Burns

Question 1

Why does partial/full thickness burns result in disruption of the barrier function and contribute to free water deficits?

Answer 1

because the skin provides the semipermeable barrier to prevent evaporate water loss

Question 2

Fluid and electrolyte abnormalities seen in burn shock are result of alterations of _________________

Answer 2

cell membrane potentials.
-intracellular influx water and sodium
-extracellular migration of potassium

Question 3

Burns >60% body surface area (BSA) is associated with decreased _____________ > lack of response to aggressive fluid resuscitation

Answer 3

cardiac output

Question 4

The rule of 9’s (look at pic on slide 8)

Answer 4

quantified as the percentage of BSA. All of the numbers add to nine or are all divisble by 9

Question 5

________ degree burn involves the epidermal layer ONLY. The skin is red, painful, tender, NO _______ formation. E.g. sunburn. It heals within ______ days with no scarring, requires only symptomatic tx

Answer 5

First
blister
7

Question 6

________ degree burns extend into the dermis. What are the two types?

Answer 6

second
1. superficial partial thickness
2. deep partial thickness

Question 7

In a superficial partial thickness burn, the __________ and ______________ are damaged. It heals in _____________ scarring minimal, full return of function.

Answer 7

epidermis
superficial dermis (papillary layer)
14-21 days

Question 8

Blistering of skin, exposed dermis is red and moist at blister base. Very painful to the touch, good profusion best describes which type of burn?

Answer 8

superficial partial thickness burn

Question 9

A deep partial thickness burn extends deep into the ____________. Damage is done to the ________, ____________ and ________ glands.

Answer 9

dermis(reticular layer)
hair follicles, sweat, sebaceous glands

Question 10

Skin is blistered, exposed dermis is pale white to yellow color, burned area does not blanch, absent cap refill, absent pain sensation best describes which type of burn?

Answer 10

deep partial thickness burn

Question 11

A deep partial thickness burn may be hard to distinguish from a _______ degree burn

Answer 11

3rd

Question 12

A deep partial thickness burn heals in _________ and scarring is common. May need surgical debridement, skin graft to return to normal function.

Answer 12

3weeks to 2 months

Question 13

What are the common causes of deep partial thickness burns?

Answer 13

hot liquid, steam, grease, flame

Question 14

Third degree burns are also called _______________. All ___________ and _________ structures are destroyed.

Answer 14

full thickness burns.
epidermal, dermal

Question 15

Skin is charred, pale, painless, and leathery best describes which type of burn?

Answer 15

3rd degree akak full thickness burn

Question 16

What are the causes of a third degree burn?

Answer 16

flame, hot oil, contact with hot objects

Question 17

What is the treatment for third degree burns?

Answer 17

they will NOT spontaneously heal. need surgical repair, grafting, significant scarring.

Question 18

Fourth degree burns extend through the skin to the ___________, __________ and even __________. These are life threatening injuries and you need amputation, extensive reconstruction.

Answer 18

subq fat, muscle, bone

Question 19

How do you care for minor burn: 1st degree and superficial 2nd degree burn

Answer 19

1. analgesics
2. clean with soap and water
3. debride as needed
4. topical antimicrobial (bacitracin ointment, triple antibiotic ointment)
5. synthethetic occlusive dressing
6. tetanus

Question 20

__________ can be covered with moist saline soaked dressing while ___________ can use sterile drapes

Answer 20

small wounds
large wounds (application of saline soaked could cause hypothermia, avoid sterile dressing in ED > they have to undress to eval wound)

Question 21

Airway

Answer 21

re-evaluation of airway

early intubation
-signs of airway burn (mouth, nose) swelling, inhalation injury

Question 22

Breathing

Answer 22

continuous pulse ox monitor with supplemental O2

determine carboxyhemoglobin level
-carbon monoxide

bronchoscopy if inhalation injury is concern

Question 23

Circulation

Answer 23

BP, HR, cap refill, UO, mental status

establish TWO large bore access lines in UNBURNED skin if possible

cardiac monitoring

IV administration of lactaid ringers (LRs) solution using parkland formula

Question 24

Fluid resuscitation: Parkland Formula

Answer 24

Adults
LR4ml x weight (kg) x BSA burned over initial 24 hrs
Half= over first 8 hrs from time of burn

Example: 154 lb, 40% 2nd and 3rd degree burns
4mL x 70kg x 40 = 11,200 mL over 24 hours
5600mL in the first 8 hours

Question 25

What labs do you want to run as part of the secondary exam?

Answer 25

1. routine: CBC, BMP 2. If inhalation suspected: ABG, carboxyhemoglobin, CXR, EKG, bronchoscopy

Question 26

You want to take pulses in all patients especially in those with .....

Answer 26

circumferential/deep burns of the limbs. Compartment syndrome!!

Question 27

What is an escharotomy?

Answer 27

you cut through damaged skin to relieve the pressure and swelling. for compromise of circulation incised to the level of fat not to level of fascia= fasciotomy

Question 28

_____________ is the main cause of mortality in burn patients

Answer 28

inhalation injury. carbon monoxide poisoning, edematous airways

Question 29

Thermal injuries below vocal cords only due to __________ inhalation

Answer 29

steam

Question 30

Smoke inhalation will cause mucosal edema. What are the signs/symptoms of this?

Answer 30

hoarseness, singed nasal hair, soot in mouth, nose

Question 31

What are the indications for ET (endotracheal) intubation

Answer 31

1. full thickness burns of face or peri oral region 2. circumferential neck burns 3. acute respiratory distress 4. progressive hoarseness 5. respiratory depression 6. altered mental status 7. supraglottic edema and inflammation on bronchoscopy

Question 32

During emergent treatment for pain control, the preferred route is _________. Examples of meds are ________ and __________. ___________ agents are used along with pain meds.

Answer 32

IV morphine, fentanyl anxiolytic

Question 33

What are ongoing treatment options for pain control?

Answer 33

codeine, hydrocodone, oxycodone, NSAIDs

Question 34

You want to transfer these types of patients to the burn unit

Answer 34

1. full thickness burn >10% any age 2. electrical burns 3. chemical burns 4. inhalation injury 5. burn in pts with preexisting conditions 6. burns with trauma 7. circumferential limb burns 8. burns in pts needing social, emotional, long term rehab needs 9. burns of hands, face, feet, perineum 10. >20% partial thickness (>50 yo <10 yo) 11. >25% partial thickness (ages 10-50)

Question 35

Dispo: hospitalization

Answer 35

1. partial thickness: 15-25% age 10-50 2. partial thickness 10-20% age <10/ >50 3. full thickness <10% anyone

Question 36

Dispo: outpatient

Answer 36

partial thickness <15% age 10-50 partial thickness <10% age <10/>50 full thickness <2% anyone

Question 37

What is the method of action for an acid burn?

Answer 37

coagulation necrosis

Question 38

What is the method of action for an alkali burn?

Answer 38

liquefaction necrosis

Question 39

1. _________ burn has less tissue damage 2. __________ burn has deep penetration of substance 3. ________ burn: lethargy escahr forms which prevents deep penetration of substance

Answer 39

1. acid 2. alkali 3. acid

Question 40

What causes acid burns? What causes alkali burns?

Answer 40

hydrochloric acid, sulphuric acid, nitric acid bleach, sodium hydroxide, calcium hydroxide, ammonium hydroxide

Question 41

In the general treatment for chemical burns, you want to immediately remove any particles/solution/saturated clothing. Contact time with the skin is the most important chemical burn feature that healthcare professionals can alter. The amount of time it takes to initiate _______/________ of chemical agent directly related to the _______ of the injury.

Answer 41

dilution, removal severity

Question 42

What is the treatment for chemical burns?

Answer 42

topical abx, tetanus, morgan lens

Question 43

What are tar burns?

Answer 43

roofing, asphalt, heated tempts 500F(burns tend to be more thermal than chemical) use emulsifying agent to remove tar from skin

Question 44

What is MSDS (material safety data sheet)

Answer 44

contains info on the potential hazards of chemical products

Question 45

During blast injuries, it is important to remember that _________ injuries do not correlate with ____________ injuries.

Answer 45

external, internal

Question 46

What are primary-quaternary blast injuries?

Answer 46

1. primary- affects air filled structures (lungs, ears, GI tract)- air is a poor conductor of blast wave energy 2. secondary- collateral damage from flying objects 3. tertiary- victim propelled in air and hits stationary object 4. quaternary- burns, smoke inhalation, chemical agent release

Question 47

What is the most common fatal primary blast injury secondary to pressure differentials across the alveolar capillary interface?

Answer 47

pulmonary (more on slides 59-60)

Question 48

What is a crush inury?

Answer 48

when a body part is subjected to a high degree of force or pressure, usually squeezed between two heavy or immobile objects

Question 49

When crush injury produces an ongoing ischemia of fascia muscle compartment =

Answer 49

compartment syndrome

Question 50

What is compartment syndrome?

Answer 50

increased pressure within a confined space that leads to microvascular compromise and cell death as a result of oxygen starvation

Question 51

Crush injuries are clinically seen in 2 different scenarios

Answer 51

1. single patient scenarios 2. diasters of varying magnitude e.g. earthquakes, tsunamis

Question 52

Normal muscle compartment pressure is ___________. ___________ produces ischemia. Greater than ______ to ______ hours = irreversible damage

Answer 52

<10mmHg, >30mmHg, 4-6

Question 53

What are the 5 P's to diagnose a crush injury? How is the pressure measured?

Answer 53

1. pain 2. paresthesias 3. passive stretch 4. pressure 5. pulseless Saline filled needle connected to an intravascular pressure system to record pressure

Question 54

How is a crush injury treated?

Answer 54

1. fasciotomy -lots of complications -only indicated: loss of distal pulses, debride necrotic tissue, compartment pressures >30mmHg 2. Hyperbaric oxygen therapy to supplement O2 to hypoxic tissues

Question 55

What are examples of types of chemical agents

Answer 55

1. asphyxiates e.g. methane 2. irritants e.g. ammonia 3. agents that interrupt delivery of O2 to tissues e.g. CO 4. agents that interfere with O2 utilization in the mitochondria e.g. cyanide 5. nerve agents e.g. sarin 6. incapacitating agents e.g. mace 7. vesicants e.g. sulfur gas

Question 56

ED recognition of a bioterrorism

Answer 56

1. patient presents with obvious indicators (small pox rash) 2. symptoms are nonspecific but enough historical/clinical data is obtained to make a dx 3. not diagnosed, pt dc home and gets worse 4. multiple pts presenting with same sx in the same area

Question 57

What are accidental vs intentional radiation injuries?

Answer 57

accidental- transport, storage, working with radioactive materials intentional- nuclear weapons, dirty boms

Question 58

Radiation injuries have cutaneous involvement. Explain the presentation of a pt from weeks 1-4

Answer 58

week 1: transient symptoms week 2: erythema progresses to hair los week 3: tenderness, swelling, puritus week 4: wound will form

Question 59

Radiation injuries may be clinically indistinguishable from a thermal burn. In this case, _______________ is key.

Answer 59

delayed onset

Question 60

What is the tx for radiation injuries?

Answer 60

local injury: traditional wound care, topical steroid (betamethasone) acute radiation syndrome: support and recovery of hematologic system