Thermal injury Flashcards
Burn management in ER
Use sterile technique when touching patient. Saline soak for analgesia if burns less than 25% of BSA. Weight patient. Begin fluid resuscitation. Elevate burns when possible to avoid edema.
Size of palm is what percent of BSA?
1%
Rule of 9s for estimating BSA
18% for anterior torso and for posterior torso, 9% for each side (anterior and posterior) legs, 4.5% for each side arm and for each side head
What types of burns can be treated outpatient?
Most first degree burns. Second degree burns that are less than 10% BSA, excluding most burns of hands, face, perineum, eyes.
Parkland formula for fluid resuscitation for burns
For the first 24 hours: LR at 4 cc/kg/%BSA burn. Give half in the first 8 hours and half in the next 16 hours. For the second 24 hours: D51/2 NS and replace albumin as needed.
For peds do 3 cc/kg/%BSA
Endocrine response to burn is ..
Hyperglycemia
Cardiovascular system changes in response to burn
Increased micro vascular permeability from release of vasoactive substances. Increased LVEF but decreased CO, peripheral vasoconstriction, decreased renal perfusion and oliguria.
After resuscitation, hyper dynamic state persists. There are elevated metabolic requirements, with a catabolic state.
Pulmonary changes with burn
Shallow respirations in response to hypovolemia. After resuscitation, hyperventilation leads to mild respiratory alkalosis.
GI effects of burn
Most patients with greater than 25% BSA will have an ileus that usually resolves between days 3 and 5. GI permeability is increased which can lead to bacterial translocation. Need NG tube and h2 blocker
Endocrine effects of burn
Decreased insulin and t3. Increased glucagon, cortisol, catecholamines.
Immunologic effects of burn
Loss of skin barrier function. Decreased WBC, esp lymphocytes. Dysfunction of PMNs.
What may be required if escharotomy fails?
Fasciotomy, which does require general anesthesia. Escharotomy does not. Most common compartment requiring fasciotomy is anterior tibial compartment.
Feature of burn excision operations
Required for most deep second and third degree burns, after stabilization of patient. Limit operations to less than 20% BSA at a time, or less than 2 hours OR time.
What can skin be grafted with once debridement is complete?
Split-thickness skin graft (STSG), full thickness skin graft, or biologic dressing (allograft, zenograft aka pig, or biobrane). Note that biologic dressings come off when reepithelialization occurs
Treatment of invasive burn infection
Change to Sulfamylon (mafenide acetate, penetrates eschar well) and start systemic antibiotics.
Treatment of pseudomonal or pediatric burn infections
Infuse subeschar piperacillin and do emergent debridement in 12 hours
Treatment of viral infection of burn such as HSV
Topical acyclovir for 7 days
Treatment of Candidal burn infection
Anti fungal creams first, amphotericin B IV if fails
What is the type of infection that is the cause of death in over half of fatal burns?
Pneumonia
What complications of burns occur because of need for prolonged IV and NG?
Endocarditis and suppurative sinusitis, respectively
Marjolins ulcer
Burn scar cancer. Rare. Usually squamous cell cancer.
What are the criteria for admission to a burn center?
2nd or 3rd deg burn of > 10% BSA in child or elderly, or > 20% in other ages, or significant burns to face, hands, feet, genitalia, perineum, or skin over major joints, or full thickness burns > 5% of any age, significant electrical or chemical injury, lesser burn injury in association with other injuries or medical conditions, or special needs such as child abuse
Treatment of mild inhalational injury
Warm humidified oxygen and IS. Note that half life of carbon monoxide is decreased from 4 hours to 60 min with 100% oxygen.
Treatment of moderate and severe inhalational injury
Moderate- repeated bronchoscopy if patient unable to clear continued mucosal sloughing.
Severe- intubate.
Carbon monoxide poisoning
Occurs in closed space burns. Has way more affinity for hemoglobin than oxygen does, shifts oxygen curve to the left, decreasing oxygen carrying capacity of blood. Treatment is hyperbaric oxygen.
Lightning injury
Fatal in 1/3 of cases. Likely to cause cardiac arrest. Can cause transient coma or other neuro deficits, can cause myoglobinuria.
Alkali chemical burns cause what type of injury?
Liquefaction necrosis
Petroleum products cause what type of injury?
Depilidation
Irrigation of chemical burns
Use copious water irrigation only. At least 30 min for acid burns, and longer for alkali burns since these penetrate deeper
Appearance of mild frostbite
Bright red, warm, painful, paresthesia, rapid edema, large vesicles, late superficial eschar that resolves in one to two weeks
Appearance of deep frostbite
Deep purple, cool, minimally painful, small hemorrhagic vesicles, slow edema, mummification of deep structures
Treatment of frostbite
Remove wet clothing, wrap in warm blankets and give warm fluid. Immediately place frozen parts in 40 deg C circulating water until pink and perfused. Should not take longer than 20-30 min. Daily wound care with whirlpool cleansing. No debridement until demarcation has occurred, which can take several weeks or even months.
Types of nonfreezing cold injury
Trench foot. Immersion foot. Chillblain (pernio): due to prolonged exposure to dry cold above freezing temps and appears as superficial ulcers, hemorrhagic bullae, or localized cyanosis. Treat the same as frostbite.
