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ABSITE > Fiser Chapter 17 BURNS > Flashcards

Fiser Chapter 17 BURNS Flashcards

1
Q

1st degree burn

A

Epidermis (sunburn)

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2
Q

2nd degree burn

A

Superficial dermis (papillary): Painful to touch, blebs/blisters, hair follicles intact, blanches, do NOT need skin graft

Deep dermis (reticular): decreased sensation, LOSS OF HAIR FOLLICLES, need skin graft

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3
Q

3rd degree burn

A

Leathery (charred parchment); down to subcutaneous fat

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4
Q

4th degree burn

A

Down to bone; into adjacent adipose or muscle tissue

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5
Q

Which burns heal?

A

1st and superficial 2nd degree burns: epithelialization from hair follicles

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6
Q

Complications of burns

A

Compartment syndrome
Rhabdomyolysis with myoglobinuria

Tx: hydration, alkalinize urine

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7
Q

Who gets admitted to a burn center?

A

No 1st degree burns

2nd and 3rd degree:
>20% (>10% if <10 or >50)
Or if significant hand/face/feet/genital/perineal/joint skin burns

3rd degree: >5% any age group

Electrical and chemical burns

Concomitant inhalational injury

Mechanical trauma, preexisting medical conditions, patients with special needs, child abuse/neglect

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8
Q

TBSA assessment

A

Rule of 9s

Head 9
Arms 9 each
Chest 18
Back 18
Legs 18 each
Perineum 1

Or palm = 1%

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9
Q

Parkland formula

A

Use for burns >/= 20%

Volume LR = 4 cc/kg x kg x % TBSA
Give 1/2 in first 8 hours, second half in second 16 hours

UOP best measure: goal 0.5-1.0 cc/kg/h in adults, 2-4 cc/kg/h in <6mo

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10
Q

When can Parkland formula grossly underestimate volume requirement?

A

inhalational injury
EtOH
electrical injury
post-escharatomy

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11
Q

What do you use in burn resuscitation?

A

LR in first 24 hr

Albumin in first day can cause increased pulmonary complications. Can use after 24hr

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12
Q

Escharotomy indications

A
  • Circumferential deep burns
  • Low temp
  • Weak pulse
  • Decreased capillary refill
  • Decreased pain sensation
  • Decreased neurological function in extremitiy
  • Problems ventilating patient with chest torso burns

Perform within 4-6 hours

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13
Q

Fasciotomy indication in burn patient

A

If compartment syndrome suspected after escharotomy

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14
Q

Risk factors for burn injuries

A 
EtOH
Drugs
Age (very young or very old)
Smoking
Low socioeconomic status
Violence
Epilepsy
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15
Q

H&P signs that suggest abuse

A
  • Delayed presentation for care
  • Conflicting histories
  • Previous injuries
  • Sharply demarcated margins
  • Uniform depth
  • Absence of splash marks
  • Stocking or glove patterns
  • Flexor sparing
  • Dorsal location on hands
  • Very deep localized contact injury

Child abuse accounts for 15% of burn injuries in children

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16
Q

Lung injury MoA

A

Carbonaceous materials and smoke (not heat)

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17
Q

Risk factors for airway injury in burn

A
  • EtOH
  • Trauma
  • Closed space
  • Rapid combustion
  • Extremes of age
  • Delayed extrication
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18
Q

Signs and symptoms of possible airway injury

A
  • Facial burns
  • Wheezing
  • Carbonaceous sputum
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19
Q

Indications for intubation

A
  • Upper airway stridor or obstruction
  • Worsening hypoxemia
  • Massive volume resuscitation can worsen symptoms
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20
Q

Most common infection in patients with >30% BSA burns

A

Pneumonia

Also MCC death after >30% BSA burns

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21
Q

MCC death after 30% BSA burns

A

Pneumonia

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22
Q

Acid and alkali burns tx

A

Copious water irrigation

Alkalis produce deeper burns due to liquefaction necrosis

Acid burns produced coagulation necrosis

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23
Q

Hydrofluoric acid burns tx

A

Calcium

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24
Q

Powder burns tx

A

Wipe away before irrigation

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25
Tar burns tx
Cool, then wipe away with lipophilic solvent (adhesive remover)
26
Electrical burns tx and complications
Cardiac monitoring Monitor for rhabdo and compartment syndrome Watch for polyneuritis, quadriplegia, transverse myelitis, cataracts, liver necrosis, intestinal perforation, gallbladder perforation, pancreatic necrosis
27
Lightning burn complication
Cardiopulmonary arrest 2/2 electrical paralysis of brainstem
28
Caloric need in burns
25 kcal/kg/day + (30 kcal x % burn)
29
Protein need in burns
1 g/kg/day + (3 g x % burn)
30
Glucose need in burns
Best source of nonprotein calories in patients with burns | Burn wounds use glucose in an obligatory fashion
31
Burn wound excision
- Perform AFTER fluid resusc but <72h - Used for deep 2nd, 3rd, 4th degree burns - For each burn wound excision, want <1 L blood loss, <20% skin excised, and <2 hr in OR. Patient can otherwise get very sick. - Viability based on color/texture/punctate bleeding after removal -Wounds to face, palms, soles, genitals deferred for 1 week
32
Skin graft contraindications
Positive beta-hemolytic strep or bacteria > 10^5 in culture
33
Autografts
- Decrease infection, desiccation, protein loss, pain, water loss, heat loss, RBC loss compared to dermal subtitutes - Donor skin site regenerated from hair follicles and skin edges on STSGs
34
Imbibition
Osmotic blood supply to skin graft for days 0-3
35
Neovascularization
Starts day 3
36
Poor vascularized beds unlikely to support skin grafting
Tendon, bone without periosteum, XRT areas
37
STSG thickness
12-15 mm (epidermis and part of dermis)
38
Homograft use
(Allografts from cadaveric skin) - Can be a good temporizing material, last 2-4 weeks - Vascularize and are eventually rejected, then must be replaced
39
Xenografts (porcine)
- Not as good as autografts or homografts - Last 2 weeks - Do NOT vascularize
40
Dermal substitutes
worst
41
Meshed grafts
-Use for back, flank, trunk, arms, legs
42
Most common reason for skin graft loss
- Seroma or hematoma | - Need to apply pressure dressing (cotton balls) to skin graft to prevent this
43
STSG versus FTSG
STSG: more likely to survive, graft not as thick so easier for imbibition and revascularization FTSG: less wound contraction, good for hands
44
Burn scar hypopigmentation and irregularities prevention
Dermabrasion thin split-thickness grafts
45
Face burn care
Topical antibiotics for 11st week | FTSG for unhealed areas (nonmeshed)
46
Hand burn care
Superficial: ROM exercises, splint in extension if too much edema Deep: FTSG, immobilize in extension for 7 days after, then PT, may need wire fixation of joints if unstable or open
47
Palm burn care
Try to preserve specialized palmar attachments | FTSG, then splint hand in extension for 7 days
48
Genitals burn care
STSG meshed is ok
49
Burn wound infection prevention
Bacitracin or Neosporin immediately No role for IV abx ppx Need 10^5 organisms for infection
50
Burn wound infection organism
MCC is pseudomonas (burn wound sepsis) > staph, e coli, enterobacter Candida increased 2/2 topical antimicrobials HSV most common viral
51
Burn wound infection risk factors
> 30% BSA
52
Burn wound infection pathophysiology
Impaired granulocyte chemotaxis and cell-mediated immunity
53
Silver sulfadiazine side effects
``` Neutropenia Thrombocytopenia Sulfa allergy reaction Limited eschar penetration Can inhibit epithelialization Ineffective against some pseudomonas (but effective for candida) ```
54
Silver nitrate side effects
``` Electrolyte imbalances Discoloration Limited eschar penetration Ineffective against some pseudomonas and GPCs Methemoglobinemia (in G6PD deficiency) ```
55
Mafenide sodium (sulfamylon) characteristics
Painful application Metabolic acidosis d/t carbonic anhydrase inhibition (decreased renal conversion of H2CO3 -> H2O and CO2) Good eschar penetration, good for burns overlying cartilage Broadest spectrum against pseudomonas and GNRs
56
Mupirocin
Good for MRSA, but very expensive
57
Signs of burn wound infection
- Peripheral edema - 2nd to 3rd degree burn conversion - Hemorrhage into scar - Erythema gangrenosum - Green fat - Black skin around wound - Rapid eschar separation - Focal discoloration
58
Best way to detect burn wound infection (and differentiate from colonization)
Biopsy of burn wound
59
Complications after burns
- Seizures - Peripheral neuropathy (small vessel injury and demyelination) - Ectopia (burned adnexa contraction, tx eyelid release) - Eye injury (fluorescein stain, tx topical fluoroquinolone or gentamicin) - Coreneal abrasion (tx topical abx) - Symblepharon (eyelid stuck to conjunctiva, tx release with glass rod) - Heterotopic ossification of tendons (tx PT, may need surgery) - Fractures (Tx external fixation to allow for burn tx) - Curling's ulcer - Marjolin's ulcer - Hypertrophic scar
60
Curling's ulcer
Gastric ulcer that occurs with burns
61
Marjolin's ulcer
Highly malignant squamous cell CA that arises in chronic non-healing burn wounds or unstable scars
62
Hypertrophic scar
- Usually occurs 3-4 months after injury 2/2 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: steroid injection into lesion (best), silicone, compression; wait 1-2 yr before scar modification surgery
63
Erythema multiforme
least severe, self-limited, target lesions
64
SJS
more serious | <10% BSA
65
TEN
most severe form
66
Staph scalded skin syndrome
Caused by staphylococcus aureus
67
Skin epidermal-dermal separation
Seen in EM, SJS, TEN
68
TEN causes
Dilantin Bactrim PCN Viruses
69
TEN tx
- Fluid resuscitation - Supportive - Prevent wound desiccation with homografts/xenografts wraps - Topical abx - IV abx if due to staphylococcus - NO Steroids

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