Chapter 17 - Burns Flashcards
What is a first degree burn?
epidermis only, ie sunburn
What is are the two types of second-degree burns?
- superficial dermis (papillary) - painful to touch; blebs and blisters; hair follicles intact; blanches; no intervention needed
- deep dermis (reticular) - decreased sensation; loss of hair follicles; needs excisional debridement and likely graft
What are 3rd-degree burns?
through dermis, down to subcutaneous fat; leathery feeling (charred parchment); requires surgical debridement and graft
What are 4th-degree burns?
Down to bone, adjacent adipose tissue, or muscle tissue
What are admission criteria for 2nd and 3rd-degree burns?
- >10% BSA in pts 50yo (higher risk)
- >20% in all other pts (needs burn resuscitation)
- burns to significant portions of hands, face, feet, perineum, or skin on joints (may cause loss of fct if not treated in hospital)
- 3rd degree in >5% any age
Other than the dimensional/locational criteria for 2nd and 3rd-degree burns, what are some etiological/associated-injury criteria for burn admission?
- electrical and chemical
- concomitant inhalation injury
- trauma
- child abuse or neglect
Why are kids and elderly highest mortality?
difficulty escaping fire - longer exposure
What are most common types of burns?
scalds
What are the most common types of burns to come to the hospital and get admitted?
flame-burns
What is the rule of 9’s?
- head 9
- arms 9/9
- chest 18
- back 18
- legs 18/18
- perineum 1
What is the Parkland formula?
- for burns >20%
- 4cc/kg x %burn in first 24 hours
- give half in the first 8 (LR)
- can grossly underestimate in inhalation injury, EtOH, electrical, post escharotomy
Indications for escharotomy?
- circumferential burns
- extremity w/low temperature, weak pulse, low cap refill, low pain sensation, decreased neuro function
- problems ventilating with chest/torso burns
Lung injury from smoke caused by what?
carbonaceous materials and smoke, not heat
What are the risk factors for airway injury?
What are the signs and symptoms of possible airway injury?
Risks: EtOH, trauma, closed space, rapid combustion, delayed extrication
Signs: facial burns, wheezing, carbonaceous sputum
What are the indications for intubation in smoke lung injury?
upper airway stridor or obstruction, worsening hypoxemia
What is the most common infection in burn patients?
Pneumonia. Also most common cause of death
What do you do with acid and alkali burns?
What is the difference in the pathology of alkali vs acid burns?
- copious water irrigation
- alkalis produce deeper burns than acid due to liquefaction necrosis
- acid burns produce coagulation necrosis
What do you do with hydrofluoric acid burns?
spread calcium gluconate gel on wound
What do you do with powder burns?
wipe away before irrigation
What do you do with tar burns?
cool, then wipe away with a lipophilic solvent (Neosporin works)
What do you do with electrical burns?
- cardiac monitoring
- watch for:
- compartment syndrome
- polyneuritis
- intestinal/gallbladder perf
- pancreatic necrosis
- liver necrosis
How does lightning kill you?
cardiopulmonary arrest secondary to electrical paralysis of brainstem
In the first week of early excision burns…
- What happens to CO?
- What is caloric need?
- What is protein need?
- CO decreased for 24-48h then increases
- 25kcal/day + 30kcal x %burn
- protein 1g/kg + 3g x %burn
- need glucose
- excise in first 72 hours
- viability based on color, texture, punctate bleeding after removal
When is skin graft contraindicated (bacteria)?
beta hemolytic strep + or bacteria >10^5
What are the different types of skin graft?
- split thickness/full thickness
- decrease infection, desiccation, protein loss, pain, water loss, heat loss, RBC loss
- increases granulation and improves survival
How thick should STSG be?
12-15mm - include epidermis and part of dermis
Homografts used when?
temporizing - last 2-4wks
How long do xenografts last?
2 wks; they do not vascularize
When do you graft wounds to face, palms, soles, perineum?
defer for first week
What are reasons to delay autografting?
Skin septic, unstable, do not want to create more blood loss with donor sites
Most common reason for skin graft loss?
How do you prevent this?
seroma or hematoma formation under graft
apply pressure dressing to skin graft
Benefits of STSG compared to FTSG?
more likely to survive; not as thick, so easier for imbibition and subsequent neovascularization
Benefits of FTSG compared to STSG?
less wound contraction; good for palms and back of hands
How can burn scar hypopigmentation and irregularities be improved?
Dermal abrasion, thin split thickness grafts
What to do with burns to the face?
Topical antibiotics for two weeks, full thickness grafts for unhealed areas – nonmeshed
What to do with hand burns for weeks 2-5?
- superficial – ROM exercises, splint in functional position if too much edema
- deep – immobilize for seven days after operation, then physical therapy
- may need wire fixation if joints unstable or open
- treat with full thickness graft
What to do with palm burns for weeks 2 to 5?
- Try to preserve specialized palmer attachments.
- Splint hand in extension for one week.
- Graft in week two with full thickness non-meshed autograft graft
How do you prevent burn wound infections?
Apply Neosporin immediately after burns, no role for prophylactic IV antibiotics
What are the most common bacteria in burn infections?
Pseudomonas is most common organism in Burn infection, followed by Staphylococcus, E coli, and Enterobacter
What are side effects of Silvadene?
What allergy can it not be used with?
Can cause neutropenia and thrombocytopenia.
Cannot use with sulfa allergy.
Ineffective against Pseudomonas and GNRs.
Can cause methemoglobinemia.
What are the side effects of silver nitrate?
- Can cause electrolyte imbalances – hyponatremia, hypochloremia, hypocalcemia and hypokalemia
- Discoloration
- Limited eschar penetration
- Ineffective against some Pseudomonas species and GPCs
What are the problems with Sulfamylon?
- Painful application
- Metabolic acidosis due to carbonic anhydrase inhibition
- Good eschar penetration
- Good for burns overlying cartilage
- Broadest spectrum against Pseudomonas and GNRs
What are signs of burn wound infection?
- Peripheral edema, second to third-degree burn conversion, hemorrhage into scar
- Erythema gangrenosum
- Green fat, black skin around wound, rapid eschar separation
What is burn wound sepsis usually caused by?
Pseudomonas
What is the most common viral infection in burn wounds?
HSV
What is the best way to detect burn wound infection?
Biopsy the wound
What are seizures after burns usually caused by?
Usually iatrogenic and related to sodium concentration; can also be benzodiazepine withdrawal
What is peripheral neuropathy after burns caused by?
Secondary to small vessel injury and demyelination
What is Ectapia caused by after Burns?
Burned adnexa. Treatment is eyelid release.
What is a symblepharon after a burn?
Eyelid stuck to conjunctiva. Treat with Eyelid release with a glass rod.
What is a Curlings ulcer?
Gastric ulcer that occurs with burns
What is a Marjolin’s ulcer?
Highly malignant squamous cell carcinoma that arises in chronic nonhealing burn wounds or unstable scars
What is a hypertrophic scar, and when does it occur?
- Deposits of excessive amounts of collagen which give rise to a raised scar
- Not outside boundaries of injury
- Usually occurs 3 to 4 months after injury
- More likely to be deep thermal injuries that take more than three weeks to heal
- Wait 1 to 2 years before scar modification
- Treat with grafting, steroids, silicone, compression
What is toxic epidermal necrolysis Caused by?
- Caused by a variety of drugs including Dilantin, Bactrim, penicillin and viruses
- Epidermal dermal separation -Treatment is supportive. Need to prevent wound desiccation with topical antimicrobials and xenograft
What is seen with Stevens-Johnson syndrome?
Subepidermal bullae, epidermal cell necrosis, dermal edema
Hypersensitivity reaction
