Purple - Burns

Question 1

How are burns classified based on depth?

Answer 1

1st degree: confined to epidermid

2nd degree:

• Superficial: superficial dermis
• Deep: into reticular dermis

3rd degree: full thickness

4th degree: deeper organs/muscle

Question 2

First degree burn is:

Answer 2

• Painful
• Erythematous
• Blanch to touch

Question 3

Second degree burn (superficial) is:

Answer 3

• Painful
• Blanch
• Often blister
• Re-epithelize from retained epidermal structures in skin ridges, hair follicles, sweat glands
• Some discolouration

Question 4

Second degree burn (deep) is:

Answer 4

• Remain painful to pinprick
• Re-epithelize from sweat gland and hair follicle keratinocytes
• Severe scarring

Question 5

Third degree burn is:

Answer 5

• Hard leathery eschar that is painless

- Heal by re-epithelization from edges

Question 6

What are the TBSA for each body compartment?

Answer 6

• Head and neck: 9%
• Upper extremities = 2 x 9 = 18%
• Lower extremities = 2 x 18 = 36%
• Anterior trunk = 18%
• Posterior trunk = 18%
• Genitals/perineum = 1%

Question 7

What is the initial management for burns?

Answer 7

• Remove sources of continuing heat
• Douse with room temperature H20
• Dress with clean dry dressing or sheets
• NG tube
• IVF (Parkland Formula)
• Tetanus prophylaxis

Question 8

What is the parkland formula?

Answer 8

4ml/kg/%TBSA (excluding 1st degree) of Ringers Lactate within 24 hours

• 1/2 1st 8 hours
• 1/2 2nd 16 hours

PLUS maintenance fluid
- 2nd 24h = 20-60% of calc. plasma volume

Timepoint of maximal edema = first 24h, therefore aggressive fluid management first 24-28h

Question 9

What type of burns require an increase from the Parkland Formula?

Answer 9

• High voltage electrical burns (2cc/kg/hr)
• Inhalational injuries (add 2xx/kg/%TBSA)
• Meds burns
• Major trauma
• > 80% TBSA
• 4th degree burns
• Osmotic diuresis
• Burn while drunk
• Delayed resuscitation (6, 7, 8 = b/c behind on fluids)

Question 10

What is important to consider with high voltage burns?

Answer 10

• Most significant injuries are deep and subsequent edema formation can cause distal vascular compromise
• Need early exploration of affected muscle beds and debridement

Question 11

When should tetanus prophylaxis be considered in burns?

Answer 11

> 10%TBSA burns

• 0.5mL tetanus toxoid
• 250 unit Ig if immunization status unclear

Question 12

What are the most common infective organisms in burns?

Answer 12

• S. auerus = 85%
• Enterococcus = 55%
• E. coli = 40%
• Candida = 40%
• Pseudomonas
• Beta-hemolytic streptococcus

Question 13

How do you treat 1st degree burns?

Answer 13

• No dressing
• Topical salves (gelatinous abs preparations)
• Mafenide acetate (sulfmylon) salve

Question 14

How do you treat superficial 2nd degree burns?

Answer 14

• Daily dressing changes
• Topical antibiotics (salves or soaks)
• Cotton gauze
• Elastic wraps
• Temporary biologic or synthetic covering

Question 15

How do you treat deep 2nd and 3rd degree burns?

Answer 15

• Excision and grafting for sizeable burns
• Early excision and grafting of thermal injuries: eschars surgically removed within 3-7 days, immediately followed by skin graft/flap

Question 16

What is silver sulfadiazine?

Answer 16

• Broad spectrum antimicrobial: gram positive, gram negative, some fungi
• Mild inhibition of epithelization
• Does not penetrate eschar
• Transient leukopenia in 3-5 days

Question 17

How do nutrition needs differ for burn patients?

Answer 17

• Thermal injuries cause a hyper metabolic state via increased release of catecholamines
• Increased caloric need: 25kcal/kg + 40kcal/%TBSA (normal = 35kcal/kg/day)
• Optimal dietary protein = 1-2g/kg/day

Question 18

When are skin grafts indicated?

Answer 18

• Deep 2nd and 3rd degree burns
• Improved survival, blood loss, and length of hospital stay
• Most burns excised in 1st week

Question 19

What are the advantages of full thickness skin grafts?

Answer 19

Include entire dermis and epidermis, provide:

• Diminished contracture
• Superior cosmesis
• Better sensation

Question 20

What are the disadvantages of full thickness skin grafts?

Answer 20

• Lower rate of survival (less durable)

- Limited donor sites

Question 21

Why can’t skin grafts be used for tissue infected with beta-hemolytic strep?

Answer 21

• Beta-hemolytic strep produces streptokinase: breaks down fibrin and prevents graft take

Question 22

How do you manage inhalation injuries?

Answer 22

• Mild: warm, humidified O2; incentive spirometry
• 2cc/kg/%TBSA more on Parkland Formula
• Prophylactic high frequency ventilation: minimizes airway collapse and atelectasis, reduces pneumonia and mortality