Basic Principles in Burn Management

Question 1

What layer of the skin is involved in the 1st & 2nd degree burns?

Answer 1

Epidermis

Question 2

What layer of the skin has bulk of structures for pain sensitization?

Answer 2

The skin

Question 3

What is the rules of nines?

Answer 3

Estimation of burn size by dividing the body into regions to which total body surface area is dividide in multiples of nine

Question 4

What are the rule of nines in adult?

Answer 4

Anterior trunk: 18% TBSA
Posterior trunk: 18% off TBSA
Each lower extremity: 18% TBSA
Each upper extremities: 9% TBSA
Head: 9% TBSA (4.5% front, 4.5% back)
Palm: 1% TBSA

Question 5

What accounts for rule of nines in the children <3 y/o?

Answer 5

Head has larger relative surface area & taken into account when estimating burn size

Question 6

What is the rule of the palm?

Answer 6

Used for smaller, odd-shaped burns where palmar surface of the hand including digits is 1% TBSA

Question 7

What is a diagram that gives a more accurate account of the burn size in children & adults?

Answer 7

Lung & Browder chart

Question 8

What is an important use for Lung & Browder chart?

Answer 8

Basis of how a px will be resuscitated = so make sure to accurately assess burn size

Question 9

What type of burn should not be included in calculating burn size?

Answer 9

SUperficial or 1st degree burns

Question 10

Why shouldn’t u include 1st degree burns in assessing burn size? What should be done instead?

Answer 10

Because it can lead to over-resuscitation

Clean off soot & debris to avoid confusing soiled skin with burns

Question 11

WHat are the 3 classifications or causes of burns?

Answer 11

Thermal burns
Electrical burns
Chemical burns

Question 12

What are the 3 types of thermal burns?

Answer 12

Flame burns
COntact burns
Scald burns

Question 13

What type of thermal burn is the most common cause of hospital admission of burns & has the highest mortality rate?

Answer 13

Flame burns

Question 14

What type of thermal burn is due to contact with hot solids

Answer 14

Contact burns

Question 15

What type of thermal burns is from a large amt of heat delivered in liquid form like boiling water?

Answer 15

Scald burns

Question 16

What usually comes out of scalded burns?

Answer 16

Bullae and skin slough

Question 17

What assoc conditions occur with electrical burns?

Answer 17

Cardiac arrhythmia
Compartment syndrome
COncurrent rhabdomyolsysi

Question 18

What is a special typ eof burn injury that is important to take note of in electrical burns?

Answer 18

Entrance & exit points

Question 19

What is the appearance of electrical burns?

Answer 19

Soft, pliable & doughy

Question 20

What should immediately be done in cases of electrical burns?

Answer 20

check for baseline ECG to see if cardiac tissue is affected

Question 21

In high voltage electrical burns >1,000V, what are the common injuries?

Answer 21

COmpartment syndrome
Rhabdomyolysis

Question 22

What long-term symptoms can develop as cause of the electrical burn?

Answer 22

Neurological symptoms and Cataract devt

• so check check

Question 23

What are the most common high-voltage electrical injuries?

Answer 23

COmpartment syndrome
Rhabdomyolysis

Question 24

What procedure is done in high voltage electrical burns to relieve the compartment of the hands so blood flow is less compromised?

Answer 24

Fasciotomies

Question 25

What is another type of burn resulting from acid/alkali chemicals?

Answer 25

Chemical burns

Question 26

What is the result of an acid chemical burn?

Answer 26

Coagulation necrosis

Question 27

What is the result of an alkali chemical burn?

Answer 27

Liquefactive necrosis

Question 28

What are the effects of hydrofluoric acid burn?

Answer 28

LIquifactive necrosis Hypocalcemia —> Cardiac arrhythmias Common offender -> industrial use

Question 29

What are the mainstays of tx of Hydrogluoric acid?

Answer 29

Ca based therapies: - Topical application of Ca gluconate on wounds - IV Ca gluconate = systemic hypocalcemia symptoms - Intra-arterial Ca gluconate infusion = effective tx of progressive tissue injury & intense pain

Question 30

What chemical causes very corrosive & severe burns + tissue damage? In what products is this seen?

Answer 30

Na hydroxide/Iye Products: Drain cleaners, Oven cleaners, Dishwasher detergent, soaps

Question 31

What is the effect of burning yourself w/ Formic acid?

Answer 31

Hemolysis & Hemogloburia

Question 32

What is formic acid used for?

Answer 32

Preservative & antibacterial agent

Question 33

What is the most importnat component of initial therapy?

Answer 33

1. Careful removal of toxic substance from the px 2. Irrigation of the affected area w. H2O for a min of 30mins

Question 34

What is done in cases where there is exposure to dry chemicals?

Answer 34

1. Do not attempt to irrigate affected area 2. Substance should be swept from the px to avoid thermal rxn w/ H2O

Question 35

What are the 2 types of second deg burns?

Answer 35

Superficial partial thickness Deep partial thickness

Question 36

What layers of the skin are affected in superfiical partial and deep partial thickness?

Answer 36

SUperifical = red, painful, w/ blisters, min scarring, 2wks healing Deep = less painful, white, mottled, 3-6wks healing w/ hypertrophic scarring

Question 37

What layers of the skin are affected in 3rd degree burn and what does it look like?

Answer 37

Epidermis & Dermis No pain, white, leathery

Question 38

What are the 2 ways 3rd degree burns can heal?

Answer 38

Tangential excision Split-thickness skin graft tangential excision

Question 39

What layers are affected in the 4th, 5th & 6th degree burns?

Answer 39

4th degree = undelrying tissue 5th degree = bone 6th deg = charred bone

Question 40

WHat are the zones described in Jackson Zone of injury of burns?

Answer 40

Zone of coagulation Zone of stasis Zone of hyeperemia

Question 41

What zone of injury is the most severely burned portioned & has frank necrosis whih needs to be excisioned & grafted (full thickness typically)?

Answer 41

Zone of coagulation

Question 42

What is the zone of injury where there is peripheral to zone of coagulaltion w/ var degrees of vascoonstriction & ischemia like a 2nd deg burn?

Answer 42

Zone of stasis

Question 43

What zone of injury is found at the outermost zone and will heal w/ minimal or no scarrinl?

Answer 43

Zone of hyperemia

Question 44

Upon burn evaluation, what should be done during primary survey?

Answer 44

Insert large-bore peripheral IV catheres Initiate fluid resucitation

Question 45

In px with burns larger than 40% total TBSA, what type of catheter should be inserted?

Answer 45

2 large-bore IVs

Question 46

What should be done if peripheral access is not obtaned of burn px?

Answer 46

Central venous access & intraosseous access

Question 47

What should you do if the burn is smaller than 15%?

Answer 47

Hydrate orallyt

Question 48

What should be done if pedia px have burns >15%?

Answer 48

IO access in emergent situations

Question 49

What % of burn is considered as a big burn?

Answer 49

20% in adults

Question 50

What should u do upon initial assessment of burnt patient?

Answer 50

Airway management Eval of other injuries Estimation of burn size Eval of CO & cyanide posioning

Question 51

When should u administer IV resuscitation?

Answer 51

>20% TBSA for adults >15% pedia px

Question 52

What is the px’s TBSA is >40%, what should u do?

Answer 52

Administer 2 large bore IV catheters for resuscitation

Question 53

How do you evaluate a px for CO poisoning?

Answer 53

Administer 100% normobaric O2 via nasal cannua or mask to reduce 1/2 life of CO from 250 mins to 40-60mins

Question 54

What are the guidelines for referral to burn center?

Answer 54

1. Partial thickness burns >10% TBSA 2. Burns involving the face, hands, feet, genitalia, perineum or major joints 3. 3rd degree burn in any age grp 4. Electrical burns 5. Chemical burns 6. Inhalation injury

Question 55

What should u do if the px’s greatest risk is their burn lesions?

Answer 55

Px should be stabilized in a trauma center before being transferred to a burn center

Question 56

Which of the 2 is more accurate in assessing burn px: rule of nines or Lund & Browder chart?

Answer 56

Lund & Browder chart

Question 57

What is the Parkland formula?

Answer 57

4 x %TBSA x kg = 24hr fluid ntake - half given during 1st 8 hrs post burn - half given during next 16hrs post burn

Question 58

What is the concensus formula for?

Answer 58

This formula is meant to be a guide in resuscitation

Question 59

What are end parameters of Concesus formula in critically ill px?

Answer 59

Mean Arterial Pressure (MAP) of 60mmHg to ensure organ perfusion

Question 60

What are the conventional goals of Consensus formula?

Answer 60

30mL/hr in adults 1-1.5mL/kg/hr in pedia px

Question 61

What is the formula for Consensus formula?

Answer 61

2mL x %TBSA x kg = 24hrs fluid intake

Question 62

What are the rx for burn wounds? There are 6

Answer 62

1. Silver sulfadiazine dressing 2. Mafenide acetate 3. Silver nitrate 4. Dakin’s solution 5. Antibacterials 6. Other dressings: Ag containing dressings, Hydrocolloid dressings

Question 63

What is the 1st line of tx & most widely used in clin practice of treating burn wounds?

Answer 63

Silver sulfadiazine dressing

Question 64

Why is Ag SUlfadiazine dressing used as a propylaxis against burn wound infections?

Answer 64

It has a wide range of antimicrobial activity

Question 65

What are side effects of Ag Sulfadiazine dressing?

Answer 65

Leukopenia/Neutropenia Alleviation: cessation of usage - rashes of delayed HSN - destroys skin grafts - retards epithelial migration in healing partial thickness wounds

Question 66

What tx of burn wounds is goon on eschar penetraiton & an excellent antimicrobial for fresh skin grafts?

Answer 66

Mafenide acetate

Question 67

What is a SE of Mafenide acetate?

Answer 67

Metabolic acidosis since it is a Carbonic anhydrase inhibitor

Question 68

What is a tx of burn wounds that has a broad spectrum atnumicrobial activity as topical soln?

Answer 68

Ag Nitrate

Question 69

If u administer Ag nitrate for a long time, what is the SE?

Answer 69

Electrolyte exxtravation & hyponatremia

Question 70

What is a rare complication of Ag nitrate?

Answer 70

Methemoglobinemia

Question 71

WHat is an inexpensive burn dressing that combines saline w/ Na hypochlorite, an alternative topcial antimicrobial?

Answer 71

Dakin’s soln

Question 72

What are antimicrobials used in txing smaller burn wounds?

Answer 72

Bacitracin Neomycin Polymyxin B

Question 73

What is a SE of Antibacterials in txing burn wounds?

Answer 73

Nephrotoxicity

Question 74

For what are Ag containing dressings & HYdrocolloid dressing used for?

Answer 74

1. Ag containing dressings = antibacterial; for donor sites, skin grafts, partial thickness burns to avoid daily dressing changes 2. Hydrocolloid dessings = stable burns; occlude wounds while healing as long as it’s not affected

Question 75

What are the 2 formulas used for nutrition of burn wounds?

Answer 75

Harrison Benedict Formula Curreri formula

Question 76

What formula for nutrition is used to calculate caloric needs using factors like gender, age, ht & weight

Answer 76

Harrison BEnedict formula

Question 77

What are precautions/guidelines in using Harrison Benedict formula?

Answer 77

Inaccurate in burns <40% TBSA Basa energy expenditure is multiplied by 2

Question 78

What is the most appropriate nutritional formula for px w/ <40% TBSA?

Answer 78

Curreri formula - may overestimte nutritional reqs

Question 79

What is the Curreri formula?

Answer 79

Estimated daily caloric needs: [25 x body wt (kg)] + [40 x %BSA burned]

Question 80

When do u use early enteral feeding in burn px?

Answer 80

1.Those w/ burns >20% TBSA 2. Loss of lean body mass 3. Slow hypermetabolic response 4. More efficient protein metabolism

Question 81

What are the 4 types of burn surgeries done?

Answer 81

Fasciotomy Skin grafting Contact burn reconstruction Release of contracture & flaps

Question 82

WHat type of surgery is done to relieve swelling and pressure in a compartment of the body?

Answer 82

Fasciotomy

Question 83

What is the diff betw Fasciotomy & Escharotomy?

Answer 83

Escharotomy = skin is cut (tough & crunchy) Fasciotomy = skin is still flreshy

Question 84

What is a net-like skin that is uses mesh to put holes in order for surface area of the skin to INC & have a bigger surface area of granulation of tissue?

Answer 84

Split thickness skin grafting

Question 85

What type of surgery is done where the zone of coagulation is replaced and reconstructed?

Answer 85

Contact burn re=construction

Question 86

In contact burn reconstruction, when is the initial placement of skin graft?

Answer 86

1 week after the inj=ury

Question 87

What do you do in contact burn recnstruction?

Answer 87

1. Remove devitalized tisssue 2. Perform Debridement 3. Good granulation tissue 4. Inital placement of skin graft 5. Healing, good color match

Question 88

what happens if a burn px suffers from full thickness burns?

Answer 88

Since there are no more pliable & viable area of the skin => contacting the tissue since there’s no skin => closes the skin with contracture

Question 89

What are the 2 main complications of burns?

Answer 89

1. Contactures 2. Malignancy transformation

Question 90

What happens if contracture is in the joint area?

Answer 90

The body wiol try to close that area

Question 91

What is the ave time of malignant transformation in burn wounds?

Answer 91

30-40yrs