99: Burns Flashcards
(134 cards)
1
Q
What are the four general phases in managing large burns?
A
- Initial evaluation and resuscitation 2. Wound debridement and biologic closure 3. Rehabilitation and reconstruction 4. Long term outcome quality assessment.
2
Q
What safety implementations have contributed to a 60% decrease in burn injuries since the early 1990s?
A
- Reduction in tobacco use and alcohol abuse 2. Prevention education programs 3. Change in home cooking practices 4. Decreased industrial employment.
3
Q
What is the most common mechanism of burn injury in the outpatient setting?
A
Scald burns.
4
Q
What percentage of burn patients admitted to burn centers are due to electrical burns?
A
4%.
5
Q
What is the relationship between the duration of contact with an electrical source and tissue destruction?
A
The duration of contact with the electrical source is proportional to tissue destruction; longer contact times increase tissue damage.
6
Q
What are the characteristics of flame burns?
A
- Caused by fire or flames
- Most common burn etiology over the past decade
- Associated with the highest risk of death and complications
- 64% occur at home; 12% at work; 6% recreational
- 17% involve smoke inhalation injury, especially if indoors or in an enclosed space
- 24% mortality if with inhalation injury; 4% if without.
7
Q
What factors determine the severity of electrical burns?
A
The severity of electrical burns is determined by: 1. The current (amperage) of electricity 2. The direction of travel of the current 3. Duration of contact with the electrical source.
8
Q
What is the ‘no let-go’ phenomenon in electrical burns?
A
The ‘no let-go’ phenomenon refers to the increased contact time during electric shock, which leads to greater tissue destruction due to the strength of flexors being greater than extensors.
9
Q
What is the likelihood risk of fire-related death in the United States?
A
1.5: 1000.
10
Q
What is the mortality rate for burn patients with inhalation injury compared to those without?
A
24% mortality if with inhalation injury; 4% if without.
11
Q
What is the primary cause of contact burns in children?
A
Touching a hot object.
12
Q
What is the significance of TBSA in assessing burn severity?
A
TBSA is an unreliable surrogate for burn severity as it does not reflect the degree of internal tissue and organ damage caused by electrical current penetration.
13
Q
What are the common causes of chemical burns and their associated injuries?
A
Common causes of chemical burns include:
- Acids bind hydrogen ions to proteins, inducing coagulation.
- Alkali causes deeper and more serious injuries with liquefactive necrosis.
Chemical | Associated Injury |
|———-|——————|
| Carbon monoxide | High frequency of associated injury |
| Ammonia | High frequency of associated injury |
| Chlorine | High frequency of associated injury |
| Hydrochloric acid | High frequency of associated injury |
| Sulfuric acid | High frequency of associated injury |
14
Q
What are the treatment steps for chemical burns?
A
The treatment steps for chemical burns include:
- Remove clothing and accessories.
- Brush or dust solids or powders off the skin.
- Irrigate the wound with copious amounts of water.
- Hydrate the area with saline.
- Avoid attempts at neutralizing the chemical, as this may worsen the reaction.
- Administer antidotes as necessary.
15
Q
What are the clinical features used to characterize different regions of burns?
A
The clinical features used to characterize different regions of burns include:
- Zone of coagulation: Cell death occurs in this area.
- Zone of stasis: Cell injury that can either recover or transform into the zone of coagulation.
- Zone of hyperemia: Cells in this area will recover from injury.
16
Q
What are the complications associated with smoke inhalation injury?
A
Complications associated with smoke inhalation injury include:
- Burns sustained in structural fires.
- Exposure to carbon monoxide and cyanide toxicity.
- Symptoms typically present as perioral burns and the presence of ashes and soot around the mouth and oropharynx.
- Direct thermal injury to the pulmonary epithelium, leading to edema and airway obstruction.
- Smoke inhalation injury can double the mortality rate.
17
Q
What factors contribute to the higher prevalence of permanent disability from burns in low to middle income countries?
A
The higher prevalence of permanent disability from burns in low to middle income countries is attributed to:
- Inadequate safety measures.
- Lack of specialized burn centers.
- Limited prevention outreach.
- Deficiencies in training and resources necessary to provide impactful burn care.
18
Q
A patient with a chemical burn caused by hydrofluoric acid presents to the emergency department. What is the specific antidote and its administration?
A
The antidote is topical calcium gluconate gel, intra-arterial calcium infusion, or subeschar injection of dilute 10% calcium gluconate solution.
19
Q
A patient with a burn injury has a zone of stasis. What does this zone represent, and what is its clinical significance?
A
The zone of stasis represents cell injury that can either recover or progress to cell death. It is critical to optimize perfusion to prevent further damage.
20
Q
A patient with a burn injury is found to have tympanic membrane rupture. What is the likely cause?
A
The rupture is likely due to secondary electrical injury from explosive shock waves generated by electric arcs.
21
Q
A patient with a burn injury is found to have a zone of coagulation. What does this zone represent?
A
The zone of coagulation represents cell death and is the area of greatest tissue damage.
22
Q
A patient with a burn injury is found to have a toxic level of cyanide. What is the likely source and management?
A
The likely source is smoke inhalation from structural fires. Management includes administering hydroxocobalamin or sodium thiosulfate.
23
Q
A patient with a burn injury is found to have a zone of hyperemia. What does this zone represent?
A
The zone of hyperemia represents cells that will recover from injury.
24
Q
What is the leading cause of injury-related deaths?
A
Burns are the 4th leading cause of injury-related deaths.
25
What are the common chemicals associated with chemical burns?
Carbon monoxide, ammonia, chlorine, hydrochloric acid, and sulfuric acid.
26
What is the recommended treatment for chemical burns?
Remove clothing, irrigate with water, hydrate with saline, and give antidote if necessary.
27
What is the significance of the zone of coagulation in burn injuries?
It represents the area of cell death due to the most severe damage from the burn.
28
What are the long-term disability statistics for children who survive burn injuries?
15% experience long-term temporary disability and 8% have permanent disability.
29
What complications can arise from smoke inhalation injuries?
Direct thermal injury to the pulmonary epithelium, leading to edema and airway obstruction, which can double mortality rate.
30
What should not be done when neutralizing chemical burns?
Attempts at neutralizing should not be undertaken as heat from exothermic reactions may worsen the severity of the reaction.
31
What are the three zones of burn injury characterization?
Zone of coagulation, zone of stasis, and zone of hyperemia.
32
What is the risk for patients who survive a lightning strike?
They are at high risk for arrhythmias and compartment syndrome between the entry and exit points.
33
What is compartment syndrome and what are its causes?
Compartment syndrome occurs due to circumferential burns of the extremities, leading to increased swelling and edema, which causes:
1. Nerve impingement
2. Vascular compromise.
34
What defines abdominal compartment syndrome and how is it treated?
Abdominal compartment syndrome is defined as bladder pressure over 30 mmHg, usually presenting with oliguria and abdominal distension. Treatment includes:
1. Lay the patient flat; restrict movement.
2. Escharotomy of the abdominal full thickness burns.
3. Decrease fluids.
4. Start diuresis or continuous renal replacement therapy to avoid decompressive laparotomy.
35
What is a Curling ulcer and what causes it?
A Curling ulcer, also known as acute stress gastritis, is caused by intravascular volume depletion and may lead to bleeding in the gastric or duodenal mucosa.
36
What are the consequences of acute renal failure in burn patients?
Acute renal failure in burn patients is often due to massive myoglobinuria, which is common in electrical burns.
37
What is ectopic bone formation in burn patients and its common site?
Ectopic bone formation occurs due to heterotopic ossification in patients with large total body surface area (TBSA) burns, presenting with severe pain, contractures, and restricting range of motion. The most common site is the elbow (upper extremity).
38
What is the hypermetabolic state in burn patients?
The hypermetabolic state in burn patients is often proportional to the size of the injury and involves muscle catabolism, hyperglycemia, and increased lipid liberalization with steatosis.
39
What are the two paradigms of etiology and pathogenesis in burn injuries?
The two paradigms of etiology and pathogenesis in burn injuries are:
1. Loss of skin organ function
2. Production of inflammatory response.
40
How does loss of skin organ function affect burn patients?
Loss of skin organ function leads to:
- Impaired barrier against microbes and absorption
- Unregulated insensible water losses causing IV volume depletion
- Increased susceptibility to infections like cellulitis and sepsis
- Loss of thermoregulation and sensory perception
- Development of Marjolin ulcers due to UV radiation exposure.
41
What is the inflammatory response in burn injuries?
The inflammatory response in burn injuries is profound and biphasic, characterized by:
1. Vasodilation and increased capillary permeability
2. Promotion of transudate production
3. Promotion of insensible fluid losses
- In cases of >20% BSA, systemic inflammatory response occurs, leading to fever, hyperdynamic circulation, and increased basal metabolic rate for 1-2 years.
42
What is the primary goal when assessing a burn patient?
The primary goal is to stabilize the patient and ensure proper assessment of the burn.
43
What percentage of burn patients experience inhalation injuries, and what is the significance of this statistic?
Inhalation injuries occur in approximately 10% of all burn patients but are present in 70% of those who eventually die, indicating a high risk of mortality associated with inhalation injuries.
44
What is the Parkland formula used for in burn management?
The Parkland formula (4ml x TBSA) is used for calculating fluid resuscitation in burn patients.
45
What percentage of burn patients experience inhalation injuries?
Approximately 10%, but they present in 70% of those who eventually die.
46
What is the Parkland formula used for in burn management?
The Parkland formula (4ml x TBSA x weight in kg) is used to calculate fluid requirements for burn patients within the first 24 hours after injury.
47
What is the recommended fluid administration schedule according to the Parkland formula?
Half of the calculated fluid volume is administered in the first 8 hours, and the second half is administered over the next 16 hours.
48
What is the gold standard for monitoring fluid status in burn patients?
The gold standard for monitoring fluid status is urine output.
49
What are the recommended fluids for burn resuscitation to avoid complications?
Lactated Ringer solution is recommended to avoid complications associated with metabolic acidosis and abnormal fluid shifts with colloid fluids.
50
What are the potential complications of aggressive hydration in burn patients?
Aggressive hydration can lead to potential rhabdomyolysis, which may result in acute kidney injury.
51
What should be closely monitored in burn patients to determine organ perfusion trends?
Close monitoring of the patient’s laboratories, including lactate, base deficit, central venous O2, and pH, is necessary to determine the trend in organ perfusion.
52
What is the initial fluid resuscitation plan using the Parkland formula for a 35-year-old male with 30% TBSA burn?
For a 35-year-old male weighing 70 kg with 30% TBSA burn: 4 × 30 × 70 = 8400 mL in 24 hours. Administer half (4200 mL) in the first 8 hours and the remaining half over the next 16 hours.
53
What are the key considerations for fluid resuscitation in a pediatric patient with 15% TBSA scald burn?
For children, the goal is 1 mL/kg/h urine output. Use the Parkland formula to calculate fluid needs and monitor closely for signs of overhydration or underhydration.
54
What is the immediate intervention for a patient with a full-thickness burn on the face experiencing difficulty breathing?
Immediate endotracheal intubation is required to secure the airway and prevent obstruction due to edema.
55
What is the next diagnostic step for a patient with carbonaceous sputum and facial burns?
Perform a nasopharyngeal scope or bronchoscopy to assess for inhalation injury.
56
What is the treatment to reduce the half-life of carbon monoxide in a burn patient?
Treatment includes 100% oxygen to reduce the half-life to 30-90 minutes or hyperbaric oxygen at 2.5 atm to reduce it to 15-23 minutes.
57
What is the goal for urine output during fluid resuscitation in adults and children?
Adults: 0.5ml/kg/h; Children: 1ml/kg/h.
58
What are the most important factors to consider in the assessment of a burn?
The most important factors to consider in the assessment of a burn are: Depth, Location, Size, Duration.
59
What is the recommended management for outpatient care of burn patients?
Remove all hot or constricting items such as clothes, rings, or belts. Decontamination. Wash with antimicrobial soap and wrap in an antimicrobial dressing for transport. Cleanse desiccated exudates and topical medications at least once daily. Instruct the patient to return promptly if erythema, swelling, increased tenderness, lymphangitis, odor, or drainage develops.
60
What vaccination should be given to burn patients?
The tetanus toxoid vaccine should be given to all burn patients with partial thickness or full thickness burns, burns older than 6 hours at presentation, patients with immunodeficiency, and patients with soil contamination in the wound.
61
What are the common pain management strategies for burn patients?
Common pain management strategies for burn patients include: Narcotics as first-line medications for outpatient burn pain. Acetaminophen and NSAIDs as secondary options. Scheduled dosing for superior control in burn patients. Pain intolerance associated with wound dressing changes. Silver-coated dressings to reduce the frequency of dressing changes and aid in pain management. Low-dose anxiolytics to manage pain without increasing narcotic dosages.
62
What is the typical timeline for infection development in burn patients?
Infections in burn patients typically develop within the first 7 to 10 days. The most common pathogen is Staphylococcus.
63
What should be done if a burn patient shows signs of infection after the first 10 days?
Wound culture and empiric coverage with ciprofloxacin should be considered.
64
What are the recommended treatments for chronic pruritus following a burn injury?
Treatment options for chronic pruritus include: Topicals: Moisturizers, especially non-fragranced, should be applied multiple times daily. Antihistamines: Such as Cetirizine, Diphenhydramine, and Hydroxyzine. Neuropathic agents: Pregabalin and gabapentin are used for chronic pruritus.
65
What are the risk factors for developing chronic pruritus after a burn injury?
Risk factors for developing chronic pruritus include: Female, Young age, Skin grafting, Raised or thick scars, Dry skin.
66
What is the prevalence of hypertrophic scarring in burn patients?
Hypertrophic scarring is a major complication with a prevalence ranging from 32% to 72% in burn patients.
67
What are the critical steps in the healing process of burn injuries that affect scarring?
The critical steps altered in the healing process that affect scarring include: The transition from granulation tissue into normal scarring. A gradual decrease in cellularity due to apoptosis of myofibroblasts, typically noted 12 days after injury.
68
What are the recommended steps to optimize the healing of a burn scar?
Several steps to optimize a burn scar include: Wound closure of a burn that is likely not to heal on its own by 3 weeks. Avoidance of sun contact with the scar during the first 6 months. Compression garments for those who can tolerate treatment for up to 1 year. Keeping the scar moist.
69
What is the next step in management for a burn wound showing black spots and foul odor?
The wound should be re-evaluated for infection. Empiric antibiotic therapy with ciprofloxacin may be initiated, and wound culture should be performed.
70
What are the treatment options for a patient with persistent pruritus and sleep disturbances after a burn?
Treatment includes moisturizers, antihistamines like cetirizine, and neuropathic agents such as pregabalin or gabapentin.
71
What is the most likely causative organism and initial treatment for a burn injury developing signs of sepsis 10 days post-injury?
After 10 days, Gram-negative rods are the most likely cause. Empiric treatment with ciprofloxacin is recommended.
72
What is the key pathological factor in hypertrophic scars?
The key pathological factor is tension, which alters the healing process and leads to hypertrophic scarring.
73
What is the pathophysiology of severe pruritus in burn patients?
The condition is due to mast cell degranulation, neuropathic hyperinnervation, and degeneration of central inhibitory pathways regulating nociception.
74
What should be considered if a patient has a fever over 38°C after a burn?
Inpatient admission should be considered.
75
What is the recommended action to avoid infection in burn patients?
Compression wrap or elevation of the extremity is a must.
76
What percentage of burn patients experience pruritus during the first month?
90%.
77
What are common treatments for chronic pruritus in burn patients?
Topicals, antihistamines, and neuropathic agents.
78
What is a major complication associated with burn injuries?
Hypertrophic scarring.
79
What is a critical step altered in the healing process of burns?
The transition from granulation tissue into normal scarring.
80
What should be avoided during the first 6 months to optimize a burn scar?
Avoidance of sun contact with the scar.
81
What is one method of 'scar rejuvenation'?
Release the area of greatest tension without excision.
82
What is the purpose of Z plasty in scar management?
Z plasty lengthens the scar at the expense of the width, alleviating tension along the central access of the hypertrophic angle.
83
What are the benefits of fat grafting in burn treatment?
Fat grafting improves skin texture and thickness 6 months after the procedure, with histological evidence of new collagen deposition, neovascularization, and dermal hyperplasia.
84
What is the role of ILSI in burn management?
ILSI diminishes collagen synthesis, enhances collagen degradation, and suppresses inflammation.
85
What are the effects of cryotherapy on burn scars?
Cryotherapy can cause vascular damage (anoxia) and tissue necrosis, and is limited to the management of small scars.
86
What is the significance of 585 nm wavelength PDL in treating hypertrophic scars?
585 nm wavelength PDL is an excellent treatment option for younger hypertrophic scars, promoting collagen fiber realignment and neocollagenesis, requiring 2 to 6 treatments for optimal resolution.
87
How does CO2 laser treatment benefit burn recovery?
CO2 laser targets water in underlying tissues, stimulates collagen production, and allows for rapid tissue regeneration, resulting in a smoother appearance and less tightness in meshed grafts.
88
What is the correct flow of diagnosis in burn management?
The correct flow of diagnosis is to check for ABC (Airway, Breathing, Circulation), ask for complete history, and then start fluid resuscitation.
89
What are important factors to consider in the assessment of burns?
Important factors in burn assessment include depth, color, size, and pulse.
90
What is the mortality impact of abdominal compartment syndrome in burn patients?
Abdominal compartment syndrome doubles the mortality rate in burn patients.
91
What are the four general phases in the management of burns?
The four general phases in the management of burns include: 1. Emergent phase, 2. Acute phase, 3. Rehabilitation phase, 4. Long-term follow-up.
92
What are the surgical options to improve a hypertrophic scar 6 months after a burn injury?
Options include Z-plasty to lengthen the scar and reduce tension, or V-Y advancement flaps if there is healthy surrounding tissue.
93
What is the purpose of Z plasty in scar treatment?
To lengthen the scar at the expense of the width, alleviating tension along the hypertrophic angle.
94
What is the benefit of fat grafting after a burn procedure?
Improvement in skin texture and thickness 6 months after the procedure.
95
What does ILSI do in the context of burn treatment?
Diminishes collagen synthesis, enhances collagen degradation, and suppresses inflammation.
96
What is the main limitation of cryotherapy in scar management?
It is limited to the management of small scars.
97
What is the significance of the 585 nm wavelength PDL in treating hypertrophic scars?
It is an excellent treatment option that promotes collagen fiber realignment and neocollagenesis.
98
What is the role of CO2 laser in burn treatment?
It targets water in underlying tissues and stimulates collagen production in adjacent uninjured columns of tissue.
99
What is a key factor in assessing a burn?
Depth, color, size, and pulse.
100
What is the correct flow of diagnosis in burn management?
Check for ABC, ask for complete history, then start fluid resuscitation.
101
What is the mortality impact of abdominal compartment syndrome?
It doubles the mortality rate.
102
What is the importance of understanding the phases in the management of burns?
To effectively treat and manage burn injuries.
103
What are the clinical appearances of first degree burns?
First degree burns are characterized by:
- Painful, dry, erythematous, blanching burn (similar to sunburn)
- No blisters or eschar formation
- Blanching present
104
What is the prognosis for second degree superficial partial thickness burns?
Second degree superficial partial thickness burns typically:
- Heal in 2 weeks with proper wound care
- Have a low risk of scarring
105
What management is required for third degree burns?
Management for third degree burns includes:
1. Surgical excision with skin grafting or tissue transposition
2. Performed within the first 3-5 days to avoid cellulitis and wound infections
106
What distinguishes deep partial thickness burns from superficial partial thickness burns in terms of clinical appearance?
Deep partial thickness burns are:
- Less painful, pink or pale, nonblanching
- In contrast, superficial partial thickness burns are exquisitely painful, wet, hyperemic, and erythematous with blanching.
107
What is the risk of scarring associated with deep partial thickness burns?
Deep partial thickness burns have a high risk for scarring and pigmentary changes during the healing process.
108
What is the recommended timing for surgical excision in a patient with a full-thickness burn?
Surgical excision with skin grafting or tissue transposition should be performed within the first 3-5 days to avoid cellulitis and wound infections.
109
What type of burn is characterized by severe pain and erythema?
This is likely a superficial partial-thickness burn, characterized by painful, wet, hyperemic, and erythematous appearance.
110
What type of burn is characterized by a dry, waxy, non-blanching wound with eschar formation?
This is a full-thickness burn, characterized by insensate, dry, waxy, non-blanching appearance with eschar formation.
111
What type of burn is characterized by a pink, non-blanching wound?
This is a deep partial-thickness burn, characterized by less pain and a pink or pale, non-blanching appearance.
112
What type of burn is characterized by severe pain and erythema without blisters?
This is a first-degree burn, characterized by painful, dry, erythematous, and blanching appearance without blisters.
113
What are the clinical appearances of a first degree burn?
Painful, dry, erythematous, blanching burn with no blisters or eschar formation.
114
What is the prognosis for a second degree superficial partial thickness burn?
Heals in 2 weeks with proper wound care; low risk of scarring.
115
What is the management for a deep partial thickness burn?
Excision, debridement, and grafting.
116
What characterizes a third degree burn?
Insensate, dry, waxy, nonblanching with eschar formation, shades of brown, white, gray, or black.
117
What is the risk associated with a deep partial thickness burn?
High risk for scarring and pigmentary changes.
118
What is the management for a first degree burn?
Dressing changes or xenograft.
119
What is a characteristic of a fourth degree burn?
Burn injuries that penetrate to and expose deep structures (bone, muscle, tendon).
120
What factors influence decisions regarding outpatient care, hospitalization, or transfer for burn management?
Factors include:
- Burn location
- Size
- Extent
- Depth
- Circumferential components
121
How is burn percentage estimated in adults and children according to the Lund and Browder diagram?
In adults:
- Head and neck: 9%
- Each arm: 9%
- Each leg: 18%
- Chest/Abdomen: 18%
- Genitalia: 1%
In children:
- Head and neck: 18%
- Each lower extremity: 14%
- Each upper extremity: 9%
122
What are the indications for using Silvadene in burn treatment?
Indications for Silvadene include:
- Partial and full-thickness injuries
- Burns over cartilaginous areas
- Soaking treatments (2-4 times a day)
123
What precautions should be taken when using Silvadene for burn treatment?
Precautions include:
- Contaminated in sulfa-allergic patients
- Avoid use near eyes
- Leukopenia known side effect
124
What is the mechanism of action for Silver nitrate in burn management?
Silver nitrate provides broad-spectrum coverage against Gram-positive and Gram-negative bacteria and is used for antifungal coverage in certain cases.
125
What are the recommended dressing change intervals for partial-thickness skin graft donor sites?
Dressing changes for partial-thickness skin graft donor sites should be done daily or every other day.
126
What factors influence decisions regarding outpatient care for burn patients?
Burn location, size, extent, depth, and circumferential components.
127
What is the purpose of the Lund and Browder diagram in burn management?
To estimate burn percentage by compensating for body proportions with age.
128
In the adult rule-of-nines, what percentage is given to the head and neck?
9%.
129
What is the recommended dressing change frequency for partial-thickness injuries with low risk for infection?
Every 5 days.
130
What is a precaution when using Silvadene for burn treatment?
Contaminated in sulfa-allergic patients; avoid use near eyes.
131
What is the mechanism of action for Silver nitrate in burn care?
Broad-spectrum coverage against Gram-positive and Gram-negative bacteria.
132
What is the recommended frequency for soaking burns treated with antifungal coverage?
2-4 times a day.
133
What is the significance of the 'Rule of Nines' in burn assessment?
It helps estimate the total body surface area affected by burns.
134
What dressing option is indicated for facial burns?
Antibacterial dressings, changed daily or every other day.
