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Surgery M4 part 1 > Burns > Flashcards

Burns Flashcards

1
Q

What is the classification of burns based on percentage?

A

MILD (minor)
- partial thickness <15% in adult or <10% in children

INTERMEDIATE

MAJOR (SEVERE)

  • 2nd degree burns >30% in adults & >20% in children
  • all 3rd degree burns 10% or more
  • burns involving eyes, ears, feet, hands, perineum
  • all inhalation & electrical burns
  • burns with fractures or major mechanical trauma
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2
Q

What is the classification of burns depending on thickness?

A

First degree: red & painful
Second degree: mottled, red, painful with blisters
Third degree: charred, painless & insensitive
Fourth degree: involves muscles & bones

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3
Q

How does a first degree burn heal?

A

epithelialization in 5-7 days without scarring

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4
Q

How do 2nd degree burns heal?

A

epithelialization in 14 - 21 days

  • SUPERFICIAL: healing causes pigmentation
  • DEEP: healing cases scarring & pigmentation
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5
Q

How do 3rd degree burns heal?

A
  • require GRAFTING

- charred, denatured, insensitive, contracted full thickness burn is called ESCHAR

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6
Q

How do we assess burns based on surface area in adults?

A 
HEAD & NECK -> 9% 
FRONT OF CHEST -> 9%
FRONT OF ABDOMEN -> 9%
BACK OF CHEST -> 9%
BACK OF ABDOMEN -> 9%
LOWER LIMB -> 18%
UPPER LIMB -> 9%
PERINEUM -> 1%
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7
Q

How do we assess burns based on surface area in children?

A 
HEAD & NECK -> 18% 
FRONT OF CHEST -> 9%
FRONT OF ABDOMEN -> 9%
BACK OF CHEST -> 9%
BACK OF ABDOMEN -> 9%
LOWER LIMB -> 13.5%
UPPER LIMB -> 9%
PERINEUM -> 1%
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8
Q

What are the clinical features of a burn?

A
  • history of burn
  • pain, burning, anxious status, tachycardia, tachypnea, & fluid loss
  • if severe -> shock (tolerable temperature is 40 for a brief period)
  • massive edema
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9
Q

What is the pathophysiology of burns?

A

1- coagulation necrosis of skin & subcutaneous tissue
2- vasoactive peptides
3- altered capillary permeability
4- loss of fluid
5- severe hypovolemia
6- decreased cardiac output
7- decreased renal blood flow -> oliguria
8- altered pulmonary resistance -> pulmonary edema
9- infection
10- SIRS
11- MODS

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10
Q

What is the cause of cardiac dysfunction due to burns?

A

HYPOVOLEMIA

hormonal (catecholamines, vasopressin, angiontensins)

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11
Q

What are the causes of pulmonary changes due to burns?

A
  • altered ventilation-perfusion ratio
  • pulmonary edema (burn injury or inhalation injury)
  • ARS & aspiration
  • Septicemia
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12
Q

What is the cause of renal changes in burns?

A
  • release of ADH from posterior pituitary to cause maximum water reabsorption
  • release of aldosterone from adrenal to cause maximum sodium reabsorption
  • toxins from the wound & sepsis causes ATN
  • myoglobin released from muscles (electric injury or eschar)
  • incompatible blood transfusion -> hematoglobinuria
  • circumferential eschar -> compartment syndrome
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13
Q

when should be assess airway injury?

A

in burns around face & neck OR trapped in a room

requires early elective intubation or tracheostomy

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14
Q

Why is assessment of airway injury VERY important in burns?

A
  • BURNING GASES -> upper airway burns, laryngeal edema, hoarseness, or stridor
  • SMOKE INHALATION -> chemical alveolitis, pulmonary edema, ARDS & respiratory failure
  • STEAM INHALATION -> damage to respiratory epithelium & subglottic edema
  • CARBON MONOXIDE -> has higher affinity to hemoglobin
  • CHEST WALL BURNS -> mechanical block of ventilation
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15
Q

What are the causes of GIT changes in burns?

A
  • acute gastric dilatation (occurs in 2-4 days)
  • paralytic ileus
  • Curling’s ulcer (erosive gastritis due to stress)
  • Cholestasis & hepatic damage
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16
Q

What are the metabolic changes that occur in burns?

A
  • Hypermetabolic rate (catabolic state)
  • electrolyte imbalance
  • vitamin & essential element deficiencies
  • metabolic acidosis due to hypoxia & lactic acid
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17
Q

What is the most common cause of infection in burns?

A

streptococci (beta hemolytic)

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18
Q

What are the effects of burn injury?

A
  • hypovolemic shock
  • renal failure
  • pulmonary edema, respiratory infection, ARDS, respiratory failure
  • bacteremia or septicemia
  • ischemia of mucosa, erosive gastritis (Curling ulcer) in burns >35% due to hypovolemia
  • post burn immunosuppression -> opportunistic infections
  • eschar -> defective circulation & ischemia when circumferential
  • DVT, pulmonary embolism, bed-sores, severe malnutrition with catabolic status
  • hypertrophic scar, keloid
  • toxic shock syndrome
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19
Q

What are the effects of electrical injuries?

A

fractures, major internal organ injury, convulsions

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20
Q

A burn patient later develops contracture, what could it lead to?

A
  • ectropion -> keratitis & corneal ulcer
  • microstomia
  • disability of different joints
  • defective hand functions
  • growth retardation causing shortening
  • hypertrophic scar & keloid
  • repeated breaking of scar, infection, ulcer, cellulitis
  • pain & tenderness in scar contracture
  • Marjolin ulcer (squamous cell carcinoma)
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21
Q

What will chemical injury lead to?

A

severe GIT disturbances

erosions, perforation, stricture esophagus (alkali), pyloric stenosis (acid)

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22
Q

What is the cause of death in burns?

A
  • hypovolemia & shock
  • renal failure
  • pulmonary edema & ARDS
  • septicemia
  • multiorgan failure
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23
Q

What are the indications for admission in burns?

A
  • any moderate or severe burns (>15%)
  • airway burns of any type
  • burns in extremes of age
  • all electrical/deep chemical burns
24
Q

What is the initial management that should be done for a burn victim?

A 
1- remove clothing 
2- cool with running water for 20 mins 
3- clean part to remove dust or mud 
4- chemoprophylaxis (tetanus toxoid - antibiotics - local antiseptics)
5- cover with dressing 
6- comfort with sedation & pain killer
25
Q

What is the first aid management of burns?

A
  • stop burning process

- cool area with tap water by continuous irrigation for 20 mins

26
Q

What is the definitive treatment in burns?

A
  • admit patient
  • ABC
  • assess percentage, degree, & type of burn
  • keep patient in a clean environment
  • sedation & proper analgesia
  • patient should be in burn unit
27
Q

What is Parkland’s regimen?

A

fluid replacement calculation (CRYSTALLOIDS)

4ml/kg/% of burn in 24 hours
HALF is given in first 8 hours
the rest is given in 16 hours

28
Q

What is the modified Brooke formula?

A

FIRST 24 HOURS
- RINGER’S LACTATE 4ml/kg/% of burn first half in first 8 hours

SECOND 24 HOURS

  • CRYSTALLOIDS: maintain urine output
  • COLLOIDS: 0.3ml to 0.5ml/kg/burn % in 24hrs (albumin in RL)
29
Q

What is Evan’s formula?

A

FIRST 24HRS
- crystalloids 1ml/kg/burn % + colloids 1ml/kg/burn% + 2000ml 5% dextrose

SECOND 24HRS
- half of the volume used in first 24hrs

30
Q

after fluid resuscitation what should be done?

A
  • urinary catheterization to monitor output
  • tetanus toxoid
  • monitor hourly (pulse, BP, PO2, PCO2, electrolytes, blood urea..)
  • IV omeprazole (Ranitidine) 50mg 8th hourly
  • Enteral feeding
  • Antibiotics
  • culture of discharge
  • TPN (total parenteral nutrition) for faster recovery
31
Q

What local management should be done for burns?

A
  • dressing (under GA if large surface area) using paraffin gauze, hydrocolloids, plastic films, vaseline impregnated gauze or fenestrated silicone sheet
  • open method using SILVER SULFADIAZINE in face, head & neck (isolate patient)
  • closed method with dressing done to soothen & to protect the wound, reduce pain & absorb
32
Q

When can tangential excision of burn wound with skin grafting be performed?

A

within 48 hours in patient with <25% burns

33
Q

What topical agent boosts cell mediated immunity & forms sterile eschar?

A

Silver sulphadiazine & cerium nitrate

34
Q

What topical agent is used on granulation tissue after eschar separation but is VERY IRRITANT & PAINFUL?

A

Povidone iodine 5%

35
Q

which topical agent penetrates very well into tissues but is very irritant & painful & could cause acidosis?

A

Sulfamylon 5% (mafenide acetate)

36
Q

What is eschar?

A
  • charred, denatured, full thickness deep burns with CONTRACTED DERMIS
  • insensitive thrombosed superficial veins
37
Q

What is the effect of a circumferential eschar & what should be performed?

A

can increase edema in upper & lower limbs, neck & thorax -> venous compression -> arterial compression -> ischemia, gangrene of distal parts

  • ESCHAROTOMY to prevent collection of fluids & compression
38
Q

What is the side effect of escharotomy?

A

causes large quantity of blood loss

BLOOD TRANSFUSION IS NEEDED while doing it

39
Q

if there is early rapid eschar separation, what does that indicate?

A

severe sepsis underneath

40
Q

repeated silver sulphadiazine application could lead to?

A

pseudoeschar (thickened burnt skin)

41
Q

What does Marjolin’s ulcer look like & how is it treated?

A
  • raised & everted edge with fixed induration base & necrotic floor
  • if it spreads out of scar tissue it can spread to regional lymph nodes
  • wide excision or amputation
42
Q

How is contracture treated?

A
  • Z plasty or flaps
  • proper physiotherapy & rehabilitation
  • pressure garments to prevent hypertrophic scars
  • itching in scar tissue -> aloe vera, antihistamines, & moisturizers
43
Q

How do we prevent the development of contracture?

A
  • joint exercise in full range during recovery period of burns
  • pressure garments for a long period
  • topical silicon sheeting
  • saline expanders for scars
44
Q

What are the types of electrical injury?

A

low tension
high tension
- flash injury -> electrical arc up to 4000C
- flame injury -> catching fire to clothing & body
- traumatic injury -> fractures & internal organ injuries

45
Q

What does a high tension electrical injury cause?

A
  • always deep burn (major 3rd degree)
  • wound of entry & exit
  • convulsions
  • cardiac arrhythmias (instant death due to VF)
  • gas gangrene is common
  • myoglobin release can cause renal tubular damage & renal failure
  • acidosis
  • fractures & dislocations
46
Q

How is an electrical injury managed?

A
  • Mafenide acetate: penetrates well & useful against clostridial infection
  • Mannitol: to prevent myoglobin induced renal failure
  • wound excision, amputation, surgery for internal organ injury, cardiac monitoring
47
Q

how is inhalation injury caused?

A
  • inhalation of heat
  • oxygen concentration is less than 2% at site of fire -> death in 45 seconds due to hypoxia
  • inhaled carbon monoxide bind with hemoglobin immediately -> severe anoxia & death
  • hydrocyanide -> tissue hypoxia & acidosis
  • laryngeal edema & laryngospasm
48
Q

What are the symptoms of carbon monoxide intoxication?

A
  • headache
  • disorientation
  • visual changes
  • fatigue
  • vomiting
  • hallucinations
  • shock
  • cardiac arrest
49
Q

What are the clinical features of carbon monoxide poisoning?

A
  • low oxygen saturation
  • charring of mouth, oropharynx with facial burns
  • carbon sputum
  • changes in voice
  • singed facial & nasal hair
  • decreased level of consciousness with stridor or dyspnea
50
Q

How should a patient with carbon monoxide intoxication be managed?

A
  • move patient from site ASAP
  • ventilator support
  • antibiotics
  • bronchoscopy
  • tracheostomy
51
Q

What does a chemical burn cause?

A

tissue destruction more progressive

always a deep burn

52
Q

What does an acid burn cause, and where does it occur?

A

in skin, soft tissues, & GIT

  • GIT -> NITRIC ACID or SULPHURIC ACID -> severe gastritis or pyloric stenosis
  • HYDROFLUORIC ACID -> metabolic acidosis, renal failure, ARDS, or hemolysis
53
Q

What does an alkali burn cause?

A

saponification of fat, fluid loss, release of alkali proteinates & hydroxide ions (toxic)

54
Q

How should a chemical burn be treated?

A
  • dilution with water for at least 20 mins
  • neutralization with antidote is done later
  • mannitol diuresis, hemodialysis, calcium gluconate
  • IV, pain relief, serum electrolyte management, TPN, ventilator support
  • later -> reconstruction of face
55
Q

What is esophageal dilatation or colonic transposition done for?

A

esophageal stricture due to alkali burn

56
Q

what is gastrojejunostomy done for?

A

acid induced pyloric stenosis

Surgery M4 part 1 (47 decks)

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