Burns principles and treatment Flashcards
A 19-year-old woman presents with a 2 × 3-cm burn to the left dorsal thumb sustained from brief exposure to hot bacon grease. During the next 24 hours, the burned area becomes erythematous and several blisters containing clear fluid have formed and then ruptured. Examination shows no erythema extending proximally. A photograph is shown. Which of the following is the most appropriate next step in management?
A) Dry dressing
B) Hydrogen peroxide soaks
C) Leave open to air
D) Topical antibiotic ointment
The correct response is Option D.
Based on the information provided, this is likely a superficial partial-thickness burn. It is not deep enough or large enough to warrant transfer to a burn center. Local wound care should lead to full resolution, with appropriate follow-up to detect delays in healing. Partial-thickness wounds like this will heal fastest when a moist environment is maintained. Antibiotic ointment or other neutral moisturizing agents (e.g., petrolatum ointment) are appropriate for local wound care. Leaving the wound open to air or covering with a dry dressing will delay healing. Hydrogen peroxide is appropriate for cleansing dirty or infected wounds, but it is not necessary in the scenario presented. Furthermore, sustained use of hydrogen peroxide may delay healing in clean wounds.
An otherwise healthy 20-year-old man is brought to the emergency department after sustaining burns to the right forearm and upper arm while trying to light an outdoor grill. Examination of the burned extremity shows red, blistered, painful areas, as well as areas that are white in color and not tender to palpation. The burns are noncircumferential. The patient is breathing comfortably, and pulse oximetry is 99% on room air. This patient should be transferred to a burn center on the basis of which of the following criteria?
A) Age of the patient
B) Burn depth
C) Burn location
D) Burn mechanism
E) Total body surface area of the burn
The correct response is Option B.
The depth of this patient’s burns, being third-degree (white, not tender to palpation), would qualify him for transfer to a burn center for treatment. In this patient, the arm represents a total body surface area of 9% of the patient. He is young and otherwise healthy; thus, he does not warrant transfer based on age. The burn does not involve sensitive areas such as the face, hands, feet, or genitalia/perineum. Also, since this is not an electrical or chemical burn, and it occurred in an outdoor area, inhalation injury is unlikely.
A 29-year-old man presents with deep second- and third-degree burns on 35% of total body surface area. Fluid resuscitation via the Parkland formula is performed. Which of the following parameters is most commonly used to assess for adequacy of resuscitation?
A) Blood pressure
B) Heart rate
C) Pulmonary wedge pressure
D) Pulse oximetry
E) Urine output
The correct response is Option E.
Patients who sustain greater than 20% total body surface area second- or third-degree burns will require aggressive resuscitation to prevent development of burn shock. While the Parkland formula and other such resuscitation protocols are useful for initiation of proper burn resuscitation, these measures should only be used as a starting point, with the resuscitation being guided by the physiologic response of the patient. The most important parameter to assess the adequacy of resuscitation is urine output. A goal for adequate resuscitation efforts should be above 0.5 mL/kg/hr for adults and closer to 1 mL/kg/hr for children. It is important to note that over-resuscitation can also result in what has been recently described as “fluid creep,” and includes significant complications such as excessive edema, third spacing, and even abdominal compartment syndrome, so fluid infusions should also be lowered if urine output is significantly higher than these rates. While monitoring of other physiologic parameters such as blood pressure, heart rate, and pulse oximetry are important, and serial measurements of cardiac output are increasingly being used, they are not more commonly used than urine output to assess the adequacy of resuscitation or help to prevent over-resuscitation. Pulmonary wedge pressure is no longer a common modality for monitoring fluid resuscitation status.
A 38-year-old electrician suffers an electrical burn to the right hand. Which of the following types of tissue has the lowest inherent resistance?
A) Bone
B) Fat
C) Muscle
D) Skin
E) Tendon
The correct response is Option C.
The tissue with the least resistance from the choices provided is muscle. The amount of electrical current that is conducted through tissue is proportional to the voltage and inversely proportional to the tissue’s resistance, as is dictated by Ohm’s Law, V=IR. Therefore, more current will flow through tissue with lower resistance, given all other variables being equal. Other variables that effect current flow include tissue volume and the amount of moisture.
The body tissue with the highest inherent resistance is cortical bone, followed by cancellous bone, fat, tendon, skin, muscle, vessel, then nerve.
So, in the setting of a high-voltage electrical burn, it is not uncommon to have more underlying structural and organ damage than the visible soft tissue damage may indicate. An EKG, cardiac monitoring, CBC, cardiac enzymes, and urinalysis for myoglobin may, therefore, be necessary for workup.
A 30-year-old man sustained a third-degree burn to his right arm from a flame while cooking over a grill. The burn is 5% total body surface area (TBSA). Two days after the injury, he undergoes debridement of the dorsal wrist and forearm. The paratenon is not present after the debridement. A bilaminate neodermis (Integra) graft is selected and placed on the wound. Use of this graft is associated with which of the following?
A) Decreased cost to the hospital
B) Decreased number of hospital stays
C) Decreased number of surgeries
D) Decreased risk for hypertophic scar
E) Increased skin sensation after reconstruction
The correct response is Option D.
The literature states that there is a decrease in hypertrophic scarring associated with the use of bilaminate neodermis (Integra) with burn reconstruction. The cost of the product is high. Use of the product requires a second surgery for the skin graft. There has not been any literature supporting improved sensation following use of the graft. The downside to the graft is that it can result in longer hospital stays for the patient in order to get the second surgery completed.
A 19-year-old man reports severe, worsening arm pain and finger swelling accompanied by distal numbness. He sustained a circumferential burn to the arm 12 hours ago. The area of burned skin itself is noted to be leathery and insensate. Examination demonstrates loss of distal pulses. Which of the following is the most appropriate next step?
A) Angiography
B) CT scanning
C) Duplex ultrasonography
D) Escharotomy
E) Fasciotomy
The correct response is Option D.
The most appropriate next step is escharotomy. The patient exhibits signs of vascular compromise due to tight restrictive burn eschar arising from a circumferential full-thickness burn. Edema following a burn due to inflammation and fluid resuscitation can cause increased swelling of the tissues, and the presence of tight circumferential eschar can give rise to vascular compromise. Release of the burn eschar (escharotomy) is indicated to relieve pressure on the tissues and allow for restoration of blood flow.
Burns are classified into partial thickness and full thickness, and into different degrees based on the depth of injury. In the case of full-thickness (third-degree or fourth-degree) burns, the area of burned skin is insensate and may appear charred or leathery. Eschar formation in circumferential burns can lead to a tourniquet effect, with impaired circulation. In some cases, circumferential burns of the torso may even give rise to respiratory compromise or abdominal compartment syndrome.
Escharotomy differs from fasciotomy in that the incision is made more superficially, to open the thick burn eschar, and does not need to extend deep to the fascia.
Angiography would be useful in evaluating vasculature and blood flow, but would not be needed in this situation and would delay treatment.
CT scanning can provide detailed imaging, but it would not be indicated in this situation and would delay treatment.
Duplex ultrasonography can evaluate the presence of deep vein thrombosis, which could cause pain and swelling. However, in this case, the clinical scenario suggests that circulatory restriction is due to the circumferential burn scar.
Fasciotomy is recommended in the case of increased compartment pressures, which may also present with pain, paresthesia, and loss of pulses, although in this instance the presence of a circumferential burn would indicate escharotomy as the treatment.
Fasciotomy is advised if compartment pressure exceeds 30 mmHg, or if the difference between intracompartmental pressure and diastolic blood pressure is less than 30 mmHg.
A 50-year-old woman with a history of hypertension is brought to the hospital 1.5 hours after sustaining burn injuries in a house fire. Initial examination shows deep, second-degree burns (partial-thickness) to 35% of the trunk, non-circumferential third-degree burns (full-thickness) to 5% of the left forearm, and first-degree burns to 2% of the head. In addition to time from injury, which of the following common aspects of the burn evaluation should be used in both the Parkland formula and Brooke formula for determining fluid resuscitation in this patient?
A) Total body surface area (TBSA) (determined by first-, second-, and third-degree burns), gender, weight
B) TBSA (determined by first-, second-, and third-degree burns), weight
C) TBSA (determined by second- and third-degree burns), age, weight
D) TBSA (determined by second- and third-degree burns), gender, weight
E) TBSA (determined by second- and third-degree burns), weight
The correct response is Option E.
While there are different resuscitation formulas for initial burn resuscitation, such as the Brooke formula or the Parkland formula, they rely on giving a certain amount of fluid multiplied by total body surface area (as determined by partial- and full-thickness burns) and weight in kilograms of the patient. The fluid is then given initially as determined from time of injury, and divided into half given in the first 8 hours of injury and then half in the next 16 hours. This is a guideline only and resuscitation can be altered based on physiologic response, such as urine output. Gender and age are not a consideration and first-degree burns are not used in the calculation of total body surface area.
An otherwise healthy, 32-year-old woman with a history of burns on 20% of the total body surface area of the left upper extremity and chest, returns 1 year after her injury for evaluation of a nonhealing wound over the dorsal elbow and limited range of motion at the joint. X-ray studies show soft-tissue lamellar calcification. Which of the following is the most likely diagnosis?
A) Chronic osteomyelitis
B) Heterotopic ossification
C) Hypertrophic scar
D) Marjolin ulcer
E) Retained foreign body
The correct response is Option B.
The most likely diagnosis is heterotopic ossification (HO). An important complication of massive burn injury (greater than 20 % BSA) is heterotopic ossification, with the elbow region being the most common site of occurrence. This may result in wound issues, stiffness, and nerve injury. HO can occur in 0.2 to 4 % of cases. Prevention of this condition includes radiation therapy and nonsteroidal anti-inflammatory drugs. Surgical excision is the procedure of choice for restoration of range of motion.
Hypertrophic scars present as raised thickened scars following burn injury but do not show ossification within the scar. The most common scenario for development of a Marjolin’s ulcer is malignant degeneration of a previous scar, usually squamous cell carcinoma. The latency period for development of this type of malignancy is usually 10 years after the original injury at the earliest. Chronic osteomyelitis would show radiolucency and changes within the bone not the soft tissue. The x-ray finding is not consistent with a retained foreign body.
A 24-year-old man presents to the emergency department after sustaining burns from a workplace fire in a kitchen. He has a suspected inhalation injury. Physical examination shows partial-thickness burns on the forearms and thighs, as well as on one ear. The plan is to use mafenide acetate as a topical antimicrobial dressing. Because of the suspected lung injury, mafenide should be used with caution because it places him at increased risk for which of the following?
A) Gray discoloration of skin
B) Hyperosmolality
C) Metabolic acidosis
D) Methemoglobinemia
E) Pruritis
The correct response is Option C.
The topical use of mafenide acetate, a carbonic anhydrase inhibitor, can prevent the conversion of hydrogen ions in the body to carbonic acid, leading to metabolic acidosis. In patients with an inhalation injury and respiratory acidosis, the use of mafenide acetate over large surface areas can be fatal. The use of mafenide is common in areas with cartilage, such as the ear. It is also useful for eschar penetration. Common adverse effects include pain with application.
Silver sulfadiazine is associated with leukopenia and hyperosmolality.
Silver nitrate can also be used, but it causes gray-to-black staining of the wound and can also be associated with electrolyte imbalances. Methemoglobinemia has also been reported with silver nitrate use.
An otherwise healthy, 76-year-old woman sustains a deep partial-thickness facial burn following scald injury. No acute intervention is performed and the patient follows up in the clinic 6 weeks after the incident. She complains of pain in the right eye as well as frequent tearing. Physical examination of the eye shows 4 mm of lagophthalmos, conjunctival injection, and hypertrophic scarring on the upper lid with restrained motion. The surrounding skin on the cheek and forehead appears erythematous and indurated. Which of the following is the most appropriate treatment for this patient?
A) Contracture release and forehead flap
B) Contracture release and full-thickness skin grafting
C) Contracture release and placement of allograft
D) Contracture release and split-thickness skin grafting
E) Scar massage and eyelid taping
The correct response is Option B.
Facial burn injuries in the periorbital area must be quickly treated to support patient comfort and protect vision. Continued lagophthalmos and patient complaints warrant intervention, particularly with the degree of symptoms that the patient is expressing. The need for earlier intervention is specifically discussed in Klifto, et al. There is no indication for allograft placement following contracture release in this case, as a surface to graft upon should be present following contracture release in the eyelid. Of note, the contracture release usually occurs superficial to the orbicularis oculi and superior to the tarsal plate. Following contracture release, full-thickness skin grafts, but not split-thickness skin grafts, will minimize contracture after placement. Forehead flap reconstruction of the upper eyelid is a reasonable intervention and may be the most successful in preventing contracture recurrence, but it is not a treatment choice if the donor skin may be involved with the burn injury, as in the case of this patient.
A 56-year-old man who works at a fertilizer production plant presents to the emergency department with 10% hydrofluoric acid burns to the palmar surface of both hands. He is in exquisite pain. Physical examination shows no other injuries. Which of the following is the most appropriate management of this burn injury?
A) Application of a dilute alkali to neutralize the acid
B) Copious surface irrigation and application of calcium gluconate gel
C) Frequent electrolyte and renal lab analyses due to systemic toxicity
D) Mafenide acetate (Sulfamylon) dressings
E) Pain control and maintenance intravenous fluids
The correct response is Option B.
The patient has sustained a hydrofluoric acid burn, an agent used in many industrial and domestic applications. Hydrofluoric acid is a unique acidic chemical agent because it can behave as a strong acid at higher concentrations and can also cause liquefactive necrosis, as alkalis do by the dissociation of fluoride ions into subcutaneous tissues. Fluoride ions combine with calcium resulting in local hyperkalemia, which is believed to be the cause for the “pain out of proportion” examination finding associated with hydrofluoric acid burns.
Application of a dilute alkali is not recommended for the treatment of acidic burns because the resulting reaction can be exothermic, resulting in additional injury as the acid is being neutralized.
For patients with greater than 5% total body surface area (TBSA) exposure to hydrofluoric acid or injury with less than 50% concentration of hydrofluoric acid, systemic toxicity can result, causing electrolyte disturbances and organ dysfunction. This patient’s injury resulted from a low-concentration hydrofluoric acid exposure to a small surface area, making serial laboratory assessment less of a priority during presentation.
Due to the intense pain that hydrofluoric acid burns can cause, pain control will be required for management, but maintenance fluid and pain control alone will not treat the burn injury.
The hallmark of hydrofluoric acid chemical burn injury treatment is skin surface irrigation with copious amounts of water at lower pressure, followed by topical calcium gluconate to bind the fluoride ions before they penetrate into the soft tissues. This will neutralize the burn reaction, bind the fluoride ions, and help with pain control.
Mafenide acetate is an appropriate topical antiseptic for non-chemical burns, but will not neutralize hydrofluoric acid.
A 66-year-old, 132-lb (60-kg) woman presents to the emergency department with a deep second-degree, 20% total body surface area burn, with a small area of surrounding first-degree burn. This happened in an open space when she fell backwards onto a fire pit. Her burns are isolated to her buttock and back. She reports no hoarseness or difficulty breathing. She receives 9600 mL of Ringer’s lactate within the first 24 hours. Based on her fluid resuscitation, she is at highest risk for which of the following?
A) Abdominal compartment syndrome
B) Conversion of the burn to full-thickness
C) Deep venous thrombosis
D) Digit ischemia
E) Poor engraftment of autologous skin grafts
The correct response is Option A.
Numerous formulas regarding burn resuscitation have been developed to avoid under-resuscitation. This was based on previous literature suggesting that under-resuscitation was associated with significant end organ damage secondary to ischemic injury. Inadequate resuscitation was similarly associated with the potential for hemodynamic collapse, resulting in death. Weight-based resuscitation programs and establishment of urine output guidelines have largely limited under-resuscitation at burn centers. However, burn patients now suffer from the consequences of over-resuscitation, in which patients receive even more fluid than recommended by the Parkland formula. These patients suffer from increased rate of burn infections, the development of acute respiratory distress syndrome, and abdominal compartment syndrome.
In the clinical case presented, the Parkland formula would suggest that the patient receive approximately 4800 mL of resuscitation (4 × TBSA burn [20] × weight in kilograms [60]) within the first 24 hours. This patient received approximately double the amount.
Regarding engraftment, there is no evidence that over-resuscitation worsens autologous skin graft engraftment. Conversion of burn injuries to deeper injuries is usually associated with under-resuscitation, as is end organ or digit ischemia. Deep venous thrombosis does not have any reported correlation with burn resuscitation.
Which of the following is associated with the use of pressure garments in the management of burn scars?
A) Decreased scar strength
B) Increased synthesis of tissue proteinases
C) Larger and less densely packed collagen fibers
D) Reduced differentiation of fibroblasts to myofibroblasts
The correct response is Option D.
Significant differences in scar contraction were observed between scars receiving pressure garment therapy and control burns that received no pressure. Pressure garments exert compressive forces perpendicular and parallel to the surface of the scar. These forces oppose the direction of contracture. One hypothesis is that wound tension acts upon integrins by stretching them, which leads to phosphorylation of focal adhesion kinase and upregulation of smooth muscle actin and collagen production. When compression is applied to incisional wounds perpendicular to the wound tension, scarring is minimized. This suggests that the mechanical forces applied to the scar can assist in reducing differentiation of fibroblasts to myofibroblasts, decreasing scar contraction and collagen deposition.
Scar strength was improved with pressure garment therapy compared with controls, with a 34% increase in ultimate tensile strength. Pressure garment therapy scars were also found to be composed of smaller, more densely packed collagen fibers.
Increased synthesis of tissue proteinases is a mechanism of corticosteroids.
An 8-year-old girl presents with burns on 60% of the total body surface area. Physical examination shows second- and third-degree burns involving her face, neck, and torso. After initial resuscitation, wound care, burn debridement, and skin grafting are performed, rehabilitation protocol is initiated. Administration of which of the following agents is most appropriate for improving bone mineral content (BMC) in this patient?
A) Ascorbic acid
B) Glutamine
C) Insulin
D) Oxandrolone
E) Testosterone
The correct response is Option D.
A randomized clinical trial of safety and efficacy of 1-year oxandrolone administration to severely burned children (over 30% total body surface area burns) demonstrated significant benefits of this medication. Improvements were noted in height, bone mineral content (BMC), cardiac work, and muscle strength, and were statistically higher compared to the control group. Mechanism of action is not totally clear but increase in insulin-like growth factor-1 secretion during the first year after burn injury, and, in combination with exercise, considerable increase in lean body mass and muscle strength has been demonstrated. The maximal effect of oxandrolone was found in children aged 7 to 18 years. No deleterious side effects were attributed to long-term administration.
Oxandrolone, a synthetic oral nonaromatizable testosterone derivative, has only 5% of the virilizing activity and low hepatotoxicity when compared with testosterone administration. Oxandrolone reaches peak serum concentrations within 1 hour and is excreted through the urine. Oxandrolone binds to androgen receptors in the skeletal muscle to initiate protein synthesis and anabolism. Because oxandrolone cannot be aromatized to estrogen, the likelihood of estrogen-dependent bone-age advancement is reduced, making oxandrolone a safe therapeutic approach for growing children.
Testosterone is not currently approved for treatment of burned children due to increased risks of virilization in female patients and aromatization effects among other health risks.
Glutamine and ascorbic acid supplementation can aid in burn recovery; however, it has not shown to have similar effects on bone density as oxandrolone. Several studies support the use of enteral glutamine supplements in the adult burn population. Research has also shown that glutamine supplementation is favorable as it has the potential to decrease length of stay and associated costs through improving wound healing and decreasing rates of infection and mortality.
Antioxidant therapies including: ascorbic acid; glutathione; N-acetyl-L-cysteine; vitamins A, C, and E; alone or in combination have been previously shown to protect microvascular circulation, mitigate changes in cellular energetics, decrease tissue lipid peroxidation, and decrease the volume of fluid required for resuscitation.
Insulin is used to treat hyperglycemia and primarily used in diabetic patients. It may have limited use in burn care patients but has not shown to increase bone mineral density.
A 25-year-old man presents with partial-thickness burns involving 15% of the total body surface area that he sustained during a house fire. The patient is stabilized and resuscitated. Topical 1% silver sulfadiazine cream is applied to the burns. Which of the following properties is most characteristic of this antimicrobial agent?
A) Greatly enhanced efficacy when compounded with thiol chelators
B) Metabolic acidosis
C) Poor capacity for wound bed penetration
D) Poor efficacy against Candida albicans
E) Potential for transient leukocytosis
The correct response is Option C.
In the United States, silver is the most commonly used topical antimicrobial. It is available as a liquid solution of AgNO3 or ointments such as silver sulfadiazine (Silvadene). Despite its many advantages, its capacity to penetrate into the wound bed is limited to the surface epithelium, particularly in the presence of eschar because of the binding of silver ions to surface proteins. In this setting, different modalities should be used for optimal effects. Silver sulfadiazine is not only effective against Pseudomonas species and enteric bacteria, but it also provides coverage against fungi, including Candida albicans, with antimicrobial effects lasting up to 24 hours.
Regarding the potential for transient leukocytosis, silver sulfadiazine has been shown to cause reversible neutropenia, which usually improves within a few days after discontinuation of the agent.
Enhanced efficacy when compounded with thiol chelators is consistent with bismuth compounds, not silver. Bismuth is another heavy metal with antimicrobial properties. The most commonly used formulation of bismuth for wound care is bismuth subgalactate, found in xeroform (Covidien) gauze. This heavy metal disrupts biofilm formation by inhibiting polysaccharide capsule production in bacteria. Bismuth’s antibacterial activity is enhanced when compounded with thiol chelators.
Metabolic acidosis is associated with mafenide acetate use.
A 51-year-old farmer is brought to the emergency department after sustaining extensive burns in a fertilizer explosion. Examination shows white phosphorus embedded in his burn wounds. In addition to burn resuscitation and examination of the wounds under ultraviolet light, application of which of the following is the most appropriate next step in management?
A) Calcium gluconate
B) Mafenide (Sulfamylon)
C) Mineral oil
D) Polyethylene glycol
E) Saline irrigation
The correct response is Option E.
White phosphorus is sustained in both military and civilian circumstances. It is commonly found in fireworks, fertilizers, and pesticide. It is extremely volatile and can ignite spontaneously upon exposure to air. Additionally, phosphoric acids form during combustion and further injure tissues.
Treatment mainstays include:
Immediate debridement of visible debris
Copious irrigation
Keep the area wet and covered with saline-soaked gauze
Cardiac monitoring and electrolyte evaluation.
Profound hypocalcemia, hyperphosphatemia, and sudden death have been associated with this injury.
Calcium gluconate gel is used in the management of hydrofluoric acid burns. Polyethylene glycol is used in the management of phenol and cresol burns. Mineral oil is used to isolate potassium, sodium, and magnesium from water, with which they react explosively. Mafenide (Sulfamylon) has no role in the immediate management of white phosphorus burns.
A 25-year-old right-hand–dominant woman sustains a full-thickness circumferential burn to the right upper extremity from the shoulder to the wrist. She undergoes early excision and grafting. Six months after treatment, she undergoes operative release of a severe flexion contracture of the elbow (greater than 50% loss of joint motion), resulting in a large defect. Which of the following is the most appropriate option for reconstruction of the defect?
A) Free fasciocutaneous flap
B) Full-thickness skin grafting
C) Local perforator flap
D) Split-thickness skin grafting
E) Z-plasty
The correct response is Option A.
In severe burn scar contractures, adjacent tissue transfer (Z-plasty, VY-plasty) and skin grafts are not indicated. Perforator-based local flaps have low recurrence rates but one limitation of this technique is the availability of local normal skin. In this specific case, no normal skin is available. Free tissue transfer is the best option. Perforator vessels are normally protected and can serve as recipient vessels for the free flap transfer.
A 32-year-old man is brought to the emergency department with a full-thickness thermal burn injury to the left ear. Which of the following therapeutic agents allows for the most effective preservation of involved cartilage?
A) Acetic acid
B) Honey
C) Mafenide acetate
D) Nanocrystalline silver dressings
E) Silver sulfadiazine
Mafenide acetate effectively penetrates burn eschar as well as cartilage and decreases the risk of suppurative chondritis in the setting of burns of the auricle. Twice-daily application is recommended. Care must be taken to monitor for metabolic acidosis, as mafenide acetate is metabolized to sulfamoylbenzoic acid, a carbonic anhydrase inhibitor. Silver sulfadiazine, nanocrystalline silver dressings, honey, and acetic acid have not demonstrated similar efficacy in preventing burn-associated chondritis.
A 43-year-old woman comes to the emergency department 2 hours after sustaining deep second-degree burns to the right elbow from a campfire. The wound measures 8 x 20 cm. After surgical excision, placement of autografts, and coverage with petrolatum gauze, which of the following dressings is most likely to promote graft survival?
A) Cotton balls and tie-over bolster dressing
B) Dry gauze and compressive wrap
C) Negative pressure wound therapy
D) Occlusive dressing
E) No additional dressing
The correct response is Option C.
In the patient described, the most effective way to fixate autografts is negative pressure wound therapy (NPWT). Several studies in burn patients have demonstrated the superiority of NPWT over the other conventional dressings listed. Whether staples or sutures are used has little effect on graft survival, although sutures may offer more precise graft placement. Most dressings for graft fixation use petrolatum gauze of some form, followed by some type of dressing that offers compression to fixate grafts. Dry gauze and a compressive wrap is the simplest option. Cotton balls with a tie-over bolster dressing are also effective, especially for small grafts. Larger surface areas are more difficult to secure with this method. A simple occlusive dressing, while acceptable for a donor site, will not effectively fixate autografts. NPWT offers good graft fixation, exudate removal, and promotion of local perfusion, which may explain the improved graft survival observed.
A 45-year-old man is brought to the burn unit after sustaining injuries during a house fire. Heart rate is 112 bpm, respiratory rate is 10/min, blood pressure is 113/63 mmHg, and oxygen saturation on room air is 98%. Physical examination shows charring of the face, singed eyebrows, and coarse breath sounds on inspiration. Which of the following is the most appropriate first step in management?
A) Application of a face mask at 40% oxygen
B) Bilevel positive airway pressure
C) Hyperbaric oxygen therapy
D) Intubation with 100% oxygen delivery
E) Oxygenation with 6 L nasal cannula
The correct response is Option D.
The patient is at risk for carbon monoxide (CO) toxicity and impending airway collapse. This patient was involved in a house fire and he has signs of lung injury. He should be intubated for airway protection because of his high potential for respiratory collapse. The patient’s normal-appearing oxygen saturation is a result of CO poisoning leading to carboxyhemoglobin being mistaken for oxyhemoglobin. Getting a carboxyhemoglobin level will assist in the diagnosis. The treatment for CO toxicity is 100% inhaled oxygen, which will lead to dissociation of the CO molecule from hemoglobin.
Hyperbaric oxygen treatment has been proposed as a potential treatment for CO toxicity, but the data are controversial, and treatment may be inappropriate in a burn patient undergoing resuscitation.
Even though the patient has an oxygen saturation of 98%, it is falsely elevated in CO poisoning.
This patient has stridor and is at risk for airway edema and should be immediately intubated.
Bilevel positive airway pressure does not protect the airway.
A 27-year-old man is evaluated in the intensive care unit for polytrauma 12 hours after sustaining burns on 10% of the total body surface area over the bilateral lower extremities during an industrial accident. The patient is sedated, intubated, and is being resuscitated appropriately. Examination shows the wounds are waxy and thick, but not circumferential. He has a nondisplaced fracture of the left tibia; physical examination of the left lower extremity shows that the toes are cool and cyanotic, which is markedly different from the right foot. Left lower extremity pulses are intact, but the left calf is much larger and firmer. Which of the following is the most appropriate next step in management of the left lower extremity?
A) Ankle brachial index
B) CT angiography
C) Elevation
D) Escharatomy
E) Fasciotomy
The correct response is Option E.
Compartment syndrome consists of increased pressure within enclosed compartments, resulting in decreased blood flow. For extremities, the concern is for muscle ischemia, as decreased perfusion is unable to supply the metabolic demand. The five P’s of compartment syndrome (pain, pallor, paresthesia, pulselessness, and paralysis) are a good guideline, but are not entirely helpful in this case. As the patient is intubated, pain, paresthesia, and paralysis are unable to be assessed. Skin pallor is confused by the burn eschar, and pulselessness is an extremely late finding. Compartment syndrome needs to be diagnosed early for intervention to be effective. High clinical suspicion is mandatory for this patient because of his clinical condition and trauma. Although measurement of intracompartmental pressures can be done, his ongoing fluid resuscitation and current clinical examination would prompt an emergent surgical intervention.
Elevation is not adequate treatment for compartment syndrome.
Escharotomy would be inadequate as all four fascial compartments will need to be released. Although a circumferential eschar can cause compartment syndrome, this patient does not have circumferential eschar and has a tibial fracture, which points to requiring fascial release.
CT angiography and ankle brachial index are good evaluations of flow and perfusion; however, they are not appropriate in the time sequence of this patient.
A 19-year-old man is undergoing open reduction and internal fixation of multiple facial fractures when the nasal endotracheal tube is accidentally disconnected from the breathing circuit. The surgeon, who is performing electrocauterization, witnesses an unexpected flash in the operative field. The surgeon immediately stops the procedure and alerts the anesthesiologist. Smoke and a burning odor coming out of the patient’s airway are noted. Which of the following is the most appropriate next step in management?
A) Decrease the flow of airway gases by half
B) Immediately remove the endotracheal tube
C) Pack the oral and nasal cavities with sponges
D) Perform emergency bronchoscopy
E) Reconnect the endotracheal tube
The correct response is Option B.
This surgical team is confronted with a fire in the operating room, involving the airway. The most appropriate next step is immediate removal of the endotracheal tube, without waiting.
The incidence of operating room fires in the United States is estimated to be around 600 cases per year. Fire requires the presence of three components: fuel, an oxidizer, and an ignition source. Common fuels in the operating room include alcohol-containing prepping agents, drapes and bandages, gowns and other personal protection equipment, petroleum jelly, etc. Ignition sources include the electrocauterization lasers, fiberoptic light sources, and defibrillators. The two most common oxidizing agents in the operating room are oxygen and nitrous oxide.
Early warning signs of fire include unexpected flash, flame, smoke or heat, unusual sounds (e.g., a “pop,” “snap,” or “foomp”) or odors, unexpected movement of drapes, discoloration of drapes or breathing circuit, and unexpected patient movement or complaint. The surgical procedure should be immediately halted so the team can evaluate whether fire is indeed present.
In cases of airway fire, the ASA practice advisory recommends immediate (without waiting) removal of the tracheal tube, interruption of flow of all airway gases, removal of all sponges or any other flammable materials from airway, and pouring of saline into the airway. Once the fire is extinguished, subsequent steps consist of re-establishing ventilation, avoiding oxidizer-enriched atmosphere if clinically appropriate, examining of the endotracheal tube for possible fragments left behind in the patient’s airway, and considering bronchoscopy.
A 25-year-old man sustains a high-voltage electrical injury of the right upper extremity with an entrance wound over the volar aspect of the wrist. If increased compartment pressures are not adequately relieved in time, which of the following muscles is most likely to develop an ischemic contracture?
A) Brachioradialis
B) Extensor carpi radialis brevis
C) Flexor carpi radialis
D) Flexor digitorum profundus
E) Palmaris longus
The correct response is Option D.
The above patient did not undergo forearm compartment release and has flexion contractures of the interphalangeal joints of the fingers and thumb due to ischemic necrosis of the flexor digitorum profundus (FDP) and flexor pollicis longus (FPL).
Volkmann ischemic contracture is the end result of untreated compartment syndrome. The deeper muscles in the forearm sustain higher pressure sooner and for longer, causing them to be the most affected by compartment syndrome. The FDP to the middle and ring fingers lies against the ulnar and interosseous membrane in the deep compartment of the forearm. These two muscle segments, in addition to the remaining segments of the FDP to the index and small fingers and the FPL, are the most likely to develop contracture. All other muscles listed are more superficial. While brachioradialis, palmaris longus, extensor carpi radialis brevis, and flexor carpi radialis can all become necrotic in untreated compartment syndrome, FDP and FPL are the most likely to do so due to their depth in the forearm.
In a patient with burns covering more than 30% of the total body surface area, which of the following parameters is most likely to increase in the first few hours of the pre-resuscitation phase?
A) Cardiac output
B) Peripheral blood flow
C) Plasma volume
D) Systemic vascular resistance
E) Urine output
The correct response is Option D.
Extensive burn injuries are characterized by the hemodynamic changes seen in hypovolemia, including decreased cardiac output, decreased peripheral blood flow, and decreased urine output. Decreased plasma volume is seen secondary to extravasation of plasma into the burn wound and surrounding tissues. Increased systemic vascular resistance is found in hypovolemia.
A 30-year-old man who sustained burns on 35% of the total body surface area 24 hours ago is being treated in the burn unit. The patient was resuscitated according to the Parkland formula and is maintaining adequate urine output. Gastric feeding access was established on initial presentation, and the patient is being fed according to his initial body weight. Which of the following clinical indices is most suggestive of the need to decrease his feeding to trophic feeds?
A) Early operative excision with planned start time in 8 hours
B) Hypotension requiring vasopressin support
C) Mild abdominal distension that is soft to palpation
D) Nasogastric output of 100 mL for the past 24 hours
E) Need for escharotomy
The correct response is Option B.
There is no doubt that nutritional support for burn patients is integral. A multidisciplinary approach to nutritional assessment and support is ideal, and general knowledge of the indications of when to delay or decrease enteral feeding is essential.
Since the patient has gastric and not post pyloric feeding access, nil per os (NPO) for eight hours allowing adequate gastric emptying to decrease risk of aspiration is necessary.
Gut mucosal integrity is important during the stress of large trauma including burn, and enteral feeding is the preferred modality of access. However, during times of extreme stress, decreased splanchnic flow can cause poor intestinal perfusion, and there is the possibility of gut ischemia due to increased metabolic demand of the gut. Decreasing the gastric feeds to trophic feeds is recommended to decrease the risk of inducing gut ischemia. Clinical indications for threatened intestinal perfusion include firm, obvious abdominal distension and gastric output greater than 200 mL per day; the patient doesn’t exhibit any of these clinical signs.
Hypotension requiring vasopressor support indicated decreased perfusion, which can lead to possible mismatch of gut perfusion with required metabolic demand. Trophic feeds are recommended for patients who exhibit signs of significant decreased perfusion requiring vasopressor support.
Escharotomy will increase fluid losses, but will not change caloric needs.
A 22-lb (10-kg), 18-month-old male infant is brought to the emergency department because of second- and third-degree thermal burns on the torso and lower extremities. Examination shows burns on 30% of the total body surface area. Administration of which of the following solutions is most appropriate for initial resuscitation of this patient?
A) Hypertonic saline
B) Normal saline
C) Normal saline with 5% dextrose
D) Ringer’s lactate
E) Ringer’s lactate with 5% dextrose
The correct response is Option E.
Fluid resuscitation is critical to combat the inflammatory response that occurs after a large burn and prevent the patient from going into shock. Burn injury leads to a combination of hypovolemic and distributive shock resulting from generalized microvascular injury and interstitial third spacing. The goal of fluid resuscitation is to ensure end-organ perfusion while avoiding intracompartmental edema. Ringer’s lactate solution is a relatively isotonic solution that has been advocated as the key component for almost all resuscitation strategies during the first 24 to 48 hours. It is preferable to isotonic normal saline in large-volume resuscitation because its lower sodium concentration (130 mEq/L vs 154 mEq/L) and higher pH concentration (6.5 vs 5.0) are closer to physiologic levels. Ringer’s lactate also has the potential added benefit of the buffering effect of metabolized lactate on the associated metabolic acidosis.
Toddlers in particular are susceptible to inadequate fluid resuscitation and should be monitored closely to ensure adequate urine output of at least 1 mg/kg/hr. In children with burns greater than 15% total body surface area, weighing less than 20 kg and younger than 2 years of age, 5% dextrose should be added to the resuscitation fluid to prevent life-threatening hypoglycemia. These younger patients have lower hepatic glycogen reserves that can be quickly depleted after such significant injuries.
Hypertonic saline and colloid solutions have been advocated and successfully used by some in large-volume resuscitation, but their use still remains controversial and not universally accepted in initial resuscitation.
A morbidly obese woman is brought to the emergency department after being found unconscious at home. Her family reports that both of the patient’s arms were pinned beneath her body when emergency medical service responders arrived. Physical examination shows tense swelling of the upper extremities. The now conscious patient reports severe pain to passive extension of the digits. In addition to appropriate urgent operative management, the surgeon should anticipate which of the following?
A) Decreased glomerular filtration rate
B) Hypercalcemia
C) Hyperglycemia
D) Hypokalemia
E) ST-segment elevation
The correct response is Option A.
This patient has bilateral upper extremity compartment syndrome. The emergency department examination of concern for a long-standing period of upper extremity ischemia. The surgeon should anticipate rhabdomyolysis and its consequent renal and metabolic disorders. Supportive treatment should be undertaken. Hyperkalemia is common in rhabdomyolysis manifesting as peaked T waves on ECG as serum potassium concentrations rise. Glucose D50W, 50 mL intravenously, plus regular insulin (5 to 10 units) move potassium from the extracellular fluid to the intracellular fluid. Intravenous mannitol increases renal blood flow (GFR), attracts fluid from the interstitium (thereby counterbalancing hypovolemia), increases urinary flow (prevents myoglobin cast obstruction), and functions as a free radical scavenger. Allopurinol may be helpful in reducing the production of uric acid. It also acts as a free radical scavenger.
Hypocalcemia is commonplace in the initial phase of rhabdomyolysis; however, it does not usually require correction because this would increase the risk of intramuscular calcium deposition. Indication for correcting hypocalcemia would be impending seizures.
A 154-lb (70-kg) man is evaluated 1 hour after sustaining deep partial-thickness burns to 50% of his total body surface area when attempting to light a gas grill. Paramedics administered 2 L of intravenous fluid during ground transport. Using the Parkland formula, which of the following is the starting rate for fluid resuscitation in this patient?
A) 375 mL/hr
B) 437 mL/hr
C) 583 mL/hr
D) 714 mL/hr
E) 875 mL/hr
The correct response is Option D.
The Parkland formula estimates the amount of crystalloid fluid needed for resuscitation of the burn patient, over the first 24 hours after injury. Volume needed = 4 mL × mass (kg) × % TBSA × 100. This patient would require 4 × 70 × 50% × 100 = 14,000 mL over the first 24 hours. Half of this, or 7 L, is given in the first 8 hours after injury. Because the patient received 2 L prior to arrival, during the first hour he would still need 5 L over the next 7 hours, or 714 mL/hr. Eight hours after injury, he would receive the other half, over 16 hours, or 437 mL/hr. It should be stressed that the Parkland formula serves as an initial guide to fluid resuscitation, and that actual volumes are titrated up or down, depending on urine output.
A 42-year-old lineman is evaluated after sustaining a high-voltage electrical injury while working on a transformer. Physical examination shows entrance wounds on the volar aspect of the right distal forearm. He reports numbness and tingling of the little finger and weakness of the grip of the right hand. Which of the following is the most appropriate next step in management?
A) Elevation of the forearm and observation
B) Escharotomy and carpal tunnel release
C) Escharotomy and excision of the burned tissue
D) Fasciotomy of the forearm
E) Fasciotomy and release of Guyon canal
The correct response is Option E.
This lineman has developed compartment syndrome involving at least the ulnar nerve and has signs of motor and sensory impairment. Escharotomy is not an adequate release in electrical injuries, which often involve deeper structures, such as the pronator quadratus. Therefore, fasciotomy is required. While a carpal tunnel release should be performed in this case, release of Guyon’s canal and decompression of the ulnar nerve in the forearm, wrist, and hand must be performed.
A 4-year-old boy is brought to a small community hospital by his grandmother, who reports that he fell into a bathtub filled with hot water while under the care of his stepfather. Physical examination shows deep partial-thickness burns on the lower extremities, including the feet, with a clear line of demarcation on the upper ankles; there are no splash marks. Multiple bruises scattered across the chest and periorbital ecchymoses are noted. Child abuse is suspected. Which of the following is the most appropriate next step?
A) Admit the patient to the community hospital for a full skeletal survey
B) Admit the patient to the community hospital for local wound care
C) Notify local police to apprehend the stepfather
D) Transfer the patient to a burn center by emergency medical services
E) Transfer the patient to a burn center by private vehicle
The correct response is Option D.
This child meets several criteria for transfer to a burn center: suspected child abuse, significant burns to the hands or feet, and a history that does not match the physical examination. While local police and the department of social services should be notified about this case, the role of the burn care provider is to make sure that the patient receives appropriate treatment and is transferred or discharged to a safe environment. The child will require assessment of the household by a social worker, as well as a pediatric consult to help look for other occult injuries, such as acute or healing long-bone fractures. Transfer to a burn center by private vehicle, despite the wishes of the family, would be placing the child at excessive risk for further injury. Transfer must be coordinated and performed by emergency medical services.
A 58-year-old man is brought to the emergency department for frostbite injury of the right thumb. A photograph is shown. Which of the following is the inciting mechanism of the injury?
A) Failure of DNA repair mechanisms
B) Formation of extracellular ice crystals
C) Osteonecrosis secondary to vasoconstriction
D) Polymerization of intracellular amino acids
E) Vascular endothelial damage
The correct response is Option B.
Frostbite occurs by the formation of ice crystals in the intracellular and extracellular spaces. During the cooling process, the extracellular ice crystals form, and osmotic pressure increases, dragging water out of the cells. This leads to intracellular dehydration and an increase in intracellular electrolytes, proteins, and enzymes that lead to cell death. Additionally, there is vascular endothelial damage leading to intravascular thrombosis and decreased blood flow. Arteriovenous shunting occurs at the capillary level, and end-organ tissue damage is compounded.
During the warming process, there is an influx of fluid back into the cells, causing intracellular swelling. The warming process also allows reflow, vasodilation, and reactive hyperemia to occur, leading to increased inflammatory mediators causing further cell death.
Frostbitten extremities should be rapidly rewarmed in water at a temperature of 104.0°F (40.0°C). Typically, rewarming can be completed in 20 to 30 minutes. Adjunctive use of anti-inflammatory medications and anticoagulants also has been described. Patience is required in determining which areas need debridement.
A 154-lb (70-kg), 45-year-old man undergoes excision and skin grafting after sustaining total body surface area burns to over 40% of his body. Using the Curreri formula, which of the following is this patient’s total daily caloric need?
A) 2250 kCal/day
B) 3350 kCal/day
C) 4450 kCal/day
D) 5550 kCal/day
E) 6650 kCal/day
The correct response is Option B.
The Curreri formula is used to calculate caloric needs.
25 kCal / kg / day + 40 kCal / %TBSA / day
So 25 × 70 + 40 × 40 = 3350 kCal/day.
An otherwise healthy 35-year-old woman is brought to the burn unit because of severe scalding injury to 50% of the total body surface area. Physical examination shows circumferential full-thickness burns to the right upper extremity, and absent distal pulses. Capillary refill time in the fingers is more than 3 seconds. Appropriate airway control and fluid resuscitation are initiated. Emergent right upper extremity escharotomies are performed. Despite surgical intervention, the blood flow to the distal extremity remains poor based on capillary refill time and Doppler flows. Which of the following is the most appropriate next step in management?
A) Additional escharotomies
B) Administration of an intravenous fluid bolus
C) Angiography
D) Elevation of the extremity and reexamination in 45 minutes
E) Fasciotomy of the upper extremity
The correct response is Option E.
The most appropriate next step in management is to proceed with urgent fasciotomies of the upper extremity. Indications for emergency extremity escharotomy are the presence of a circumferential eschar with impending or established vascular compromise of the extremities or digits. Progressive flow reduction by Doppler ultrasound is the primary indication for escharotomy. When evaluating upper extremities, it is advised to Doppler ultrasound the palmar arch, not the wrist, so as to evaluate distal blood flow. Other indications include decreased capillary refill time (more than 2 seconds), cyanosis, and/or relentless deep pain progressing to numbness (in awake patients). Neurovascular integrity should be monitored frequently and in a scheduled manner. Capillary refill time, Doppler signals, pulse oximetry, and sensation distal to the burned area should be checked hourly. After the escharotomy, any continued increase in capillary refill time, decrease in Doppler signal, or change in sensation should lead to immediate further decompression via fasciotomy. A carpal tunnel release is vital during the fasciotomy.
Escharotomies typically are performed at bedside under sterile conditions with intravenous sedation using electrocautery. The aim is to make surgical incisions through burned eschar to allow expansion of underlying tissues. In extremity escharotomies, full-thickness incisions along medial and lateral mid-axial lines should be made. Escharotomies should be carried to just beyond the area of the full-thickness burn. Digital escharotomies are performed along the mid-axial line between neurovascular bundle and extensor apparatus. The ideal side to perform escharotomy allows for preservation of pinch: thumb requires radial incision only, and the index finger, long finger, ring finger, and little finger require ulnar incisions only.
In the scenario described, further fluid boluses, escharotomies beyond the standard releases, and management would not be appropriate next steps, and would increase the risk of local complications like further ischemia, tissue necrosis/gangrene, or systemic complications like hyperkalemia, metabolic acidosis, and renal failure.
A 27-year-old man is brought to the emergency department after sustaining second- and third-degree burns to most of the anterior torso and the upper extremities. Which of the following describes the appropriate amount of Ringer’s lactate, according to the Parkland formula, for fluid management of this patient’s condition?
A) 1 mL/% TBSA/kg given over the first 6 hours
B) 2 mL/% TBSA/kg given over the first 8 hours
C) 2 mL/% TBSA/kg, half given over the first 8 hours
D) 4 mL/% TBSA/kg given over the first 6 hours
E) 4 mL/% TBSA/kg given over the first 8 hours
The correct response is Option B.
The amount of Ringer’s lactate (mL) needed for initial resuscitation is formulated by the Parkland formula of 4 mL/kg/% the total body surface area (TBSA) burned, with half this volume infused over the first 8 hours from the time of injury. In other words, for the first 8 hours, the patient should receive 2 mL/% TBSA/kg. All other options are not accurate based on the Parkland formula and this patient’s TBSA.
One easy way to determine the hourly rate for the first 8 hours is to multiply the % TBSA and kg, and divide by 4. Because the Parkland formula is 4 mL/% TBSA/kg, with half given over the first 8 hours, the 4 in the Parkland formula can be divided by 16 (2 × 8) to give a denominator of 4.
It is absolutely critical to perform accurate estimation of the burn size and weight, because overzealous fluid administration can lead to fluid creep, compartment syndromes, and pulmonary complications.
An otherwise healthy 22-year-old man is brought to the emergency department after sustaining full-thickness skin loss to the hands. Two-stage reconstruction is planned using a bilaminate neodermis (Integra), followed by skin grafting and simple gauze dressings. Which of the following is the average time for maturation (time from application to removal of silicone layer) of Integra with simple gauze dressings only?
A) 1 week
B) 3 weeks
C) 6 weeks
D) 9 weeks
E) 12 weeks
The correct response is Option B.
Integra is a bilaminar skin substitute, composed of a silicone outer layer (mimicking the epidermis) and a biologic scaffold for the inner, dermal layer. Typical maturation (time from application to removal of silicone layer) is 21 days. This process can be accelerated with the use of negative-pressure dressings, but that is not described in this scenario.
A 26-year-old lineman is brought to emergency department after accidentally grabbing a high-voltage power line. The most severe injury is seen at which of the following anatomical locations?
A) Chest wall
B) Neck
C) Shoulder
D) Upper arm
E) Wrist
The correct response is Option E.
Severity of injury is proportional to the cross-sectional area of tissue able to carry current. Thus, the most severe injuries are seen at the wrists and ankles, with decreasing severity proximally. The extremities are the most frequently injured body parts, with the upper extremity predominating.
Most high-voltage injuries occur in workers on the job, so the voltage is known. Temperature increase parallels changes in amperage with tissue temperature being a critical factor in the magnitude of tissue damage. Tissue resistance from lowest to highest is nerve, blood vessels, muscle, skin, tendon, fat, and bone. Deep tissue seems to retain heat so that periosseous tissues, especially between two bones, often sustain a more severe injury than more superficial tissue. The associated macro- and microscopic vascular injury seems to occur nearly immediately and is not reversible. Alternating current (AC) causes tetanic muscle contraction, which may either throw victims away from contact or draw them into continued contact with the electrical source, the latter being more common, given our propensity to grasp at objects and the greater strength in our forearm flexors relative to extensors. This effect is often described as the “no-let-go” phenomenon. Altered levels of consciousness are reported in about half of high-voltage injuries. The tissue injury in electrical burns seems to be a combination of thermal and nonthermal mechanisms. If enough heat is generated, the tissue heats to supraphysiologic temperatures causing denaturation of macromolecules, which is usually irreversible. Electroporation refers to the formation of aqueous pores in lipid bilayers exposed to a supraphysiologic electric field. The applied electric field alters the transmembrane potential, with muscle fibers and nerves being the most susceptible. Subsequent pore formation likely allows calcium influx into the cytoplasm, thereby triggering apoptosis and cell death. Electroporation can therefore induce cell necrosis in the absence of heating.
Transmembrane protein molecules contain polar amino acid residues that can change orientation in an electric field. This effect, known as electroconformational protein degradation, may be irreversible and form yet another mechanism of nonthermal injury.
A 72-year-old man with advanced congestive heart failure who recently received a left ventricular assist device (LVAD) comes to the office with an ulcerated mass in the mid-parietal region. Punch biopsies reveal squamous cell carcinoma of the skin. The patient has a history of bilateral temporal and midline craniotomies for resection of symptomatic meningiomas. Wide local excision of the tumor creates a scalp defect measuring 8 cm in diameter, with calvarial bone denuded of periosteum at its base. Which of the following is most appropriate for coverage of this patient’s defect?
A) Dermal regeneration template, followed by skin autograft
B) Fasciocutaneous free tissue transfer
C) Full-thickness skin autograft
D) Interpolated scalp flaps, with skin autograft to cover the secondary defect
E) Pericranial flap, covered with skin autograft
The correct response is Option A.
The most appropriate coverage of the oncologic defect in this patient is with a dermal regeneration template, such as Integra, followed by skin autograft.
Integra is a synthetic bilaminate neodermis composed of a collagen lattice covered with a thin silastic sheet. A single-layer version (collagen only) is also available, allowing stacking of the product for increased soft-tissue thickness. Vascularization of the collagen layer usually occurs in 3 to 4 weeks, at which point the silastic sheet is removed and a thin split-thickness skin autograft is applied. In the absence of pericranium, burring of the exposed calvarium down to healthy bleeding bone is recommended.
A skin autograft applied directly to calvarial bone denuded of periosteal coverage is unlikely to “take.” Interpolated scalp flaps, most likely requiring grafting of a secondary defect (donor site), would be appropriately indicated for coverage of a midparietal 8-cm defect. These are large flaps, based on the major blood vessels supplying the scalp, with an area of undermining that frequently involves the entire scalp. Unfortunately for this patient with multiple previous craniotomies, the resulting scars impose an unacceptably high risk for flap ischemia.
Similarly, a scar-free, well-vascularized pericranial flap large enough to cover the described defect is unlikely to be found in this patient. The safety and success of free tissue transfer in patients depending on LVADs for hemodynamic stability is still to be determined.
An otherwise healthy 35-year-old man is exposed to subzero temperatures for 24 hours. After initial management of hypothermia and rapid rewarming of the hands, bilateral upper extremity frostbite is evaluated. Physical examination shows severe frostbite of the hands and up to the wrists bilaterally. Which of the following is the most appropriate next step in management?
A) Corticosteroid therapy
B) Heparin therapy
C) Surgical debridement
D) Systemic antibiotic therapy
E) Thrombolytic therapy
The correct response is Option E.
The most appropriate next step in management is to consider intra-arterial thrombolytic therapy. The treatment of frostbite has remained essentially unchanged for the past 25 years. Classic management of frostbite injury includes resuscitation, rewarming, and watchful waiting. The outcome is either tissue recovery or progressive gangrene leading to eventual amputation. A variety of maneuvers aimed at advancing the care of patients with frostbite have been attempted, including hyperbaric oxygen, surgical and medical sympathectomy, pharmaceutical agents, and anticoagulation. None of these have resulted in alterations in the management of this disorder. Recent reports have described the use of thrombolytic therapy using urokinase or tissue plasminogen activator (tPA) as a potential therapy for frostbite.
The rationale for this therapy is based on the understanding that tissue injury in frostbite occurs from two distinct components. Initially, tissue freezing and crystal formation occur and then are improved with tissue rewarming. The more significant cause of tissue injury occurs after thawing, and it is the robust local tissue inflammation and coagulation that stimulate microvascular thrombosis and progressive cell death. By reversing local microvascular thrombosis, tPA has been postulated to restore perfusion before irreversible ischemia and necrosis.
Systemic corticosteroids or antibiotics are not indicated at this time. Systemic heparinization is usually employed as an adjunct after intra-arterial thrombolytics have been initiated. However, it is delivered intravenously. Surgical debridement is done in a delayed fashion after the area of frostbite has demarcated, sometimes weeks to months later.
A 35-year-old man is admitted to the burn unit after sustaining superficial partial-thickness burns involving 25% of the total body surface area. Medical history includes an allergy to sulfonamide. The burns are cleaned, and silver nitrate–soaked dressings are applied. Which of the following is most likely in this patient?
A) Hyponatremia
B) Metabolic acidosis
C) Neutropenia
D) Painful application
E) Thrombocytopenia
The correct response is Option A.
Because of the skin’s important function as a microbial barrier, prevention of infection after burn injury is still one of the most difficult challenges in caring for burn patients. The development of effective topical antimicrobial agents has markedly reduced the incidence of invasive burn wound infection and sepsis. Topical therapy should be started after the initial wound debridement. The three most common topical antimicrobial agents are silver sulfadiazine (Silvadene), silver nitrate, and mafenide acetate (Sulfamylon).
Silver nitrate is typically delivered as a 0.5% solution as a wet dressing. Silver nitrate has excellent antibacterial properties and is effective for most Staphylococcus species and most gram-negative aerobes, including Pseudomonas. This agent is typically used when there is a history of sulfonamide allergy or when sensitivity to the other agents has developed. A common use of silver nitrate is in the setting of toxic epidermal necrolysis. Application is painless, but tissue penetration is poor. Concentrations above 5% are cytotoxic to healthy tissues. Because leaching of sodium, potassium, and calcium is common, this effect should be anticipated and replaced appropriately.
Painful application is associated with mafenide acetate (Sulfamylon). Mafenide acetate is delivered as suspension in a water-soluble base. As a result of its solubility, it has excellent tissue penetration and is often used in heavily contaminated wounds with thick eschar. Because of excellent cartilage penetration, it is also the agent of choice with ear burns. Mafenide acetate is highly effective against gram-negative organisms. Adverse effects include hypersensitivity reactions (7% of patients) and inhibition of carbonic anhydrase with a resultant hyperchloremic metabolic acidosis.
Silver sulfadiazine is the most common topical antimicrobial agent used. It has intermediate tissue penetration secondary to its limited water solubility. This agent has a good antibacterial spectrum, a low incidence of development of resistant organisms, and is applied painlessly. Transient leukopenia is a common adverse effect of silver sulfadiazine. This condition is self-limited and does not appear to increase mortality in burn patients. Switching to a different topical agent for a few days will allow the white blood cell count to return to normal.
Thrombocytopenia is not associated with silver nitrate.
An 18-year-old woman who sustained a flame burn involving 50% of the total body surface area is resuscitated to a stable cardiovascular and respiratory status. Four days after injury, she undergoes tangential excision and xenografting of all burned areas. Following surgery, the patient returns to the ICU intubated and ventilated. She has thick pulmonary secretions. She received 2 units of packed red blood cells during surgery. Vital signs are as follows:
Temperature99.5°F (37.5°C)
Heart Rate130 bpm
Respiratory Rate22/min
Blood Pressure80/50 mmHg
Oxygen saturation is 96% on 40% FIo2. Cardiac output is 6 L/min, and urine output is 0.1 mL/kg/h. Which of the following is the most likely explanation for these abnormal findings?
A) Acute respiratory distress syndrome
B) Hypovolemic shock
C) Pneumonia
D) Pulmonary embolism
E) Sepsis
The correct response is Option B.
The most likely explanation for this patient’s abnormal physiology is hypovolemic shock. The patient just underwent tangential excision of a 50% total body surface area burn, and marked blood loss is to be expected. She received 2 units of packed red blood cells, but this is unlikely to be adequate for such a large burn excision. In addition, her vital signs are typical for hypovolemic shock. Sepsis and acute respiratory distress syndrome (ARDS) are often seen in patients with large burns, but they are usually seen later in the hospital course. Sepsis is associated with fever and a high cardiac output. ARDS is associated with previous large-volume transfusions and lung injury, and should not cause hypotension in isolation. It is also associated with more severe hypoxia. Pneumonia and pulmonary embolism are also associated with a more profound hypoxia than this patient exhibits and are usually seen later in a burn patient’s hospital course.
A 27-year-old man is brought to the regional burn center 4 hours after he got lost in a snowstorm while he was hiking. Physical examination shows severe frostbite of the feet, purple coloring of the toes, heavy blistering, and marked edema. On Doppler examination, pulses are absent bilaterally. He sustained no other injuries and is otherwise healthy. In addition to warming and pain control, which of the following is the most appropriate next step in the treatment of this patient?
A) Angiography
B) Fasciotomy
C) Hyperbaric oxygen therapy
D) Intravenous administration of heparin
E) Technetium-99 triple-phase scanning
The correct response is Option A.
Frostbite is a common injury to the homeless and outdoor adventurers. Direct injury is caused by extracellular freezing of tissues with significant changes of the osmotic gradient of cells which can cause significant electrolyte imbalances. Many inflammatory mediators, including thromboxanes, prostaglandins, histamine, and bradykinin are released which lead to significant edema, endothelial injury, and tissue damage.
The mainstay of frostbite injuries, regardless of severity, includes rewarming, pain control, administration of tetanus prophylaxis, and frequent dressing changes and wound care. In cases of severe frostbite injuries with absent pulses, emergent angiography and infusion of tissue plasminogen activator (tPA) have been shown to significantly decrease the rate of amputation if administered within 24 hours of the onset of frostbite.
Although fasciotomy might be necessary after reperfusion, it is not indicated as a first-line therapy for frostbite. Likewise, heparin and hyperbaric oxygen have not been shown to improve the outcomes in frostbite injuries.
Technetium-99 triple-phase scanning can accurately estimate the level of eventual amputation required if performed in the first several days, but it is not a therapeutic modality and would delay the angiography and administration of tPA if indicated.
A 165-lb (75-kg), 40-year-old man is brought to the emergency department 3 hours after sustaining first-degree burns to the hands and second- and third-degree burns to the entire anterior thorax and both anterior and posterior lower extremities. According to the Parkland formula, administration of which of the following is the most appropriate method of initial fluid resuscitation in this patient?
A) Hypertonic saline solution 253 mL/hr for 5 hours
B) Hypertonic saline solution 1181 mL/hr for 8 hours
C) Ringer’s lactate 506 mL/hr for 24 hours
D) Ringer’s lactate 1013 mL/hr for 8 hours
E) Ringer’s lactate 1620 mL/hr for 5 hours
The correct response is Option E.
Massive injury and burns result in a systemic inflammatory response with resultant leakage of fluid into the interstitial space. Large fluid shifts can decrease perfusion to vital organs and inadequate resuscitation will result in acidosis, oliguria, and relative polycythemia. Fluid replacement is based on the observation that intravascular fluid loss into the interstitium is relatively constant during the first post-injury day. All fluid, therefore, is administered at a constant rate to avoid excessive interstitial edema. Patients are monitored for an adequate clinical response by measurement of hourly urine output (0.5–1 mL/kg/hr for adults) with adjustments as needed. Invasive monitoring may be necessary in elderly patients, patients with cardiac dysfunction, or patients with severe pulmonary injury.
A variety of fluid resuscitation formulas are available to guide the initial management of fluid replacement. The Parkland formula and its variations have become the standard methods for resuscitation. Isotonic crystalloid, Ringer’s lactate in particular (sodium concentration of 130 mEq/L) is the fluid of choice. The Parkland formula directs the resuscitation as follows: 4 mL of fluid × patient weight in kilograms × total body surface area (TBSA) percentage of second- and third-degree burns. Half of this total volume is delivered in the first 8 hours and the second half over the ensuing 16 hours. In a delayed presentation (3 hours in this clinical example), half of the total volume must be delivered within the 8-hour window (remaining 5 hours in this example).
The TBSA is calculated using the “Rule of Nines,” as follows:
Head/Neck = 9%
Each upper extremity = 9%
Anterior thorax = 18%
Posterior thorax = 18%
Each lower extremity = 18%
Groin = 1%
In this patient example, the TBSA of burn is 54%: Anterior thorax (18%) + each lower extremity (18% + 18%). The Parkland formula considers only second- and third-degree burns for calculation of resuscitation volume; therefore, the first-degree burns in this case are ignored.
In this clinical example, 4 mL × 75 kg × 54% TBSA = 16,200 mL total fluid over 24 hours. The patient will require 8100 mL in the first 8 hours and 8100 mL over the ensuing 16 hours. Because the patient presented 3 hours post burn, he will require 8100 mL over the next 5 hours which gives an hourly rate of 1620 mL/hr.
An otherwise healthy 25-year-old chef comes to the office 2 hours after sustaining scald burns when she accidentally spilled a large pot of soup. She says she washed the area immediately and dressed the burns with silver sulfadiazine. She is alert and her condition is stable. Physical examination shows partial-thickness burns on the lower abdomen, perineum, external genitalia, and anterior thighs involving approximately 15% of the total body surface area. Which of the following is the most appropriate next step in management?
A) Administration of oral antibiotics
B) Outpatient care with silver sulfadiazine
C) Parkland formula fluid resuscitation
D) Referral to the inpatient burn center
E) Split-thickness autografting
The correct response is Option D.
The patient described with a partial-thickness burn greater than 10% of the total body surface area (TBSA) and a burn to the perineum meets the criteria for referral to the burn center. Other criteria for burn center referral, as advised by the American Burn Association, include burns that involve the face, hands, feet, genitalia, perineum, or major joints in both young or old patients (younger than age 5 years or older than age 60 years); third-degree burns in any age group; inhalation injury; electrical and lightning burns; chemical burns (especially hydrofluoric acid burns); and any patients with preexisting medical or social conditions that could adversely affect outcomes. Also, children admitted to a hospital without pediatric specialty care should be transferred, if possible.
Studies suggest that outcomes of complex burns improve at high-volume care centers. Most types of small burns can be managed well as outpatient cases, especially by motivated, healthy patients. Others may be eligible for home care to help with dressings if needed. High-volume fluid resuscitations, such as the Parkland formula, are employed for burns greater than 20% TBSA, as the inflammatory response mechanisms that necessitate high-volume resuscitations rarely occur with burns under 20% TBSA. Usually, oral fluids and/or modest intravenous supplementation are sufficient. Autografting should be reserved for deep or function-impeding burns that fail to respond to initial optimal burn wound care.
A 25-year-old woman is brought to the emergency department after sustaining deep partial-thickness and full-thickness burns to the face, neck, chest, back, and bilateral upper extremities in a grease fire. The patient is intubated and resuscitated, and the wounds are managed surgically. Which of the following is the most appropriate position to splint the burned areas?
A) Elbow extended at 180 degrees
B) Hands in intrinsic minus position
C) Neck flexed at 45 degrees
D) Shoulder abducted at 60 degrees
E) Wrist flexed at 10 degrees
The correct response is Option A.
The most appropriate position to splint the different burned areas is neck in slight extension, shoulder fully abducted to about 90 degrees, elbow fully extended at 180 degrees, wrist in neutral or slightly extended, and hands in intrinsic plus position or position of function. This is done to prevent contractures that would pull these joints into positions that would lead to functional deficits.
A 59-year-old postal worker comes to the emergency department because of numbness and discoloration of the right thumb. He says he was outdoors for 8 hours in a temperature of -15°F (-26°C) and had taken ibuprofen before arrival. Physical examination shows distal bluish skin without capillary refill. A photograph of the thumb is shown. Which of the following is the most appropriate initial management?
A) Debridement or amputation of dead tissue, if necessary, to avoid infection
B) Debridement of any hemorrhagic blisters
C) Discontinue antiprostaglandins
D) Observe and allow the tissue to fully demarcate
E) Rapid rewarming with radiant heat
The correct response is Option D.
The decision to allow tissue to fully demarcate is essential in the scenario described because it is difficult to determine which tissue may survive in the immediate postinjury period. This period may be 6 months.
Clear blisters are debrided because they contain high concentrations of inflammatory mediators. Inflammatory mediators lead to greater tissue injury. Hemorrhagic blisters are not debrided because this may cause exposure of deep structures and increase the risk of desiccation and subsequent necrosis.
Early debridement and amputation are necessary if soft-tissue infection develops during the waiting period; otherwise, they are not indicated. Premature amputation risks sacrifice of potentially salvageable tissue.
Antiprostaglandins, either topical (such as 70% aloe cream) or oral (ibuprofen 12 mg/kg), are beneficial to block the cascade of arachidonic acid by cyclooxygenase and the inflammatory process. Beneficial effects of antiprostaglandins include vasodilatation and antiplatelet aggregation.
Rapid rewarming decreases further tissue damage as it halts both direct injury and continued release of secondary mediators. Submersion of the injured part in 104°F (40°C) water for 15 to 30 minutes is ideal. This maneuver stops ice crystal formation and reverses the deleterious effects of vasoconstriction. Use of radiant heat sources in frostbite can lead to iatrogenic injury due to uneven thawing and, in unusual cases, secondary thermal burn to insensate tissue. Before and after photographs are shown.
A 25-year-old woman with burns on 85% of the total body surface area undergoes staged wound excision but shows limited donor sites for skin grafting. Cultured epidermal autografts (CEAs) are prepared to help resurface the wounds. Which of the following properties is the primary advantage of the use of CEAs over split-thickness skin grafts?
A) Cultivation period of 1 week
B) Expansion of donor keratinocytes
C) Negligible production cost
D) Stable coverage of the lesion
E) Use of autologous materials during cell culture
The correct response is Option B.
Theoretically, cultured epidermal autografts (CEAs), also known as cultured keratinocytes, are an attractive option to help resurface large wounds, such as in the massively burned patient with limited donor sites. After obtaining a small skin biopsy, tissue is then processed ex-vivo by a commercial tissue-engineering laboratory. Within 3 weeks, keratinocytes can be expanded 10,000-fold and are ready for grafting. CEAs, however, must be grown with murine fibroblasts and fetal calf serum, both of which contain xenogeneic proteins that survive at the time of transplantation and may account for ?rejection? of these autografts. Furthermore, CEAs lack a dermal component and are extremely fragile, susceptible even to mild sheer forces. Finally, CEAs are very expensive, costing as much as ,000 for every 1% of the total body surface area that is ultimately covered.
A 25-year-old woman who sustained burns to 85% of the total body surface area in a house fire undergoes staged excision of the wound but has limited donor sites for skin grafting. Cultured epidermal autografts are applied for resurfacing. Which of the following is the most significant advantage of this procedure?
(A) Cost effectiveness
(B) Expansion of donor keratinocytes
(C) Immediate availability of autogenous materials
(D) Short cultivation period
(E) Stable coverage of grafted wounds
The correct response is Option B.
Cultured epidermal autografts (CEAs), also known as cultured keratinocytes, are theoretically attractive to help resurface large wounds, such as in the massively burned patient with limited donor sites. After obtaining a small skin biopsy, tissue is then processed ex vivo by a commercial tissue-engineering laboratory. Within three weeks, keratinocytes can be expanded 10,000-fold and are ready for grafting. CEAs, however, must be grown with murine fibroblasts and fetal calf serum, both of which contain xenogeneic proteins, which survive to transplantation and may account for “rejection” of these autografts. Furthermore, CEAs lack a dermal component and are extremely fragile, susceptible even to mild sheer forces. Finally, CEAs are very expensive, costing as much as $13,000 for every 1% total body surface area ultimately covered.
A 40-year-old man has second- and third-degree burns involving 55% of the total body surface area. Which of the following immunologic responses is most likely in this patient during the first week after injury?
A) Downregulation of integrins
B) Downregulation of cytokines tumor necrosis factor (TNF)-a and interleukins 1 and 8
C) Increased B-lymphocyte function
D) Increased levels of circulating immunoglobulins
E) Increased T-suppressor lymphocyte function
The correct response is Option E.
Nearly all aspects of immune function are affected by thermal injury, and the effect is directly related to the extent of the injury. Burns that are on greater than 30% of the total body surface area result in a greater systemic inflammatory response because of circulating cytokines and immune mediators.
Both humoral and cellular-mediated immunity are impaired by thermal injury and are manifested by diminished activation of complement and depressed levels of circulating immunoglobulins; upregulation of integrins and the cytokines TNF-a and interleukins 1 and 8 (IL-1, IL-8); decreased B-lymphocyte, natural killer cell, and T-helper lymphocyte function; and an increased number and activity of T-suppressor lymphocytes. These changes normalize during the ensuing 2 to 3 weeks in patients whose course is uncomplicated.
TNF-a and IL-1 and IL-8 increase neutrophil chemotaxis into the wound as well as the upregulation of cell surface integrin receptors. These migrating neutrophils can degranulate, releasing proteases and oxygen-free radical species, leading to further tissue damage. Experimental studies using monoclonal antibodies directed against cell surface receptors have shown diminished tissue necrosis and a subsequent decrease in the surface area of burn.
Diminished phagocytosis and reduced activation of complement result in diminished antibody-presenting complexes and membrane-attacking complexes. Along with diminished T-helper lymphocyte function, this results in decreased B-lymphocyte numbers, lymphocyte function, and levels of circulating immunoglobulins, especially immunoglobulin G. In addition to decreased production, circulating antibodies are also lost due to increased protein turnover and plasma leakage resulting from increased capillary permeability. Serum immunoglobulin levels gradually return to normal during the ensuing 2 to 4 weeks as the patient recovers.
Impairment of cell-mediated immunity resulting from alterations in T-lymphocyte function is evidenced by a decrease in T-cell function and number, reduced T-helper and natural killer cell activity, and increased T-suppressor function and number. Impairment in T-cell mediated immunity is demonstrated by delayed rejection of allograft skin, suppression of graft-versus-host response, and skin hypersensitivity reactions. Better understanding of altered T-helper lymphocyte activity and the associated cytokine profiles may allow for immune-directed therapies that may decrease morbidity and mortality.
A 19-year-old woman comes to the office for a follow-up examination 18 months after skin grafting for burns over 25% of her total body surface area that includes the face, neck, chest, and shoulders. Physical examination shows persistent restriction of neck excursion and lateral range of motion. A photograph is shown. Which of the following is the most appropriate management?
A) Compression therapy
B) Corticosteroid injection
C) Silicone sheeting
D) Skin grafting
E) Z-plasty tissue rearrangement
The correct response is Option E.
The patient described has a condition that is common among burn patients with significant burns to the neck area; that is, contracture band formation, even after primary attempts at skin grafting. Contractures are produced not only by absolute skin loss and/or skin contraction along a straight line scar, but also by the differential growth rate between the burn scar and the rest of the adjacent normal skin and tissues, especially in younger patients.
There are various techniques used to release contractures. Management depends on both the location of the contracture as well as the availability of unaffected adjacent skin. Methods of release include tissue expansion, local and distant flaps, ?alphabet plasties? (Z, W, V-Y, etc.), and skin grafting. The most appropriate option for the patient described is a Z-plasty, especially as she has failed a prior attempt at skin grafting. Through soft-tissue rotation, Z-plasty accomplishes three things: (1) lengthens a contracted scar, (2) breaks up a straight line, and (3) shifts soft-tissue contour.
Compression therapy/splinting is useful as an adjunct therapy but not as a primary treatment of this deformity. The patient described does not have a hypertrophic or keloid scar – it is a contracture band. Therefore, the injection of corticosteroids and silicone sheeting are not indicated in the treatment of this deformity.
The advantage of skin grafts, in general, is the transfer of new skin from a previously uninjured area of the body to the area in need with low donor site morbidity, though full-thickness grafts generally have larger donor site morbidity than split grafts. The disadvantage of skin grafts is that they tend to recontracture, necessitating further release through reoperation, as in the scenario described. Prolonged periods of postoperative physiotherapy and splinting are required to maximize aesthetic and functional results.
A 50-year-old woman comes to the emergency department because of an itchy skin rash 2 weeks after administration of trimethoprim-sulfamethoxazole for treatment of a urinary tract infection. Temperature is 99.5°F (37.5°C), pulse rate is 110 bpm, respiratory rate is 28/min, and blood pressure is 95/60 mmHg. Oxygen saturation on pulse oximetry is 96%. Physical examination shows an exfoliating skin rash on 35% of the total body surface area. Which of the following is the most appropriate next step in management?
A) Administration of systemic corticosteroids
B) Full-thickness skin biopsy
C) Intravenous administration of immune globulin
D) Topical application of silver sulfadiazine
E) Transfer to a burn center
The correct response is Option E.
A patient who develops an exfoliating rash 1 to 3 weeks after starting a specific medication, such as trimethoprim-sulfamethoxazole (Bactrim), allopurinol, or phenytoin (Dilantin), has toxic epidermal necrolysis syndrome (TENS, also known as Stevens-Johnson syndrome) until proven otherwise. Patients with TENS often have several days’ worth of indolent and nonspecific symptoms, such as malaise, fever, and dysphagia. These symptoms progress rapidly to hemodynamic collapse, skin exfoliation, and mucosal sloughing.
Mortality for patients with TENS is 30%. The proposed mechanism is an acute autoimmune response to the basement membrane of epithelial structures, induced by drug exposure. Incidence is one case per million.
Skin biopsy is pathognomonic but should not delay treatment. Administration of intravenous immune globulin and systemic corticosteroids are both controversial and may have negative effects. Application of topical silver sulfadiazine as a wound care cream is contraindicated because of the potential for exacerbation of the immune response from the sulfa moiety of this agent. Although many modalities of treatment have been proposed, only transfer to a burn center has been universally accepted as a priority because of the critical care and wound care necessary to impact survival.
A 34-year-old man comes to the emergency department after sustaining electrical burns to the right upper extremity while working on high-voltage power lines. Physical examination shows full-thickness burns on the right volar forearm involving 3% of the total body surface area. Poikilothermia and pallor are noted over the affected area. Pulses are not palpable. Supplemental oxygen is administered, and fluid resuscitation is initiated. Which of the following is the most appropriate next step in management?
A) Elevation of the arm
B) Escharotomy of the volar forearm
C) Fasciotomy of the volar forearm only
D) Fasciotomy of the volar forearm and carpal tunnel release only
E) Fasciotomy of the volar forearm, including decompression of the pronator quadratus, and carpal tunnel release
The correct response is Option E.
Following high-voltage injury with full-thickness or partial-thickness skin loss, patients may develop compartment syndrome. In such cases, immediate decompression is mandated. Patients typically show the pentad of pain, paresthesias, pallor, poikilothermia, and pulselessness. In addition to releasing the eschar and the fascia of the forearm, carpal tunnel release is important to decompress both the palmar arch and median nerve. Exploration of the deep compartment of the forearm, including the pronator quadratus, is essential, as tissue injury may increase in proximity to the radius and ulna due to the heat generated by passage of the electrical current. The other options are helpful but not sufficient.
A 57-year-old man develops exposure keratitis, corneal ulceration, and bilateral upper and lower eyelid ectropions 2 months after sustaining burns to the head and neck during a gas grill explosion. A photograph is shown. A tracheostomy was performed at the time of the accident for inhalation injury. Which of the following is the most definitive treatment modality for this patient’s condition?
A ) Adhesion tarsorrhaphy
B ) Bilateral tarsoconjunctival flaps
C ) Frost sutures
D ) Lateral tarsal strip canthoplasty
E ) Staged upper and lower ectropion releases with skin grafts
The correct response is Option E.
The patient described requires definitive treatment of the burn ectropions, which involves release of the ectropion and resurfacing of the orbicularis muscle with high-quality skin that will resist contraction. Although full-thickness skin grafts will have less of a tendency to contract than
split-thickness skin grafts, the shoulder and supraclavicular fossa are superior to the groin as donor sites in terms of texture and color match. Photographs are shown.
Tarsorrhaphy alone will provide temporary coverage of the cornea but neither addresses the underlying pathophysiology nor provides definitive correction of the ectropion. Simultaneous correction of all four eyelids does not permit adequate release of the ectropions, which must be overcorrected before grafting.
Although Frost sutures, tarsoconjunctival flaps, and lateral tarsal strip canthoplasties will provide temporary corneal protection, these procedures do not address the underlying problem, which is contracture of eyelid, forehead, and cheek skin, secondary to burn injury.
A 62-year-old woman comes to the office for consultation regarding problems with her left eye (shown) 6 months after sustaining a 25% total body surface area (TBSA) burn that involved the face and neck. She reports that the upper eyelid turns outward, that she cannot close the eye completely, and that the eye tears excessively. These symptoms have persisted despite skin grafting several months ago by another surgeon. Physical examination confirms ectropion of the upper eyelid, lagophthalmos, and epiphora of the left eye. Which of the following is the most appropriate next step in management?
A ) Insertion of a gold weight
B ) Paramedian forehead flap
C ) Permanent lateral tarsorrhaphy
D ) Reverse tarsoconjunctival flap
E ) Skin grafting
The correct response is Option E.
Patients with significant burns to the periocular area commonly have ectropion with corneal exposure, even after primary attempts at skin grafting. It is clear that damaged contracted skin has left this patient’s skin short, thereby preventing complete closure of the eyelid. The optimal method of eyelid reconstruction in this patient is a release of the burn scar contracture with placement of nonburned, thin, pliable skin to the area in order to bring tissue to the area, thereby correcting the underlying problem. Although multiple options for reconstruction exist, the most reasonable would involve regrafting the upper eyelid. While the literature’s dogma has been to graft the upper eyelid with split grafts and the lower eyelid with full-thickness grafts, this has not been definitely proven one way or the other by the available data. However, repeat grafting (either with thin or full-thickness grafts) to correct this problem has been used successfully to achieve good outcomes.
A gold weight is used for the paralytic eyelid after facial nerve injury.
A permanent lateral tarsorrhaphy can be performed but will narrow the ocular aperture and can be irritating to the patient.
Forehead flaps have been described to reconstruct eyelids, especially large full-thickness defects. Their biggest downside, however, is the thickness of the tissue transferred, which certainly does not reapproximate the thickness of the native upper eyelid. It also involves a two-stage procedure. The patient described has suffered burns to her face and neck, including the forehead, which renders this method of reconstruction suboptimal.
A reverse tarsoconjunctival flap can be used to reconstruct upper eyelids; however, it is generally used when the lower eyelid is not involved in the injury. It also has the disadvantages of requiring two operations, occluding the visual axis, and can only be performed with a minimum of lower eyelid tarsus, as only 2 to 3 mm is available for transfer. This patient’s upper eyelid requires more tissue than what this technique can deliver.
A 5-year-old boy is brought to the emergency department after he sustained burns in a gasoline fire. Physical examination shows burns to 70% of the total body surface area, including the right ear (shown). Which of the following is the most appropriate initial management of the burns to this patient €™s ear?
(A) Application of mafenide acetate (Sulfamylon) cream and auto-amputation
(B) Costochondral reconstruction with a temporoparietal flap
(C) Debridement and coverage with a retroauricular pocket flap
(D) Excision and full-thickness skin grafting
(E) Excision and unmeshed split-thickness skin grafting
The correct response is Option A.
Ear burns are usually aggressively managed with mafenide acetate (Sulfamylon) cream, monitoring for chondritis, and allowing the severely burned region to auto-amputate. This is especially true for large total body surface area (TBSA) burns such as the one sustained by the patient described, where large areas of excision and grafting must be done to save the patient €™s life. This is largely a problem of ear deformity, not function, and therefore has a lower priority.
Mafenide acetate (Sulfamylon) cream is the best topical antibiotic agent suitable for the ear because it penetrates the eschar and cartilage. It is applied twice daily. Trauma to the ear by dressings, endotracheal tapes, or pillows should be avoided. The eschar should not be completely debrided, as it acts as a biological dressing that prevents desiccation.
The more aggressive managements of costochondral reconstruction or retroauricular flap reconstruction are not warranted in the acute phase and can limit future reconstructive options.
Excision and full-thickness skin grafting can be considered in the intermediate management but are generally contraindicated in such a large burn after the wounds become heavily colonized. Excision and split-thickness skin grafting can be considered as well.
A 19-year-old man who sustained burns to 40% of the total body surface area at 4 years of age comes to the burn clinic for consultation regarding correction of the scalp defect shown. Physical examination shows patchy alopecia of the temporal scalp and hypertrophic scarring. Which of the following is the most appropriate surgical procedure for reconstruction of this patient=s scalp?
(A) Hair transplantation with micrografts and minigrafts
(B) Orticochea flap
(C) Serial excision and closure
(D) Temporoparietooccipital (Juri) flap
(E) Tissue expansion
The correct response is Option E.
The patient shown has a large (>25 cm2) parietal scalp defect that resulted from a flame burn. It is clear that hair transplantation has already been attempted with minimal take and coverage. Hair transplantation with micrografts and minigrafts is a technique that has been described to treat large areas of burn alopecia. However, it is usually reserved for smaller areas, or as a revisional procedure to camouflage incisions that result from rotational flaps.
Tissue expansion is the preferred method for secondary reconstruction of a large parietal scalp defect. Approximately 50% of scalp can be reconstructed with expanded scalp tissue, although this may require multiple stages. Expander complication rates may be as high as 25% and may include infection, exposure, extrusion, and device failure. Scalp expansion in children is difficult. There is a higher incidence of infection and decreased tolerance of pain. Moreover, there is a risk of skull deformation after a prolonged period of expansion. Therefore, deferral until the patient reaches young adulthood is reasonable.
Direct closure in a staged manner with serial excision or as a single €‘stage procedure with rotation advancement flaps is appropriate for small to medium-sized defects of the anterior and parietal scalp. The size of this defect would preclude this therapy in this case.
Temporoparietooccipital flaps as described by Juri are optimally suited for reconstruction of large defects of the anterior scalp. Orticochea flaps are classically described for reconstruction of large defects of the occipital scalp. They are not useful for parietal defects because tissue advancement from the contralateral parietal scalp up over the vertex is often inadequate for defect closure.
A 35-year-old man is brought to the emergency department because of deep burn injury to the dorsum of the index, middle, and ring fingers of the dominant left hand (shown) resulting from direct contact with a hot motorcycle engine during a motor vehicle collision. On tangential excision, tendons are exposed in each finger and loss of the paratenon is noted. Which of the following is the most appropriate surgical management?
(A) Split-thickness skin grafting
(B) Dorsal metacarpal artery flaps
(C) Cross-finger flaps
(D) Reverse radial forearm flap
(E) Groin flap
The correct response is Option D.
Because the paratenon has been removed, immediate split-thickness skin grafting will result in areas of graft loss. Dressing changes could be performed followed by grafting on a granulated bed. This method of treatment risks tendon desiccation while awaiting granulation tissue.
Dorsal metacarpal artery flaps can be useful in reconstructing dorsal hand and proximal finger defects. To repair a dorsal finger defect more distally, a reverse dorsal metacarpal artery flap could be used.
Cross-finger flaps use dorsal skin of adjacent fingers to resurface palmar defects. A variation of the cross-finger flap can be used to resurface a dorsal defect. This requires de-epithelialization of the flap and then skin grafting of the deeper surface of the flap.
The groin flap is a pedicled flap based on either the superficial circumflex iliac artery or the superficial inferior epigastric artery that can resurface wounds of the upper extremity. It has the disadvantages of requiring two surgical stages and the hand remaining dependent during the initial period of flap attachment, which can encourage edema and stiffness. In addition, groin flaps are bulky and require revisional surgery on the dorsal hand.
A reverse radial forearm flap would be the best choice for resurfacing the dorsal hand and fingers because it is soft, thin, and compliant. This may be most safely accomplished in stages with syndactylization performed at a second stage. This flap, however, has been longitudinally split to simultaneously resurface two areas of the hand. The two main disadvantages of this flap include the sacrifice of a major artery and an unaesthetic and potentially unstable grafted donor site.
A 24-year-old man has a mentosternal contracture (shown above) one year after sustaining burns over 90% of the total body surface area. Which of the following reconstructive interventions is the most appropriate management of the contracture?
(A) Scar release and coverage with a dorsal scapular island flap
(B) Scar release and coverage with a free scapular flap
(C) Scar release and skin graft coverage with a thin split-thickness skin graft harvested from the scalp
(D) Scar release and use of the dermal regeneration template (Integra)
The correct response is Option D.
A mentosternal contracture usually requires a wide scar release and extensive tissue coverage. However, this patient who has burns over nearly the total body surface area has limited donor sites. Therefore, the dermal regeneration template should be used with thin split-thickness grafting. This reconstructive intervention provides an acceptably low rate of long-term recurrence of contracture and it uses available donor sites.
Scar release and coverage with a thin split-thickness skin graft have an unacceptable rate of recurrence of contracture. Scar release and coverage with a free scapular flap or dorsal scapular island flap are ideal options for reconstruction. However, unburned scapular skin is not likely to be available in a patient with burns over 90% of the total body surface area.
A 63-year-old man who was in a house fire has burns on 55% of his body including the upper limbs, chest, abdomen, and left leg. He underwent escharotomies and has been resuscitated, but he requires mechanical ventilation because of an inhalation injury. He has an evolving acute kidney injury. A photograph is shown. Immediate excision is planned for management of a suspected fungal infection of the burn wounds. Which of the following is the most appropriate method for initial excision in this patient?
A) Excision down to fascia without a tourniquet
B) Excision down to viable tissue using tumescence
C) Excision down to viable tissue with a tourniquet
D) Excision down to viable tissue without a tourniquet
E) Hydrosurgical debridement without a tourniquet
The correct response is Option A.
The best method for initial excision in this critically ill patient is excision down to fascia (fascial excision). Excision down to viable tissue (tangential excision) with or without a tourniquet would result in a large amount of blood loss, which would be a significant physiologic insult for this patient; additionally, it may not eradicate the suspected fungal infection. Tangential excision using tumescence may not result in significant blood loss, but the ability to judge viable from nonviable tissue is compromised, and this approach would have a high likelihood of requiring further debridement to achieve a healthy tissue bed unless performed by extremely experienced burn surgeons. Fascial excision is also much faster than tangential excision, which is an important consideration in this critically ill patient. Hydrosurgical debridement is adequate for superficial burns but has no role in a large flame burn and would result in excessive blood loss and operative time.
