Wise MD: Burn Management Flashcards
A 74 year old male suffered a burn to his lower leg 15 years ago which was treated with debridement and skin graft. Past medical history of non-insulin dependent diabetes for 30 years, hypertension, and coronary artery disease. His leg wound has always required some dressings and has never completely healed. It has recently changed and become more open and friable, and had increased drainage. What is the most the most appropriate next step in his management is?
a. Measure the ankle-brachial index, and consult a vascular surgeon for possible bypass surgery
b. Debride and regraft the wound
c. Swab the wound and start a course of antibiotics
d. Debride the wound and refer to a wound care clinic
e. Biopsy the wound
e. Biopsy the wound
In a longstanding wound with recent changes, a biopsy should be done to determine if there has been a malignant transformation to a squamous cell cancer (Marjolin’s ulcer)
A 46 year old is admitted to hospital following a high voltage electrical injury while working on power lines. He is being resuscitated with iv Ringers Lactate based on Parkland formula, but his urine output is less than 20 ml in the past hour. His urine looks dark and he has an increasing creatinine phosphokinase level. What is the appropriate management of this patient?
a. Increase iv fluids
b. Plan for Fasciotomies for compartment syndrome
c. iv bolus of Mannitol
d. Administer iv Sodium Bicarbonate to cause a metabolic alkalosis
e. All of the above
e. All of the above
High voltage electrical injuries are highly suspicious for deep injuries causing muscle necrosis leading to compartment syndrome and rhabdomyolysis. A fasciotomy (not escharotomy) must be performed to prevent further necrosis, and effort must be made to encourage excretion of the myoglobin to prevent accumulation leading to renal failure. Increased fluid volume and alkalinization of the urine and diuresis allows increased excretion of the myoglobin. In addition, Parkland formula alone often underestimates fluid requirements with electrical burns as internal injuries are not included in the TBSA calculations.
A 6 year old girl was extracted from an apartment fire. She arrives with her voice being raspy and she has audible stridor on presentation. You are concerned about inhalation injury resulting in airway swelling and narrowing. In this age group, where is the narrowest part of the airway?
a. 3rd tracheal ring
b. Vocal cords
c. 2nd tracheal ring
d. Cricothyroid junction
e. Uvula
d. Cricothyroid junction
The correct answer is the cricothyroid junction. In children, the narrowest part of the airway is at the level of the cricothyroid membrane. Because of this, cricothyroidotomy is contraindicated in young children and emergent surgical airway access usually consists of needle jet ventilation and eventual tracheostomy.
A 12 year old boy suffers 70% TBSA second and third degree burns when his clothes catch on fire after a can of model rocket fuel combusts. Indirect calorimetry indicates that his metabolic rate is 150% of normal. The current standard of care for this patient to receive the calories and protein he requires assuming normal gut function is?
a. Total parenteral nutrition
b. Rectal clysis
c. Enteral nutrition
d. Peripheral parenteral nutrition
e. Patient oral intake
c. Enteral nutrition
Enteral nutrition is the preferred method of feeding the patient with a large burn. TPN was popular in the 1960s and 1970s but cost, conerns about pro-inflammatory effects of TPN lipids, and fatty infiltration of the liver have made TPN less widely used. Rectal clysis can be used in an emergency for fluid resuscitation but can not be used for nutrition administration. Most burn patients simply cannot eat enough calories by mouth in the acute phases to meet their caloric goals.
Enteral nutrition directly nourishes the bowel mucosa, stimulates the function of intestinal cells, maintains microvillous architecture and normal mucosal function, preserves blood supply to the intestine, and may reduce bacterial translocation and preserve gut-associated immune function.
A 45 year old gentleman has 80% TBSA burns from entrapment in a house fire. He is started on topical antimicrobial medical therapy over his burn wounds. Despite adequate resuscitation, he develops a metabolic acidosis. which antimicrobial topical cream has this as a known complication and was probably used in this situation?
a. Sodium hypochlorite
b. Silver sulfadiazene
c. Mafenide acetate
d. Bacitracin
e. Silver nitrate
c. Mafenide acetate
The answer is mafenide acetate. Mafenide is a carbonic anhydrase inhibitor and thus can lead to a metabolic acidosis, especially when applied to large percentage of the body.
- Silver sulfadiazene is associated with a transient leukopenia.
- Silver nitrate can cause electrolyte abnormalities from leaching.
- Bacitracin can cause a yeasty rash.
- Sodium hypochlorite solution (aka Dakin’s solution) can cause redness, irritation, and pain.
A 28 year old gentleman works at an electronic manufacturing plant. A large container of hydrofluoric acid spills onto him, leading to chemical burns to about 50% TBSA. In the ER, he is in excruciating pain. After you decontaminate the patient with copious irrigation, the next appropriate treatment for this specific chemical burn is?
a. Bacitracin ointment
b. Zinc oxide cream
c. Calcium gluconate gel
d. Silver sulfadiazene cream
e. Sodium bicarbonate solution
c. Calcium gluconate gel
The answer is calcium gluconate gel. Hydrofluoric acid burns are a unique chemical exposure as the fluoride ion has exceptionally high avidity for calcium ions and can lead to severe hypocalcemia. Severe exposure can lead to direct cardiotoxicity, multiorgan failure, and even death.
Sodium bicarbonate solution is contraindicated because neutralization of an acid with a base can lead to an exothermic reaction causing thermal injury in addition to the already existing chemical injury. All of the other therapies will soothe some of the pain but will not address the life threatening hypocalcemia.
A 54 year old woman suffers 50% TBSA burn wounds after falling into a fire pit and igniting her clothes. Her wounds are all second or third degree in depth. She weighs approximately 80 kg. Based on the Parkland formula, you calculate her initial fluid rate for the first 8 hours of resuscitation to be:
a. 120 mL/hr
b. 540 mL/hr
c. 80 mL/hr
d. 2000 mL/hr
e. 1000 mL/hr
e. 1000 mL/hr
The Parkland formula provides the estimated volume needed for the first 24 hours by multiplying the TBSA % of second and third degree burns times the weight of the patient in kilograms and a multiplying factor of 4.
Total volume = TBSA % (2nd and 3rd degree) * Weight (in kg) * 4
The rate for the first 8 hours is determined dividing half of the calculated volume and dividing by 8 hours. Then classically, the rate would be dropped in half for the next 16 hours.
For the patient described above, the calcuation would be:
50% * 80 * 4 = 16000 mL over 24 hours
So taking half of this amount would be 8000 mL; dividing 8000 mL by 8 hours yields a fluid rate of 1000 mL/hr
A 19 year old right handed lady is skiing in the back country when she gets lost and is found 12 hours later after being exposed to subfreezing temperatures the entire time. On initial physical exam, the fingers of her right hand are completely cold and blue. After gentle re-warming, there are still no palpable radial, ulnar, or digital pulses in the right hand. There are no detectable Doppler signals in these vessels either. What would be the best therapy for this patient?
a. Urgent angiogram and thrombolysis
b. Antiplatelet therapy
c. Several week clinical observation to permit demarcation of necrosis
d. Emergent amputation of the right hand
e. Conservative wound care
a. Urgent angiogram and thrombolysis
This patient clearly has severe frostbite with thrombosed arteries. This is a limb-threatening injury. The best available therapy currently is urgent consultation of interventional radiology. Protocols have been developed at several medical centers to perform urgent angiography in patients with < 24 hours of cold exposure; if limited or no flow is seen, thrombolysis with tPA and subsequent continuous heparin infusion is utilized to restore blood flow.
A 50 y/o field worker arrives to a free clinic to discuss a “sore” on his lower lip. He has had no trauma to the face. He reports that he first noticed the “sore” 6 months ago, and it has slowly gotten bigger. On exma, he has an ulcerated 1 cm nodule on his lower lip. There are no telangiectasias present. What is the most likely dx?
a. BCC
b. SCC
c. Lichen Planus
d. Dermatitis herpetiformis
e. Melanoma
b. SCC
C. Abdominal CT scan
The skin lesions = seborrheic keratosis (SK)
Isolated SKs occur commonly in the elderly
Sudden onset of multiple SKIs (leser-Trelat sign) suggests an underlying carcinoma of the GI tract, most often gastric cancer. It is considered to be a result of a paraneoplastic syndrome associated with the cancer. The best next step –> abdominal CT scan
A. Second-look operation
A rising WBC and lactate after debridement = highly suggestive of progression of the NSTI
A second-look operation is often required, but in this case would be essential in order to ensure that no additional tissues have become involved since the initial debridement.
