Burns & Reconstruction Flashcards
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
The correct response is Option C.
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.
2018
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.
2018
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.
2018
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.
2018
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.
2018
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.
2018
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 - escharotomy incisions over UE and trunk. 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.
2017
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.
2017
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.
2017
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.
2017
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.
2016
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.
2016
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.
2016
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.
2016
A 58-year-old man is brought to the emergency department for frostbite injury of the right thumb. A photograph is shown - purple discoloration over distal phalanx including nail. 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.
2016
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.
2016
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.
2015
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.
2015
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.
2015
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.
2015
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.
2015
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.
2014
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.
2014
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:
Temperature 99.5°F (37.5°C) Heart Rate 130 bpm Respiratory Rate 22/min Blood Pressure 80/50 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.
2014
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.
2013
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.
2013
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.
2012
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.
2012
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.
2011
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.
2011
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 post-injury 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.
2011
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.
2011
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.
2011
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 - neck contracture band. 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.
2011
A 55-year-old man is brought to the emergency department after sustaining electrical burns. He has numbness of the left hand; pulse in the hand and sensation to touch are diminished. Which of the following is the most effective management to restore perfusion to the left hand?
A ) Anticoagulation B ) Embolectomy C ) Burn excision D ) Escharotomy E ) Fasciotomy
The correct response is Option E.
The patient described has a circumferential electrical injury to the forearm consistent with compartment syndrome. Fasciotomy is indicated.
Acute burn injury exceeding 20% can lead to a significant systemic response, with release of vasoactive mediators, third spacing, increased metabolic requirement, and immune suppression. Surgical debridement and closure of the wound can limit the inflammatory process.
Anticoagulation and embolectomy do not address the underlying problem, which is increased compartment pressure in a confined space. Burn excision is a method of removing devitalized burned tissue, usually in a tangential fashion down to the fascia, followed by split-thickness skin grafting. This is not a treatment for compartment syndrome.
When there is circumferential injury of an extremity or in deep burns to the chest wall, escharotomy, or creating incisions through the burn eschar, is important in releasing constriction and allowing circulation to the extremity or airflow to the chest. Incisions must extend beyond the zone of the burn injury to assure complete release of the constriction to restore circulation. Escharotomy is performed within the first 24 hours of admission.
2010
Which of the following skin substitutes contains foreskin-derived neonatal human fibroblasts and keratinocytes?
A ) AlloDerm B ) Apligraf C ) Biobrane D ) Integra E ) Surgisis
The correct response is Option B.
Apligraf is a permanent, biosynthetic, bilayered living construct of cultured foreskin-derived neonatal human keratinocytes and fibroblasts. They are cultured on a matrix consisting of bovine-type collagen.
AlloDerm is a human cryopreserved, acellular, cadaveric, de-epidermalized dermis. The complex is immunologically inert and becomes repopulated with host fibroblasts and endothelial cells.
Biobrane contains Type I porcine collagen peptides in a bilaminate of silicone film and nylon fabric.
Integra is a temporary bilaminate composed of silicone and a matrix of cross-linked bovine tendon collagen and shark-derived glycosaminoglycans.
Surgisis is derived from porcine small intestine and is processed into a biocompatible three-dimensional, extracellular matrix composed of collagen, noncollagenous proteins, and other biomolecules.
2010
A 30-year-old woman who is morbidly obese is admitted to the burn unit with partial-thickness burns on 40% of the total body surface area involving the trunk and lower extremity. Maintenance of which of the following is the most appropriate measure to guide proper fluid management of the patient?
A ) Arterial systolic pressure greater than 90 mmHg
B ) Cardiac output greater than 5 L/min
C ) Mean arterial pressure greater than 55 mmHg
D ) Pulse rate less than 120 bpm
E ) Urinary output of 0.5 mL/kg/h
The correct response is Option E.
Routine vital signs, such as blood pressure and heart rate, can be very difficult to interpret in patients with large burns. Catecholamine release during the hours after the burn can support cardiac output despite the extensive intravascular depletion that exists. The formation of edema in the extremities can limit the usefulness of noninvasive blood pressure measurements. Evaluation of arterial line pressures is subject to error from peripheral vasospasm from the high-catecholamine state. Tachycardia, normally a clue to hypovolemia, can be secondary to pain and is also almost universally present from the adrenergic state. Moreover, placement of a central line to measure the cardiac output in a morbidly obese patient may pose risks and should be avoided unless the burns involve the upper part of the body, which will lead to edema in the later stages of resuscitation. Blood pressure is not an accurate measure of tissue perfusion.
Hourly urine output is a well-established parameter for guiding fluid management. The rate of fluid administration should be titrated to a urine output of 0.5 mL/kg/h or approximately 30 to 50 mL/h in most adults and older children (> 50 kg [110 lb]). The urge to maintain urine output at rates greater than 30 to 50 mL/h should be avoided. Fluid overload in the critical hours of early burn management leads to unnecessary edema and pulmonary dysfunction. It can necessitate morbid escharotomies and extend the time required for ventilator support. Several complicating factors exist with monitoring urine output as a guide for volume status and end-organ perfusion. The presence of glycosuria can result in an osmotic diuresis and lead to artificially elevated urine output values. Performing a urinalysis at some point during the first 8 hours is prudent, especially for patients with larger burns, to screen for this potentially serious overestimation of the intravascular volume.
2010
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 - eyes do not close. 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.
2010
A 42-year-old man is brought to the emergency department after being rescued from an avalanche. History includes type 2 diabetes mellitus that is well controlled by diet. He has smoked one pack of cigarettes daily for the past 10 years. Physical examination shows erythema, edema, and blistering of the right lower extremity extending from the distal tibia to the tips of the toes. Which of the following is the most appropriate first step in management?
A ) Debridement and negative pressure wound therapy
B ) Hyperbaric oxygen therapy
C ) Intravenous administration of heparin
D ) Primary amputation
E ) Rewarming in a water bath 104 °F (40 °C)
The correct response is Option E.
The mainstay of treatment for frostbite injuries is rapid rewarming by submersion of the affected body part in a water bath maintained at a constant temperature of 104 to 108 °F (40 to 42 °C). Frostbite involves the formation of extracellular ice crystals that produce cellular damage. Rapid rewarming is the primary treatment for frostbite and has not changed in nearly three decades. The optimal temperature was demonstrated in controlled experiments by Entin and Baxter in 1952. Rewarming may take 20 to 40 minutes and is deemed adequate when there is evidence of distal perfusion, such as a blush. Addition of an antibacterial soap solution to the water bath is often recommended. The affected body part should then be splinted and elevated. It may take weeks or months for tissues to fully declare themselves. Delayed amputation is often required in severe frostbite injuries.
Debridement and negative pressure wound therapy have not been shown to be an effective initial step in management compared with rapid rewarming, but they may have a role in secondary wound management.
Hyperbaric oxygen (HBO) therapy has been reported as an adjunctive treatment to frostbite, but mostly as case reports. HBO may have a role in limiting the progressive tissue necrosis that follows the acute injury, but the lack of a prospective randomized controlled study has prevented it from achieving wide acceptance.
Heparin and other anticoagulants and thrombolytics have been tried with some variable success, but they should be instituted only after rapid rewarming measures have been applied. There is experimental and clinical evidence to suggest that one of the mechanisms of tissue injury is
thrombosis of the microvasculature that occurs from direct tissue injury and is mediated through free radicals.
Primary amputation would not be appropriate as an initial step in management, as this would commit the patient to a morbid operation with significant disability.
Gradual rewarming should not be used, as this has been associated with greater tissue injury.
2010
A 32-year-old man is brought to the emergency department after being lost during a snowstorm in the mountains for 24 hours. Physical examination shows significant edema, loss of sensation, grayish blue discoloration, and hemorrhagic blisters on both hands and feet. Which of the following is the most appropriate initial management?
A ) Debridement of the hemorrhagic blisters
B ) Oral administration of ibuprofen
C ) Rapid cycles of freezing and thawing
D ) Rapid rewarming using a radiant heat source
The correct response is Option B.
Ibuprofen provides antiprostaglandin activity to limit the potential for secondary mediator damage.
Debridement of hemorrhagic blisters may cause exposure of the deeper structures and run the risk of desiccation and subsequent necrosis. Traditionally, early and aggressive debridement and amputation are avoided. The development of deep, dry gangrene can be allowed to declare the specific regions that must undergo amputation. On the other hand, triple-phase scanning can be used to delineate viable tissue early on and obviate prolonged demarcation.
Cycles of freezing and thawing lead to greater inflammatory mediator release and, in the long run, greater tissue injury.
Rapid warming decreases further tissue damage by halting both direct injury and continued release of secondary mediators. This occurs by submersion of the injured part in 104 °F (40 °C) water for 15 to 30 minutes. Use of radiant heat sources in frostbite can lead to iatrogenic injury because of uneven thawing and secondary thermal burn to insensate tissue.
2010
A 4-year-old boy has wound cellulitis, pneumonia, and bacteremia one week after sustaining burns on 38% of the total body surface area in a house fire. He undergoes debridement of the wounds. Grafting is performed to reconstruct the resulting defects. Debrided tissue is sent for culture. While awaiting the results of culture, which of the following is the appropriate empiric antibiotic therapy?
A ) Ampicillin-sulbactam, ciprofloxacin, and tobramycin
B ) Penicillin G, clindamycin, and gentamicin
C ) Vancomycin and piperacillin-tazobactam
D ) Vancomycin, piperacillin-tazobactam, and amphotericin
E ) Vancomycin, piperacillin-tazobactam, and fluconazole
The correct response is Option C.
The most common bacteria causing burn wound infections include methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas, and Klebsiella. Empiric antibiotic therapy for the patient described would need to cover these gram-positive cocci and gram-negative rods.
Of the antibiotics listed, only vancomycin covers MRSA. Piperacillin-tazobactam is the most appropriate choice for pseudomonal coverage. Antifungal coverage with fluconazole or amphotericin is not necessary and is not supported by the literature. Antifungal prophylaxis remains controversial.
2010
An unconscious 25-year-old man is brought to the emergency department after being electrocuted while working near high-voltage power lines. The patient is resuscitated. Examination shows a 4 x 3-cm burn on the skin over the left antecubital fossa and significant swelling of the forearm. Which of the following is the most appropriate next step in management?
A ) Dressing of the affected area and observation in the burn unit
B ) Excision and coverage with a local flap
C ) Excision and coverage with a split-thickness skin graft
D ) Fasciotomy of the forearm
E ) Splinting of the hand in the intrinsic plus position
The correct response is Option D.
In high-voltage injuries, the electrical current often travels deep into the skin, causing internal damage that may not be readily visible. The current causes tissue damage at the entry point in the skin and along its path through the muscle, nerves, and bone. As electrical current is conducted through the body, heat is generated in direct proportion to the tissue resistance. Because bone has a high resistance, heat is generated rapidly in this area, resulting in deep tissue injury. Compartment syndrome can develop in a patient with an electrical injury because of the deep tissue injury and subsequent subfascial edema. Immediate treatment is aimed at resuscitation of the patient, followed by salvage of the affected limb. The key to the acute management of electrical injuries to the upper extremity is to have a high index of suspicion for potential damage to deeper tissues, even at a distance from the point of contact. The optimal management of electrical injuries to the upper extremity includes initial exploration, decompression (fasciotomy), and aggressive repeated debridement, followed by reconstruction. Fasciotomy serves a dual role as both a therapeutic and diagnostic tool in the treatment of electrical injuries.
2010
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.
2019
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.
2019
