General Surgery - Burns

Question 1

# Define:
TBSA

Answer 1

Total Body Surface Area

Question 2

Define STSG

Answer 2

Split Thickness Skin Graft

Question 3

Are acid or alkali chemical
burns more serious?

Answer 3

In general, ALKALI burns are more
serious because the body cannot buffer
the alkali, thus allowing them to burn for
much longer

Question 4

Why are electrical burns so
dangerous?

Answer 4

Most of the destruction from electrical
burns is internal because the route of
least electrical resistance follows nerves,
blood vessels, and fascia; injury is
usually worse than external burns at
entrance and exit sites would indicate;
cardiac dysrhythmias, myoglobinuria,
acidosis, and renal failure are common

Question 5

How is myoglobinuria
treated?

Answer 5

To avoid renal injury, think “HAM”:

Hydration with IV fluids
Alkalization of urine with IV
bicarbonate
Mannitol diuresis

Question 6

Define level of burn injury:

Answer 6

First-degree burns: Epidermis only
Second-degree burns: Epidermis and varying levels of
dermis
Third-degree burns: A.k.a. “full thickness”; all layers of the
skin including the entire dermis (Think:
“getting the third degree”)
Fourth-degree burns: Burn injury into bone or muscle

Question 7

How do first-degree burns
present?

Answer 7

Painful, dry, red areas that do not form blisters (think of sunburn)

Question 8

How do second-degree burns
present?

Answer 8

Painful, hypersensitive, swollen, mottled areas with blisters and open weeping
surfaces

Question 9

How do third-degree burns
present?

Answer 9

Painless, insensate, swollen, dry, mottled white, and charred areas; often described
as dried leather

Question 10

What is the major clinical
difference between second-
and third-degree burns?

Answer 10

Third-degree burns are painless, and second-degree burns are painful

Question 11

By which measure is burn
severity determined?

Answer 11

Depth of burn and TBSA affected by second- and third-degree burns
TBSA is calculated by the “rule of
nines” in adults and by a modified
rule in children to account for the
disproportionate size of the head and
trunk

Question 12

What is the “rule of nines”?

Answer 12

In an adult, the total body surface area
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%

Question 13

What is the “rule of the palm”?

Answer 13

Surface area of the patient’s palm is ~1%
of the TBSA used for estimating size of
small burns

Question 14

What is the burn center referral
criteria?

Answer 14

Second-degree burns: >20% TBSA

Third-degree burns: >5% TBSA
Second degree >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

Question 15

What is the treatment of
first-degree burns?

Answer 15

Keep clean, _+_Neosporin®, pain meds

Question 16

What is the treatment of
second-degree burns?

Answer 16

Remove blisters; apply antibiotic ointment (usually Silvadene®) and
dressing; pain meds
Most second-degree burns do not require
skin grafting (epidermis grows from
hair follicles and from margins)

Question 17

What are some newer
options for treating a
second-degree burn?

Answer 17

1. Biobrane® (silicone artificial epidermis—temporary)
2. Silverlon® (silver ion dressings)

Question 18

What is the treatment of
third-degree burns?

Answer 18

Early excision of eschar (within first week postburn) and STSG

Question 19

How can you decrease
bleeding during excision?

Answer 19

Tourniquets as possible, topical epinephrine, topical thrombin

Question 20

What is an autograft STSG?

Answer 20

STSG from the patient’s own skin

Question 21

What is an allograft STSG?

Answer 21

STSG from a cadaver (temporary
coverage)

Question 22

What thickness is the STSG?

Answer 22

10/1000 to 15/1000 of an inch (down to
the dermal layer)

Question 23

What prophylaxis should the
burn patient get in the ER?

Answer 23

Tetanus

Question 24

What is used to evaluate the
eyes after a third-degree burn?

Answer 24

Fluorescein

Question 25

What principles guide the
initial assessment and
resuscitation of the burn
patient?

Answer 25

ABCDEs, then urine output; check for eschar and compartment syndromes

Question 26

What are the signs of
smoke inhalation?

Answer 26

Smoke and soot in sputum/mouth/nose, nasal/facial hair burns, carboxyhemoglobin,
throat/mouth erythema, history of loss of
consciousness/explosion/fire in small
enclosed area, dyspnea, low O₂ saturation,
confusion, headache, coma

Question 27

What diagnostic imaging is
used for smoke inhalation?

Answer 27

Bronchoscopy

Question 28

What lab value assesses smoke
inhalation?

Answer 28

Carboxyhemoglobin level (a carboxyhemoglobin level of >60% is associated
with a 50% mortality); treat with 100%
O₂ and time

Question 29

How should the airway be
managed in the burn patient
with an inhalational injury?

Answer 29

With a low threshold for intubation; oropharyngeal swelling may occlude the airway so that intubation is impossible;
100% oxygen should be administered
immediately and continued until significant
carboxyhemoglobin is ruled out

Question 30

What is “burn shock”?

Answer 30

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

Question 31

What is the “Parkland
formula”?

Answer 31

V = TBSA Burn (%) x Weight (kg) x 4

Formula widely used to estimate the
volume (V) of crystalloid necessary for
the initial resuscitation of the burn
patient; half of the calculated volume
is given in the first 8 hours, the rest
in the next 16 hours

Question 32

What burns qualify for the
Parkland formula?

Answer 32

_>_20% TBSA second- and third-degree burns only

Question 33

What is the Brooke formula
for burn resuscitation?

Answer 33

Replace 2 cc for the 4 cc in the Parkland formula

Question 34

How is the crystalloid given?

Answer 34

Through two large-bore peripheral
venous catheters

Question 35

Can you place an IV or central
line through burned skin?

Answer 35

F*CK YEAH

Question 36

What is the adult urine
output goal?

Answer 36

30–50 cc (titrate IVF)

Get it, or URINE trouble! heheheheheh….

Question 37

Why is glucose-containing
IVF contraindicated in burn
patients in the first 24 hours
postburn?

Answer 37

Patient’s serum glucose will be elevated on its own because of the stress response

What a sweet burn…

Question 38

What fluid is used after the
first 24 hours postburn?

Answer 38

Colloid; use D5W and 5% albumin at 0.5 cc/kg/% burn surface area

Question 39

Why should D5W IV be
administered after 24 hours
postburn?

Answer 39

Because of the massive sodium load in the first 24 hrs of LR infusion and because of the massive evaporation of
H₂O from the burn injury, the patient
will need free water; after 24 hours, the
capillaries begin to work and then the
patient can usually benefit from albumin
and D5W

Question 40

What is the minimal urine for burn patients?

Answer 40

Adults 30 cc; children 1–2 cc/kg/hr
output

Question 41

How is volume status
monitored in the burn
patient?

Answer 41

Urine output, blood pressure, heart rate, peripheral perfusion, and mental status; Foley catheter is mandatory and may be supplemented by central venous
pressure and pulmonary capillary wedge
pressure monitoring

Question 42

Why do most severely
burned patients require
nasogastric decompression?

Answer 42

Patients with greater than 20% TBSA burns usually develop a paralytic ileus → vomiting → aspiration risk → pneumonia

Question 43

What stress prophylaxis must
be given to the burn patient?

Answer 43

H₂ blocker to prevent burn stress ulcer (Curling’s ulcer)

Question 44

What are the signs of burn
wound infection?

Answer 44

Increased WBC with left shift, discoloration of burn eschar (most
common sign), green pigment, necrotic
skin lesion in unburned skin, edema,
ecchymosis tissue below eschar, second-degree
burns that turn into third-degree
burns, hypotension

Question 45

Is fever a good sign of
infection in burn patients?

Answer 45

NO

Question 46

What are the common
organisms found in burn
wound infections?

Answer 46

Staphylococcus aureus, Pseudomonas, Streptococcus, Candida albicans

Question 47

How is a burn wound infection diagnosed?

Answer 47

Send burned tissue in question to the
laboratory for quantitative burn wound
bacterial count; if the count is >10⁵/gram,
infection is present and IV antibiotics
should be administered

Question 48

How are minor burns dressed?

Answer 48

Gentle cleaning with nonionic detergent
and débridement of loose skin and broken
blisters; the burn is dressed with a topical
antibacterial (e.g., neomycin) and
covered with a sterile dressing

Question 49

How are major burns
dressed?

Answer 49

Cleansing and application of topical antibacterial agent

Question 50

Why are systemic IV antibiotics contraindicated in fresh burns?

Answer 50

Bacteria live in the eschar, which is
avascular (the systemic antibiotic will
not be delivered to the eschar); thus,
apply topical antimicrobial agents

Question 51

Note some advantages
and disadvantages of the
following topical antibiotic
agents:

Silver sulfadiazine (Silvadene®)

Mafenide acetate (Sulfamylon®)

Polysporin®

Answer 51

Silver sulfadiazine (Silvadene®): Painless, but little eschar penetration, misses Pseudomonas, and has idiosyncratic neutropenia; sulfa allergy is contraindication
Mafenide acetate (Sulfamylon®): Penetrates eschars, broad spectrum (but misses Staphylococcus), causes pain on application; triggers allergic reaction in
7% of patients; may cause acid-base
imbalances(Think:MafenideACetate
Metabolic ACidosis); agent of choice in
already-contaminated burn wounds
Polysporin®: Polymyxin B sulfate; painless, clear, used
for facial burns; does not have a wide
antimicrobial spectrum

Question 52

Are prophylactic systemic antibiotics administered to burn patients?

Answer 52

No—prophylactic antibiotics have not
been shown to reduce the incidence
of sepsis, but rather have been shown to
select for resistant organisms; IV
antibiotics are reserved for established
wound infections, pneumonia, urinary
tract infections, etc.

Question 53

Are prophylactic antibiotics
administered for inhalational
injury?

Answer 53

No

Question 54

Circumferential, full-
thickness burns to the
extremities are at risk for
what complication?

Answer 54

Distal neurovascular impairment

Question 55

How is it treated?

Circumferential, full-
thickness burns to the
extremities

Answer 55

Escharotomy: full-thickness longitudinal
incision through the eschar with scalpel
or electrocautery

Question 56

What is the major infection
complication (other than
wound infection) in burn
patients?

Answer 56

Pneumonia, central line infection (change central lines prophylactically every 3 to 4 days)

Question 57

Is tetanus prophylaxis required in the burn patient?

Answer 57

Yes, it is mandatory in all patients except
those actively immunized within the past
12 months (with incomplete immunization:
toxoid x 3)

Question 58

From which burn wound is
water evaporation highest?

Answer 58

Third degree

Question 59

Can infection convert a
partial-thickness injury into
a full-thickness injury?

Answer 59

Yes!

Question 60

How is carbon monoxide
inhalation overdose treated?

Answer 60

100% O_² ( + hyperbaric O₂)

Question 61

Which electrolyte must be
closely followed acutely
after a burn?

Answer 61

Na⁺ (sodium)

Question 62

When should central lines be
changed in the burn patient?

Answer 62

Most burn centers change them every 3 to 4 days

Question 63

What is the name of the
gastric/duodenal ulcer
associated with burn injury?

Answer 63

Curling’s ulcer (Think: CURLING iron burn = CURLING’s burn ulcer)

Question 64

How are STSGs nourished
in the first 24 hours?

Answer 64

IMBIBITION (fed from wound bed exudate)