Burny Stuff Flashcards
Pathophysiology from burns
Localized and Systemic inflammatory responses
What is happening at the cellular level tissue after a burn?
thermal energy denatures and coagulates proteins
Systemic responses from a burn
Typically occur with >20% BSA burns. Inflammatory mediators are released from burned tissue. Systems include Cardio, Resp, Metabolic rate, immune
Systemic effects (cardio)
Capillary permeability increased-> fluid is lost into interstitial spaces (edema). Myocardial contractility decreases->hypotension, shock
Systemic effects (resp)
inhalation/inflammation induces bronchoconstriction. Can lead to resp failure or ARDS
Systemic effects (metabolic)
Basal metabolic rate increases which leads to high nutritional demands
Different types of burns
Heat, electrical, friction, chemical, radiation
Systemic effects (immune)
Down regulation of immune responses, which can lead to infection
How is burn size estimated and why is it important?
Extent of burns is estimated as % off TBSA (Does not include superficial burns). Accurate estimation is important to guide therapy and determining transfer to a burn center
3 Methods to estimate TBSA
Lund-Browder chart (Children)
Rule of Nines (Fastest for adults)
Palm Method (1 Palm = 0.5% of TBSA, Palm w/ fingers = 1%)
Rule of 9s
Head 4.5F, Chest 9F, Abdomen 9F, Arms 4.5F (each), Legs 9F (each), Groin 1
Use the rule of nines to estimate the TBSA of a burn that covers the abdomen, chest, and front of the right arm.
22.5% (9 Abdomen + 9 Chest + 4.5 R Arm)
Lund-Browder Chart
Adjusted Rule of 9s for children. Head 9F, Torso 18F, Arms 4.5F (each), Legs 7F (each)
Name some suspicious features of burns that may indicate abuse (especially in children)
- Scald burns with sharply demarcated edges and symmetrical
- shape of an object
- small circular burns (cigarettes)
- perineal area
Burn classifications by depth
1st: Superficial
2nd: Partial thickness (superficial or deep); blistering
3rd: Full thickness
4th: involves muscle or bone (loss of burned part)
Superficial burns
Involves epidermis only
No blistering
Painful, dry, erythematous, and blanching
typical heal time is 3-5 days
No scarring generally
Ex: Sunburns
Treatment for superficial burns
Immediate: remove clothing/jewelry. Cool the burn (no ice)
Expectations: self limiting
Symptom management: Room temp/cool tap water. Gently clean with mild soap and water. Oral NSAIDs. No Ice directly to the skin. No topical corticosteroids, cool showers
Spectrum of light that causes sunburn
UVA and UVB wavelengths cause burn. Most effective at inducing erythema are in the UVB range.
Sunburn differential Dx
Phytophotodermatitis
Sunburn prevention and treatment
Reduce exposure, protective clothing
Keep infants out of direct sunlight
Suncreen SPF 30 or higher
Treat with cool compresses or soaks. Stay hydrated
SPF
Sun Protection Factor. The ability of a sunscreen to protect against a sunburn reaction from UVB light
What populations would benefit from sunscreen use
Everyone (regardless of skin tone). AAD recommends SPF 30+ with water/sweat resistance. Avoid with infants <6months
Proper use (qty) of sunsecreen
Teaspoon rule: 1tsp face and neck, 2 tsp to front and back torso, 1 tsp each upper extremity, 2 tsp each lower extremity.
Apply 15-30 minutes before sun exposure, reapply every 2 hours
Superficial partial thickness burns
Epidermis and papillary dermis.
Yes Blisters
Painful, erythematous, moist skin, weeping and blanchable.
Healing time: 1-3 weeks. No scarring but may alter pigment
Increased infection risk
Superficial partial thickness burn treatment
cool (room temp or cool tap H2O)
AVOID direct ice/ice water
Pain management (Acetaminophen and NSAIDs)
Clean with mild soap and tap water
debridement (before dressing)
Wet dressing (saline infused, individual wrapping)
topical ABx
Tetanus update (if needed)
wet gauze
What is the different in Tx between superficial and superficial partial thickness burns?
When burns enter the dermis there is an increased risk for infection and topical ABx are indicated.
Examples of topical ABx for superficial and partial thickness burns
Bacitracin zinc-Polymyxin B sulfate, Neomycin.
Easier to apply and remove than silver containing agents.
Neomycin is associated with allergic reactions
+/- of silver containing agents as an antimicrobial
It can work! Silver Sulfadiazine
Contras:
Can’t use of the face (yellowing of the skin)
No pregnant or breastfeeding people
Sulfa allergies
impedes reepithelialization
When is Bismuth-impregnated Petroleum Gauze indicated?
Skin graft donor sites, covering fresh skin grafts.
Benefits of Mafenide Acetate as topical antimicrobial
Alternative to silver sulfa, although pain when applied, metabolic acidosis can also occur in addition to allergic reactions and tachypenea
Benefits of Chlorhexidine as topical antimicrobial
Long lasting
does not interfere with re-epithelialization like silver sulfa
What are the components of a basic burn dressing?
Topical ABx, nonadherent gauze, dry gauze, elastic gauze roll
Considerations during dressing changes
Individually wrap all toes or fingers to prevent adherence and maceration. Adequate pain control is essential. Topical ointment and nonadherent gauze should be changed at least 1x per day
Deep partial thickness burn
Epidermis and reticular dermis involved. Damages hair follicles and glandular tissues
Yes blisters
Painful to pressure only, waxy, dry, red yellow or pale skin. Non blanchable (no capillary refill)
Healing time: 2-9 weeks and hypertrophic scarring is expected. Joint involvement leads to chronic joint impairment
Tx for deep partial thickness burn
No cooling or submerging
Pain management, tetanus update
Wound excision and burn wound closure
Dry, nonstick gauze only if transferring to a burn center
Early burn excision and coverage is essential
Admission to ICU (1/2 – 1 day per % TBSA)
Management includes nutritional support, management of contractures, and psych support
Full thickness burn
Destroys dermis and enters hypodermis
No blistering
painless, waxy white/grey skin, charred, dry, leathery, non-blanchable
Eschar will be present
severe scarring and contractures is expected w/o surgery
Tx for full thickness burn
Trauma ABCs eval (airway, breathing, circulation)
Same mgmt as deep partial thickness.
Pain control (high doses of opiods may be needed)
Increased severe infection risk–but use of prophylactic ABx is controversial
4th Degree burn
Dermis and subcute destroyed–burn extends into fat, muscle, and bone.
No sensation and non-blanchable (nerves destroyed)
Damage is often permanent (amputation indicated)
Dx testing for major burns
CBC (Hematocrit increased initially)
BMP (hyperkalemia)
Creatinine Kinase (CK) with UA and myoblobin to eval for Rhabdomyolysis
Carboxyhemoglobin (CO poisoning)
Serum lactate (cyanide poisoning)
Arterial blood gas (O2, CO2, pH in serum)
Chest Xray
Monitor end-tidal CO2 (EtCO2) and pulse ox
ECG
Blood typing and cross matching in anticipation of need for transfusion
Burn center referral criteria
Importance of preserving hands and feet
aggresive PT and OT is vital
minor burns but with underlying health conditions (DM, PVD, immunosuppresion, age)
3rd degree burns
Indications for an escharotomy
deep partial and full thickness burns that cover >20 % TBSA. Release of compression that could relate to compartment syndrome
General approach to burn tramtment
A (Airway): Signs of significant smoke inhalation injury (leading cause of death in adult burn victims) and need for potential intubation. Supplemental O2 prn, listen to lungs. upper airway edema is a major concern
B (Breathing): look for signs of breathing impairment (mental status, hypoxia, tachypnea, accessory muscle use). Use bronchodilators for bronchospasms. No corticosteroids
C (Circulation): Risk of Burn Shock, maintain aggressive fluid resuscitation (but not too much). use PARKLAND Formula, monitor urine output
D (Disability and exposure): Neuro status, core body temp (hypothermia risk), tetanus immunization, topical ABx
What severity of burn indicates formal fluid resuscitation?
> 15% TBSA non-superficial
PARKLAND Formula
most common method for calculating initial fluid resuscitation.
Management of chemical burns
Remove individual from exposure area, copious irrigation (especially alkali substances). Monitor pH. Don’t irrigate dry lime, phenols, or elemental metals.
common cause of alkalotic burns
wet cement
Considerations for hydrofluoric acid burns
it’s highly corrosive and can cause hypocalcemia and hypomagnesemia (cardiotoxic). Manage with copious water irrigations and topical Ca gluconate gel
Treatment for tear gas exposure
remove clothing and wash with lots of soap and water
What type of electrical injury has the highest morbitiy
Low voltage; AC
Does skin have high or low resistance? (in regards to electrical burns)
high resistance (compared to underlying tissue). Parkland formula not used since skin appearance masks damage to underlying tissue
Frostnip
1st stage of frostbite; reversible. Localized paresthesia that resolves with rewarming
Frostbite
freezing of tissue (classified as grade 1-4)
Non-freezing cold injuries
trench and immersion foot. 2-3 days of cold exposure
