Burns management Flashcards by Lorna Chapman

How can you predict burns severe mortality?

Age + % body surface area burned

and if >10 then = severe mortality predictor

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Define a burn

Coagulative destruction of the surface layers of the body

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What is a superficial partial thickness burn?

predominantly epidermal loss

- the majority of adnexal structures e.g. in dermis are preserved (they are fine)

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What type of burn does this describe: bright red, moist, BLISTERS, blanches on pressure, V painful?

Superficial partial thickness burn

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What is a deep dermal/deep partial thickness burn?

more adnexal structures are damaged e.g. into the dermis

epitheliasation TF is slower…

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What type of burn does this describe: leathery and insensate (no sensation),
scarring, contractures, needs skin grafting?

Full thickness burn

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What type of burn does this describe: white/red with fixed staining, no blanching on pressure (is coagulated), prolonged healing, risk of hypertrophic scarring - may need graft?

Deep dermal/deep partial thickness

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What is a full thickness burn?

loss of entire dermis

all skin constituents are damaged

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How long do superficial partial thickness vs dermal / deep partial thickness take to heal?

Deep dermal/deep partial thickness = ~6 wks

Superficial partial thickness = ~ 2-3 wks

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What kind of burns are flame burns, prolonged contact burns and corrosive chemicals likely to cause?

full thickness

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What kinds of burns are flash burns, sunburn, some hot water scalds likely to cause?

superficial partial thickness

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What kinds of burns are some hot water scalds, hot fat, contact burns likely to cause?

deep dermal / deep partial thickness

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What is the rules of 9’s in body surface area for burns?

rules of 9 - head and arms = 9
front/back = 18
legs front & back = 18
genitals = 1%

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What is the ruled of 9’s in children?

it is the rules of 10 in children
TF head and arm = 10 (5 each side)
legs = 20 (10 each side)

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What different categories of burn deliveries can you get?

1 - Thermal
2 - Chemical
3 - Electrical
4 - Radiation
5 - Cold

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What types of thermal burns are there?

Thermal = 90% of all burns –> severity related to temperature and duration

Wet heats - scalds - most common & tend to be partial thickness

Dry heat - flame, contact, radiant heat - contact burns tend to be deep

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What types of chemical burns are there and how do you test?

Chemical is 5% of all burns and severity depends on chemical:

Acid burns: damage by coagulative necrosis - local and short lived
Alkali e.g. cement: progressive liquefactive necrosis, deep and prolonged

Rx: remove clothing - “dilution is solution to pollution”
Ix - use litmus paper

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What types of electrical burns are there?

Electrical burns = 5% of all

wide variation in severity,
entry & exit points mark the path of current
-> low voltage <1,000V = household electricity
-> high voltage >1,000

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How do you monitor high voltage (>1,000V) electrical burns?

ECG monitoring & serial cardiac enzymes

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What can monitor high voltage (>1,000V) electrical burns lead to?

Extensive tissue damage
– Rhabdomyolysis
—> Renal failure
– Compartment syndrome (movement exacerbates pain & pain is out of proportion to injury)
Asystole & arrhythmias (hence: cardiac enzymes and ECG)

What may cause a radiation burn?

superficial radiotherapy –> local erythema

anything due to radiation exposure

There are 3 zones involved in a burn (pathophysiology) what are they?

zone of coagulation
zone of stasis
zone of hyperaemia

What zone does this describe: tissue NECROSIS due to destruction by injury?

the zone of coagulation AKA the CENTRE

necrosis = dead

What zone does this describe: ISCHAEMIA - can progress & increase the area/depth of injury?

the zone of stasis

ischaemia = dying

What zone does this describe: INFLAMMATION - manifested by increased vascular permeability?

zone of hyperaemia | -aemia means subst. is present in blood

What effect do local release of inflammatory mediators have?

increased microvascular permeability oedema formation microvascular stasis thrombosis

at what BDSA % do you get systemic release of mediators into circulation?

>25-30%

What does systemic release of mediators into circulation cause?

- Burn oedema - the protein loss = oedema even in non burnt tissue - Impaired microvascular integrity - leaky endothelium, vasoactive substance (PG, LT, free radicals, histamine) - Hypovolaemia - Myocardia depression - RBC destruction - Glucose intolerance

What do you need to ask in a burns history?

causative agent Time & duration of insult First aid applied

What Ssx of burns are there?

pain plasma loss (leaky endothelium systemic release >30% BSA) anaemia (RBC destruction in skin capillaries; toxic inhibition of bone marrow) pharyngeal/laryngeal oedema stress reaction toxaemia

What complications may occur at the burn site?

``` Wound sepsis (strep or pseudomonas) Wound contracture Scarring Sepsis Curling ulcers (in stomach, stress response) Seizures (electrolyte imbalance) Renal failure (hypovolaemia, plasma loss) Psychological ```

Other indications of severity are there for burns?

1) Location: hands (1%), feet, genitalia 2) Age 3) Co-morbidities and medications 4) Presence of multisystems trauma 5) Inhalation injury

What should be examined on someone with a burn?

Distribution consistent with history? (hand =1% BSA) Capillary refill - absent in deep burns Sensation = absent in deep burns Estimation of depth Other indications of depth: location, age, co-morbs, multi-system trauma, inhalation

What are these criteria for? burns on: - Face, hands, feet, genitalia, perineum, major Joints - Circumferential burns (risk compartment syndrome) - Electricity burns - Inhalation injury - Significant pre-existing medical conditions - Co-existing trauma - NAI >10% BSA in children > 15 % in adults

these are the criteria for the BURNS UNIT

The burns unit management will use the Parkland formula. What is this?

the parkland formula for the total fluid requirement in 24 hours is: 4ml x TBSA (%) x body weight (Kg) 50% given in first 8 hours, 50% in next 16

What is the management of burns in the burns unit?

``` obs bloods (FBC, Hct, Gp & save, U&Es, COHb, ABG) Pt weight burn area estimation IV access and fluid resuscitation catherterise analgesia, NG feeding, H2 antagonists (dc leaky endothelium), tetanus prophylaxis photograph, dressings phystiotherapy (if burns on chest/limbs) ```

What is an fasciotomy?

cutting in the fascia to relieve pressure in compartment | - avoids necrosis and renal failure

What is a Escharotomy?

cutting into tissue used in full thickness circumferential burns the tough leathery tissue remaining after a full thickness burn = eschar

What is the pathophysiology & Rx of inhalation injury?

Airway oedema - Give O2, fluids Bronchospasm - salbutamol (for dilation) Depression of ciliary function -- Mucosal plugging (= lung casts --> nebs of heparin, acetyl choline = mucolytic too) :oss of surfactant Rx also: lavage, physio

What is it important to intubate early in inhalation injury?

as inflammation /swelling can severely compromise airway

What ix can you do for inhalation injury?

COHb (carbon monoxide poisoning) ABG - metabolic acidosis CXR fibreoptic bronchoscopy w/lavage

``` What do these represent: renal dysfunction haemoglobinuria over-transfusion infection pulmonary damage burn encephalopathy toxic shock syndrome (children- fever, rash, BP drop, myalgia, ) malnutrition? ```

the complications of inhalation injury

What are these: | paraffin, flamazine, Ag?

1ry dressings (covers wound, absorbent and non-adehering)

What are these: | jelonet, mepital?

2ry dressings (covers the 1ry dressing)

what are these: | gauze, J-cloths, wool, crepe?

3ry dressings (covers 1ry and 2ry)

What is the surgical managment of burns?

1) excision and grafting 2) scar release - as late stage of wound healing = contraction of the scar 3) reconstruction

What is the benefits of each meshed vs sheet grafts?

meshed = larger area | sheet grafts = better cosmetic

What is an alternative to autograft?

allograft = cadaveric - leave on for ~2 weeks as temporary measure

What skin substitutes are there?

pig skin, skin cultures | biobrane - silicon/nylon mesh and contains porcine demal collagen peptides