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Questions pratiques de l'Université Montréal > Brulures, Engelures, TEN/S > Flashcards

Brulures, Engelures, TEN/S Flashcards

1
Q

What are the 5 guiding principles for burn management

A

Resuscitation
Resurfacing
Reconstruction
Rehabilitation
Recovery

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2
Q

What are the 3 major predictor of burn mortality

A

Age
TBSA
Inhalation

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3
Q

3 mécanismes de transfert d’énergie?

A

Convection, Conduction, Radiation

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4
Q

Décrire les Zones de Jackson

A

Nécrose (Coagulation) – doit être excisé

Stase – salvage possible avec ressuscitation

Hyperémie – viable

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5
Q

5 mechanism de brulure

A
  • Chaleur
  • Électrique
  • Friction
  • Chimique
  • Radiation
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6
Q

Qu’est-ce que le burn shock? Nommez 3 mécanismes

A

Réaction systémique à la brulure lorsque extensive où la perfusion tissulaire est insuffisante pour maintenir le delivery de O2

Environ 10-15% TBSA chez une personne âgée, 20% chez un adulte et 30% chez un enfant

3 mécanismes :
1. Relaxation endothéliale de NO
2. Augmentation de la perméabilité capillaire
3. Translocation de fluide interstitiel

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7
Q

Phase of edema with burns

A

Immédiate – minutes, augmente dans les tissus brulés

Delayed – 12-24h, dans les tissus brulés et non brulés

Maximum : à 12h dans une petite brulure et 24h dans une grosse brulure

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8
Q

Indication for burn resucitation and duration

A

> 20% (>15% if geriatric or peds) (does not include 1st degree)
For the first 24-48h crystalloids firth 24h and colloids 2nd 24h

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9
Q

Endpoint of resuscitation

A
  • Débit urinaire
  • BP
  • Base deficit
  • Lactates
  • Autres : Index cardiaque >3.5L/min/m2, TVC
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10
Q

Modified Brooke Formula

A

2xTBSAxkg
first half in first 8h and second have in next 16h

+ add maintenance for children

Target 0.5cc/kg/h or 30-50cc/h average

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11
Q

What is fluid creep

A

Surviens quand >6cc/kg/h repletion

Conséquences :
ARDS
Infections nosocomiales
Augmente la mortalité
Risque de compartiment

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12
Q

Score for mortality prediction in Burns

A

Baux score: Age + %TBSA + 17 if inhalation
50% mortality if score >110
Is inhalation injury present 50% mortality if score >100

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13
Q

Describe rule of 9’s

A

Palm without digits 1%
Head and neck: 9%
Anterior chest and abdomen: 18%
Back :18%
Each upper limb: 9%
Each lower limb: 18%
Geneitals: 1%

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14
Q

Difference between second degree deep and third degree burns

A

Both do not blanch
3rd degree burn is insensate
Blistering absent in third degree

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15
Q

Signs of inhalation injury

A

Carboxyhemoglobine >10%
Sooth in airway
Singed nasal hairs
Respiratory distress

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16
Q

Workup for electrical injury

A

CK
Tropo
ECG
Cardiac monitoring

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17
Q

Alkali versus acids that cause deeper injury

A

Alkali

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18
Q

Treatment of alkali and acids burns

A

Copious 15-20 minute irrigation

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19
Q

hydrofluoric acid: systemic irregularities and treatment

A

Systemic hypocalcemia
Treat with calcium gel, intradermal calcium gluconate or intraarterial calcium gluconate if severe
Cardiac monitoring

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20
Q

What is the end point for use of calcium gluconate

A

resolution of pain

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21
Q

What is the antidote to white phosphorous

A

Copper sulfate 0.5%

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22
Q

What are the metabolic changes seen with white phosphorous

A

HypOcalcemia, hypERphosphatemia, cardiac arrythmias

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23
Q

What is the mechanism of copper sulfate

A

Binds to phosphorous sulfate and prevents oxidization with contact to air. Turns particles black to remove them

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24
Q

What is the antidote for phenol burns

A

Polyethylene glycol (IV sodium bicarbonate can also be given to help with cardiac arrythmia)

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25
Q

In electrical burns what is the tissue with the most resistance

A

Bones

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26
Q

In electrical burns what is the tissu with the least resistance

A

Nerves

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27
Q

In increasing magnitude, list tissues resistance to electrical injuries

A

Trick: NeVer Mind PeTit GrOs

  • nerves -> vessels ->muscles -> peau -> tendons -> gras -> os
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28
Q

Other than joule heating, name another mechanism of electrical burn that causes destruction of cells

A

Electroporation (formation of pores in cell lipid bilayer. This results in calcium influx and apoptosis)

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29
Q

What areas as the most severity injured in electrical injuries

A

Wrists and Ankles

(severity of injury is proportional to cross-sectional area of tissue able to carry current) The severity of injury is inversely proportional to the cross-sectional area of the involved body part

30
Q

Name 5 things that can be done to prevent rhabdomyolysis and renal damage

A
  • Decompression of compartment syndromes
  • Titrating fluid resuscitation to maintain urine output double the goal rate of the standard burn patient (1 to 2 mL/kg/h)
  • Sodium bicarbonate ( alkalinisation of the urine by preventing precipitation)
  • Loop diuretics (prevention of oliguria)
  • Mannitol (osmotic diuresis)
31
Q

What ingredient is in Acticoat making it a good dressing

A

Nanocrystalline silver

32
Q

What is the mechanism of action of Acticoat

A

Silver ions disrupt DNA replication and electron transport chain

33
Q

What type of organisms to silver based dressings useful against

A

gram +
gram -
fungi
some viruses

34
Q

Name 3 biological dressings

A
  • Cadaveric allograft
  • Xenograft
  • Amnion
35
Q

Which dressing should you avoid in a potential face transplant candidate

A

Allograft

36
Q

Name 3 advantages of acellular dermal matrix in breast reconstruction/expansion

A
  • Prevents implant migration
  • Reduces the risk of implant exposure
  • Decreases risk of capsular contracture
  • Decreased risk of malposition
37
Q

Name 2 disadvantages of acellular dermal matrix in breast reconstruction/expansion

A
  • Increased risk of infection
  • Increased risk of seroma
  • Risk of red breast syndrome
  • Cost is prohibitive
38
Q

Other than human sources, what other sources can provide acellular dermal matrix

A
  • Porcine acellular dermal matrix
  • Bovine acellular dermal matrix
39
Q

What is the main reason why acellular dermal matrices are not used in all centers in Canada

A

High cost

40
Q

What method is used to calculate caloric needs in the burn adult

A

Curreri formula
25kcal/kg+40kcal/TBSA%

41
Q

How much protein should you aim for in the burn patient

A
  • 1.5-2g/kg per day adults
  • 2.5-4g/kg per day in children
42
Q

How much carbs should you give the burn patient

A

50% of total caloric intake

43
Q

How much fats should you give the burn patient

A

3-15% of total caloric intake

44
Q

Name 2 methods for nutritional support in burn patients

A
  • Enteral feeding
  • Parenteral feeding
45
Q

Name 1 advantage and 1 disadvantage for enteral feeding

A
  • Advantage
    o Less ischemia
    o Maintain GI tract motility
    o Reduces risk of bacterial translocation
  • Disadvantage
    o Increased risk of aspiration
    o Increased N/V
    o Increased abdominal distension
46
Q

Name 1 advantage and 1 disadvantage for parenteral feeding

A
  • Advantage
    o Provide nutrition when GI tract is compromised.
  • Disadvantage
    o Atrophy of GI tract
    o Hyperglycemia
    o Increased risk of infection
47
Q

Name 2 medication that can be used to reduce catabolism in burns

A
  • Propranolol (aims to reduce HR by 15-20%)
  • Oxandrolone (10mg daily x 1 year)
  • Recombinant human growth hormone (rhGH)
  • Fenofibrate
48
Q

Name 4 criteria for referral to burn centre

A
  1. Partial thickness burns on greater than 10% TBSA
  2. Burns involving the face, hands, feet, genitalia, perineum, and major joints
  3. Third degree burns in any age group
  4. Electrical burns, including lightning injury
  5. Chemical burns
  6. Inhalation injury
  7. Burn injury in patients with preexisting medical disorders that could complicate management and prolong recovery, or affect mortality
  8. Any patient with burns and concomitant trauma (e.g., fractures) in which the burn injury posed the greatest risk of morbidity and mortality.
  9. Burned children in hospitals without qualified personnel or equipment for the care of children
  10. Burn injury in patients who will require special social, emotional, or rehabilitative intervention
49
Q

Name 2 issues with using the parkland formula to estimate fluid need in burn patients

A
  • Over estimates fluid requirements
  • Underestimates fluid requirements in electrical burns, inhalation injury (increases need by 50%), alcohol intoxication
50
Q

Name 2 indications for escharotomies

A
  • Full thickness circumferential burns of the extremities
  • Full thickness circumferential burns of the thorax with difficulty ventilating
  • Abdominal burns with impending abdominal compartment syndrome
51
Q

What the most common causes of TEN/S

A
  • Medication
  • Viral infections
52
Q

What medications are most associated with TEN/S

A
  • Allopuriniol
  • Sulfonamides
  • Antiepilectic drugs (lamotrigine)
  • Oxicam-NSAIDs
  • Nevirapine (anti-HIV)
  • Phenytoin
53
Q

What 2 clinical signs of TEN/S

A
  • Nikolsky sign (epidermolysis with finger dissection)
  • Asboe-Hansen (pressure on the blister expands the bullae)
54
Q

Name 6 reasons for cardiac monitoring in the context of electrical injuries

A
  • Loss of consciousness
  • ECG abnormality or evidence of ischemia
  • Documented dysrhythmia either before or after admission to ED
  • CPR in the field
  • > 1000 volts
  • Trajectory passing through the chest
55
Q

How long do you do cardiac monitoring in electrical injury

A
  • No risk factors – no monitoring
  • Risk factors 24hrs
56
Q

What are 3 explanations for dark coloured urine in burn patients

A
  • Myoglobinuria (rhabdomyolysis)
  • Hemoglobinuria (hemolysis)
  • Concentrated urine from decreased circulating volume with decreased renal blood flow (e.g., dehydration, burn shock)
57
Q

Name 2 medications that can be used to increase urine output

A
  • Loop diuretics
  • Mannitol
58
Q

What urine output should you target in the context of rhabdomyolysis

A

1-2cc/kg/hr (100cc/hr)

59
Q

What is the pathognomonic sign of lightning strike

A

Lichtenberg figure (dendritic, fernlike, blanching erythematous pattern on skin)

60
Q

What is the risk of rewarming the patient before transfer?

A

Risk of thawing and refreezing which has a deleterious effect on the outcome of frostbite

61
Q

Name an effective treatment to salvage digits with frostbite in the 1st 24hrs

A

tPA

62
Q

Name 3 long term sequalae that can occur following frostbites

A
  • Cold sensitivity
  • Sensory loss
  • Chronic pain
  • Heterotopic ossification
  • Growth plate disturbances
63
Q

Why is the absence of pain not a valid endpoint for the treatment of phenol burns

A

Phenol has local anesthetic properties

64
Q

Post-op considerations burn surgery

A

Systemic antibiotic, adjust with cultures
Topical antimicrobial
Optimism nutrition
Aggressive OT

65
Q

Types of antimicrobial dressings/solutions and covers which bacteria

A

Silver nitrate: against staph and gram neg aerobes (pseudo)

Mafenide acetate/Sulfamylon: covers gram +, penetrates deep

Sodium hypochlorite (anasept): broad spectrum

Nystatin: covers fungus

66
Q

Define heterotropic ossification

A

Formation fo ectopic osseus lesions causing severe pain, non healing wounds, restricted ROM

67
Q

Most lethal and common complication fo burn

A

Commune : Sepsis

Prévention : excision précoce, utilisation soignée des accessoires invasifs, pansements antimicrobiens, éliminer les infections H2O, isolement

Létale : Pneumonie

68
Q

Define Burn wounds sepsis

A

1 : Pathologic infection (culture) OR Pathogen >105 OU Amélioration avec ATBx

Hypothermie ou fièvre >39C
Tachycardie >110
Tachypnée >25 ou débit ventilatoire >12L/min
HypoTA réfractaire
Leucocytose/pénie
Thrombocytopénie x 3jours
Hyperglycémie chez un non db
Inabilité de toléré la nutrition entérale >24h (Iléus)

69
Q

Comment diminuer les pertes sanguines dans une excision de brulure?

A

Limiter l’excision à 10-20% TBSA par SOP = meilleure façon de contrôler les pertes

Épinéprine en injection/tumescence

Compresses d’épinéphrine topique

Tourniquet

Colle de thrombine

Cautère

Cyclokapron

Prévenir l’hypothermie (Augmente les infections, pertes sanguines et acute lung injury)

70
Q

When to supect child abuse

A
  • Brulures pattern de « dipping » (LE/fesses)
  • Épargne les plis cutanés
  • Uniforme, rebord net
  • Autre blessure non reliée
  • Enfant introverti
  • Examen et histoire incompatible
71
Q

Abdominal compartment criteria

A
  • Pression intra-vésicale >20mmHg avec 1+ dysfonction organe nouvel
  • Risques : Inhalation, brulures extensives, ressuscitation inadéquate avant l’admission, haut volume de réplétion, brulures circonférentielles du tronc
  • Abdomen tendu, oligurie, hypercapnie, diminution compliance respiratoire
72
Q

Abdominal hypertension treatment

A
  • Laparotomie de décompression (50% mortalité)
  • HTN abdominale >12mmHg
    i. Escharotomie
    ii. Drainge percutané (Paracenthèse)
    iii. Décompression tube NG
    iv. Sonde urinaire
    v. Mannitol

Questions pratiques de l'Université Montréal (41 decks)

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