Thermal injury

Question 1

Burn management in ER

Answer 1

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.

Question 2

Size of palm is what percent of BSA?

Answer 2

1%

Question 3

Rule of 9s for estimating BSA

Answer 3

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

Question 4

What types of burns can be treated outpatient?

Answer 4

Most first degree burns. Second degree burns that are less than 10% BSA, excluding most burns of hands, face, perineum, eyes.

Question 5

Parkland formula for fluid resuscitation for burns

Answer 5

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

Question 6

Endocrine response to burn is ..

Answer 6

Hyperglycemia

Question 7

Cardiovascular system changes in response to burn

Answer 7

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.

Question 8

Pulmonary changes with burn

Answer 8

Shallow respirations in response to hypovolemia. After resuscitation, hyperventilation leads to mild respiratory alkalosis.

Question 9

GI effects of burn

Answer 9

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

Question 10

Endocrine effects of burn

Answer 10

Decreased insulin and t3. Increased glucagon, cortisol, catecholamines.

Question 11

Immunologic effects of burn

Answer 11

Loss of skin barrier function. Decreased WBC, esp lymphocytes. Dysfunction of PMNs.

Question 12

What may be required if escharotomy fails?

Answer 12

Fasciotomy, which does require general anesthesia. Escharotomy does not. Most common compartment requiring fasciotomy is anterior tibial compartment.

Question 13

Feature of burn excision operations

Answer 13

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.

Question 14

What can skin be grafted with once debridement is complete?

Answer 14

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

Question 15

Treatment of invasive burn infection

Answer 15

Change to Sulfamylon (mafenide acetate, penetrates eschar well) and start systemic antibiotics.

Question 16

Treatment of pseudomonal or pediatric burn infections

Answer 16

Infuse subeschar piperacillin and do emergent debridement in 12 hours

Question 17

Treatment of viral infection of burn such as HSV

Answer 17

Topical acyclovir for 7 days

Question 18

Treatment of Candidal burn infection

Answer 18

Anti fungal creams first, amphotericin B IV if fails

Question 19

What is the type of infection that is the cause of death in over half of fatal burns?

Answer 19

Pneumonia

Question 20

What complications of burns occur because of need for prolonged IV and NG?

Answer 20

Endocarditis and suppurative sinusitis, respectively

Question 21

Marjolins ulcer

Answer 21

Burn scar cancer. Rare. Usually squamous cell cancer.

Question 22

What are the criteria for admission to a burn center?

Answer 22

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

Question 23

Treatment of mild inhalational injury

Answer 23

Warm humidified oxygen and IS. Note that half life of carbon monoxide is decreased from 4 hours to 60 min with 100% oxygen.

Question 24

Treatment of moderate and severe inhalational injury

Answer 24

Moderate- repeated bronchoscopy if patient unable to clear continued mucosal sloughing.

Severe- intubate.

Question 25

Carbon monoxide poisoning

Answer 25

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.

Question 26

Lightning injury

Answer 26

Fatal in 1/3 of cases. Likely to cause cardiac arrest. Can cause transient coma or other neuro deficits, can cause myoglobinuria.

Question 27

Alkali chemical burns cause what type of injury?

Answer 27

Liquefaction necrosis

Question 28

Petroleum products cause what type of injury?

Answer 28

Depilidation

Question 29

Irrigation of chemical burns

Answer 29

Use copious water irrigation only. At least 30 min for acid burns, and longer for alkali burns since these penetrate deeper

Question 30

Appearance of mild frostbite

Answer 30

Bright red, warm, painful, paresthesia, rapid edema, large vesicles, late superficial eschar that resolves in one to two weeks

Question 31

Appearance of deep frostbite

Answer 31

Deep purple, cool, minimally painful, small hemorrhagic vesicles, slow edema, mummification of deep structures

Question 32

Treatment of frostbite

Answer 32

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.

Question 33

Types of nonfreezing cold injury

Answer 33

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.