Fiser.17.Burns Flashcards
1
Q
Which layer of skin is affected by a first-degree burn
A
epidermis
2
Q
Which layer of skin is affected by a superficial second degree burn?
A
superficial dermis (papillary)
3
Q
Which layer of skin is affected by a deep second degree burn?
A
deep dermis (reticular)
4
Q
Which layer of skin is affected by a third degree burn?
A
down to subcutaneous fat
5
Q
Which layer of skin is affected by a fourth degree burn?
A
down to bone into adjacent adipose or muscle tissue
6
Q
what is the clinical presentation of a first-degree burn?
A
sunburn
7
Q
what is the clinical presentation of a superficial second-degree burn?
A
painful to touch; blebs and blisters; hair follicles intact; blanches
8
Q
does a superficial second-degree burn require grafting?
A
does not require skin grafting
9
Q
what is the clinical presentation of a deep second-degree burn?
A
decreased sensation, loss of hair follicles
10
Q
does a deep second-degree burn require skin grafting?
A
yes, needs skin grafts
11
Q
what is the clinical presentation of a third degree burn?
A
leathery, charred parchment, down to subcutaneous fat
12
Q
what is the clinical presentation of a fourth degree burn?
A
down to bone into adjacent adipose or muscle tissue
13
Q
what is the MOA of burn healing for a first-degree burn
A
epithelialization primary from hair follicles
14
Q
what is the MOA of burn healing for a superficial second-degree burn
A
epithelialization primary from hair follicles
15
Q
name three burn causes of rhabdomyolysis
A
extremely deep burns, electric burns, or compartment syndrome
16
Q
how do you treat rhabdomyolysis with myoglobinuria?
A
hydration, alkalanize urine
17
Q
what are admission criteria for patients < 10 y/o with second and third-degree burns?
A
> 10% BSA
18
Q
what are the admission criteria in terms of BSA for patients > 50 y/o with second and third-degree burns
A
> 10% BSA
19
Q
what is the admission criteria for patients between 10-50 y/o with second and third-degree burns in terms of BSA?
A
> 20% BSA
20
Q
Name 7 locations of second or third-degree burns that require hospitalization
A
overlying significant portions of the hands, face, feet, genitalia, perineum, or skin overlying joints
21
Q
what BSA of third degree burns is an indication for admission for any age group?
A
>5% TBSA of third degree burns
22
Q
what five comorbidities / types of burns are indications for admission (outside of second or third-degree burns)
A
electrical burns, chemical burns, concomitant inhalational injury, mechanical trauma, pre-existing medical conditions
23
Q
name two underlying social issues in burn patients that necessitates admission?
A
suspected child abuse / neglect; pts with long-term rehab needs
24
Q
what two age groups have the highest rates of burn-associated mortality and why?
A
children and elderly, difficulty escaping source of fire
25
what is the MC MOI for burns?
scald burns
26
what is the MC indication for admission for burns?
flame burns
27
Describe the rule of 9s for adults
head 9, arms 18, chest 18, back 18, legs 36, perineum 1
28
describe the rule of 9s for kids
head 18 , arms 18, chest 18, back 18, legs 28, perineum 1
29
Describe the parkland formula
4cc/kg \* %TBSA. Administer first 1/2 over 8 hours and the second 1/2 over the next 16 hours
30
when is resuscitation with the parkland formula indicated?
with burns \> or = 20% TBSA
31
what IVF do you use for burn resuscitation in the first 24 hours?
LR
32
what is the goal UOP during burn resuscitation for adults?
0.5-1cc/kg/hr
33
what is the goal UOP during burn resuscitation for children \< 6mo?
2-4cc/kg/hr
34
Name four comorbidities that can cause the Parkland formula to underestimate fluid resuscitation requirements for burn patients?
inhalational injury, EtOH, electrical injury, post-escharotomy
35
why is colloid for burn resuscitation contraindicated in the first 24 hours after injury?
causes increased rates of pulmonary and respiratory compromise
36
when can you use colloid for burn resuscitation?
when its \> 24 hours post-burn
37
when should you perform an escharotomy?
4-6 hours post-burn
38
Name six indications for extremity escharotomy
circumferential deep burs, low temperature, weak pulse, reduced capillary refill, reduced pain sensation, reduced neurologic function in extremity
39
name an indication for chest escharotomy
problems with ventilation in patient with signficant torso burns
40
when would fasciotomy be indicated in a patient s/p escharotomy
if there is clinical suspicion for underlying compartment syndrome
41
name 6 risk factors for burn injuries
EtOH, drugs, age (children/elderly), smoking, low SES, violence, epilepsy
42
what percent of pediatric burns are 2/2 child abuse?
15%
43
name three history findings in a pediatric burn patient that are concerning for abuse
delayed presentation, conflicting histories, previous injuries
44
name six physical exam findings in a pediatric burn patient that are concerning for abuse
sharply demarcated margins, uniform depth, absence of splash marks, stocking/glove patterns, flexor sparing, dorsal location on hands, very deep localized contact injury
45
name the two underlying causes of lung injury in burn patients
carbonaceous materials and smoke, not heat
46
name six risk factors for airway injury in a burn patient
EtOH, trauma, closed space, rapid combustion, extremes of age, delayed extrication
47
name three S/Sx concerning for airway injury
facial burns, wheezing, carbonaceous sputum
48
Name three indications for intubation in a burn patient
upper airway stridor/obstruction, worsening hypoxemia, massive volume resuscitation can worsen symptoms
49
what is the MC infection in patients with \>30% TBSA burns
pneumonia
50
what is the MCC of death in patients with \>30% TBSA burns
pneumonia
51
what is the initial treatment for acid burns?
copious water irrigation
52
what is the initial treatment for alkali burns?
copious water irrigation
53
what is the MOI of acid burns?
coagulation necrosis
54
what is the MOI of alkali burns
liquefactive necrosis
55
which type of burn is more severe and why: alkali or acid?
alkali 2/2 liquefactive necrosis
56
how do you treat a hydrofluoroacid burn?
spread calcium on the burn
57
how do you treat powder burns?
wipe away the powder before you irrigate
58
how do you treat tar burns?
cool, then wipe away with a lipophilic solvent (adhesive remover)
59
why should you admit electrical burns?
will require admission for cardiac monitoring
60
name 10 possible complications of electrical burns
rhabdomyolysis, compartment syndrome, polyneuritis, quadriplegia, transverse myelitis, cataracts, liver necrosis, intestinal perforation, gallbladder perforation, pancreatic necrosis
61
name the mechanism of cardiac arrest that occurs 2/2 lightning strike
cardiac arrest 2/2 electrical paralysis of brainstem
62
what is the caloric need of burn patients according to TBSA?
25 kcal/kg/day + (30kcal \* %TBSA)
63
what is the protein need of burn patients according to TBSA?
1 g/kg/day + (3g \* %TBSA)
64
what is the best source of nonprotein calories for burn patients and why?
glucose, used in burn wounds in an obligatory fashion
65
what is the time frame for excision of burn wounds?
\< 72 hours after the burn after appropriate fluid resuscitation
66
what depth of burn is indicated for excision?
deep 2nd, 3rd, and some 4th
67
name three intraoperative indicators of skin viability after burn excision?
punctate bleeding, color, texture
68
on which four locations of burns is burn excision delayed for the first week?
face, palms of hands, soles of feet, and genitalia
69
name three intraoperative goals for burn excision and why?
\<1L EBL, \<20% skin excised, and \<2 hours in OR. Patients can become very sick if they spend more time in the OR
70
Name two bacterial findings that are contraindications for skin grafting
burn culture positive for beta-hemolytic strep OR wound culture \>10^5 concentration of bacteria
71
name 7 reasons autografts are superior (and preferred) to cadaveric or xenografts
reduced infection, dessication,
72
name two sites of donor site regeneration for STSG
hair follicles and skin edges
73
what is the mechanism of blood supply to an autograft for POD 0-3
imbibition (osmotic) - blood supply to skin graft days 0-3
74
what is the mechanism of blood supply to an autograft for POD 3+
neovascularization
75
name three burn sites that are unlikely to support grafts and why
poorly vascularized beds are unlikely to support skin grafting. This includes tendons, bone without periosteum, and XRT areas
76
what is the thickness in mm of a STSG and what layers of skin are included?
12-15mm thickness includes epidermis and parts of dermis
77
what are homografts / allografts made from and how do they compare to autografts?
made from cadaveric skin, not as good as autografts
78
how long do homografts / allografts last for?
a good temporizing measure and last 2-4 weeks
79
why are homografts/ allografts only a temporary solution for burns?
allografts vascularize and are eventually rejected at which time they must be replaced
80
what is the source of xenografts?
porcine
81
how do xenografts compare to allografts?
they are not as good as allografts / homografts
82
how long do xenografts last for?
they last for 2 weeks and do not vascularize
83
how do dermal substitutes compare to homografts/allografts and xenografts
inferior to both
84
name five locations for meshed grafting?
back, flank, trunk, arms legs
85
name four reasons to delay autografting
infection, not enough skin donor sites, patient unstable/septic, do not want to create any more donor sites with concomitant blood loss
86
what is the MC reason for skin graft loss
seroma or hematoma formation under the skin graft
87
why are STSGs more likely to survive than FTSGs
graft is not as thick so its easier for imbibition and revascularization to occur
88
where is a good location for FTSGs and why? (2)
palms and dorsum of hands because they have less wound contraction
89
name two ways to treat burn scar hypopigmentation and irregularities
dermabrasion, thin STSGs
90
how should you treat facial burns for the first week?
topical antibiotics
91
how should you treat facial burns after 1 week post-burn?
FTSG for unhealed areas, nonmeshed
92
how do you treat superficial hand burns during weeks 2-5 s/p burn?
ROM exercises, splint in extension if too much edema
93
how do you treat deep hand burns during weeks 2-5 s/p burn?
immobilize in extension for 7 days after FTSG, then PT. May need to wirefixate joints if unstable or open
94
how do you treat palmar burns 2-5 weeks s/p burn?
try to preserve specialized palmar attachments. Splint hand in extension 7 days after FTSG
95
how do you treat genital burns 2-5 weeks s/p burn?
can use meshed STSG
96
what two topical abx can you apply immediately after burns?
topical neosporin or bacitracin
97
are prophylactic abx indicated in burn patients?
nope
98
what is are the 4 MCC of burn wound infections in order of incidence?
Pseudomonas, staphylococcus, E. coli, enterobacter
99
what TBSA burns are at increased risk of burn wound infections?
\> 30% TBSA
100
how have topical agents affected the incidence of burn infections?
topical agents have decreased the incidence of burn wound bacterial infections but increased incidence of candida infections
101
name two immunologic processes that are impaired in burn patients
granulocyte chemotaxis and cell-mediated immunity are impaired in burn patients
102
name two adverse effects of silvadene
can cause neutropenia and thrombocytopenia
103
what is a CI to using silvadene?
sulfa allergy
104
name two issues with burn healing a/w silvadene
poor eschar penetration, can inhibit epithelialization
105
which bax is silvadene ineffective and effective against?
ineffective against pseudomonas, effective against candida
106
name 6 AEs a/w silver nitrate for burn treatment
electrolyte imbalances (hyponatremia, hypochloremia, hypocalcemia, hypokalemia), skin discoloration, methemoglobinemia
107
name an issue a/w burn healing when using silver nitrate
poor eschar penetration
108
name two bax silver nitrate is ineffective against
GPCs, pseudomonas
109
name a CI to silver nitrate use
can cause methemoglobinemia and CI in G6PD deficiency
110
name 2 AE a/w sulfamylon (mafeinde sodium)
painful application, can cause metabolic acidosis
111
name the MOA of metabolic acidosis a/w sulfamylon
inhibits renal carbonic anhydrase, reducing renal conversionn of bicarb to water + CO2
112
name two burn pathology indications for sulfamylon use
good eschar penetration, good for burns overlying cartilage
113
which bax is sulfamylon (mafenide sodium) effective against?
pseudomonas and GNRs
114
what is mupirocin effective against?
MRSA
115
what is a downside to using mupirocin
very expensive
116
name 7 S/Sx a/w 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
117
what is the MCC of burn wound sepsis?
pseudomonas
118
what is the MC viral infection in burn wounds?
HSV
119
what is the threshold of organism growth to define burn wound infection?
\<10^5 organisms is NOT a burn infection
120
what is the best way to detect burn wound infection and differentiate from colonization?
biopsy the burn wound
121
what is the MCC of seizures after burns?
iatrogenic, related to sodium concentration
122
what is the MCC of peripheral neuropathy in burn patients? (2)
small vessel injury, demyelination
123
what is the MCC of ectopia in burn patients
eyelid contracture
124
what is the treatment of ectopia in burn patients?
eyelid release
125
how do you evaluate the eyes for injury in burn patients?
fluoroscein staining to find injury
126
what is the treatment of eye injury s/p burn?
topical fluoroquinolone or gentamicin
127
define symbelepharon in a burn patient
eyelid stuck to the conjunctiva
128
how do you treat symbepharon in a burn patient?
release with a glass rod
129
how do you treat corneal abrasion in a burn patient?
topical abx
130
how do you treat heterotopic ossification of tendons in burn patients?
PT\< may need surgery
131
how do you treat fractures in burn patients?
often need external fixation to allow for treatment of burns
132
what is a Curling's ulcer?
gastric ulcer that occurs with burns
133
what is a Marjolin's ulcer?
highly malignant squamous cell CA that arises in chronic non-healing burn wounds or unstable scars
134
when do hypertrophic scars present in burn patients and what is their underlying pathophysiology?
usually occur 3-4 months after injury 2/2 increased neovascularity
135
name three burn associated risk factors for hypertrophic scars
more likley to be in deep thermal injuries that take \> 3 weeks to heal, heal by contraction and epithelial spread, or heal across flexor surfaces
136
name three treatments for hypertrophic scars s/p burn
steroid injection into lesion (best therapy), silicone, compression
137
how long should you wait for scar modification surgery in burn patients with hypertrophic scars?
wait 1-2 years before scar modification surgery
138
how does erythema multiforme present?
least severe form of erythema multiform, is self-limited with target lesions
139
how does Stevens-Johnson Syndrome present?
more serious form of erythema multiform at \<10% BSA
140
how does toxic epidermal necrolysis present?
most severe form, \>10% BSA
141
what is the cause of staph scalded skin syndrome?
staph aureus
142
what is the underlying pathophysiology of erythema multiforme?
skin epidermal-dermal separation
143
what is the underlying pathophysiology of SJS?
skin epidermal-dermal separation
144
what is the underlying pathophysiology of TEN?
skin epidermal-dermal separation
145
what is the underlying pathophysiology of staph scalded skin syndrome
skin epidermal-dermal separation
146
name four underlying causes (three drugs, one pathogen) that can cause erythema multiforme, SJS, or TEN
drugs (Dilantin, Bactrim, PCN) and viruses
147
how do you treat erythema multiforme, SJS, and TEN
fluid resuscitation, supportive care, prevent wound dessication with homograft/xenograft wraps, topical abx
148
when are IV abx indicated with erythema multiforme variants?
if it is staph scalded skin syndrome and is due to staph
149
are steroids indicated in erythema multiforme variants?
nope
