Thermal Injuries Flashcards

1
Q

Highest age group incidence of thermal burns

A

20-29 years old

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2
Q

Most common cause of thermal burns in children less than four years old

A
  • contact with hot surfaces

- liquid scalds

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3
Q

Three types of burns

A
  • scalds
  • contact burn
  • fire burns
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4
Q

Subcategories of scalds? Fire burns?

A

Scalds:

  • spill burns
  • immersion burns

Fire burns:

  • flash burns
  • flame burns
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5
Q

What does the severity of a burn relate to

A

the rate of heat transfer to the skin

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6
Q

A full thickness burn has how many zones of tissue injury

A

3 concentric zones

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7
Q

What are the 3 zones in a full thickness burn

A
  1. coagulation- dead or dying cells d/t coagulation necrosis and absent blood flow
  2. Stasis- red and may blanch with pressure, becomes avascular and necrotic by day 3
  3. Hyperemia- blanches on pressure, healing by day 7
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8
Q

SIRS aka

A

systemic inflammatory response

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9
Q

When does SIRS happen? Why?

A

occurs in burns greater than 30% of TBSA due to the systemic release of cytokines and immune mediators

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10
Q

What does SIRS cause

A
  • increased vascular permeasbility
  • hypovolemia
  • end organ damage
  • long lasting hypermetabolic response
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11
Q

What does burn survival depend on?

A
  • burn size/depth
  • patient age
  • inhalation injury
  • comorbidities
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12
Q

What burns are fist degree burns

A
  • flash burns

- sunburns

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13
Q

Characteristics of a first degree burn

A
  • minor epithelial damage to epidermis
  • redness, tenderness, pain
  • no blisters
  • healing occurs over several days without scaring
  • metabolic response and infection risk are minimal
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14
Q

Two subcategories of second degree burns

A
  • superficial partial thickness

- deep partial thickness

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15
Q

Characteristics of superficial partial-thickness burns. Healing time?

A
  • thin walled, fluid filled blisters
  • pink, moist, soft and tender to touch
  • healing over 2 to 3 weeks, usually no scarring
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16
Q

Characteristics of deep partial thickness burns. Healing time?

A
  • burns of deeper dermis
  • red and blanched white skin, slow cap refill
  • thick walled blisters
  • some decline in 2 point discrimination
  • healing over 3 to 6 weeks, scaring likely
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17
Q

Examples of third degree burns

A
  • immersion scalds
  • flame burns
  • chemical burns
  • high voltage electrical injuries
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18
Q

Characteristics of third degree burns

A
  • full thickness of dermis and epidermis
  • white or leathery appearance with underlying clotted vessels
  • no sensation
  • burns larger than 1cm require grafting to heal
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19
Q

Characteristic of fourth degree burns

A
  • full thickness
  • destruction of skin/subcutaneous tissues including fascia, muscle, bone
  • requires surgical debridement and repair
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20
Q

Treatment of inhalation injury

A

typically occurs withing 12 to 24 hours, intubate if signs of upper airway compromised

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21
Q

Fluid resuscitation in burn pts

A
  • oral and IV fluids for <20% TBSA

- 1 large bore IV for moderate burns, 2 for severe

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22
Q

When does maximal edema occur in burn patients

A

24 to 48 hours

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23
Q

Goal for fluid resuscitation in burn patients

A

urine output 2ml/kg/hr in children <2 years

1mg/kg/hr in older children

30-40 ml/hr in adults (0.3-0.5 ml/kg/hr)

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24
Q

Parkland formula

A

LR 4ml/kg/%TBSA burned

1/2 in first 8 hours

second 1/2 in the next 16

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25
Q

Galveston formula

A

5% dextrose in LR 5000/mlm2 of TBSA + 2000ml/m2

half in first 8 hours

second half in the next 16 hours

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26
Q

Burns in kids less than 6 months?

A
  • catabolism of brown fat regulates temperature requiring large amounts of oxygen
  • prone to metabolic acidosis from lactate production
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27
Q

Cold water for treatment of burns?

A

-immediate use beneficial

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28
Q

What is the benefit to using cold water for burns

A
  • inhibits lactate production and acidosis
  • inhibits wound histamine release, reducing vascular permeability–> minimizes edema and volume loss
  • suppresses thromboxane production–> vascular occlusion nd progressive dermal ischemia
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29
Q

Wound care for burns

A
  • debridement
  • irrigation
  • daily dressing changes
  • topical anti microbials or occlusive dressings-surgery if burn not healed in 3wks
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30
Q

When should you send a patient with burns to a burn center

A
  • partial thickness of >25% TBSA in adults
  • partial thickness of >20% in children <10 or adults >50
  • full thickness burn of >10%
  • burns involving face, eyes, ears, hands, feet, perieum
  • burns from caustic agents, high voltage electrical injury, complicated by inhalation injury or major trauma, high risk patients
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31
Q

When should you hospitalize a burn patients

A
  • partial thickness 15 to 25% in adults
  • partial thickness 10 to 20% in children or older adults
  • full thickness burns 2 to 10% that do not fit major burn criteria
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32
Q

When can a patient with a burn be managed at home

A
  • partial thickness <15% in adults
  • partial thickness <10% in children and older adults
  • full thickness burns <2% that do not fit major burn criteria
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33
Q

Complications of burns

A
  • infection

- burn shock

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34
Q

What is typically the cause of low voltage burns

A

usually hand or mouth due to contact with exposed wire from an extension cord in children 5 years and younger

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35
Q

What does a low voltage electrical burn look like

A

small, deep burn that can result in need for amputation

+/- LOC

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36
Q

Most common cause of VF

A

low voltage AC

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37
Q

Initial treatment of a low voltage burn

A
  • clean and dress with topical anti microbial
  • splint, elevate and reassess in 48 to 72 hours to assess tissue viability
  • EKG
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38
Q

Surgical treatment for low voltage electrical burns

A

skin loss only–> skin graft

deep injury–> amputation or flap coverage

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39
Q

2 mechanisms of oral injury due to low voltage burns. What does each cause?

A
  1. electric arc between 2 wires of opposite polarity–> excessive heat and severe tissue damage
  2. contact burn–> entry and exit wounds, can lead to VF
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40
Q

Pain with oral low voltage burn injuries?

A

initially painless because all veins/arteries are occluded from injury

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41
Q

Low voltage injuries are voltage less than what

A

1000 V

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42
Q

What does a direct current cause

A

causes single muscle contraction–> throws victim from the source

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43
Q

Electric arc burn current course

A

external to the body from a contact point to the ground

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44
Q

What type of lesion is associated with underlying tissue damage in high voltage burns

A

flexor point “kissing” lesions due to tetanic muscle contractions

45
Q

Course of current in electric current high voltage burns

A

passes between point of contact on the body and between the patient adn ground

46
Q

What causes the burn in a high voltage electrical burn

A

electrical energy is converted to thermal energy

47
Q

Tissue complications of high voltage burns

A
  • limb necrosis–> amputation in 2 to 3 days
  • periosteal necrosis/melting of the calcium phosphate mix d/t high resistance
  • extravasation of fluids into wounds d/t increased vascular permeability
  • muscle ischemia d/t increased interstitial pressure
48
Q

Neurologic complications of electricalburns

A

Central

  • transient agitation/confusion
  • mild personality and mental capacity changes long term
  • hemiplegia, aphasia, epilepsy, HA

Peripheral

  • local tissue contact sites more permanent damage
  • temporary paraesthesias or numbness

Spinal cord:

  • may be delayed 2 years, distal to site of contact
  • ALS
  • transverse myelitis
  • quadripelegi or paraplegia
49
Q

Cardiac complications of electrical burns

A
  • rhythm conduction disturbances
  • sinus tach and nonspecific ST changes
  • afib after high voltage
50
Q

Vascular complications of electrical burn

A

inflammation, vascular wall necrosis–> vessel rupture or thrombosis–> progressive muscle fibrosis

51
Q

Pulmonary complications of electrical burn

A
  • pleural damage–> effusions, local lobar pneumonitis

- infection

52
Q

Prehospital treatment of electrical burns

A
  • scene safety
  • ACLS
  • trauma
  • burns
53
Q

Treatment of electrical burns in the ER

A
  • IVF, foley
  • labs, imaging, EKG
  • tetanus
  • splint after NVF eval
  • fetal monitoring
  • compartment pressure
  • burn specialist for high voltage
54
Q

When do admit patients with electrical burns?

A
  • anything beyond minor low voltage injury

- pts with mild sxs, minor burns, normal CPK and EKG can be sent home after several hours of obs

55
Q

When should a patient with a electrical burn be transported to a burn center

A
  • high voltage
  • significant burns
  • oral burns
56
Q

Risk factors for frostbite

A
  • inadequate shelter
  • inadequate/constrictive clothing
  • wind chill factor
  • high altitude
  • prolonged cold exposure
  • prolonged moisture exposure
  • immobilization
  • malnutrition and exhaustion
  • previous cold injury
57
Q

Symptoms of frostbite

A
  • coldness
  • stinging, burning, throbbing
  • numbness and complete loss of sensation
  • loss of muscle dexterity
  • severe joint pain
58
Q

Soft, palpable skin–> ??

A

superficial frostbite

59
Q

Pitting edema—> ??

A

more viable underlying tissue

60
Q

Hard to touch—> ??

A

deeper frostbite

61
Q

Signs of frostbite

A
  • excessive sweating
  • joint pain
  • pallor/blue skin
  • hyperemia
  • skin necrosis
  • gangrene
62
Q

Characteristic of first degree frostbite

A
  • poor sensation
  • central, white plaque qith ring of hyperemia
  • epidermal involvement
  • erythema
  • mild edema
63
Q

Long term characteristics of first degree frostbite

A

desquamination over several weeks, transient swelling, erythema, and cold sensitivity

64
Q

Characterisitc of second degree frostbite

A
  • full thickness freezing
  • clear blister with surrounding erythema
  • hard outer skin, resillient tissue underneath
  • substantial edema
65
Q

Characteristics of third degree frostbite

A
  • subdermal plexus freezing
  • hemorrhagic blister formation
  • blue gray discoloration
  • deep burning pain on rewarming (lasts 5 weeks)
  • thick gangrenous eschar within 2 weeks
66
Q

Characteristic of fourth degree frostbite

A
  • involvement of muscle, bone and tendons
  • frozen, hard, avascular skin and tissue underneath
  • mottled tissue, non blanching skin becomes dry, black and mummified
  • little pain and edema on rewarming
  • spontaneous amputation after 2 months
67
Q

What is frostnip

A
  • no ice crystal formation in tissues
  • no tissue loss
  • blanching of skin with transient numbness and paraesthesias that resolve with rewarming
68
Q

What is trench foot? What causes it?

A

peripheral neurovascular damage without crystal formation caused by prolonged exposure to wet, nonfreezing cold

69
Q

Symptoms of trench foot

A
  • pain
  • paresthesias
  • pallor
  • pulselessness
  • paralysis
70
Q

What is pernio? What causes it?

A
  • painful, inflammatory lesions from chronic repeated exposure to damp, non freezing cold temperatures
  • damage to capillary beds
71
Q

Symptoms of pernio

A

localized edema, erythema, plaques, nodules, vesicles or bullae as long as 12hrs after injury

resolves in 7 to 14 days

72
Q

Timeline of post rewarming injury

A
  • edema withing 3 hours–> lasts one week
  • large clear blebs within 6 to 24 hours
  • small hemorrhagic blebs after 24hrs
  • eschar in 9 to 15 days
  • self amputation withing 3 to 6 weeks
73
Q

Complications of cold injuries

A
  • permanent sensory loss
  • increased risk of repeated frostbite
  • wound infection
  • tetanus
  • tissue loss
  • bactermia, lymphedema
  • compartment syndrome
74
Q

Goals of treatment of cold injuries

A
  • salvage tissue
  • maximize return of function
  • prevent complications
75
Q

Most effective therapy for frostbite?

A

rapid rewarming

  • circulating water at 40 t 42
  • continue until thawing is complete
  • encourage gentle movement
  • avoid too slow or over rewarming
76
Q

What pathogens should you cover after rewarming a cold injury

A
  • staph
  • strep
  • enterococcus
  • pseudomonas
77
Q

Only surgical intervention that shows early benefit for cold injuries?

A

fasciotomoy

78
Q

Indicative factors of a favorable prognosis after a cold injury

A
  • more superficial
  • early sensation to pinprick
  • healthy appearing skin after rewarming
  • clear blister over hemorrhagic blister
79
Q

Indicative factors of a poor prognosis after a cold injury

A
  • absence of edema
  • hemorrhagic blebs
  • persistent mottling/violaceous hue and anesthesia after rewarming
  • frozen appearance of tissue
80
Q

How long can a cold injury take to heal

A

6 to 12 months

81
Q

Shivering increases heat production by how much

A

2 to 5 times

82
Q

Why might CNS injury compromise temperature control

A

damage to the hypothalamus affects heat conservation and heat production

83
Q

Hypothermia on EKG

A

J or osborne waves

84
Q

J or osborne waves are due to what

A

differences in conduction time between endocardium and epicardium

85
Q

How to get an accurate core temperature

A
  • rectal
  • esophageal
  • bladder
86
Q

body temperature 34-35–>

A

shivering

87
Q

body temperature less than 34–>

A
  • altered judgement
  • amnesia
  • dysarthria
  • increased RR
88
Q

body temperature 33–>

A
  • ataxia
  • apathy
  • tachypnea
  • tachycardia
  • cold diuresis
89
Q

Moderate hypothermia will present with what

A
  • decrease o2 consumption
  • CNS depression
  • decreased RR
  • hyporelexia
  • decreased renal flow
  • parradoxical undressiing
90
Q

At what temperature does shivering stop

A

31 degrees

91
Q

What body temperature mimics brain death

A

29-30 degrees

92
Q

Severe hypothermia presents with what

A
  • Vfib
  • pulmonary edema
  • oliguria
  • coma
  • hypotension
  • ridgidity
  • apnea
  • fixed pupils
  • decreased or absent EEG activity
93
Q

Labs for patient in hypothermia

A
  • ABG
  • CBC
  • chemistries
  • DIC
94
Q

Prehispital treatment of hypothermia

A
  • prevent further heat loss
  • rewarming
  • airway establishment
  • manage arrhythmias
95
Q

Treatment in ER is body temperature is less than 30 and stupor or dysrhythmia

A
  • CPR
  • high flow, warmed, humidified O2
  • handle gently
96
Q

Slow rewarming techniques

A
  • warmed IV fluids
  • heated humidified O2 by mask
  • warmed blankets
97
Q

Moderate rewarming techniques

A
  • warmed gastric lavage
  • warmed IV fluids at 65C
  • peritoneal lavage
98
Q

Rapid rewarming techniques

A
  • thoracic lavage
  • cardiopulmonary bypass
  • ECM), AV dialysis
  • warm water immersion
99
Q

Warm=

A

32C

100
Q

Complications of hypothermia

A

-rewarming shock
-cardiac arrhythmias
-infection
-acute pulmonary edema
-pancreatitis
0GI bleed
-peritonitis
-bleeding diathesis
-bladder atony
-local cold injuries
-rhabdo
-electrolyte imbalance
-compartment syndrome
-iatrogenic hyperthermia

101
Q

Hyperthermia is core temp over what

A

38.5C

102
Q

What are some causes of hyperthermia

A
  • increased ambient heat
  • increased heat production
  • decreased heat dissipation
103
Q

Elevate temperature does what to the body

A
  • denatures proteins
  • liquefies membrane lipids
  • destabilizes phospholipids and lipoprotiens
104
Q

On a microvascular level heat stroke resembles what

A

sepsis

  • inflammation
  • translocation of lippolysaccharides from the gut
  • activation of coagulation cascade
105
Q

What causes heat cramps

A
  • muscle fatigue

- electrolyte abnormalities

106
Q

Physical exam for a person with hyperthermia

A
  • temp >40.5 common
  • HR >130
  • hypotension that corrects with normalization of temp
  • CNS dysfunction
  • nystagmus
  • tachypnea
  • hypoxia
  • AKI
107
Q

Treatment of heat exhaustion

A
  • noninasive cooling techniques

- electrolyte and hydration management

108
Q

Treatment of heat stroke

A
  • reduce core temp to <40 within 30 minutes

- dantrolene if suspect NMS and malignant hyperthermia