Derm part 2: burns Flashcards by Deborah Karp

Are acid or alkali chemical burns more serious?

In general, alkali burns are more serious because the body cannot buffer the alkali, thus allowing them to burn for much longer

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How is myoglobinuria treated?

Hydration with IVF
Alkalization of urine with IV bicarb
Mannitol diuresis

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Superficial burns

Epidermis only

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Partial-thickness burns

Epidermis and varying levels of dermis

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Full-thickness burns

All layers if the skin, including the entire dermis

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How do superficial burns present?

Painful, dry, red areas that do not form blisters

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How do partial thickness burns present?

Painful, hypersensitive, swollen, mottled areas with blisters and open weeping surfaces

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How do full thickness burns present?

Painless, insensate, swollen, dry mottled white, and charred areas

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What is the major clinical difference between partial and full-thickness burns?

Full thickness burns are painless, and partial thickness burns are painful

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By which measure is burn severity determined?

Depth of burn and TBSA affected by partial and full thickness burns
TBSA is calculated by the rule of nines in adults and by a modified rule in children

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What is the rule of nines?

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%

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What is the rule of the palm?

Surface area of the pt’s palm is ~1% of the TBSA used for estimating size of small burns

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What is the burn center referral criteria for partial thickness burns?

> 20% TBSA

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What is the burn center referral criteria for full thickness burns

> 5% TBSA
Partial thickness >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

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What is the tx of superficial burns?

Keep clean
+/- Neosporin
Pain meds

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What is the tx of partial thickness burns?

Remove blisters: apply antibiotic ointment and dressing
Pain meds
Some use silver bandages
Most partial-thickness burns do not require skin grafting

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What is the tx of full thickness burns?

Early excision of eschar (within first week postburn) and STSG

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How can you decrease bleeding during excision of full thickness burns?

Tourniques as possible
Topical epinephrine
Topical thrombin

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What prophylaxis should the burn pt get in the ER?

Tetanus

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What principles guide the initial assessment and resuscitation of the burn pt?

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ABCDEs, then urine output

Check for eschar and compartment syndromes

What are the signs of smoke inhalation?

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Smoke and soot in sputum/mouth/nose
Nasal/facial hair burns
Throat/mouth erythema
Hx of loss of consciousness/explosion/fire in small enclosed area
Dyspnea
Low O2 saturation
Confusion
HA
Coma

What diagnostic imaging in used for smoke inhalation?

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Bronchoscopy

What lab value assesses smoke inhalation?

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Carboxyhemoglobin level

Treat with 100% O2 and time

How should the airway be managed in the burn pt with an inhalational injury?

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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= TBSA Burn (%) x weight (kg) x 4 | Half of the calculated volume is given in the first 8 hrs, the rest in the next 16 hrs

What burns qualify for the Parkland formula?

Greater than or equal to 20% TBSA partial and full thickness burns only

What is the Brooke formula for burn resuscitation?

Replace 2 cc for the 4 cc in the Parkland formula

What is the rule of 10s?

For determining hourly IVF rate: TBSA x 10 (pts 40-80 kg)

How is the crystalloid given?

Through two large-bore peripheral venous catheters

Can you place an IV or central line through burned skin?

Yes

What is the adult urine output goal?

30-50 cc (titrate IVF)

Why is glucose containing IVF contrainidcated in burn pts in the first 24 hours postburn?

Pt's serum glucose will be elevated on its own because of the stress response

What fluid is used after the first 24 hrs postburn?

Colloid | Use D5W and 5% albumin at 0.5 cc/kg/% burn surface area

What is the minimal urine output for burn pts?

Adults 30 cc | Children 1-2 cc/kg/hr

What is the most important for volume status monitroing in the burn pt?

Urine output

Why do mostl severely burned pts require nasogastric decompression?

Pts with >20% TBSA burns usually develop a paralytic ileus, which leads to vomiting, which leads to aspiration risk, which leads to pneumonia

What stress prophylaxis must be given to the burn pt?

PPI to prevent burn stress ulcer

What are the signs of burn wound infection?

``` Increased WBC with left shift Discoloration of burn eschar Green pigment Necrotic skin lesion in unburned skin Edema Ecchymosis tissue below eschar Partial-thickness burns that turn into full thickness burns Hypotension ```

What are the common organisms found in burn wound infections?

S. aureus Pseudomonas Streptococcus C. 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 to the fifth/gram, infection is present and IV abx should be administered

Why are systemic IV abx contraindicated in fresh burns?

Bacteria live in the eschar, which is avascular | Thus apply topical antimicrobial agents

Advantages and disadvantages of silver sulfadiazine

Painless, but little eschar penetration Misses Pseudomonas and has idiosyncratic neutropenia Sulfa allergy is a contraindication

Advantages and disadvantages of mafenide acetate

``` Penetrates eschars Broad spectrum (that misses Staph) Causes pain on application Triggers allergic reaction in 7% of pts May cause acid-base imbalances Agent of choice for ear burns ```

Advantages and disadvantages of polysporin

``` Polymyxin B sulfate Painless Clear Used for facial burns Does not have a wide antimicrobial spectrum ```

Circumferential, full thickness burns to the extremities are at risk for what complication?

Distal neurovascular impairment

How are circumferential, full thickness burns to the extremities treated?

Escharotomy: full thickness longitudinal incision through the eschar with scalpel or electocautery

How is carbon monoxide inhalation overdose treated?

100% O2 (+/- hyperbaric O2)

Which electrolyte must be closely followed acutely after a burn?

Sodium

Derm part 2: burns Flashcards

(49 cards)