Derm part 2: burns Flashcards
Are acid or alkali chemical burns more serious?
In general, alkali burns are more serious because the body cannot buffer the alkali, thus allowing them to burn for much longer
How is myoglobinuria treated?
Hydration with IVF
Alkalization of urine with IV bicarb
Mannitol diuresis
Superficial burns
Epidermis only
Partial-thickness burns
Epidermis and varying levels of dermis
Full-thickness burns
All layers if the skin, including the entire dermis
How do superficial burns present?
Painful, dry, red areas that do not form blisters
How do partial thickness burns present?
Painful, hypersensitive, swollen, mottled areas with blisters and open weeping surfaces
How do full thickness burns present?
Painless, insensate, swollen, dry mottled white, and charred areas
What is the major clinical difference between partial and full-thickness burns?
Full thickness burns are painless, and partial thickness burns are painful
By which measure is burn severity determined?
Depth of burn and TBSA affected by partial and full thickness burns
TBSA is calculated by the rule of nines in adults and by a modified rule in children
What is the rule of nines?
In an adult the TBSA that is burned can be estimated by the following: Each upper limb= 9% Each lower limb= 18% Anterior and posterior trunk= 18% each Head and neck=9% Perineum and genitalia = 1%
What is the rule of the palm?
Surface area of the pt’s palm is ~1% of the TBSA used for estimating size of small burns
What is the burn center referral criteria for partial thickness burns?
> 20% TBSA
What is the burn center referral criteria for full thickness burns
> 5% TBSA
Partial thickness >10% TBSA in children and the elderly
Any burns involving the face, hands, feet, or perineum
Any burns with inhalation injury
Any burns with associated trauma
Any electrical burns
What is the tx of superficial burns?
Keep clean
+/- Neosporin
Pain meds
What is the tx of partial thickness burns?
Remove blisters: apply antibiotic ointment and dressing
Pain meds
Some use silver bandages
Most partial-thickness burns do not require skin grafting
What is the tx of full thickness burns?
Early excision of eschar (within first week postburn) and STSG
How can you decrease bleeding during excision of full thickness burns?
Tourniques as possible
Topical epinephrine
Topical thrombin
What prophylaxis should the burn pt get in the ER?
Tetanus
What principles guide the initial assessment and resuscitation of the burn pt?
ABCDEs, then urine output
Check for eschar and compartment syndromes
What are the signs of smoke inhalation?
Smoke and soot in sputum/mouth/nose Nasal/facial hair burns Throat/mouth erythema Hx of loss of consciousness/explosion/fire in small enclosed area Dyspnea Low O2 saturation Confusion HA Coma
What diagnostic imaging in used for smoke inhalation?
Bronchoscopy
What lab value assesses smoke inhalation?
Carboxyhemoglobin level
Treat with 100% O2 and time
How should the airway be managed in the burn pt with an inhalational injury?
With a low threshold for intubation
Oropharyngeal swelling may occlude the airway so that intubation is impossible
100% O2 should be administered immediately and continued until significant carboxyhemoglobin is ruled out
What is burn shock?
Describes the loss of fluid from the intravascular space as a result of burn injury, which causes leaking capillaries that require crystalloid infusion
What is the Parkland formula?
V= TBSA Burn (%) x weight (kg) x 4
Half of the calculated volume is given in the first 8 hrs, the rest in the next 16 hrs
What burns qualify for the Parkland formula?
Greater than or equal to 20% TBSA partial and full thickness burns only
What is the Brooke formula for burn resuscitation?
Replace 2 cc for the 4 cc in the Parkland formula
What is the rule of 10s?
For determining hourly IVF rate: TBSA x 10 (pts 40-80 kg)
How is the crystalloid given?
Through two large-bore peripheral venous catheters
Can you place an IV or central line through burned skin?
Yes
What is the adult urine output goal?
30-50 cc (titrate IVF)
Why is glucose containing IVF contrainidcated in burn pts in the first 24 hours postburn?
Pt’s serum glucose will be elevated on its own because of the stress response
What fluid is used after the first 24 hrs postburn?
Colloid
Use D5W and 5% albumin at 0.5 cc/kg/% burn surface area
What is the minimal urine output for burn pts?
Adults 30 cc
Children 1-2 cc/kg/hr
What is the most important for volume status monitroing in the burn pt?
Urine output
Why do mostl severely burned pts require nasogastric decompression?
Pts with >20% TBSA burns usually develop a paralytic ileus, which leads to vomiting, which leads to aspiration risk, which leads to pneumonia
What stress prophylaxis must be given to the burn pt?
PPI to prevent burn stress ulcer
What are the signs of burn wound infection?
Increased WBC with left shift Discoloration of burn eschar Green pigment Necrotic skin lesion in unburned skin Edema Ecchymosis tissue below eschar Partial-thickness burns that turn into full thickness burns Hypotension
What are the common organisms found in burn wound infections?
S. aureus
Pseudomonas
Streptococcus
C. albicans
How is a burn wound infection diagnosed?
Send burned tissue in question to the lab for quantitative burn wound bacterial count
If the count is >10 to the fifth/gram, infection is present and IV abx should be administered
Why are systemic IV abx contraindicated in fresh burns?
Bacteria live in the eschar, which is avascular
Thus apply topical antimicrobial agents
Advantages and disadvantages of silver sulfadiazine
Painless, but little eschar penetration
Misses Pseudomonas and has idiosyncratic neutropenia
Sulfa allergy is a contraindication
Advantages and disadvantages of mafenide acetate
Penetrates eschars Broad spectrum (that misses Staph) Causes pain on application Triggers allergic reaction in 7% of pts May cause acid-base imbalances Agent of choice for ear burns
Advantages and disadvantages of polysporin
Polymyxin B sulfate Painless Clear Used for facial burns Does not have a wide antimicrobial spectrum
Circumferential, full thickness burns to the extremities are at risk for what complication?
Distal neurovascular impairment
How are circumferential, full thickness burns to the extremities treated?
Escharotomy: full thickness longitudinal incision through the eschar with scalpel or electocautery
How is carbon monoxide inhalation overdose treated?
100% O2 (+/- hyperbaric O2)
Which electrolyte must be closely followed acutely after a burn?
Sodium
