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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
Who should be referred to the Maricopa Integrated Health System’s Arizona Burn Center?
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
26
Initial evaluation of a burn patient should start with...
ABC’s 🙄 Airway Breathing Circulation
27
Burn patients should be intubated if...
``` 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
28
Number one cause of death related to fires
Smoking inhalation 50-80% of fire deaths
29
What is the most important thing to remember about intubating a patient with hx of smoke inhalation?
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
30
______ is responsible for most prehospital deaths
Carbon Monoxide poisoning
31
What is the half-life of CO?
4-6 hours on room air 40-80 min on 100% oxygen 15-30 min in a hyperbaric chamber
32
Why does sticking someone with CO inhalation in a hyperbaric chamber significantly reduce the likelihood of CO poisoning?
It reduces the half-life of CO from 4-6 hours to 15-30 min
33
Is pulse ox reliable for patients with CO poisoning?
NOPE Carbon monoxide has a 200x higher affinity for Hb so Oximeter will read it as O2
34
What should you do instead of pulse ox for patients with carbon monoxide poisoning?
ABGs Test Carboxyhemoglobin levels (COHb) too
35
WHo is likely to end up with delayed neurologic sequelae following CO poisoning?
Symptomatic initial clinical picture Elderly patients Prolonged exposure
36
Symptoms of Cyanide poisoning
Headache to altered mental status Hypotension, arrhythmia, CV collapse Shock
37
What is the preferred treatment for cyanide toxicity?
Hydroxocobalamin (Cyanokit) Heme-like molecule with a complex cobalt atom Binds to CN to form cyanocobalamin (vitamin B-12) and is renally excreted
38
Symptoms of upper airway inhalation
Hoarseness Stridor Substernal retractions
39
Symptoms of lower airway inhalation
Tachypnea Decreased breath sounds Wheezing/rales/rhonchi Accessory muscle use
40
What are the approaches for treating inhalation?
Mechanical ventilation Aggressive pulmonary toilet (ie coughing stuff up) PNA prevention and treatment Supplemental nutrition
41
What kind of IV access do burn patients get?
2 large bore IVs, preferably on unburned skin if possible
42
Burns ≥ ______ require Parkland Resuscitation
≥20% TBSA
43
What is the Rule of Nines for calculating TBSA in adults?
Head = 9% Front torso = 18% Back torso = 18% Each arm = 9% Each leg = 18% Genitals = 1%
44
What is the Rule of Nines for calculating TBSA in babies?
Head = 18%*** Front torso = 18% Back torso = 18% Each arm = 9% Each leg = 13.5%*** Genitals = 1%
45
Circulation resuscitation goals for burn patients
Maintain tissue perfusion to end organs***** Use Foley catheter to monitor Diuretics not indicated in acute setting
46
What is the urinary output goal for adult burn patients?
0.5 mL/kg/hr
47
What is the urinary output goal for pediatric burn patients?
1 mL/kg/hr
48
What is the urinary output goal for electrical burn patients?
1-2 mL/kg/hr
49
Should you give diuretics to a burn patient if they’re not peeing enough?
NOPE
50
What is the parkland formula?
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
What type of fluid do you give to patients under the parkland formula?
Lactated ringers (LR) 4mL LR x kg x TBSA = 24 hour total
52
Factors influencing fluid requirements
Burn depth Inhalation injury (can increase needs by 30-50%)***** Delay in resuscitation Compartment syndrome Electrical burns
53
Under-resuscitation of burn patients can result in...
Intravascular volume depletion (hemoconcentration) Suboptimal tissue perfusion —> end organ failure —> death
54
Over-resuscitation of burn patients can result in...
ABDOMINAL COMPARTMENT SYNDROME • Decreased renal blood flow —> renal failure • Intestinal ischemia • Airway obstruction —> respiratory failure*** Compartment syndrome of extremities Pulmonary edema
55
Clinical presentation of abdominal compartment syndrome
Decreased urine output Elevated bladder pressure (>25 mmHg) Increased peak expiratory pressure Poor ventilation
56
What monitoring do you need for a patient with abdominal compartment syndrome?
Hourly bladder pressures Decrease IV fluids CRRT if needed (type of dialysis) Possible intraperitoneal catheter for decompression If unable to reverse —> decompressive laparotomy
57
Primary complication of burns
Tetanus - from C. tetani, an anaerobic, motile gram (+) rod that forms an oval, colorless, terminal spore
58
Incubation period for tetanus?
4-14 days More severe clinical courses can become symptomatic in the first week
59
65% of tetanus infections are from...
Minor wounds from wood, metal splinters, or thorns 5% from chronic skin ulcers
60
Symptoms of tetanus
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
Secondary prevention of tetanus
Wound cleansing Debridement If last tetanus booster was >5 years ago, readminister
62
What are the different types of tetanus vaccinations?
``` Td Tdap DT DPT DTaP ``` TIG when indicated (immunoglobulin)
63
Protection from the tetanus vaccine lasts ______
10 years
64
Wounds that are prone to tetanus
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
Tetanus may complicate the following conditions
``` Frostbite Middle ear infections Dental or surgical procedures Abortion Childbirth IV or SQ drug use ```
66
Tetanus immunization schedule
DTaP at 2mo, 4mo, 6mo, 15-18mo, and 4-6 years Then Tdap once adult Td booster every 10 years
67
Types of burns that require specialized care
Chemical burns Electrical burns Lightning burns Circumferential burns
68
Key points to managing chemical burns
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
What is key in identifying electrical burns?
HISTORY
70
Important points in managing electrical burns
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
2/3 of deaths from lightning burns occur within...
1 hour of injury Typically due to fatal arrhythmia or respiratory failure
72
Buzzwords for lightning injury
Feathering pattern Ferning pattern “Lichtenberg figures”
73
Circumferential burns have a high risk for ...
Compartment syndrome
74
What are the six P’s for compartment syndrome
``` Pain Paresthesia Pallor Paralysis Poikilothermia (inability to regulate body temp) Pulselessness ```
75
What are the two procedures for dealing with circumferential burns?
Escharotomy Fasciotomy
76
Incision through burned skin to underlying subcutaneous tissue
Escharotomy
77
Incision through the fascia overlying muscle compartments of an extremity
Fasciotomy
78
What are some tips for escharotomy/fasciotomy?
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
What is performed in patients with circumferential torso burns to improve ventilation?
Shield escharotomy
80
What are the different types of skin graft?
Autograft (patient’s own skin) = the only definitive coverage Allograft (from another person) Xenograft (from another species - usually porcine)
81
Autografts require...
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
What burn patients need nutritional support?
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
What type of nutritional support is preferred for burn patients?
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
Chronic ulcerations following burns develop b/c...
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
What is a Marjolin ulcer?
Squamous cell carcinoma (result of chronic ulcerations following skin graft)
86
Name that burn scar: Overgrowth of scar tissue beyond area of injury
Keloid scars
87
Name that burn scar: Thick, raised, red Do not extend beyond original injury
Hypertrophic scars
88
Name that burn scar: Connective tissue replaced by fibrotic tissue —> decreased ROM —> shortening of muscle
Scar contractures

EMED Unit 3 (5 decks)

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