L12: Burns Flashcards
1
Q
__ (M/F) get burns more often, and most deaths result from _____
A
M>F
Deaths from house fires
2
Q
Burn risk
A
Inadequate or faulty electrical wiring
Lack of or non-functioning smoke detectors
Arson
Water heater temps set too high
Carelessness with cigarettes
Young children and older adults
Workplace exposure to chemicals, electricity or irradiation
ETOH or other substances that alter function/mental status
3
Q
First degree burn aka
A
Superficial burn
4
Q
Second degree burn aka
A
Partial thickness burn
5
Q
Third degree burn aka
A
Full thickness burn
6
Q
4th degree burn aka
A
Beyond full thickness burn
7
Q
Examples of a first degree burn
A
sunburn, mild scalds, mild electrical burn
8
Q
Examples of a 3rd degree burn
A
Flame burn
9
Q
Damage from a 1st degree burn
A
Epidermal→ Only outer layer of skin, not all the way through.
10
Q
Damage from a superficial 2nd degree burn
A
Burned through 1st layer of skin and part of 2nd layer
11
Q
Damage from deep 2nd degree burn
A
Burned all the way through 1st and 2nd layers of skin.
12
Q
Damage from a 3rd degree burn
A
Extends through all layers of skin. Skin charring.
13
Q
Damage from a 4th degree burn
A
Extends through all layers of skin, sub-dermal tissue, into muscle, bone, tendon, blood vessels, nerves
14
Q
Appearance of a 1st degree burn
A
Red, swollen
Blanch with pressure. No blisters.
15
Q
Appearance of a superficial 2nd degree burn
A
Intense and splotchy redness, pink, wet blisters
16
Q
Appearance of a deep 2nd degree burn
A
Red and white, bloody blisters
Decreased cap refill
17
Q
Appearance of a 3rd degree burn
A
White and brown
18
Q
Appearance of a 4th degree burn
A
Black, charred, dead tissue
19
Q
Skin texture for varying degrees of burns
A
1st: dry Sup 2nd: moist Deep 2nd: moist 3rd: stiff, dry, leathery 4th: dry
20
Q
Pain sensation for varying degrees of burns
A
1st: painful Sup 2nd: painful Deep 2nd: pain with pressure 3rd: painless 4th: painless
21
Q
Healing time for varying degrees of burns
A
1st: 7 days
Sup 2nd: 7-21 days
Deep 2nd: 3-12 weeks
22
Q
Complications of a 1st degree burn
A
Repeated sunburns→ cancer
23
Q
Complications of a superficial 2nd degree burn
A
Local infection, cellulitis
24
Q
Complications of a deep 2nd degree burn
A
Scarring +/- skin grafting
25
Complications of a 3rd degree burn
Scarring, contractures, +/- amputation
26
Complications of a 4th degree burn
Amputation
Functional impairment
Gangrene
Death
27
For all burns, consider ________
Td booster
28
1st degree burn treatment
Cool: running water, cold compress. Clean.
Topical calamine/aloe vera gel, topical polysporin.
OTC acetaminophen or NSAIDS
29
2nd degree burn treatment
*Keep moist*, debride→ re-epithelialization
Cool: running water, cold compress
Cover: loose, sterile gauze, occlusive dressing (Xeroform)
Petroleum based moisturizer vs Bacitracin
Change dressing 1-2X daily, wash wound each time, +/- opioids
30
Deep 2nd degree burn with eschar treatment
silver sulfadiazine cream on 4x4 covered with gauze
31
Eschar
slough or piece of dead tissue that is cast off from the surface of the skin
32
Burns starting at _____ and beyond require "immediate medical attention"
Deep 2nd degree (partial thickness)
33
Treatment for 3rd degree burns
will not heal well spontaneously→ surgical repair and skin grafting
Wash, debride, silver sulfadiazine
Change dressing 2x daily, opioids
34
Treatment for 4th degree burns
"Immediate medical attention"
35
Superficial burn prevention
Reduce sun exposure, Protective clothing, SPF > 30
Unplug appliances, Plugs for outlets
Do not leave stove when cooking, Use back burners
Avoid hot liquids near children→ supervise infants and toddlers
36
ABA Referral criteria for burns
Partial-thickness burns of > 10% of total body surface area
Third-degree burns in any age group
Burns that involve the face, hands, feet, genitalia, perineum, or major joints
Electrical burns, including lightning injury
Chemical burns
Inhalation injury
Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality (DM included during pharm)
Any patients with burns and concomitant trauma
Children in hospitals without qualified personnel or equipment to care for their burn injuries
Burn injury in patients who will require special social, emotional, or rehabilitative intervention
37
Number one cause of fire related deaths
SMOKE INHALATION
| so you gotta intubate them before edema compromises the airway
38
Indications for intubation
History suggests airway compromise:
```
Closed space smoke exposure
Carbonaceous sputum
Facial burns, Singed facial hair
COHb>5
Hoarse voice
Patient unable to protect airway:
Trauma, Opioids
```
39
______ is responsible for most prehospital deaths
Carbon monoxide inhalation
40
Labs for CO inhalation
Pulse ox not reliable→ use carboxyhemoglobin (COHb) levels
41
Delayed neurologic sequelae of CO inhalation likely if....
Symptomatic initial clinical picture
Elderly patients
Prolonged exposure
42
The deadly product of combustion is
cyanide inhalation/poisoning
43
Symptoms of cyanide poisoning
HA to AMS
| Hypotension, Arrhythmia, Cardiovascular collapse, Shock
44
Treatment for cyanide poisoning
Hydroxocobalamin (Cyanokit)
Heme-like molecule with a complex cobalt atom
Binds to CN forming cyanocobalamin (vitamin B-12)
Renal excretion
45
Symptoms of inhalation
Upper airway inhalation→ hoarseness, stridor, substernal retractions
Lower airway inhalation→ tachypnea, decreased breath sounds, wheezing/rales/rhonchi, accessory muscle use
46
Managing inhalation
mechanical ventilation
aggressive pulmonary toilet (mucus clearance)
pneumonia tx/prevention
supplemental nutrition
47
Managing circulation (in order)
1. 2 large bore IVs→ in unburned skin
2. Calculate total body surface area (TBSA)
Rule of 9s or Lund-Browder
3. >20% TBSA→ Parkland resuscitation
Increased risk of shock
Magnitude influenced by: depth and extent of burn, pre-existing illness, inhalation injury
48
Goals of Circulation Resuscitation
Maintain tissue perfusion to end organs
49
Monitor urine output to monitor the effects of circulation resuscitation
Foley catheter
• Adults: 0.5 mL/kg/hr
• Children: 1 mL/kg/hr
• Electrical burns: 1-2mL /kg/hr
50
Are diuretics indicated in acute setting for circulation resuscitation?
No???? Why is this even mentioned
51
Parkland formula for fluid replacement
IF >20% TBSA
4mL LR x kg x TBSA = 24 hour post burn total
Half of volume in first 8 hours post burn
Other half in remaining 16 hours
Calculate mL/hr
52
Factors influencing fluid requirements
```
Burn depth
Inhalation injury→ increase needs by 30-50%
Delay in resuscitation
Compartment syndrome
Electrical burns
```
53
Complications from under-resuscitation
Intravascular volume depletion→ Hemoconcentration
Suboptimal tissue perfusion→ End organ failure, Death
54
Complications from over-resuscitation
Results in resuscitation morbidity
Abdominal compartment syndrome→ Decreased renal blood flow leading to renal failure, Intestinal ischemia, Airway obstruction leading to respiratory failure
Compartment Syndrome→ Extremities
Pulmonary edema
55
Abdominal compartment syndrome presentation
Decreased urine output
Elevated bladder pressure (>25 mmHg)
Increased Peak Expiratory Pressure,
Poor ventilation
56
Abdominal compartment syndrome monitoring
Hourly bladder pressures
Decrease IV fluids
+/- Continuous renal replacement therapy
+/- intraperitoneal catheter for
decompression
57
Abdominal compartment syndrome treatment
If unable to reverse→ decompressive
| laparotomy
58
C tetani
anaerobic, motile, G+ rod
Oval, colorless, terminal spore→ survive for years in some environments
Resistant to disinfectants and to boiling for 20 minutes
acquired outdoors or indoors
59
Major complication from burns
Tetanus
60
Tetanus incubation
4-14 days
61
______ is prognostic for a more severe course of tetanus
Being symptomatic in the first week
62
Infection sources for tetanus
Minor wounds from wood, metal splinters or thorns (65%)
Chronic skin ulcers (5%)
No obvious source is identified
63
Wounds prone to tetanus
```
Present >6 hours
Deep >1 cm wounds
Grossly contaminated wounds
Exposed to saliva or feces
Avulsions, punctures, crush injuries
BURNS
Complication of chronic conditions→ abscess or gangrene
```
64
Tetanus may complicate
```
Frostbite
middle ear
infections
dental or surgical
procedures
abortion
childbirth
SQ/IVDU
```
65
Tetanus symptoms
+/- Sore throat with dysphasia
Localized tetanus→ 1 limb or where the wound is located
Generalized tetanus→ trismus (75%)
Subsequently:
Muscle rigidity
Descending pattern from the jaw and facial muscles
Extend within 24-48 hours→ extensor muscles of the extremities
Other signs:
Temperature, sweating, elevated blood pressure,
episodic rapid heart rate, neck rigidity, restlessness,
reflex spasms
66
Secondary prevention of tetanus
wound cleansing and debridement
67
Recommended vaccine prophylaxis for tetanus
Tetanus toxoid if >5 years since last shot: Td, Tdap, DT, DPT, DTap
+/- TIG
68
Pin control for tetanus? burns? idk
IV opioids, transition to oral
| *avoid IM*
69
Types of pain
background
breakthrough
procedural
70
Immunization schedule for tetanus
Children:
DTaP-2mo, 4mo, 6mo, 15-18mo, 4-6yrs
Adults:
Substitute Tdap once
Td booster every 10 year
71
Chemical burns management
Acids/bases
Identify agent→ material safety data sheet (MSDS)
May not appear to be as deep initially
Copious irrigation with water→ delay transport for decontamination, do not try to neutralize
Monitor progress with litmus paper
72
Electrical burns management
```
History
Monitor for cardiac abnormalities
Injuries may be much worse than they
appear
Current follows path of least resistance→ damage may be hidden under good skin
Risk of rhabdomyolysis→ Muscle damage
Fluid resuscitate even small appearing
injuries→ Goal 1-2 cc urine/kg/hour
```
73
Lightning burns management
2/3 deaths occur within 1 hour of injury→ fatal arrhythmia or respiratory failure
Most survivors have permanent injury
DC current lasting from 1/10-1/1000 or a second→ Often exceeds 10 million V
Feathering skin injuries
74
Do you transport or decontaminate first for a chemical burn?
Delay transportation to copiously irrigate with water
75
Feathering skin injuries:
*Pathognomic for lightning burns*
“Lichtenberg figures/flowers”
Keraunographic markings, Arborescent burns
Not true burns→ fade within a few hours
76
Goal urine output for electrical burns
1-2 cc urine/kg/hour
| *even small burns need fluid resuscitation*
77
Which kind of burn has a high risk for compartment syndrome?
Circumferential ubrns
78
Preventing/treating compartment syndrome in circumferential burns
Escharotomy→ Incision through burned skin to underlying subcutaneous tissue
Fasciotomy→ Incision through the fascia overlying muscle compartments of an extremity
Extend incisions through unburned tissue proximally and distally if possible→ mid-medial and mid-lateral incisions on extremity
Shield escharotomy→ used in patients with circumferential torso burns→ improve ventilation
Unstable→ Do at bedside
79
Lightning burns are so likely to cause death because of....
fatal arrhythmia or respiratory failure
80
Skin grafts
Large or deep burn wounds, Necessary for wound coverage
+/- Temporary skin covering→ Allograft, Xenograft
Autograft only definitive coverage, requires a donor site
Partial thickness donor skin→ 1/1000-1/1200” thick
Donor site→ Very painful, 7-10 days to heal
81
Infection in a burn patient
Fever not always indicative of infection
Increased edema, erythema
+/- increased pain
82
Preventing infection in a burn patient
Prophylaxis→ wounds become colonized in 3-5 days with G+ organisms
83
Nutrition methods for a burn patient
Enteral support
Reduces burn–related increase in secretion of catabolic hormones
Helps maintain gut mucosal integrity
Duodenal route
Better tolerated than gastric feeding which has 18% failure rate from regurgitation
Total parenteral nutrition
Not recommended:
Does not prevent the catabolic response to burns, Impairs immunity and liver function
Increases mortality
84
Burn patients need a ______ diet because _____
```
High carb, low fat diets
Less proteolysis
More improvement in lean body mass
+/- reduce infectious morbidity
Shortens hospitalization time
```
85
Chronic complications of burns include....
```
Chronic ulceration
Keloid scars
Hypertrophic scars
Scar contractures
Pigment changes
```
86
Keloid scars, unlike hypertrophic scars...
Overgrowth of scar tissue beyond area of injury
87
Chronic ulceration occurs due to
Grafted skin lack support structures of normal tissue→ chronic non-healing ulcers in grafts→ remain open for years
Concern: development of Marjolin ulcer
