Medical & Surgical Management of Burns

Question 1

What is the parkland formula?

Answer 1

Parkland formula = 4 ml/kg/TBSA% burn-crystalloid, no colloids

Question 2

How do you fluid resuscitate a burn patient?

Answer 2

• Fluid resuscitation should begin as soon as possible, in the field if possible, and not when the patient reaches the hospital or burn center.

Use the parkland formula to calculate the total fluid needs then the fluid is divided in this manner:

• Half of the fluid in the first 8 hours
• One fourth in the next 8 hours
• Last fourth in the next 8 hours

Question 3

What 3 things do you monitor for when fluid resuscitating a burn patient?

Answer 3

1. Urine output goal – 30-50 ml/hr. If decreased, adjust fluid amount

2. Metabolic acidosis – can occur and is generally expected during the early resuscitation period

3. Hyperkalemia – commonly occurs during the first 24-48 hours after burn injury. Hypokalemia can occur as fluid resuscitation continues

• May occur around day 3

Question 4

What is one of the first things you do with a burn injury?

Answer 4

• Rinse chemical injuries copiously ASAP
• Avoid ice, lotion, toothpaste, lard, butter or other products at time of injury
• Wrap the burned area in clean dry towels. Wet towels may accelerate loss of body heat
• If dressings are applied prior to transport, use saline on sterile gauze only as these will be removed quickly at the burn center
• Maintain normal temp with warming blankets, head coverings and warming lights if necessary

Question 5

How is pain managed in burn patients?

Answer 5

• Once the patient is stabilized, pain management should be initiated. Most commonly used: IV morphine and anxiolytics in small doses. Never use IM or SQ administration – absorption is uncertain.
• Older adults that have decreased pain perception in general may develop severe neuropathic pain from tissue injury. Opioids should be titrated slowly to achieve pain relief and comfort. Acute delirium can occur due to pain, infection, inadequate sedation and intrinsic factors such as underlying dementia

Question 6

What dressings are used for burn injuries?

Answer 6

• Silver sulfadiazine (Silvadene). This is indicated for both gram positive and gram negative organisms as well as Candida.
• Mafenide acetate (Sulfamylon). Indicated for gram positive, gram negative, most anaerobes, electrical burns, and burns to the ear. This is a carbonic anhydrase inhibitor – monitor the patient for development of acidosis
• Bacitracin – used on superficial burns, facial burns and staphylococcal organism coverage
• Mupirocin (Bactroban) used for gram positives and is most commonly a secondary agent
• Enzymatic debridement agents –Collagenase (Santyl). This is the only agent in this category approved for use in the US in this category for burn care
• Other agents/dressings commonly used in the initial treatment of burn injuries include meta honey, silver impregnated barrier dressings, biologic dressing and biologic synthetics

Question 7

When should a burn patient be intubated?

Answer 7

Intubation and mechanical ventilation may be necessary for patients suffering laryngeal edema that may cause airway obstruction if it progresses. This should be suspected if your assessment of the patient shows:

• Burns to the face
• Singed nares or eyebrows
• Dark soot/mucus from the nares or mouth
• Hoarseness
• Drooling
• Difficulty swallowing

Question 8

When should a patient be transferred to a burn center?

Answer 8

• Partial thickness burn > 10% TBSA
• Burn injury of face, hands, feet, genitalia, perineum or major joints due to functional issues
• Full thickness (third degree) burns in any age group
• Electrical burns including those caused by lightening
• Chemical burn injuries
• Inhalation injuries
• Burned children
• Patients with co morbidities that are likely to result in complications or affect mortality
• Any burn patient with concomitant trauma
• Patients with burns that require or will require special, emotional, or rehabilitative intervention

Question 9

What is the criteria for a burn patient to receive surgical treatment?

Answer 9

Burns > 20% TBSA- surgical excision is done after completion of fluid resuscitation and before 7 days post burn.

Question 10

What are the 3 types of skin grafts used to treat burn injuries?

Answer 10

1. Split thickness – top layer (epidermis) and a portion of the deeper layer (dermis) is taken from a donor site (healthy skin). Typical areas used are front or outer thigh, abdomen, buttocks and back. They are used to cover large burn areas

2. Full thickness – involves removing the dermis and ALL of the epidermis. Sites include abdomen, groin, forearm or area above the clavicle. They are smaller and are generally used on areas that are highly visible on the body

3. Flaps – healthy skin and tissue that is partly detached and moved to cover a nearby wound. The flap remains attached to the original site usually to continue to receive blood supply. It can be removed totally and placed on a distant wound.

Question 11

What are some complications that can occur with skin grafting?

Answer 11

Both donor and grafted sites need to be watched carefully in the adult for inf_ection, poor wound healing and poor graft take_. If this occurs, the patient is faced with a more difficult rehabilitation and prolonged, more painful dressing changes