7 - Burns

Question 1

Epithelialization

Answer 1

Starts within one day

Skin grows in from the wound edges and up from hair follicle

If full thickness - no hair follicles, no epithelialization

Question 2

Calculating burn surface area (TBSA)

Answer 2

Patient’s palm is appx 1%

Rule of 9’s (picture on slide 4)

Question 3

Superficial burns (aka 1st degree burns)

Answer 3

Injury limited to the dermis

Manage the pain with APAP/NSAIDs

Hydrating lotions (avoid alcohol-based lotions)

Rarely long-term sequelae

Question 4

Partial thickness (aka 2nd degree)

Answer 4

Injury extends into the dermis

Initially cover and protect

Debride and clean with warm water an soap

UPDATE TETANUS

Painful - may need narcs

If small, heals from outside -> in

Topical ABX (silvadine)

If large (follicle destroyed) will need skin graft

Question 5

What’s preferred for partial thickness - cream or ointment?

Answer 5

Cream is preferred - easier to remove

Question 6

How long should you protect the skin from sunlight with a partial thickness?

Answer 6

A year

Also, keep moisturized with hydrating lotion

Avoid vigorous debridement - gentle debridement of devascularized tissue

Question 7

Primary care responsibilities for partial thickness burns:

Answer 7

Clean it
Debride blisters 
Cover with silvadine (ABX) cream
Apply dressings
Ensure tetanus is up to date
Patient education (sunlight protection, dressing changes)

Question 8

Full thickness (aka 3rd or 4th degree)

Answer 8

Extends into SQ fat, muscle, tendon, or bone

Nerves destroyed - mostly no sensation

Question 9

What to do with full-thickness?

Answer 9

Admit to burn unit for:

IV ABX
Fluids
Pain control
Serial debridements
Escharotomy 
Skin grafting

Question 10

Initial txt for full-thickness

Answer 10

Rinse with clean water
Dress
Elevate
ABX cream

Ensure bandaging between digits - do not impede circulation

Question 11

Fluid resuscitation for full thickness?

Answer 11

Aggressive

2-4mL (TBSA)(body weight in Kg)

1/2 that volume in the first 8 hrs, the remainder of 16 hrs

Adjust UOP to 0.5ml/kg/hr (adult)
-if it goes over, decrease IVF rate

Question 12

Airway considerations?

Answer 12

Full-thickness burn patients usually need ET-tube

Tale that airway before it closes up

Question 13

Heat considerations for burn victims?

Answer 13

Room needs to be kept really warm

Loss of skin barrier leads to inability to thermoregulate, which can lead to metabolic acidosis

Question 14

Ways to monitor fluid status

Answer 14

ABG
Lactate
Central venous pressure monitoring (Swan-Ganz catheters)(via central line)

Question 15

Circumferential burns typically need:

Answer 15

Escharotomy

Prevents tourniquet effect

Pain out of proportion

Especially chest or limbs

Question 16

Silver-impregnated dressing

Answer 16

Soak in water

Apply directly overtop of burned area

Apply moisture dressing over top silver dressing

Rinse off daily and can reuse bandage

Question 17

Splinting

Answer 17

Splint extremity in position of function (not comfort)

Accomplished with specialized splints

If left in position of comfort, may result in wound contraction -> disability (may be amenable to z-plasty after healed)

Question 18

Autograft

Answer 18

From self

Question 19

Allograft

Answer 19

Same species

Question 20

Xenograft

Answer 20

Another species

Question 21

Full thickness (sheet graft)

Answer 21

Only skin (no fenestration like STSG)

Covers smaller area

Reserved for covering bone, tendon, vessels

Question 22

Definitive skin graft comes from:

Answer 22

The patient (autograft)

Question 23

Split thickness skin graft (STSG)

Answer 23

Covers other surfaces

Healthy skin grafted from donor site

Meshed to maximize surface area

Question 24

Electrical burns

Answer 24

Often worse than they outwardly appear

Electricity traverses bones, nerves

Txt - admit to burn unit
Cardiac monitoring 2/2 increased cellular damage and leaking K+ (worrisome for arrhythmias)
Aggressive fluids (UOP 0.5-1mL/Kg/hr)
CMP, CK Q14-6hs
Serial evals of long bones

Question 25

Cord biting

Answer 25

Normally no surgery or debridement needed immediately Splint to avoid contracture Reconstruction of the mouth after healed

Question 26

Chemical burns

Answer 26

Acids - coagulation necrosis Alkaline - liquefaction necrosis Remove clothing from burned area Irrigate with copious amounts of running water Elevate and dress Splint in position of function Send em off to the specialists

Question 27

Evacuate to burn unit if:

Answer 27

> 20% TBSA Any exposed tendon, bone Face, genitalia, hands, feet, mouth Inhalation injury

Question 28

Target UOP for burn victims

Answer 28

Around 0.5mL/Kg/hr (but no more than 1 - if above 1, back the fluid off) Remember parkland - 2-4ml x TBSA x weight in kg) Prevent hypothermia

Question 29

Fluid for burn victimes

Answer 29

LR If you use NS, you may create an acidosis

Question 30

ADC-VAN-DISMAL

Answer 30

Slide 22 for explanations ``` Admit Diagnosis Condition Vitals Activity Nursing Diet IVF Special tests Meds Allergies Labs ```

Question 31

Burn unit team

Answer 31

``` 1:1 nursing Attending surgeons/intensivists/PAs Resp-therapy OT/dietician BHT Social workers Discharge planners ```

Question 32

What lies at the bottom of the ocean and twitches?

Answer 32

A nervous wreck