General Surgery - Burns Flashcards
# Define: TBSA
Total Body Surface Area
Define STSG
Split Thickness Skin Graft
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
Why are electrical burns so
dangerous?
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
How is myoglobinuria
treated?
To avoid renal injury, think “HAM”:
Hydration with IV fluids
Alkalization of urine with IV
bicarbonate
Mannitol diuresis
Define level of burn injury:
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
How do first-degree burns
present?
Painful, dry, red areas that do not form blisters (think of sunburn)
How do second-degree burns
present?
Painful, hypersensitive, swollen, mottled areas with blisters and open weeping
surfaces
How do third-degree burns
present?
Painless, insensate, swollen, dry, mottled white, and charred areas; often described
as dried leather
What is the major clinical
difference between second-
and third-degree burns?
Third-degree burns are painless, and second-degree burns are painful
By which measure is burn
severity determined?
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
What is the “rule of nines”?
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%
What is the “rule of the palm”?
Surface area of the patient’s palm is ~1%
of the TBSA used for estimating size of
small burns
What is the burn center referral
criteria?
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
What is the treatment of
first-degree burns?
Keep clean, _+_Neosporin®, pain meds
What is the treatment of
second-degree burns?
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)
What are some newer
options for treating a
second-degree burn?
- Biobrane® (silicone artificial epidermis—temporary)
- Silverlon® (silver ion dressings)
What is the treatment of
third-degree burns?
Early excision of eschar (within first week postburn) and STSG
How can you decrease
bleeding during excision?
Tourniquets as possible, topical epinephrine, topical thrombin
What is an autograft STSG?
STSG from the patient’s own skin
What is an allograft STSG?
STSG from a cadaver (temporary
coverage)
What thickness is the STSG?
10/1000 to 15/1000 of an inch (down to
the dermal layer)
What prophylaxis should the
burn patient get in the ER?
Tetanus
What is used to evaluate the
eyes after a third-degree burn?
Fluorescein
What principles guide the
initial assessment and
resuscitation of the burn
patient?
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, carboxyhemoglobin,
throat/mouth erythema, history of loss of
consciousness/explosion/fire in small
enclosed area, dyspnea, low O2 saturation,
confusion, headache, coma
What diagnostic imaging is
used for smoke inhalation?
Bronchoscopy
What lab value assesses smoke
inhalation?
Carboxyhemoglobin level (a carboxyhemoglobin level of >60% is associated
with a 50% mortality); treat with 100%
O2 and time
How should the airway be
managed in the burn patient
with an inhalational injury?
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
What is “burn shock”?
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
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
What burns qualify for the
Parkland formula?
_>_20% TBSA second- and third-degree burns only
What is the Brooke formula
for burn resuscitation?
Replace 2 cc for the 4 cc in the Parkland formula
How is the crystalloid given?
Through two large-bore peripheral
venous catheters
Can you place an IV or central
line through burned skin?
F*CK YEAH
What is the adult urine
output goal?
30–50 cc (titrate IVF)
Get it, or URINE trouble! heheheheheh….
Why is glucose-containing
IVF contraindicated in burn
patients in the first 24 hours
postburn?
Patient’s serum glucose will be elevated on its own because of the stress response
What a sweet burn…
What fluid is used after the
first 24 hours postburn?
Colloid; use D5W and 5% albumin at 0.5 cc/kg/% burn surface area
Why should D5W IV be
administered after 24 hours
postburn?
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
What is the minimal urine for burn patients?
Adults 30 cc; children 1–2 cc/kg/hr
output
How is volume status
monitored in the burn
patient?
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
Why do most severely
burned patients require
nasogastric decompression?
Patients with greater than 20% TBSA burns usually develop a paralytic ileus → vomiting → aspiration risk → pneumonia
What stress prophylaxis must
be given to the burn patient?
H2 blocker to prevent burn stress ulcer (Curling’s ulcer)
What are the signs of burn
wound infection?
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
Is fever a good sign of
infection in burn patients?
NO
What are the common
organisms found in burn
wound infections?
Staphylococcus aureus, Pseudomonas, Streptococcus, Candida albicans
How is a burn wound infection diagnosed?
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
How are minor burns dressed?
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
How are major burns
dressed?
Cleansing and application of topical antibacterial agent
Why are systemic IV antibiotics contraindicated in fresh burns?
Bacteria live in the eschar, which is
avascular (the systemic antibiotic will
not be delivered to the eschar); thus,
apply topical antimicrobial agents
Note some advantages
and disadvantages of the
following topical antibiotic
agents:
Silver sulfadiazine (Silvadene®)
Mafenide acetate (Sulfamylon®)
Polysporin®
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
Are prophylactic systemic antibiotics administered to burn patients?
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.
Are prophylactic antibiotics
administered for inhalational
injury?
No
Circumferential, full-
thickness burns to the
extremities are at risk for
what complication?
Distal neurovascular impairment
How is it treated?
Circumferential, full-
thickness burns to the
extremities
Escharotomy: full-thickness longitudinal
incision through the eschar with scalpel
or electrocautery
What is the major infection
complication (other than
wound infection) in burn
patients?
Pneumonia, central line infection (change central lines prophylactically every 3 to 4 days)
Is tetanus prophylaxis required in the burn patient?
Yes, it is mandatory in all patients except
those actively immunized within the past
12 months (with incomplete immunization:
toxoid x 3)
From which burn wound is
water evaporation highest?
Third degree
Can infection convert a
partial-thickness injury into
a full-thickness injury?
Yes!
How is carbon monoxide
inhalation overdose treated?
100% O2 ( + hyperbaric O2)
Which electrolyte must be
closely followed acutely
after a burn?
Na+ (sodium)
When should central lines be
changed in the burn patient?
Most burn centers change them every 3 to 4 days
What is the name of the
gastric/duodenal ulcer
associated with burn injury?
Curling’s ulcer (Think: CURLING iron burn = CURLING’s burn ulcer)
How are STSGs nourished
in the first 24 hours?
IMBIBITION (fed from wound bed exudate)
