Burns

Question 1

Burns

Answer 1

-occur when cells in the skin or deeper tissues are damaged due to heat, cold, electricity, radiation, caustic chemicals

Question 2

Types of Burns (6)

Answer 2

• thermal/heat
• cold/frostbite
• electrical
• chemical
• inhalation
• radiation

Question 3

Lund-Browder Chart

Answer 3

• most accurate for determining TBSA
• accounts for body variation and shape with age
• most accurate for kids

Question 4

Rule of Nines

Answer 4

• quick and easy way to estimate TBSA
• not always the most accurate
• only include 2nd and 3rd degree burns

Question 5

Palm Method

Answer 5

• the palm of the patient’s hand (excluding fingers) is approx .5-.8% of TBSA
• palmar surface with fingers 1%
• can be used to estimate small burns < 15% TBSA or large burns > 8% TBSA
• not as accurate for medium sized burns

Question 6

What 4 things determine the depth of tissue damage from a burn?

Answer 6

• temperature of burning object
• duration of contact
• thickness of the dermis
• blood supply

-young and old have much thinner skin –> burn deeper

Question 7

How are burns classified?

Answer 7

1. First degree: superficial
2. Second degree: partial thickness (superficial or deep)
3. Third degree: full thickness (down to SQ tissue)
4. Fourth degree: goes to tendon, bone, muscle

Question 8

Superficial (1st degree) Burn Characteristics

Answer 8

• epidermis only
• painful, erythematous skin
• dry, no oozing or weeping
• blanch with pressure
• heal quickly: over 2-3 days, pain and redness subside
• epithelial cells peel away at day 4
• healed in about 6 days

Question 9

Partial Thickness (2nd degree) Superficial Burn Characteristics

Answer 9

• entire epidermis and a variable portion of dermis
• forms blister w/in 24 hours
• painful, red, weeping
• heal in 7-21 days
• scarring unusual
• pigment changes may occur

Question 10

Partial Thickness (2nd degree) Deep Burn Characteristics

Answer 10

• extend deeper into dermis; damage hair follicles and glandular tissue
• painful only to pressure (nerves affected)
• blistered (usually unroofed)
• mottled color from white to red
• do not blanch (blood vessels have coagulated)
• heal 3-9 weeks
• hypertrophic scarring

Question 11

Full Thickness (3rd degree) Burn Characteristics

Answer 11

• entire thickness of epidermis and dermis, into subQ tissue
• whitish to black in color (charred)
• little or no pain (nerves damaged)
• no blisters
• coagulated vessels, no capillary refill
• these burns heal with contractures and severe scars
• surgery needed

Question 12

Full Thickness (4th degree) Burn Characteristics

Answer 12

• involves fat, fascia, muscle or bone

- these are potentially life threatening

Question 13

Minor Burns - Characteristics

Answer 13

• partial thickness burn 50 y.o
• full thickness burns <2% w/o other injury

-AND isolated injury; may not involve the hands, face, perineum or feet; may not cross major joints; may not be circumferential

Question 14

Minor Burns - Cooling Treatment

Answer 14

• remove any hot or burned clothing, jewelry, debris
• burned areas soaked immediately with saline or cool water
• do not use ice (hypothermia)
• monitor core temp to prevent hypothermia esp when burns >10% TBSA
• keep body temp above 95F (35C)

Question 15

Minor Burns - Cleaning/Debridement

Answer 15

• clean with gentle soap and water
• debride loose epidermis and blisters > 2 cm
• use saline and gauze
• use surgical scrub brushes
• enzymatic debriding agents (Collagenase)

Question 16

Minor Burns - Blisters??

Answer 16

• if ruptured, debride the tissue

- if intact, there is controversy regarding management

Question 17

Minor Burns - Topical Treatments

Answer 17

• topical antimicrobials and dressings are best choice
• silver sulfadiazine: thick white topical agent; can’t be used in pregnant or BF moms or infants; antibacterial activity
• bacitracin and polymyxin: easier to apply and remove w/ dressing changes; may be used on perineum and face
• fine mesh gauze
• hydrocolloid dressings
• silver containing dressings: silver = antimicrobial
• biosynthetic dressings: fewer dressing changes; semi-biologic skin substitute

Question 18

Scarring from Burns

Answer 18

• excessive scarring in form of keloid scars and contractures
• both types may be uncomfortable and can interfere with ROM

Question 19

Major Burns - Characteristics

Answer 19

• 25% TBSA in 10-40 y.o
• 20%+ TBSA in kids 40
• 10% TBSA full thicknes burns
• all burns involving eyes, ears, face, hands, feet, perineum
• burns across a major joint
• all high voltage electrical burns, chemical or inhalation
• all burns complicated by major trauma (eg broken bone)
• all patients w/ burns and serious co-morbidity (DM, renal failure)
• your facility is not equipped to care for peds

Question 20

Major Burns - Airway Assessment

Answer 20

• important to assess airway early; large % of smoke inhalation patients develop airway obstruction
• common signs of smoke inhalation: persistent cough, stridor or wheezing; hoarse; deep facial burns; nares with inflammation or singed hair; blistering/edema of oropharynx; depressed mental status; respiratory distress; hypoxia or hypercapnia

Question 21

Major Burns - Circulation Assessment

Answer 21

• normal heart rates for burn patients 100-120 bpm

- tachycardia is expected: pain, anxiety, hypovolemia, inadequate oxygenation

Question 22

Fluid Resuscitation

Answer 22

• burn shock during initial 24-48 hours = large fluid shifts and depletion of intravascular volumes
• rapid, aggressive fluids needed
• protect end organ damage
• any patient w/ > 15% TBSA should receive fluids
• lactated ringers preferred

Question 23

Parkland Formula

Answer 23

• fluids given during the initial 24 hours: 4 mL/kg for each % TBSA/24 hours
• 1/2 of fluids given over first 8 hours; other half given over 16 hours
• in infants and kids, 3 mL/kg for each %TBSA/24 hours (add dextrose)

Question 24

A 25 y.o male with TBSA of 30% weighs 70 kg.

How much fluid is needed in the first 24 hours?
How much should be given per hour in the first 8 hours?
In the next 16 hours?

Answer 24

1. 4 x 70 x 30 = 8400 mL for 24 hours
2. 4200 mL over 8 hours = 525/hour
3. 4200 mL over 16 hours = 262.5/hour

Question 25

ABLS Guidelines for Fluid Resuscitation

Answer 25

- adults: 2 mL LR x kg x TBSA - kids: 3 mL LR x kg x TBSA - electrical: 4 mL x kg x TBSA

Question 26

Subsequent Fluid Resuscitation

Answer 26

- urinary output is most reliable guide (foley cath, depends on normal renal function) - expected urine output for adults (0.5 mL/kg/hr) and for kids (1 mL/kg/hr)

Question 27

What happens in the case of excessive or inadequate volume during fluid resuscitation?

Answer 27

- excessive: exaggerates edema, compromises blood flow, exacerbates laryngeal swelling - inadequate: may cause shock and organ failure

Question 28

Pediatric Fluid Resuscitation

Answer 28

- greater surface area per unit body mass - require relatively greater amounts of resuscitation fluid - BUT are more susceptible to fluid overload

Question 29

Skin Grafting

Answer 29

- skin grafts are a biologic dressing - consist of skin taken from a donor site and grafted onto a wound - autograft: from same patient - allograft: from non-self source

Question 30

Full Thickness Skin Graft

Answer 30

- contain epidermis and dermis - retain more of the characteristics of the normal skin - skin is taken from groin, lateral thigh, lower abdomen or lateral chest

Question 31

Split Thickness Skin Graft

Answer 31

- contains epidermis and small amount of dermiss - tolerate a less than ideal wound bed and have broader range of applications - can be meshed to provide greater surface area coverage - tend to be abnormally pigmented (pale/white or hyperpigmented)

Question 32

Escharotomy

Answer 32

- eschar: stiff and unyielding tissue associated with a full thickness burn - will compress the underlying tissue and cause compression and ischemia - if circumferential around the chest, it will not allow chest expansion for respiration

Question 33

Infection Control for Burns

Answer 33

- wounds should be cleaned with a mild soap and water - topical antibiotics applied to all burns covered by a clean dry dressing - systemic antibiotics generally not needed - debridement - tetanus vaccine given for any burns greater than superficial - tetanus immune globulin should be given if patient has not completed primary immunization series

Question 34

What are the most common pathogens for a localized burn infection?

Answer 34

- pseudomonas aeruginosa - staph aureus - MRSA - enterococcus - localized infections can become a generalized cellulitis or sepsis

Question 35

Pain Management of Burns

Answer 35

- partial thickness can be especially painful - IV morphine is common for pain management, other opioids also acceptable - reasonable to give benzodiazepines to help with anxiety

Question 36

Mortality Risk Factors for Burns

Answer 36

- age greater than 60 - non-superficial burns over 40% TBSA - inhalation injury -risk increases with each risk factor a patient has

Question 37

Burns in the Pregnant Female

Answer 37

- outcome of pregnancy determined largely by outcome of woman - consider pregnancy loss in woman with >60% TBSA - pregnancy itself does not seem to alter maternal outcome - evaluate and treat the same as non-pregnant female - prevention of hypoxia and hypotension especially important to not limit blood flow to fetus - fluid resuscitation needs may be higher - fetal monitoring: OB consult

Question 38

Burns and Child Abuse

Answer 38

- common burns of abuse are contact (cigarettes, iron) and scald burns - history of injury should mesh with physical exam findings - symmetrical burns are suggestive of abuse (eg lower legs from being lowered into hot water) - index of suspicion may be higher with other physical exam findings of injury (bruises, etc)