice daily

Opioids for pain control (unless they do not have feeling)

Consider tetanus booster

Close follow up

Restoration

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24
Q

What are fourth degree burns?

A

Burns beyond full thickness of the dermis

Involvment of:
Muscle
Tendon
Bone
Blood vessels
Nerves
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25
Q

Who should be referred to the Maricopa Integrated Health System’s Arizona Burn Center?

A

Partial thickness burns of >10% of TBSA
Third degree burns in any age group
Burns that involve the face, hands, feet, genitalia, perineum, or major joints
Electrical burns, including lightning
Chemical burns
Inhalation injury
Burn injury in patients with pre-existing medical disorders that could complicate or prolong recovery
Any patients with burns and concomitant trauma
Children in hospitals without qualified personnel/equipment
Anybody else who’s special

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26
Q

Initial evaluation of a burn patient should start with…

A

ABC’s 🙄

Airway
Breathing
Circulation

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27
Q

Burn patients should be intubated if…

A 
Hx suggests airway compromise:
• Closed space smoke exposure
• Carbonaceous sputum
• Facial burns
• COHb>5
• Hoarse voice
• Singed facial hair

Patient unable to protect airway
• Trauma
• Opioids

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28
Q

Number one cause of death related to fires

A

Smoking inhalation

50-80% of fire deaths

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29
Q

What is the most important thing to remember about intubating a patient with hx of smoke inhalation?

A

INTUBATE EARLY

Airway and facial edema can happen quickly

Better to intubate early and not need it than to wait and have a difficult airway

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30
Q

______ is responsible for most prehospital deaths

A

Carbon Monoxide poisoning

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31
Q

What is the half-life of CO?

A

4-6 hours on room air

40-80 min on 100% oxygen

15-30 min in a hyperbaric chamber

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32
Q

Why does sticking someone with CO inhalation in a hyperbaric chamber significantly reduce the likelihood of CO poisoning?

A

It reduces the half-life of CO from 4-6 hours to 15-30 min

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33
Q

Is pulse ox reliable for patients with CO poisoning?

A

NOPE

Carbon monoxide has a 200x higher affinity for Hb so Oximeter will read it as O2

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34
Q

What should you do instead of pulse ox for patients with carbon monoxide poisoning?

A

ABGs

Test Carboxyhemoglobin levels (COHb) too

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35
Q

WHo is likely to end up with delayed neurologic sequelae following CO poisoning?

A

Symptomatic initial clinical picture

Elderly patients

Prolonged exposure

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36
Q

Symptoms of Cyanide poisoning

A

Headache to altered mental status

Hypotension, arrhythmia, CV collapse

Shock

37
Q

What is the preferred treatment for cyanide toxicity?

A

Hydroxocobalamin (Cyanokit)

Heme-like molecule with a complex cobalt atom

Binds to CN to form cyanocobalamin (vitamin B-12) and is renally excreted

38
Q

Symptoms of upper airway inhalation

A

Hoarseness

Stridor

Substernal retractions

39
Q

Symptoms of lower airway inhalation

A

Tachypnea

Decreased breath sounds

Wheezing/rales/rhonchi

Accessory muscle use

40
Q

What are the approaches for treating inhalation?

A

Mechanical ventilation

Aggressive pulmonary toilet (ie coughing stuff up)

PNA prevention and treatment

Supplemental nutrition

41
Q

What kind of IV access do burn patients get?

A

2 large bore IVs, preferably on unburned skin if possible

42
Q

Burns ≥ ______ require Parkland Resuscitation

A

≥20% TBSA

43
Q

What is the Rule of Nines for calculating TBSA in adults?

A

Head = 9%

Front torso = 18%

Back torso = 18%

Each arm = 9%

Each leg = 18%

Genitals = 1%

44
Q

What is the Rule of Nines for calculating TBSA in babies?

A

Head = 18%***

Front torso = 18%

Back torso = 18%

Each arm = 9%

Each leg = 13.5%***

Genitals = 1%

45
Q

Circulation resuscitation goals for burn patients

A

Maintain tissue perfusion to end organs*****

Use Foley catheter to monitor

Diuretics not indicated in acute setting

46
Q

What is the urinary output goal for adult burn patients?

A

0.5 mL/kg/hr

47
Q

What is the urinary output goal for pediatric burn patients?

A

1 mL/kg/hr

48
Q

What is the urinary output goal for electrical burn patients?

A

1-2 mL/kg/hr

49
Q

Should you give diuretics to a burn patient if they’re not peeing enough?

A

NOPE

50
Q

What is the parkland formula?

A

For burns ≥20% TBSA

4 mL lactated ringers x kg x TBSA = 24 hour post burn total

Give half of volume in first 8 hours and remaining amount in following 16 hours

51
Q

What type of fluid do you give to patients under the parkland formula?

A

Lactated ringers (LR)

4mL LR x kg x TBSA = 24 hour total

52
Q

Factors influencing fluid requirements

A

Burn depth

Inhalation injury (can increase needs by 30-50%)*****

Delay in resuscitation

Compartment syndrome

Electrical burns

53
Q

Under-resuscitation of burn patients can result in…

A

Intravascular volume depletion (hemoconcentration)

Suboptimal tissue perfusion —> end organ failure —> death

54
Q

Over-resuscitation of burn patients can result in…

A

ABDOMINAL COMPARTMENT SYNDROME
• Decreased renal blood flow —> renal failure
• Intestinal ischemia
• Airway obstruction —> respiratory failure***

Compartment syndrome of extremities

Pulmonary edema

55
Q

Clinical presentation of abdominal compartment syndrome

A

Decreased urine output

Elevated bladder pressure (>25 mmHg)

Increased peak expiratory pressure

Poor ventilation

56
Q

What monitoring do you need for a patient with abdominal compartment syndrome?

A

Hourly bladder pressures

Decrease IV fluids

CRRT if needed (type of dialysis)

Possible intraperitoneal catheter for decompression

If unable to reverse —> decompressive laparotomy

57
Q

Primary complication of burns

A

Tetanus - from C. tetani, an anaerobic, motile gram (+) rod that forms an oval, colorless, terminal spore

58
Q

Incubation period for tetanus?

A

4-14 days

More severe clinical courses can become symptomatic in the first week

59
Q

65% of tetanus infections are from…

A

Minor wounds from wood, metal splinters, or thorns

5% from chronic skin ulcers

60
Q

Symptoms of tetanus

A

Sore throat with dysphagia

Localized tetanus —> 1 limb or area where wound located

Generalized tetanus —> trismus (lockjaw) in 75%

Subsequent Sx = muscle rigidity DESCENDING from jaw and facial muscles within 24-48 hours —> extends to extensor muscles of the extremities

Other SSx - temperature, sweating, elevated BP, episodic tachycardia, neck rigidity, restlessness, and reflex spasms

61
Q

Secondary prevention of tetanus

A

Wound cleansing

Debridement

If last tetanus booster was >5 years ago, readminister

62
Q

What are the different types of tetanus vaccinations?

A 
Td 
Tdap 
DT
DPT
DTaP

TIG when indicated (immunoglobulin)

63
Q

Protection from the tetanus vaccine lasts ______

A

10 years

64
Q

Wounds that are prone to tetanus

A

Present for longer than 6 hours

Deep (>1 cm)

Grossly contaminated wounds

Exposed to saliva or feces

Avulsions, punctures, or crush injuries

BURNS

Complications of chronic conditions (Abscesses or gangrene)

65
Q

Tetanus may complicate the following conditions

A 
Frostbite
Middle ear infections
Dental or surgical procedures
Abortion
Childbirth
IV or SQ drug use
66
Q

Tetanus immunization schedule

A

DTaP at 2mo, 4mo, 6mo, 15-18mo, and 4-6 years

Then Tdap once adult

Td booster every 10 years

67
Q

Types of burns that require specialized care

A

Chemical burns
Electrical burns
Lightning burns
Circumferential burns

68
Q

Key points to managing chemical burns

A

Can be from acids or bases - find out which it was!

Locate MSDS

May not appear to be as deep initially

Copious irritation with WATER***
• Delay transport for decontamination
• Do not try to neutralize
• Monitor progress with litmus paper

69
Q

What is key in identifying electrical burns?

A

HISTORY

70
Q

Important points in managing electrical burns

A

Monitor for cardiac abnormalities

Injuries may be much worse than they appear as current follows path of least resistance (damage may be hidden under good skin)

Risk of Rhabdomyolysis (muscle damage)

Fluid resuscitation required even in small appearing injuries (goal is 1-2 cc urine/kg/hour)

71
Q

2/3 of deaths from lightning burns occur within…

A

1 hour of injury

Typically due to fatal arrhythmia or respiratory failure

72
Q

Buzzwords for lightning injury

A

Feathering pattern

Ferning pattern

“Lichtenberg figures”

73
Q

Circumferential burns have a high risk for …

A

Compartment syndrome

74
Q

What are the six P’s for compartment syndrome

A 
Pain
Paresthesia
Pallor
Paralysis
Poikilothermia (inability to regulate body temp)
Pulselessness
75
Q

What are the two procedures for dealing with circumferential burns?

A

Escharotomy

Fasciotomy

76
Q

Incision through burned skin to underlying subcutaneous tissue

A

Escharotomy

77
Q

Incision through the fascia overlying muscle compartments of an extremity

A

Fasciotomy

78
Q

What are some tips for escharotomy/fasciotomy?

A

Extend incisions through unburned tissue proximally and distally if possible

Incisions made mid-medial and mid lateral on extremities

Do at bedside if patient is unstable

79
Q

What is performed in patients with circumferential torso burns to improve ventilation?

A

Shield escharotomy

80
Q

What are the different types of skin graft?

A

Autograft (patient’s own skin) = the only definitive coverage

Allograft (from another person)

Xenograft (from another species - usually porcine)

81
Q

Autografts require…

A

A donor site of healthy skin

Graft is taken as partial thickness

Donor site will be very painful - takes 7-10 days to heal

82
Q

What burn patients need nutritional support?

A

Adults with a burn covering 25% of TBSA

Resting metabolic rate ~180% of basal rate during admission

Surface burn of 40% can lose 25% of preadmission weight in 3 weeks without nutrition support**

Patients with losses exceeding 10% have significantly poorer outcomes

83
Q

What type of nutritional support is preferred for burn patients?

A

Enteral - reduces burn-related increase in secretion of catabolic hormones and helps maintain gut mucosal integrity

Duodenal route is better tolerated than gastric feeding

TPN not recommended

Need high-carb low-fat diets

84
Q

Chronic ulcerations following burns develop b/c…

A

Grafted skin lacks many of the support structures of normal tissue —> chronic, non-healing ulcerations

May remain open for years

May develop Marjolin ulcer

85
Q

What is a Marjolin ulcer?

A

Squamous cell carcinoma (result of chronic ulcerations following skin graft)

86
Q

Name that burn scar:

Overgrowth of scar tissue beyond area of injury

A

Keloid scars

87
Q

Name that burn scar:

Thick, raised, red

Do not extend beyond original injury

A

Hypertrophic scars

88
Q

Name that burn scar:

Connective tissue replaced by fibrotic tissue —> decreased ROM —> shortening of muscle

A

Scar contractures

EMED Unit 3 (5 decks)

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