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06 - absite > Chapter 17: Burns > Flashcards

Chapter 17: Burns Flashcards

1
Q

Burn: sunburn (epidermis)

A

First degree

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2
Q

Burn: painful to touch; blebs and blisters; hair follicles intact; blanches (do not need skin grafts)

A

2nd degree burn: superficial dermis (papillary)

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3
Q

Burn: decreased sensation; loss of hair follicles (need skin grafts)

A

2nd degree burn: deep dermis (reticular)

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4
Q

Burn: leathery (charred parchment); down to subcutaneous fat)

A

3rd degree burn

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5
Q

Burn: down to bone; into adjacent adipose or muscle tissue

A

4th degree burn

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6
Q

How do first and second degree burns heal?

A

By epithelialization (primarily from hair follicles)

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7
Q

Can cause rhabdomyolysis with myoglobinuria

- Tx: hydration, alkalinize urine

A

Extremely deep burns, electrical burns, or compartment syndrome

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8
Q

Admission criteria for burns

A
  • 2nd and 3rd degree burns: > 10% BSA in patients aged 50 years. > 20% BSA. To significant portions of hands, face, feet, genitalia, perineum or skin overlying major joints.
  • 3rd degree > 5%
  • Electrical and chemical
  • Concomitant inhalational injury, mechanical trauma, preexisting medical condition.
  • Injuries in patients with special social, emotional or long-term rehabilitation needs
  • Suspected child abuse or neglect
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9
Q

Burn assessment: patient population with highest death

A

Deaths highest in children and elderly (trouble getting away)

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10
Q

MCC burns

A

Scald burns

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11
Q

Burns: more likely to come to hospital and be admitted

A

Flamer burns

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12
Q

Assessing percentage of body surface burned

  • Head
  • Arms
  • Chest
  • Back
  • Legs
  • Perineum
A
  • Head: 9
  • Arms: 18
  • Chest: 18
  • Back: 18
  • Legs: 36
  • Perineum: 1
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13
Q

When do you use Parkland’s formula?

A

Use for burns > 20% only

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14
Q

What is the Parkland’s formula?

A

4cc/kg x % burn in first 24 hours, give 1/2 the volume in the first 8 hours

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15
Q

What type of fluids should you use in burn resuscitation?

A

Lactated ringer’s solution (in the first 24 hours)

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16
Q

Best measurement of resuscitation

A

Urine output

  • Adults: 0.5 - 1.0 cc/kg/hr
  • Children
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17
Q

What are the disadvantages of the Parkland formula?

A

Can grossly underestimate volume requirements with inhalational injury, ETOH, electrical injury, post-escharotomy

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18
Q

What can colloid (albumin) cause in first 24 hours of burn resuscitation?

A

Increased pulmonary / respiratory complications -> can use colloid after 24 hours

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19
Q

Escharotomy indications (perform within 4-6 hours)

A
  • Circumferential deep burns
  • Low temperature, weak pulse, decreased capillary refill, decreased pain sensation, or decreased neurologic function in extremity
  • Problems ventilating patient with significant chest torso burns
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20
Q

What if compartment syndrome is suspected after escharotomy?

A

May need fasciotomy

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21
Q

Risk factors for burn injuries

A

Alcohol or drug use, age (very young / very old), smoking, low socioeconomic status, violence, epilepsy

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22
Q

Accounts for 15% of burn injuries in children

A

Child abuse

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23
Q

History and exam findings that suggest child abuse

A
  • History: delayed presentation for care, conflicting histories, previous injuries
  • Exam: sharply demarcated margins, uniform depth, absence of splash marks, stocking or glove patterns, flexor sparing, dorsal location on hands, very deep localized contact injury
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24
Q

What primarily causes lung injury in burns?

A

Lung injury caused primarily by carbonaceous materials and smoke, not heat.

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25
Q

Risk factors for airway injury in burns

A

ETOH, trauma, closed space, rapid combustion, extremes of age, delayed extrication

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26
Q

Signs and symptoms of possible airway injury

A

Facial burns, wheezing, carbonaceous sputum

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27
Q

Indications ofr intubation after burn

A

Upper airway stridor or obstruction, worsening hypoxemia, massive volume resuscitation can worsen symtpoms

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28
Q

MC infection in patients with > 30% BSA burns

A

Pneumonia

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29
Q

MCC death after > 30% BSA burns

A

Pneumonia

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30
Q

Tx: acid and alkali burns

A

Copious water irrigation

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31
Q

Produce deep burns due to liquefaction necrosis

A

Alkali burns

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32
Q

Produce coagulation necrosis

A

Acid burns

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33
Q

Tx: hydrofluoric acid burns

A

Spread calcium on wound

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34
Q

Tx: powder burns

A

Wipe away before irrigation

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35
Q

Tx: tar burns

A

Cool, then wipe away with lipophilic solvent (adhesive remover)

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36
Q

Burns: need cardiac monitoring

A

Electrical burns

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37
Q

Complications of electrical burns

A
  • Can cause rhabdomyolysis and compartment syndrome
  • Polyneuritis, quadriplegia, transverse myelitis, cataracts, liver necrosis, intestinal perforation, gallbladder perforation, pancreatic necrosis.
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38
Q

Cardiopulmonary arrest secondary to electrical paralysis of brainstem

A

Lightning

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39
Q

1st week: early excision of burned areas

- Caloric Need

A

25 kcal/kg/day + (30 kcal x 30% burn)

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40
Q

1st week: early excision of burned areas

- Protein need

A

1 g/kg/day + (3g x %burn)

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41
Q

Best source of nonprotein calories in patients with burns

A

Glucose

- Burn wounds use glucose in an obligatory fashion

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42
Q

Excise burn wounds in > 72 hours (but not until after appropriate fluid resuscitation for)…

A
  • Used for deep for 2nd, 3rd, and some 4th degree burns
43
Q

What is burn viability based on after excision?

A

Color, texture, punctate bleeding after removal.

44
Q

When do you treat burn wounds to face, plans, soles and genitals?

A

Deferred for the first week

45
Q

What are the goals for each burn wound excision?

A
  • Want
46
Q

When are skin grafts contraindicated?

A

If culture is positive for beta-hemolytic strep or bacteria > 10^5.

47
Q

Decreased infection, desiccation, protein loss, pain, water loss, heat loss, and RBC loss compared to dermal substitutes

A

Autografts (split-thickness [STSG] or full-thickness [FTSG])

48
Q

What regenerates the donor skin site with autografts?

A

Donor skin site is regenerated from hair follicles and skin edges on STSGs

49
Q

Vascularization of autografts

  • Days 0-3
  • Day 3
A
  • Days 0-3: Imbibition (osmotic)

- Day 3: neovascularization

50
Q

Sites: poorly vascularized beds are unlikely to support skin grafting

A

Includes tendon, bone without periosteum, XRT areas

51
Q

Measurements of split-thickness grafts

A

12-15mm (includes epidermis and part of dermis

52
Q
  • Not as good as autografts

- Can be a good temporizing material; last two to four weeks

A

Homografts (allografts; cadaveric skin)

53
Q

Vascularize and are eventually rejected at which time they must be replaced

A

Allografts (ex of Homografts)

54
Q

Not as good as homografts; last 2 weeks; these do not revascularize

A

Xenografts (porcine)

55
Q

Not as good as homografts or xenografts

A

Dermal substitutes

56
Q

Used for back, flank, trunk, arms, and legs

A

Meshed grafts

57
Q

Reasons to delay autografting

A

Infection, not enough skin donor sites, patient septic or unstable, do not want to create any more donor sites with concomitant blood loss

58
Q

Most common reason for skin graft loss

A

Seroma or hematoma formation under graft

59
Q

How do you prevent seroma or hematoma formation under skin graft?

A

Need to apply pressure dressing (cotton balls) to the skin graft to prevent serum and hematoma buildup underneath the graft.

60
Q
  • More likely to survive

- Graft not as thick so easier for imbibition and subsequent revascularization to occur

A

Split thickness skin grafts (STSGs)

61
Q
  • Have less wound contraction

- Good for areas such as the palms and the backs of hands

A

Full thickness skin grafts (FTSGs)

62
Q

How can you improve burn scar hypo pigmentation and irregularities?

A

Can be improved with dermabrasion thin split-thickness grafts.

63
Q

Treatment 2nd to 5th week:

- Face

A

Topical antibiotics for 1st week, FTSG for unhealed areas (ngnmeshed)

64
Q

Treatment 2nd to 5th week:

- Hands

A
  • Superficial: ROM exercises, splint in extension if too much edema
  • Deep: immobilize in extension for 7 days after skin graft (need FTSG), then physical therapy. May need wire fixation of joints if unstable or open
65
Q

Treatment 2nd to 5th week:

- Palms

A

Try to preserve specialized palmar attachments. Splint hand in extension for 7 days after FTSG.

66
Q

Treatment 2nd to 5th week:

- Genitals

A

Can use STSG (meshed)

67
Q

Usually applied immediately after burns

A

Bacitracin or Neosporin

68
Q

Is there a role for prophylactic antibiotics in burns?

A

No.

69
Q

MC organism in burn wound infections

A

Pseudomonas (followed by Staph, E. coli, enterobacter)

70
Q

When are burn wound infections more likely to happen?

A

> 30% BSA

71
Q

Have decreased incidence of burn wound bacterial infections

A

Topical agents

72
Q

Have increased incidence secondary to topical antimicrobials

A

Candida infections

73
Q

Impaired in burn patients (leaves them more susceptible to infection)

A

Granulocyte chemotaxis and cell-mediated immunity

74
Q
  • Do not use in patients with sulfa allergy
  • Limited eschar penetration; can inhibit epithelialization
  • Ineffective against some Pseudomonas; effective for Candida
A

Silvadene (silver sulfadiazine)

75
Q

Adverse effects: silvadene (silver sulfadiazine)

A

Can cause neutropenia and thrombocytopenia

76
Q
  • Discoloration
  • Limited eschar penetration
  • Ineffective against Pseudomonas species and GPCs
A

Silver nitrate

77
Q

Adverse effects: silver nitrate

A
  • Electrolyte imbalances (hyponatremia, hypochloremia, hypocalcemia, and hypokalemia)
  • Methemoglobinemia (contraindicated in patients with G6PD deficiency)
78
Q
  • Can cause metabolic acidosis due to carbonic anhydrase inhibition (decreased renal conversion of H2CO3 -> H2O + CO2)
  • Good eschar penetration; good for burns overlying cartilage
  • Broadest spectrum against Pseudomonas and GNRs
A

Sulfamylon (mafenide sodium)

79
Q

ADRs: sulfamylon (mafenide sodium)

A
  • Painful application

- Can cause metabolic acidosis

80
Q

Signs of burn wound infection

A

Peripheral edema, 2nd to 3rd degree burn conversion, hemorrhage into scar, erythema gangrenosum, green fat, black skin around wound, rapid eschar separation, focal discoloration

81
Q

Organism: burn wound sepsis

A

Pseudomonas

82
Q

MC viral infection in burn wounds

A

HSV

83
Q

Number of organisms: NOT a burn wound infection

A
84
Q

Best way to detect a burn wound infection (and differentiate from colonization)

A

Biopsy of burn wound

85
Q

Best way to detect a burn wound infection (and differentiate from colonization)

A

Biopsy of burn wound

86
Q

Complications after burns (x10)

A

Seizures, peripheral neuropathy, ectopia, corneal abrasion, symblepharon, heterotopic ossification of tendons, fractures, curling’s ulcer, marjolin’s ulcer, hypertrophic scar

87
Q

Why seizures after burns?

A

Usually iatrogenic and related to sodium concentration

88
Q

Why peripheral neuropathy after burns?

A

Second to small vessel injury and demyelination

89
Q

Why ectopia after burns?

A

From progressive contraction of burned adnexa (Tx: eyelid release)

90
Q

How do you detect eye injury with burns?

A

Fluorescein staining to find injury (Tx: topical fluoroquinolone or gentamicin)

91
Q

Tx: corneal abrasion (s/p burn)

A

Tx: topical antibiotics

92
Q

What is a symblepharon and treatment?

A

Eyelid stuck to conjunctiva.

- Tx: release with glass rod

93
Q

Tx: heterotopic ossification of tendons

A

Tx: physical therapy; may need surgery

94
Q

How do you treat fractures with burn injury?

A

Tx: often need external fixation to allow for treatment of burns

95
Q

Gastric ulcer that occurs with burns

A

Curling’s ulcer

96
Q

Highly malignant squamous cell CA that arises in chronic non-healing burn wounds or unstable scars

A

Marjolin’s ulcer

97
Q
  • Usually occur 3-4 months after injury seconds to increased neovascularity.
  • More likely to be deep thermal injuries that take > 3 weeks to heal, heal by contraction and epithelial spread, or heal across flexor surfaces
  • Tx?
A

Hypertrophic scar

Tx: steroid injection into lesion (best), silicone, compression; wait 1-2 years before scar modification surgery

98
Q

What is the mechanism of hypertrophic scars?

A

Usually occur 3-4 months after injury secondary to increased neovascularity

99
Q

Do you use steroids in erythema multiforme and variants?

A

No.

100
Q

Erythema multiforme
Stevens Johnson syndrome
Toxic epidermal necrolysis

A
  • Erythema multiforme: least severe form (self-limited, target lesions)
  • Stevens Johnson syndrome: (more serious) -
101
Q

What do you see in EM, SJS, and TEN?

A

Skin epidermal-dermal separation

102
Q

What causes staph scalded skin syndrome?

A

Caused by staphylococcus aureus

103
Q

Tx: EM / SJS / TEN

A

Fluid resuscitation and supportive; need to prevent wound desiccation with homografts / xenograft wraps; topical antibiotics, IV antibiotics if due to Staphylococcus

104
Q

Drugs that cause EM / SJS / TEN

A

Dilantin, Bactrim, penicillin

06 - absite (44 decks)

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