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Z.Fiser > Fiser.17.Burns > Flashcards

Fiser.17.Burns Flashcards

1
Q

Which layer of skin is affected by a first-degree burn

A

epidermis

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2
Q

Which layer of skin is affected by a superficial second degree burn?

A

superficial dermis (papillary)

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3
Q

Which layer of skin is affected by a deep second degree burn?

A

deep dermis (reticular)

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4
Q

Which layer of skin is affected by a third degree burn?

A

down to subcutaneous fat

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5
Q

Which layer of skin is affected by a fourth degree burn?

A

down to bone into adjacent adipose or muscle tissue

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6
Q

what is the clinical presentation of a first-degree burn?

A

sunburn

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7
Q

what is the clinical presentation of a superficial second-degree burn?

A

painful to touch; blebs and blisters; hair follicles intact; blanches

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8
Q

does a superficial second-degree burn require grafting?

A

does not require skin grafting

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9
Q

what is the clinical presentation of a deep second-degree burn?

A

decreased sensation, loss of hair follicles

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10
Q

does a deep second-degree burn require skin grafting?

A

yes, needs skin grafts

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11
Q

what is the clinical presentation of a third degree burn?

A

leathery, charred parchment, down to subcutaneous fat

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12
Q

what is the clinical presentation of a fourth degree burn?

A

down to bone into adjacent adipose or muscle tissue

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13
Q

what is the MOA of burn healing for a first-degree burn

A

epithelialization primary from hair follicles

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14
Q

what is the MOA of burn healing for a superficial second-degree burn

A

epithelialization primary from hair follicles

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15
Q

name three burn causes of rhabdomyolysis

A

extremely deep burns, electric burns, or compartment syndrome

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16
Q

how do you treat rhabdomyolysis with myoglobinuria?

A

hydration, alkalanize urine

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17
Q

what are admission criteria for patients < 10 y/o with second and third-degree burns?

A

> 10% BSA

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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

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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

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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

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21
Q

what BSA of third degree burns is an indication for admission for any age group?

A

>5% TBSA of third degree burns

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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

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23
Q

name two underlying social issues in burn patients that necessitates admission?

A

suspected child abuse / neglect; pts with long-term rehab needs

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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

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25
Q

what is the MC MOI for burns?

A

scald burns

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26
Q

what is the MC indication for admission for burns?

A

flame burns

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27
Q

Describe the rule of 9s for adults

A

head 9, arms 18, chest 18, back 18, legs 36, perineum 1

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28
Q

describe the rule of 9s for kids

A

head 18 , arms 18, chest 18, back 18, legs 28, perineum 1

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29
Q

Describe the parkland formula

A

4cc/kg * %TBSA. Administer first 1/2 over 8 hours and the second 1/2 over the next 16 hours

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30
Q

when is resuscitation with the parkland formula indicated?

A

with burns > or = 20% TBSA

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31
Q

what IVF do you use for burn resuscitation in the first 24 hours?

A

LR

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32
Q

what is the goal UOP during burn resuscitation for adults?

A

0.5-1cc/kg/hr

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33
Q

what is the goal UOP during burn resuscitation for children < 6mo?

A

2-4cc/kg/hr

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34
Q

Name four comorbidities that can cause the Parkland formula to underestimate fluid resuscitation requirements for burn patients?

A

inhalational injury, EtOH, electrical injury, post-escharotomy

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35
Q

why is colloid for burn resuscitation contraindicated in the first 24 hours after injury?

A

causes increased rates of pulmonary and respiratory compromise

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36
Q

when can you use colloid for burn resuscitation?

A

when its > 24 hours post-burn

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37
Q

when should you perform an escharotomy?

A

4-6 hours post-burn

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38
Q

Name six indications for extremity escharotomy

A

circumferential deep burs, low temperature, weak pulse, reduced capillary refill, reduced pain sensation, reduced neurologic function in extremity

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39
Q

name an indication for chest escharotomy

A

problems with ventilation in patient with signficant torso burns

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40
Q

when would fasciotomy be indicated in a patient s/p escharotomy

A

if there is clinical suspicion for underlying compartment syndrome

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41
Q

name 6 risk factors for burn injuries

A

EtOH, drugs, age (children/elderly), smoking, low SES, violence, epilepsy

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42
Q

what percent of pediatric burns are 2/2 child abuse?

A

15%

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43
Q

name three history findings in a pediatric burn patient that are concerning for abuse

A

delayed presentation, conflicting histories, previous injuries

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44
Q

name six physical exam findings in a pediatric burn patient that are concerning for abuse

A

sharply demarcated margins, uniform depth, absence of splash marks, stocking/glove patterns, flexor sparing, dorsal location on hands, very deep localized contact injury

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45
Q

name the two underlying causes of lung injury in burn patients

A

carbonaceous materials and smoke, not heat

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46
Q

name six risk factors for airway injury in a burn patient

A

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

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47
Q

name three S/Sx concerning for airway injury

A

facial burns, wheezing, carbonaceous sputum

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48
Q

Name three indications for intubation in a burn patient

A

upper airway stridor/obstruction, worsening hypoxemia, massive volume resuscitation can worsen symptoms

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49
Q

what is the MC infection in patients with >30% TBSA burns

A

pneumonia

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50
Q

what is the MCC of death in patients with >30% TBSA burns

A

pneumonia

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51
Q

what is the initial treatment for acid burns?

A

copious water irrigation

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52
Q

what is the initial treatment for alkali burns?

A

copious water irrigation

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53
Q

what is the MOI of acid burns?

A

coagulation necrosis

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54
Q

what is the MOI of alkali burns

A

liquefactive necrosis

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55
Q

which type of burn is more severe and why: alkali or acid?

A

alkali 2/2 liquefactive necrosis

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56
Q

how do you treat a hydrofluoroacid burn?

A

spread calcium on the burn

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57
Q

how do you treat powder burns?

A

wipe away the powder before you irrigate

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58
Q

how do you treat tar burns?

A

cool, then wipe away with a lipophilic solvent (adhesive remover)

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59
Q

why should you admit electrical burns?

A

will require admission for cardiac monitoring

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60
Q

name 10 possible complications of electrical burns

A

rhabdomyolysis, compartment syndrome, polyneuritis, quadriplegia, transverse myelitis, cataracts, liver necrosis, intestinal perforation, gallbladder perforation, pancreatic necrosis

61
Q

name the mechanism of cardiac arrest that occurs 2/2 lightning strike

A

cardiac arrest 2/2 electrical paralysis of brainstem

62
Q

what is the caloric need of burn patients according to TBSA?

A

25 kcal/kg/day + (30kcal * %TBSA)

63
Q

what is the protein need of burn patients according to TBSA?

A

1 g/kg/day + (3g * %TBSA)

64
Q

what is the best source of nonprotein calories for burn patients and why?

A

glucose, used in burn wounds in an obligatory fashion

65
Q

what is the time frame for excision of burn wounds?

A

< 72 hours after the burn after appropriate fluid resuscitation

66
Q

what depth of burn is indicated for excision?

A

deep 2nd, 3rd, and some 4th

67
Q

name three intraoperative indicators of skin viability after burn excision?

A

punctate bleeding, color, texture

68
Q

on which four locations of burns is burn excision delayed for the first week?

A

face, palms of hands, soles of feet, and genitalia

69
Q

name three intraoperative goals for burn excision and why?

A

<1L EBL, <20% skin excised, and <2 hours in OR. Patients can become very sick if they spend more time in the OR

70
Q

Name two bacterial findings that are contraindications for skin grafting

A

burn culture positive for beta-hemolytic strep OR wound culture >10^5 concentration of bacteria

71
Q

name 7 reasons autografts are superior (and preferred) to cadaveric or xenografts

A

reduced infection, dessication,

72
Q

name two sites of donor site regeneration for STSG

A

hair follicles and skin edges

73
Q

what is the mechanism of blood supply to an autograft for POD 0-3

A

imbibition (osmotic) - blood supply to skin graft days 0-3

74
Q

what is the mechanism of blood supply to an autograft for POD 3+

A

neovascularization

75
Q

name three burn sites that are unlikely to support grafts and why

A

poorly vascularized beds are unlikely to support skin grafting. This includes tendons, bone without periosteum, and XRT areas

76
Q

what is the thickness in mm of a STSG and what layers of skin are included?

A

12-15mm thickness includes epidermis and parts of dermis

77
Q

what are homografts / allografts made from and how do they compare to autografts?

A

made from cadaveric skin, not as good as autografts

78
Q

how long do homografts / allografts last for?

A

a good temporizing measure and last 2-4 weeks

79
Q

why are homografts/ allografts only a temporary solution for burns?

A

allografts vascularize and are eventually rejected at which time they must be replaced

80
Q

what is the source of xenografts?

A

porcine

81
Q

how do xenografts compare to allografts?

A

they are not as good as allografts / homografts

82
Q

how long do xenografts last for?

A

they last for 2 weeks and do not vascularize

83
Q

how do dermal substitutes compare to homografts/allografts and xenografts

A

inferior to both

84
Q

name five locations for meshed grafting?

A

back, flank, trunk, arms legs

85
Q

name four reasons to delay autografting

A

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

86
Q

what is the MC reason for skin graft loss

A

seroma or hematoma formation under the skin graft

87
Q

why are STSGs more likely to survive than FTSGs

A

graft is not as thick so its easier for imbibition and revascularization to occur

88
Q

where is a good location for FTSGs and why? (2)

A

palms and dorsum of hands because they have less wound contraction

89
Q

name two ways to treat burn scar hypopigmentation and irregularities

A

dermabrasion, thin STSGs

90
Q

how should you treat facial burns for the first week?

A

topical antibiotics

91
Q

how should you treat facial burns after 1 week post-burn?

A

FTSG for unhealed areas, nonmeshed

92
Q

how do you treat superficial hand burns during weeks 2-5 s/p burn?

A

ROM exercises, splint in extension if too much edema

93
Q

how do you treat deep hand burns during weeks 2-5 s/p burn?

A

immobilize in extension for 7 days after FTSG, then PT. May need to wirefixate joints if unstable or open

94
Q

how do you treat palmar burns 2-5 weeks s/p burn?

A

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

95
Q

how do you treat genital burns 2-5 weeks s/p burn?

A

can use meshed STSG

96
Q

what two topical abx can you apply immediately after burns?

A

topical neosporin or bacitracin

97
Q

are prophylactic abx indicated in burn patients?

A

nope

98
Q

what is are the 4 MCC of burn wound infections in order of incidence?

A

Pseudomonas, staphylococcus, E. coli, enterobacter

99
Q

what TBSA burns are at increased risk of burn wound infections?

A

> 30% TBSA

100
Q

how have topical agents affected the incidence of burn infections?

A

topical agents have decreased the incidence of burn wound bacterial infections but increased incidence of candida infections

101
Q

name two immunologic processes that are impaired in burn patients

A

granulocyte chemotaxis and cell-mediated immunity are impaired in burn patients

102
Q

name two adverse effects of silvadene

A

can cause neutropenia and thrombocytopenia

103
Q

what is a CI to using silvadene?

A

sulfa allergy

104
Q

name two issues with burn healing a/w silvadene

A

poor eschar penetration, can inhibit epithelialization

105
Q

which bax is silvadene ineffective and effective against?

A

ineffective against pseudomonas, effective against candida

106
Q

name 6 AEs a/w silver nitrate for burn treatment

A

electrolyte imbalances (hyponatremia, hypochloremia, hypocalcemia, hypokalemia), skin discoloration, methemoglobinemia

107
Q

name an issue a/w burn healing when using silver nitrate

A

poor eschar penetration

108
Q

name two bax silver nitrate is ineffective against

A

GPCs, pseudomonas

109
Q

name a CI to silver nitrate use

A

can cause methemoglobinemia and CI in G6PD deficiency

110
Q

name 2 AE a/w sulfamylon (mafeinde sodium)

A

painful application, can cause metabolic acidosis

111
Q

name the MOA of metabolic acidosis a/w sulfamylon

A

inhibits renal carbonic anhydrase, reducing renal conversionn of bicarb to water + CO2

112
Q

name two burn pathology indications for sulfamylon use

A

good eschar penetration, good for burns overlying cartilage

113
Q

which bax is sulfamylon (mafenide sodium) effective against?

A

pseudomonas and GNRs

114
Q

what is mupirocin effective against?

A

MRSA

115
Q

what is a downside to using mupirocin

A

very expensive

116
Q

name 7 S/Sx a/w 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

117
Q

what is the MCC of burn wound sepsis?

A

pseudomonas

118
Q

what is the MC viral infection in burn wounds?

A

HSV

119
Q

what is the threshold of organism growth to define burn wound infection?

A

<10^5 organisms is NOT a burn infection

120
Q

what is the best way to detect burn wound infection and differentiate from colonization?

A

biopsy the burn wound

121
Q

what is the MCC of seizures after burns?

A

iatrogenic, related to sodium concentration

122
Q

what is the MCC of peripheral neuropathy in burn patients? (2)

A

small vessel injury, demyelination

123
Q

what is the MCC of ectopia in burn patients

A

eyelid contracture

124
Q

what is the treatment of ectopia in burn patients?

A

eyelid release

125
Q

how do you evaluate the eyes for injury in burn patients?

A

fluoroscein staining to find injury

126
Q

what is the treatment of eye injury s/p burn?

A

topical fluoroquinolone or gentamicin

127
Q

define symbelepharon in a burn patient

A

eyelid stuck to the conjunctiva

128
Q

how do you treat symbepharon in a burn patient?

A

release with a glass rod

129
Q

how do you treat corneal abrasion in a burn patient?

A

topical abx

130
Q

how do you treat heterotopic ossification of tendons in burn patients?

A

PT< may need surgery

131
Q

how do you treat fractures in burn patients?

A

often need external fixation to allow for treatment of burns

132
Q

what is a Curling’s ulcer?

A

gastric ulcer that occurs with burns

133
Q

what is a Marjolin’s ulcer?

A

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

134
Q

when do hypertrophic scars present in burn patients and what is their underlying pathophysiology?

A

usually occur 3-4 months after injury 2/2 increased neovascularity

135
Q

name three burn associated risk factors for hypertrophic scars

A

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
Q

name three treatments for hypertrophic scars s/p burn

A

steroid injection into lesion (best therapy), silicone, compression

137
Q

how long should you wait for scar modification surgery in burn patients with hypertrophic scars?

A

wait 1-2 years before scar modification surgery

138
Q

how does erythema multiforme present?

A

least severe form of erythema multiform, is self-limited with target lesions

139
Q

how does Stevens-Johnson Syndrome present?

A

more serious form of erythema multiform at <10% BSA

140
Q

how does toxic epidermal necrolysis present?

A

most severe form, >10% BSA

141
Q

what is the cause of staph scalded skin syndrome?

A

staph aureus

142
Q

what is the underlying pathophysiology of erythema multiforme?

A

skin epidermal-dermal separation

143
Q

what is the underlying pathophysiology of SJS?

A

skin epidermal-dermal separation

144
Q

what is the underlying pathophysiology of TEN?

A

skin epidermal-dermal separation

145
Q

what is the underlying pathophysiology of staph scalded skin syndrome

A

skin epidermal-dermal separation

146
Q

name four underlying causes (three drugs, one pathogen) that can cause erythema multiforme, SJS, or TEN

A

drugs (Dilantin, Bactrim, PCN) and viruses

147
Q

how do you treat erythema multiforme, SJS, and TEN

A

fluid resuscitation, supportive care, prevent wound dessication with homograft/xenograft wraps, topical abx

148
Q

when are IV abx indicated with erythema multiforme variants?

A

if it is staph scalded skin syndrome and is due to staph

149
Q

are steroids indicated in erythema multiforme variants?

A

nope

Z.Fiser (22 decks)

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