WISEMD Burns

Question 1

Is a scald burn superficial or deep? Is a flame burn superficial or deep? What may a chemical burn require? What is unique about electrical burns?

Answer 1

1) Superficial
2) Can be superficial or deep
3) Immediate neutralization
4) They are deeper than they appear and there is a concern for associated trauma

Question 2

Should a burned patient with an altered mental status still be asked for a history?

Answer 2

Yes. It is important to get as many details as possible

Question 3

What PMH would prompt a possibly difficult resuscitation with fluids in a burn patient? What medications can make resuscitation challenging?

Answer 3

1) PMH of cardiac, pulmonary, or renal disease

2) Beta-blockers and anticoagulants

Question 4

How should you begin the initial care of a burn victim?

Answer 4

1) Primary survey: Airway, Breathing, Circulation, Disability, Exposure (ABCDEs)
2) Secondary survey: Full physical exam
3) Initial wound management

Question 5

What are criteria that require intubation?

Answer 5

1) High RR
2) Low PaO2
3) High PaCO2
4) Inability to protect airway
5) High suspicion for inhalation injury (closed space, elevated carboxyhemoglobin, carbonaceous sputum)
6) Burns > 30% TBSA

Question 6

To stabilize breathing, what should you do?

Answer 6

1) Oxygen is the single most important intervention
2) Use a 100% O2, non-rebreather mask
3) Do not rely on pulse oximetry
4) Don’t attempt to wean

Question 7

Why is stabilizing circulation and fluid management in a burn patient critical?

Answer 7

1) Loss of skin/associated inflammatory response may cause massive fluid shifts
2) Large bore peripheral IV’s (through burn if necessary)
3) Fluid requirements determined by Parkland formula
4) Goal of resuscitation is adequate urine output (Adults 30-50 cc/hr, Children 1cc/kg/hr)

Question 8

How can you assess disability in a burn patient? What is this important for?

Answer 8

1) Assess level of consciousness
2) Glascow Coma Score
3) Important if patient will be intubated, sedated, and paralyzed

Question 9

How do you expose and examine a burn patient? Why is this necessary? What must you avoid in these patients?

Answer 9

1) Removal all clothing, rings, and jewelry
2) Roll the patient to look posteriorly
3) Look for associated traumatic injuries
4) Necessary to determine TBSA
5) Avoid hypothermia - keep room as hot as possible

Question 10

What is the secondary survey on a burn patient?

Answer 10

1) Complete head to toe history and physical on a patient
2) Look for missed injuries
3) Accurately measure the extent and depth of burn

Question 11

What is the rule of nines?

Answer 11

1) Method to calculate TBSA burned

2) Differences in adults and children reflect proportional differences

Question 12

What laboratory studies should you conduct in a burn patient and why?

Answer 12

ABG in suspected inhalation injury to check for carboxyhemoglobin in particular

Question 13

What does associated trauma and LOC require in burn patients? What other imaging study is required?

Answer 13

1) Appropriate imaging

2) Bronchoscopy to check for carbonaceous sputum or edematous vocal cords

Question 14

If a patient is being transferred to wound specialty center, what should be done to the wound(s)?

Answer 14

1) If transferring, use clean, dry dressings and do not apply lotions or creams
2) Tetanus prophylaxis
3) Analgesia, anxiolysis (may require large doses)
4) Check for signs of compartment syndrome

Question 15

How much fluid should be given during the first 24 hours?

Answer 15

1) Parkland’s formula: 4 x kg x %TBSA burned

2) Half of LR to be given in first 8 hrs and other half to be given in next 16 hours (all given over first 24 hours)

Question 16

What does the surgical management of burn patients consist of?

Answer 16

1) Tangential excision - Remove necrotic tissue and predisposes to infection
2) Skin grafting - Autograft (patient’s skin) vs. Allograft (cadaver skin) as temporary coverage
3) Meshing - Meshing may be necessary to cover a greater surface area. Non meshed skin gives better cosmesis and functionality

Question 17

What are short term complications in burn patients?

Answer 17

1) Infected burns: leading cause of death
2) Treat infections: lung, wound, line, urine
3) Nutrition: calories, protein, supplements

Question 18

What are long term complications in burn patients?

Answer 18

1) Contractions and hypertrophic scarring
2) Psycho-social issues
3) Margolin’s ulcer - development of squamous cell carcinoma in a chronic burn wound

Question 19

Describe a first, superficial second, deep second, and third degree burn?

Answer 19

1) First degree burns have intact epithelium with erythema
2) Superficial second degree burns have a completely unroofed blister revealing the wound bed as pink, quickly blanching, moist, and quite painful
3) Deep second degree burns usually have sluggish to no blanching. The wound bed ranges in color from cherry red to white and is usually dry
4) Third degree burns have a leathery appearance and are completely dry with no blanching. In addition these burns are insensate

Question 20

In young children, where is the narrowest part of the airway? What does this indicate?

Answer 20

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

Question 21

What are common side effects of burn medications: Mafenide, silver sulfadiazene, silver nitrate, bacitracin, and sodium hypochlorite solution (aka Dakin’s solution)?

Answer 21

1) Mafenide is a carbonic anhydrase inhibitor and thus can lead to a metabolic acidosis, especially when applied to large percentage of the body
2) Silver sulfadiazene is associated with a transient leukopenia
3) Silver nitrate can cause electrolyte abnormalities from leaching
4) Bacitracin can cause a yeasty rash
5) Sodium hypochlorite solution (aka Dakin’s solution) can cause redness, irritation, and pain

Question 22

Why are hydrofluoric acid burns a unique chemical exposure? What is therefore the treatment? What is contraindicated for treatment and why?

Answer 22

1) 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
2) Calcium gluconate gel is therefore the treatment
3) 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