Burns, C39 P246-254 Flashcards
(70 cards)
1
Q
Define:
TBSA
P246
A
Total Body Surface Area
2
Q
Define:
STSG
P246
A
Split Thickness Skin Graft
3
Q
Are acid or alkali chemical burns are more burns more serious?
P246
A
In general, ALKALI burns are more serious because the body cannot buffer
the alkali, thus allowing them to burn for
much longer
4
Q
Why are electrical burns so dangerous?
P246
A
Most of the destruction from electrical burns 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
5
Q
How is myoglobinuria treated?
P247
A
To avoid renal injury, think “HAM”:
Hydration with IV fluids
Alkalization of urine with IV
bicarbonate
Mannitol diuresis
6
Q
Define level of burn injury:
First-degree burns
P247
A
Epidermis only
7
Q
Define level of burn injury:
Second-degree burns
P247
A
Epidermis and varying levels of
dermis
8
Q
Define level of burn injury:
Third-degree burns
P247
A
A.k.a. “full thickness”; all layers of the
skin including the entire dermis (Think:
“getting the third degree”)
9
Q
Define level of burn injury:
Fourth-degree burns
P247
A
Burn injury into bone or muscle
10
Q
How do first-degree burns present?
P247
A
Painful, dry, red areas that do not form blisters (think of sunburn)
11
Q
How do second-degree burns present?
P247
A
Painful, hypersensitive, swollen, mottled
areas with blisters and open weeping surfaces
12
Q
How do third-degree burns present?
P247
A
Painless, insensate, swollen, dry, mottled
white, and charred areas; often described
as dried leather
13
Q
What is the major clinical difference between second- and third-degree burns?
P247
A
Third-degree burns are painless, and
second-degree burns are painful
14
Q
By which measure is burn
severity determined?
P247
A
Depth of burn and TBSA affected by
second- and third-degree burns
TBSA is calculated by the “rule of
nines” in adults and by a modified
rule in children to account for the
disproportionate size of the head and
trunk
15
Q
What is the “rule of nines”?
P248 (picture)
A
In an adult, the total body surface area 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%
16
Q
What is the “rule of the palm”?
P248
A
Surface area of the patient’s palm is 1%
of the TBSA used for estimating size of
small burns
17
Q
What is the burn center referral criteria for the following?
Second-degree burns
P248
A
>20% TBSA
18
Q
What is the burn center referral criteria for the following?
Third-degree burns
A
>5% TBSA
Second degree >10% TBSA in children
and the elderly
Any burns involving the face, hands, feet,
or perineum
Any burns with inhalation injury
Any burns with associated trauma
Any electrical burns
19
Q
What is the treatment of first-degree burns?
P249
A
Keep clean, ± Neosporin®, pain meds
20
Q
What is the treatment of
second-degree burns?
P249
A
Remove blisters; apply antibiotic
ointment (usually Silvadene®) and
dressing; pain meds
Most second-degree burns do not require
skin grafting (epidermis grows from
hair follicles and from margins)
21
Q
What are some newer
options for treating a
second-degree burn?
P249
A
- Biobrane® (silicone artificial
epidermis—temporary) - Silverlon® (silver ion dressings)
22
Q
What is the treatment of
third-degree burns?
P249
A
Early excision of eschar (within first week
postburn) and STSG
23
Q
How can you decrease
bleeding during excision?
P249
A
Tourniquets as possible, topical
epinephrine, topical thrombin
24
Q
What is an autograft STSG?
P249
A
STSG from the patient’s own skin
25
What is an allograft STSG?
| P249
STSG from a cadaver (temporary
| coverage)
26
What thickness is the STSG?
| P249
10/1000 to 15/1000 of an inch (down to
| the dermal layer)
27
What prophylaxis should the
burn patient get in the ER?
P249
Tetanus
28
What is used to evaluate the
eyes after a third-degree burn?
P249
Fluorescein
29
What principles guide the
initial assessment and
resuscitation of the burn patient?
P249
ABCDEs, then urine output; check for
| eschar and compartment syndromes
30
What are the signs of
smoke inhalation?
P249
Smoke and soot in sputum/mouth/nose,
nasal/facial hair burns, carboxyhemoglobin,
throat/mouth erythema, history of loss of
consciousness/explosion/fire in small
enclosed area, dyspnea, low O(2) saturation,
confusion, headache, coma
31
What diagnostic imaging is
used for smoke inhalation?
P250
Bronchoscopy
32
What lab value assesses
smoke inhalation?
P250
Carboxyhemoglobin level (a carboxysmoke-
hemoglobin level of >60% is associated
with a 50% mortality); treat with 100%
O(2) and time
33
How should the airway be
managed in the burn patient
with an inhalational injury?
P250
```
With a low threshold for intubation;
oropharyngeal swelling may occlude the
airway so that intubation is impossible;
100% oxygen should be administered
immediately and continued until significant
carboxyhemoglobin is ruled out
```
34
What is “burn shock”?
| P250
```
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
```
35
What is the “Parkland formula”?
| P250
V = TBSA Burn (%) x Weight (kg) x 4
Formula widely used to estimate the
volume (V) 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
36
What burns qualify for the
Parkland formula?
P250
≥20% TBSA second- and third-degree
| burns only
37
What is the Brooke formula
for burn resuscitation?
P250
Replace 2 cc for the 4 cc in the Parkland
| formula
38
How is the crystalloid given?
| P250
Through two large-bore peripheral
| venous catheters
39
Can you place an IV or central
line through burned skin?
P250
YES
40
What is the adult urine output goal?
| P250
30–50 cc (titrate IVF)
41
```
Why is glucose-containing
IVF contraindicated in burn
patients in the first 24 hours
postburn?
P251
```
Patient’s serum glucose will be elevated
| on its own because of the stress response
42
What fluid is used after the
| first 24 hours postburn?
Colloid; use D5W and 5% albumin at
| 0.5 cc/kg/% burn surface area
43
Why should D5W IV be
administered after 24 hours
postburn?
P251
```
Because of the massive sodium load in
the first 24 hrs of LR infusion and
because of the massive evaporation of
H(2)O 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
```
44
What is the minimal urine
output for burn patients?
P251
Adults 30 cc; children 1–2 cc/kg/hr
45
How is volume status
monitored in the burn
patient?
P251
```
Urine output, blood pressure, heart
rate, peripheral perfusion, and mental
status; Foley catheter is mandatory and
may be supplemented by central venous
pressure and pulmonary capillary wedge
pressure monitoring
```
46
Why do most severely
burned patients require
nasogastric decompression?
P251
Patients with greater than 20% TBSA
burns usually develop a paralytic ileus →
vomiting → aspiration risk → pneumonia
47
What stress prophylaxis must
be given to the burn patient?
P251
H2 blocker to prevent burn stress ulcer
| Curling’s ulcer
48
What are the signs of burn
wound infection?
P251
```
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, seconddegree
burns that turn into third-degree
burns, hypotension
```
49
Is fever a good sign of
infection in burn patients?
P251
NO
50
What are the common
organisms found in burn
wound infections?
P252
Staphylococcus aureus, Pseudomonas,
| Streptococcus, Candida albicans
51
How is a burn wound
infection diagnosed?
P252
```
Send burned tissue in question to the
laboratory for quantitative burn wound
bacterial count; if the count is >105/gram,
infection is present and IV antibiotics
should be administered
```
52
How are minor burns dressed?
| P252
```
Gentle cleaning with nonionic detergent
and débridement of loose skin and broken
blisters; the burn is dressed with a topical
antibacterial (e.g., neomycin) and
covered with a sterile dressing
```
53
How are major burns dressed?
| P252
Cleansing and application of topical
| antibacterial agent
54
Why are systemic IV antibi-otics contraindicated in fresh burns?
P252
Bacteria live in the eschar, which is
avascular (the systemic antibiotic will
not be delivered to the eschar); thus,
apply topical antimicrobial agents
55
```
Note some advantages and disadvantages of the following topical antibiotic agents:
Silver sulfadiazine (Silvadene®)
```
P252
Painless, but little eschar penetration,
misses Pseudomonas, and has idiosyncratic
neutropenia; sulfa allergy is contraindication
56
Note some advantages and disadvantages of the following topical antibiotic agents:
Mafenide acetate (Sulfamylon®)
P252
```
Penetrates eschars, broad spectrum (but
misses Staphylococcus), causes pain on
application; triggers allergic reaction in
7% of patients; may cause acid-base
imbalances (Think: Mafenide ACetate
Metabolic ACidosis); agent of choice in
already-contaminated burn wounds
```
57
Note some advantages and disadvantages of the following topical antibiotic agents:
Polysporin®
P252
Polymyxin B sulfate; painless, clear, used
for facial burns; does not have a wide
antimicrobial spectrum
58
Are prophylactic systemic
antibiotics administered to
burn patients?
P253
```
No—prophylactic antibiotics have not
been shown to reduce the incidence
of sepsis, but rather have been shown to
select for resistant organisms; IV
antibiotics are reserved for established
wound infections, pneumonia, urinary
tract infections, etc.
```
59
Are prophylactic antibiotics
administered for inhalational
injury?
P253
No
60
Circumferential, full-thickness burns to the
extremities are at risk forwhat complication?
P253
Distal neurovascular impairment
61
How is it treated?
| P253
Escharotomy: full-thickness longitudinal
incision through the eschar with scalpel
or electrocautery
62
```
What is the major infection
complication (other than
wound infection) in burn
patients?
P253
```
Pneumonia, central line infection (change
central lines prophylactically every 3 to
4 days)
63
Is tetanus prophylaxis
required in the burn patient?
P253
Yes, it is mandatory in all patients except
those actively immunized within the past
12 months (with incomplete immunization:
toxoid x 3)
64
From which burn wound is
water evaporation highest?
P253
Third degree
65
Can infection convert a
partial-thickness injury into
a full-thickness injury?
P253
Yes!
66
How is carbon monoxide
inhalation overdose treated?
P253
100% O(2) ( ± hyperbaric O(2))
67
Which electrolyte must be
closely followed acutely after a burn?
P253
Na⁺ (sodium)
68
When should central lines be
changed in the burn patient?
P254
Most burn centers change them every
| 3 to 4 days
69
What is the name of the
gastric/duodenal ulcer
associated with burn injury?
P254
Curling’s ulcer (Think: CURLING iron
| burn = CURLING’s burn ulcer)
70
How are STSGs nourished
in the first 24 hours?
P254
IMBIBITION (fed from wound bed
| exudate)
