Thermal Injuries Flashcards
Burns result in both _____ and ______ inflammatory responses
local, systemic
A burn is damaged tissue from thermal energy that ______ and ______ protein leading to irreversible damage
denatures, coagulates
Systemic responses to burns (usually in 20% BSA or greater)
- cardiovascular (fluid to interstitial space, shock)
- respiratory (bronchoconstriction - respiratory failure, ARDS)
- metabolic (high nutritional demands)
- Immunological (infection risk)
5 Types of burns
- heat
- electrical
- friction
- chemical
- radiation
Why is it important to get an accurate estimation of burn size
to guide therapy and possible transfer to burn center
TBSA stands for
total % body surface area
3 methods of burn size estimation
- lund-browder chart
- rule of Nines
- palm method
Rule of 9s
Which burn size estimation is best used in pediatric cases?
Lund-Browder chart (considers relative % of body surface area affected by growth
Burns suspicious for physical abuse
- scald burns with sharp demarcations
- distinct shape of objects
- small circular burns (cigarette)
- burns on perineal area (dip in)
Burn classifications
Superficial burns
- epidermis only
- no blisters
- painful, dry, erythematous, blancing
- heals 3-5 days
- no scarring
- Tx: remove clothing/jewelry, cool burn, NSAIDs
Sunburn
- involves UVA and UVB (UVB = more erythema)
- Ddx: consider drug induced phototoxic reactions like phytophotodermatitis
Superficial partial thickness burns
- involves epidermis and papillary layer of dermis
- blisters
- pain, erythema, moist, weeping, blanches
- heals 1-3 weeks
- infection risk
- Tx: cool water, NSAIDs, clean, debridement, topical abx
Commonly used topical Antimicrobials for burns
- bacitracin, neomycin (allergic rxns)
- silver sulfadiazine (not on face, sulfa allergy, pregnancy)
- Bismuth petroleum gauze (used in skin graft)
- mefanide acetate
- chlorhexidine
Deep partial thickness burns
- involves epidermis and reticular layer of dermis (hair follicles and glands)
- blisters
- painful only to pressure
- waxy, dry, red yellow or pale, non-blanchable
- heals 2-9 weeks
- hypertrophic scarring expected, joint impairment
- Tx: don’t cool/submerge, pain control, tetanus update, excision/closure, burn center, ICU, nutritional/psychological support, contracture management
Full thickness burn
- involves epi, dermis, hypodermis
- same management as deep partial
- pain control with opioids
4th degree burn
- extends into fat, muscle, bone
- no feeling, non-blanchable
- permanent damage
- extensive tissue reconstruction and debridement
Diagnostics for major burns
- CBC
- Electrolytes (hyperkalemia)
- Creatinine Kinase for rhabdomyolysis
- carboxyhemoglobin (CO poisoning)
- serum lactate (cyanide poisoning)
- Arterial blood gas
- chest x ray
- end tidal CO2 and pulse ox
- ECG/EKG
- blood typing for transfusion
Escharotomy
indicated for deep partial and full thickness burns, performed for circumferential burns to alleviate risk of compartment syndromes
ABCDE for burns
airway
breathing
circulation
disability
exposure
Airway
- signs of smoke inhalation injury (need for intubation, leading cause of death in burn pts)
- give supp oxygen to keep sats at 90-96%
- emergency cricothyroidotomy
- succinylcholine can be used in first 72 hrs (risk of hyperkalemia after)
Breathing
- s/s of breathing impairment: decreased mental status, tachypnea, hypoxia, accessory muscle use
- use bronchodilators for bronchospasms
- DONT use corticosteroids d/t infection risk
Disability/Exposure
- neuro status
- monitor core body temp to avoid hypothermia
- tetanus immunizations
- topical abx
Circulation
- burn shock characterized by myocardial depression and increased capillary permeability
- fluid resuscitation crucial (not overly though) for burns >15% TBSA
- parkland formula
- monitor urine output
what is the parkland formula for circulation management?
method for calculating initial fluid resuscitation
Steps for chemical burns
- ensure PPE and remove patient from area of exposure
- remove clothing/jewelry
- determine chem exposure and call poison control prn
- brush dry chemicals off
- irrigate with water (except dry lime, phenols, elemental metals (Na, K, CaO, Magnesium, Phosphorus)
Common alkalotic chemical burn
wet cement
How to remove dry lime (chemical burn)
brush off prior to irrigation (can react into strong alkali with water)
how to remove elemental metals (chemical burn)
dry forceps and place in mineral oil (can combust or release hazardous byproducts with water)
how to remove phenol (chemical burn)
wipe off with sponge soaked in 50% polyethylene glycol (not water soluble)
high voltage electrical injury
- lower morbidity than low voltage
- AC more damaging than DC
- skin burns appear mild compared to internal tissues/organs
Cold injuries
frostnip, frostbite, chilblains (pernio)
Frostnip
localized paresthesia that resolves with rewarming (1st stage of frostbite)
Chilblains (pernio)
localized inflammatory lesions from repetitive exposure to damp cold above freezing
Describe Grade 1 frostbite
- frostnip
- no cyanosis, usually heals quickly
Grade 2 frostbite
- cyanosis to distal phalanx
- nail damage or soft tissue amputation
Grade 3 frostbite
- intermediate and proximal phalanx cyanosis
- bone amputation
first degree frostbite
- superficial
- central pallor surrounded by erythema
describe second degree frostbite
- large blisters with clear fluid surrounded by edema and erythema
- blisters may form eschar
- no tissue loss
third degree frostbite
- smaller blisters, hemorrhage, more proximal than 2nd degree
- black eschar in 1+ weeks
fourth degree frostbite
- muscle and bone involved
- complete tissue necrosis
- mummification in 4-10 days
Frostbite management
- remove wet clothing, splint, dont rub or expose to fire
- immerse in heated water to thaw
- thrombolysis for sever injury
- tetanus update
- surgical consult
- bulky dressing, elevate, hydrotherapy, abx controversial
4 stages of NFCI (non freezing cold injury)
1st: during cold exposure
2nd: following exposure
3rd: hyperemia
4th: following hyperemia
NFCI Treatment
- address systemic hypothermia
- allow gradual rewarming
- replace fluid loss
- update tetanus
- amitriptyline
Grade 4 frostbite
- carpal or tarsal bones involved
- bone amputation
Tear gas (chemical burn)
remove clothing, wash with water brushing down and away from face
Hydrofluoric acid (chem burns)
- highly corrosive
- can cause hypocalcemia and hypomagnesemia leading to cardiac arrhythmias
- Tx: water irrigation, topical 2.5% calcium gluconate gel
