What is TBSA?
Total Body Surface Area
What is STSG?
Split Thickness Skin Graft
Are acid or alkali chemical burns more serious?
In general, alkali burns because the body cannot buffer the alkali, thus allowing them to burn for much longer
Why are electrical burns so dangerous?
Most of the destruction is internal because the route of least electrical resistance follows nerves, blood vessels, and fascia. Injury is usually worse than external burns at entrance and exit sites would indicate. Cardiac dysrhythmias, myoglobinuria, acidosis, and renal failure are common.
How is myoglobinuria treated?
HAM: Hydration with IVF Alkalization of urine with IV bicarbonate Mannitol diuresis
What is a first-degree burn?
What is a second-degree burn?
Epidermis and varying levels of dermis
What is a third-degree burn?
All layers of the skin including the entire dermis
What is a fourth-degree burn?
Burn injury into bone or muscle
How do first-degree burns present?
Painful, dry, red areas that do not form blisters
How do second-degree burns present?
Painful, hypersensitive, swollen, mottled areas with blisters and open weeping surfaces
How do third-degree burns present?
Painless, insensate, swollen, dry, mottled white, and charred areas. Often described as dried leather.
What is the major clinical difference between second-degree and third-degree burns?
Third-degree: Painless Second-degree: Painful
By which measure is burn severity determined?
Depth of burn and TBSA affected by second and third-degree burns. TBSA is calculated by the rule of 9s in adults and by a modified rule in children to account for the disproportionate size of the head and trunk.
What is the rule of 9s in burns?
In an adult, the TBSA that is burned can be estimated by the following: Each upper limb: 9% Each lower limb: 18% Anterior and posterior trunk: 18% each Head and neck: 9% Perineum and genitalia: 1%
What is the rule of the palm?
Surface area of the patient's palm is 1% of the TBSA used for estimating size of small burns
What is the burn center referral criteria?
1. Second degree > 20% TBSA 2. Second degree > 10% TBSA in children and elderly 3. Third degree > 5% TBSA 4. Any second- or third-degree burns involving the face, hands, feet or perineum 5. Any burns with inhalation 6. Any burns with associated trauma 7. Any electrical burns
What is the treatment for first-degree burns?
Keep clean, pain meds, +/- Neosporin
What is the treatment for second-degree burns?
Remove blisters; apply antibiotic ointment (usually Silvadene) and dressing; pain meds. Most second-degree burns do not require skin grafting.
What are some newer options for treating a second-degree burn?
1. Biobrane (temporary silicone artificial epidermis) 2. Silverlon (silver ion dressings)
What is the treatment of third-degree burns?
Early excision of eschar (within first week post-burn) and STSG
How can you decrease bleeding during excision of a third-degree burn?
Tourniquets if possible, topical epinephrine, topical thrombin
What is an autograft STSG?
STSG from the patient's own skin
What is an allograft STSG?
STSG from a cadaver (temporary coverage)
What thickness is the STSG?
10/1000 to 15/1000 of an inch (down to the dermal layer)
What prophylaxis should the burn patient get in the ER?
What is used to evaluate the eyes after a third-degree burn?
What principles guide the initial assessment and resuscitation of the burn patient?
ABCDEs, then urine output. Check for eschar and compartment syndromes.
What are the signs of smoke inhalation?
Smoke and soot in sputum/mouth/nose; nasal or facial hair burns; carboxyhemoglobin; throat or mouth erythema; history of LOC/explosion/fire in enclosed area; dyspnea; low O2 saturation; confusion; headache; coma
What diagnostic imaging is used for smoke inhalation?
What lab value assesses smoke inhalation?
Carboxyhemoglobin level (> 60% is associated with 50% mortality). Treat with 100% O2 and time.
How should the airway be managed in the burn patient with an inhalational injury?
With a low threshold for intubation. Oropharyngeal swelling may occlude the airway so that intubation is impossible . 100% O2 should be administered immediately and continued until significant carboxyhemoglobin is ruled out.
What is burn shock?
Describes the loss of fluid from the intravascular space as a result of burn injury, which causes leaking capillaries that require crystalloid infusion
What is the Parkland formula?
V = (4 X TBSA X weight) cc V = volume of crystalloid necessary for the initial resuscitation of the burn patient Half of the calculated volume is given in the first 8 hours, the rest in the next 16 hours.
What burns qualify for the Parkland formula?
> 20% TBSA second- and third-degree burns only
What is the Brooke formula for burn resuscitation?
Replace 2 cc for the 4 cc in the Parkland formula
Can you place an IV or central line through burned skin?
What is the adult urine output goal in burn injuries?
Why is glucose-containing IVF contraindicated in burn patients in the first 24 hours post-burn?
Patient's serum glucose will be elevated on its own because of the stress response
What fluid is used after the first 24 hours post-burn?
Colloid (use D5W and 5% albumin at 0.5 cc/kg/% burn surface area)
Why should D5W IV be administered after 24 hours post-burn?
Because of the massive sodium load in the first 24 hours of LR infusion and because of the massive evaporation of water from the burn injury, the patient will need free water. After 24 hours, the capillaries begin to work and then the patient can usually benefit from albumin and D5W.
What is the minimal urine output for burn patients?
Adults: 30 cc/hr Children: 1-2 cc/kg/hr
How is volume status monitored in the burn patient?
Urine output, BP, HR, peripheral perfusion, mental status. Foley catheter is mandatory and may be supplemented by central venous pressure and PCWP monitoring.
Why do most severely burned patients require NG decompression?
Patients with greater than 20% TBSA burns usually develop a paralytic ileus, leading to vomiting, aspiration risk, pneumonia
What stress prophylaxis must be given to the burn patient?
H2 blocker to prevent burn stress ulcer (Curling's ulcer)
What are the signs of burn wound infection?
Increased WBC with left shift, discoloration of burn eschar (most common sign), green pigment, necrotic skin lesion in unburned skin, edema, ecchymosis tissue below eschar, second-degree burns that turn into third-degree burns, hypotension
Is fever a good sign of infection in burn patients?
What are the common organisms found in burn wound infections?
Staphylococcus aureus, Pseudomonas, Streptococcus, Candida albicans
How is a burn wound infection diagnosed?
Send burned tissue in question to the lab for quantitative burn wound bacterial count. If the count is > 10^5/g, infection is present and IV antibiotics should be administered.
How are minor burns dressed?
Gentle cleaning with non-ionic detergent and debridement of loose skin and broken blisters. The burn is dressed with a topical antibacterial and covered with a sterile dressing.
How are major burns dressed?
Cleansing and application of topical antibacterial agent
Why are systemic IV antibiotics contraindicated in fresh burns?
Bacteria live in the eschar, which is avascular
What are advantages and disadvantages of silver sulfadiazine (Silvadene)?
Painless, but little eschar penetration, misses Pseudomonas, and has idiosyncratic neutropenia. Sulfa allergy is contraindication.
What are advantages and disadvantages of mafenide acetate (Sulfamylon)?
Penetrates eschars, broad spectrum (but misses Staphylococcus), causes pain on application. Triggers allergic reaction in 7% of patients. May cause acid-base imbalances. Agent of choice in already-contaminated burn wounds.
What are advantages and disadvantages of polymyxin B sulfate (Polysporin)?
Painless, clear, used for facial burns. Does not have a wide antimicrobial spectrum.
Are prophylactic systemic antibiotics administered to burn patients?
What is a complication of circumferential, full-thickness burns to the extremities?
Distal neurovascular impairment
How are circumferential, full-thickness burns to the extremities treated?
Escharotomy (full-thickness longitudinal incision through the eschar with scalpel or electrocautery)
What is the major infection complication (other than wound infection) in burn patients?
Pneumonia, central line infection (change central lines prophylactically every 3-4 days)
Is tetanus prophylaxis required in the burn patient?
Yes (except those actively immunized within the past 12 months)
From which burn wound is water evaporation highest?
Can infection convert a partial-thickness injury into a full-thickness injury?
How is carbon monoxide inhalation overdose treated?
100% O2 +/- hyperbaric O2
Which electrolyte must be closely followed acutely after a burn?
When should central lines be changed in the burn patient?
Every 3-4 days
What is the name of the peptic ulcer associated with burn injury?
How are STSGs nourished in the first 24 hours?
Imbibition (fed from wound bed exudate)