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ABSITE > Fiser Chapter 17 BURNS > Flashcards

Fiser Chapter 17 BURNS Flashcards

1
Q

1st degree burn

A

Epidermis (sunburn)

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2
Q

2nd degree burn

A

Superficial dermis (papillary): Painful to touch, blebs/blisters, hair follicles intact, blanches, do NOT need skin graft

Deep dermis (reticular): decreased sensation, LOSS OF HAIR FOLLICLES, need skin graft

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3
Q

3rd degree burn

A

Leathery (charred parchment); down to subcutaneous fat

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4
Q

4th degree burn

A

Down to bone; into adjacent adipose or muscle tissue

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5
Q

Which burns heal?

A

1st and superficial 2nd degree burns: epithelialization from hair follicles

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6
Q

Complications of burns

A

Compartment syndrome
Rhabdomyolysis with myoglobinuria

Tx: hydration, alkalinize urine

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7
Q

Who gets admitted to a burn center?

A

No 1st degree burns

2nd and 3rd degree:
>20% (>10% if <10 or >50)
Or if significant hand/face/feet/genital/perineal/joint skin burns

3rd degree: >5% any age group

Electrical and chemical burns

Concomitant inhalational injury

Mechanical trauma, preexisting medical conditions, patients with special needs, child abuse/neglect

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8
Q

TBSA assessment

A

Rule of 9s

Head 9
Arms 9 each
Chest 18
Back 18
Legs 18 each
Perineum 1

Or palm = 1%

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9
Q

Parkland formula

A

Use for burns >/= 20%

Volume LR = 4 cc/kg x kg x % TBSA
Give 1/2 in first 8 hours, second half in second 16 hours

UOP best measure: goal 0.5-1.0 cc/kg/h in adults, 2-4 cc/kg/h in <6mo

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10
Q

When can Parkland formula grossly underestimate volume requirement?

A

inhalational injury
EtOH
electrical injury
post-escharatomy

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11
Q

What do you use in burn resuscitation?

A

LR in first 24 hr

Albumin in first day can cause increased pulmonary complications. Can use after 24hr

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12
Q

Escharotomy indications

A
  • Circumferential deep burns
  • Low temp
  • Weak pulse
  • Decreased capillary refill
  • Decreased pain sensation
  • Decreased neurological function in extremitiy
  • Problems ventilating patient with chest torso burns

Perform within 4-6 hours

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13
Q

Fasciotomy indication in burn patient

A

If compartment syndrome suspected after escharotomy

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14
Q

Risk factors for burn injuries

A 
EtOH
Drugs
Age (very young or very old)
Smoking
Low socioeconomic status
Violence
Epilepsy
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15
Q

H&P signs that suggest abuse

A
  • Delayed presentation for care
  • Conflicting histories
  • Previous injuries
  • Sharply demarcated margins
  • Uniform depth
  • Absence of splash marks
  • Stocking or glove patterns
  • Flexor sparing
  • Dorsal location on hands
  • Very deep localized contact injury

Child abuse accounts for 15% of burn injuries in children

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16
Q

Lung injury MoA

A

Carbonaceous materials and smoke (not heat)

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17
Q

Risk factors for airway injury in burn

A
  • EtOH
  • Trauma
  • Closed space
  • Rapid combustion
  • Extremes of age
  • Delayed extrication
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18
Q

Signs and symptoms of possible airway injury

A
  • Facial burns
  • Wheezing
  • Carbonaceous sputum
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19
Q

Indications for intubation

A
  • Upper airway stridor or obstruction
  • Worsening hypoxemia
  • Massive volume resuscitation can worsen symptoms
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20
Q

Most common infection in patients with >30% BSA burns

A

Pneumonia

Also MCC death after >30% BSA burns

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21
Q

MCC death after 30% BSA burns

A

Pneumonia

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22
Q

Acid and alkali burns tx

A

Copious water irrigation

Alkalis produce deeper burns due to liquefaction necrosis

Acid burns produced coagulation necrosis

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23
Q

Hydrofluoric acid burns tx

A

Calcium

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24
Q

Powder burns tx

A

Wipe away before irrigation

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25
Q

Tar burns tx

A

Cool, then wipe away with lipophilic solvent (adhesive remover)

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26
Q

Electrical burns tx and complications

A

Cardiac monitoring
Monitor for rhabdo and compartment syndrome

Watch for polyneuritis, quadriplegia, transverse myelitis, cataracts, liver necrosis, intestinal perforation, gallbladder perforation, pancreatic necrosis

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27
Q

Lightning burn complication

A

Cardiopulmonary arrest 2/2 electrical paralysis of brainstem

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28
Q

Caloric need in burns

A

25 kcal/kg/day + (30 kcal x % burn)

29
Q

Protein need in burns

A

1 g/kg/day + (3 g x % burn)

30
Q

Glucose need in burns

A

Best source of nonprotein calories in patients with burns

Burn wounds use glucose in an obligatory fashion

31
Q

Burn wound excision

A
  • Perform AFTER fluid resusc but <72h
  • Used for deep 2nd, 3rd, 4th degree burns
  • For each burn wound excision, want <1 L blood loss, <20% skin excised, and <2 hr in OR. Patient can otherwise get very sick.
  • Viability based on color/texture/punctate bleeding after removal

-Wounds to face, palms, soles, genitals deferred for 1 week

32
Q

Skin graft contraindications

A

Positive beta-hemolytic strep or bacteria > 10^5 in culture

33
Q

Autografts

A
  • Decrease infection, desiccation, protein loss, pain, water loss, heat loss, RBC loss compared to dermal subtitutes
  • Donor skin site regenerated from hair follicles and skin edges on STSGs
34
Q

Imbibition

A

Osmotic blood supply to skin graft for days 0-3

35
Q

Neovascularization

A

Starts day 3

36
Q

Poor vascularized beds unlikely to support skin grafting

A

Tendon, bone without periosteum, XRT areas

37
Q

STSG thickness

A

12-15 mm (epidermis and part of dermis)

38
Q

Homograft use

A

(Allografts from cadaveric skin)

  • Can be a good temporizing material, last 2-4 weeks
  • Vascularize and are eventually rejected, then must be replaced
39
Q

Xenografts (porcine)

A
  • Not as good as autografts or homografts
  • Last 2 weeks
  • Do NOT vascularize
40
Q

Dermal substitutes

A

worst

41
Q

Meshed grafts

A

-Use for back, flank, trunk, arms, legs

42
Q

Most common reason for skin graft loss

A
  • Seroma or hematoma

- Need to apply pressure dressing (cotton balls) to skin graft to prevent this

43
Q

STSG versus FTSG

A

STSG: more likely to survive, graft not as thick so easier for imbibition and revascularization

FTSG: less wound contraction, good for hands

44
Q

Burn scar hypopigmentation and irregularities prevention

A

Dermabrasion thin split-thickness grafts

45
Q

Face burn care

A

Topical antibiotics for 11st week

FTSG for unhealed areas (nonmeshed)

46
Q

Hand burn care

A

Superficial: ROM exercises, splint in extension if too much edema

Deep: FTSG, immobilize in extension for 7 days after, then PT, may need wire fixation of joints if unstable or open

47
Q

Palm burn care

A

Try to preserve specialized palmar attachments

FTSG, then splint hand in extension for 7 days

48
Q

Genitals burn care

A

STSG meshed is ok

49
Q

Burn wound infection prevention

A

Bacitracin or Neosporin immediately
No role for IV abx ppx

Need 10^5 organisms for infection

50
Q

Burn wound infection organism

A

MCC is pseudomonas (burn wound sepsis) > staph, e coli, enterobacter

Candida increased 2/2 topical antimicrobials

HSV most common viral

51
Q

Burn wound infection risk factors

A

> 30% BSA

52
Q

Burn wound infection pathophysiology

A

Impaired granulocyte chemotaxis and cell-mediated immunity

53
Q

Silver sulfadiazine side effects

A 
Neutropenia
Thrombocytopenia
Sulfa allergy reaction
Limited eschar penetration
Can inhibit epithelialization
Ineffective against some pseudomonas (but effective for candida)
54
Q

Silver nitrate side effects

A 
Electrolyte imbalances
Discoloration
Limited eschar penetration
Ineffective against some pseudomonas and GPCs
Methemoglobinemia (in G6PD deficiency)
55
Q

Mafenide sodium (sulfamylon) characteristics

A

Painful application
Metabolic acidosis d/t carbonic anhydrase inhibition (decreased renal conversion of H2CO3 -> H2O and CO2)
Good eschar penetration, good for burns overlying cartilage
Broadest spectrum against pseudomonas and GNRs

56
Q

Mupirocin

A

Good for MRSA, but very expensive

57
Q

Signs of burn wound infection

A
  • Peripheral edema
  • 2nd to 3rd degree burn conversion
  • Hemorrhage into scar
  • Erythema gangrenosum
  • Green fat
  • Black skin around wound
  • Rapid eschar separation
  • Focal discoloration
58
Q

Best way to detect burn wound infection (and differentiate from colonization)

A

Biopsy of burn wound

59
Q

Complications after burns

A
  • Seizures
  • Peripheral neuropathy (small vessel injury and demyelination)
  • Ectopia (burned adnexa contraction, tx eyelid release)
  • Eye injury (fluorescein stain, tx topical fluoroquinolone or gentamicin)
  • Coreneal abrasion (tx topical abx)
  • Symblepharon (eyelid stuck to conjunctiva, tx release with glass rod)
  • Heterotopic ossification of tendons (tx PT, may need surgery)
  • Fractures (Tx external fixation to allow for burn tx)
  • Curling’s ulcer
  • Marjolin’s ulcer
  • Hypertrophic scar
60
Q

Curling’s ulcer

A

Gastric ulcer that occurs with burns

61
Q

Marjolin’s ulcer

A

Highly malignant squamous cell CA that arises in chronic non-healing burn wounds or unstable scars

62
Q

Hypertrophic scar

A
  • Usually occurs 3-4 months after injury 2/2 increased neovascularity
  • More likely to be deep thermal injuries that take >3 weeks to heal, heal by contraction and epithelial spread, or heal across flexor surfaces

-Tx: steroid injection into lesion (best), silicone, compression; wait 1-2 yr before scar modification surgery

63
Q

Erythema multiforme

A

least severe, self-limited, target lesions

64
Q

SJS

A

more serious

<10% BSA

65
Q

TEN

A

most severe form

66
Q

Staph scalded skin syndrome

A

Caused by staphylococcus aureus

67
Q

Skin epidermal-dermal separation

A

Seen in EM, SJS, TEN

68
Q

TEN causes

A

Dilantin
Bactrim
PCN
Viruses

69
Q

TEN tx

A
  • Fluid resuscitation
  • Supportive
  • Prevent wound desiccation with homografts/xenografts wraps
  • Topical abx
  • IV abx if due to staphylococcus
  • NO Steroids

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