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Flashcards in Fiser Chapter 17 BURNS Deck (69):
1

1st degree burn

Epidermis (sunburn)

2

2nd degree burn

Superficial dermis (papillary): Painful to touch, blebs/blisters, hair follicles intact, blanches, do NOT need skin graft

Deep dermis (reticular): decreased sensation, LOSS OF HAIR FOLLICLES, need skin graft

3

3rd degree burn

Leathery (charred parchment); down to subcutaneous fat

4

4th degree burn

Down to bone; into adjacent adipose or muscle tissue

5

Which burns heal?

1st and superficial 2nd degree burns: epithelialization from hair follicles

6

Complications of burns

Compartment syndrome
Rhabdomyolysis with myoglobinuria

Tx: hydration, alkalinize urine

7

Who gets admitted to a burn center?

No 1st degree burns

2nd and 3rd degree:
>20% (>10% if <10 or >50)
Or if significant hand/face/feet/genital/perineal/joint skin burns

3rd degree: >5% any age group

Electrical and chemical burns

Concomitant inhalational injury

Mechanical trauma, preexisting medical conditions, patients with special needs, child abuse/neglect

8

TBSA assessment

Rule of 9s

Head 9
Arms 9 each
Chest 18
Back 18
Legs 18 each
Perineum 1

Or palm = 1%

9

Parkland formula

Use for burns >/= 20%

Volume LR = 4 cc/kg x kg x % TBSA
Give 1/2 in first 8 hours, second half in second 16 hours

UOP best measure: goal 0.5-1.0 cc/kg/h in adults, 2-4 cc/kg/h in <6mo

10

When can Parkland formula grossly underestimate volume requirement?

inhalational injury
EtOH
electrical injury
post-escharatomy

11

What do you use in burn resuscitation?

LR in first 24 hr
Albumin in first day can cause increased pulmonary complications. Can use after 24hr

12

Escharotomy indications

-Circumferential deep burns
-Low temp
-Weak pulse
-Decreased capillary refill
-Decreased pain sensation
-Decreased neurological function in extremitiy
-Problems ventilating patient with chest torso burns

Perform within 4-6 hours

13

Fasciotomy indication in burn patient

If compartment syndrome suspected after escharotomy

14

Risk factors for burn injuries

EtOH
Drugs
Age (very young or very old)
Smoking
Low socioeconomic status
Violence
Epilepsy

15

H&P signs that suggest abuse

-Delayed presentation for care
-Conflicting histories
-Previous injuries
-Sharply demarcated margins
-Uniform depth
-Absence of splash marks
-Stocking or glove patterns
-Flexor sparing
-Dorsal location on hands
-Very deep localized contact injury

Child abuse accounts for 15% of burn injuries in children

16

Lung injury MoA

Carbonaceous materials and smoke (not heat)

17

Risk factors for airway injury in burn

-EtOH
-Trauma
-Closed space
-Rapid combustion
-Extremes of age
-Delayed extrication

18

Signs and symptoms of possible airway injury

-Facial burns
-Wheezing
-Carbonaceous sputum

19

Indications for intubation

-Upper airway stridor or obstruction
-Worsening hypoxemia
-Massive volume resuscitation can worsen symptoms

20

Most common infection in patients with >30% BSA burns

Pneumonia
Also MCC death after >30% BSA burns

21

MCC death after 30% BSA burns

Pneumonia

22

Acid and alkali burns tx

Copious water irrigation

Alkalis produce deeper burns due to liquefaction necrosis

Acid burns produced coagulation necrosis

23

Hydrofluoric acid burns tx

Calcium

24

Powder burns tx

Wipe away before irrigation

25

Tar burns tx

Cool, then wipe away with lipophilic solvent (adhesive remover)

26

Electrical burns tx and complications

Cardiac monitoring
Monitor for rhabdo and compartment syndrome

Watch for polyneuritis, quadriplegia, transverse myelitis, cataracts, liver necrosis, intestinal perforation, gallbladder perforation, pancreatic necrosis

27

Lightning burn complication

Cardiopulmonary arrest 2/2 electrical paralysis of brainstem

28

Caloric need in burns

25 kcal/kg/day + (30 kcal x % burn)

29

Protein need in burns

1 g/kg/day + (3 g x % burn)

30

Glucose need in burns

Best source of nonprotein calories in patients with burns
Burn wounds use glucose in an obligatory fashion

31

Burn wound excision

-Perform AFTER fluid resusc but <72h
-Used for deep 2nd, 3rd, 4th degree burns
-For each burn wound excision, want <1 L blood loss, <20% skin excised, and <2 hr in OR. Patient can otherwise get very sick.
-Viability based on color/texture/punctate bleeding after removal

-Wounds to face, palms, soles, genitals deferred for 1 week

32

Skin graft contraindications

Positive beta-hemolytic strep or bacteria > 10^5 in culture

33

Autografts

-Decrease infection, desiccation, protein loss, pain, water loss, heat loss, RBC loss compared to dermal subtitutes

-Donor skin site regenerated from hair follicles and skin edges on STSGs

34

Imbibition

Osmotic blood supply to skin graft for days 0-3

35

Neovascularization

Starts day 3

36

Poor vascularized beds unlikely to support skin grafting

Tendon, bone without periosteum, XRT areas

37

STSG thickness

12-15 mm (epidermis and part of dermis)

38

Homograft use

(Allografts from cadaveric skin)
-Can be a good temporizing material, last 2-4 weeks
-Vascularize and are eventually rejected, then must be replaced

39

Xenografts (porcine)

-Not as good as autografts or homografts
-Last 2 weeks
-Do NOT vascularize

40

Dermal substitutes

worst

41

Meshed grafts

-Use for back, flank, trunk, arms, legs

42

Most common reason for skin graft loss

-Seroma or hematoma
-Need to apply pressure dressing (cotton balls) to skin graft to prevent this

43

STSG versus FTSG

STSG: more likely to survive, graft not as thick so easier for imbibition and revascularization

FTSG: less wound contraction, good for hands

44

Burn scar hypopigmentation and irregularities prevention

Dermabrasion thin split-thickness grafts

45

Face burn care

Topical antibiotics for 11st week
FTSG for unhealed areas (nonmeshed)

46

Hand burn care

Superficial: ROM exercises, splint in extension if too much edema

Deep: FTSG, immobilize in extension for 7 days after, then PT, may need wire fixation of joints if unstable or open

47

Palm burn care

Try to preserve specialized palmar attachments
FTSG, then splint hand in extension for 7 days

48

Genitals burn care

STSG meshed is ok

49

Burn wound infection prevention

Bacitracin or Neosporin immediately
No role for IV abx ppx

Need 10^5 organisms for infection

50

Burn wound infection organism

MCC is pseudomonas (burn wound sepsis) > staph, e coli, enterobacter

Candida increased 2/2 topical antimicrobials

HSV most common viral

51

Burn wound infection risk factors

> 30% BSA

52

Burn wound infection pathophysiology

Impaired granulocyte chemotaxis and cell-mediated immunity

53

Silver sulfadiazine side effects

Neutropenia
Thrombocytopenia
Sulfa allergy reaction
Limited eschar penetration
Can inhibit epithelialization
Ineffective against some pseudomonas (but effective for candida)

54

Silver nitrate side effects

Electrolyte imbalances
Discoloration
Limited eschar penetration
Ineffective against some pseudomonas and GPCs
Methemoglobinemia (in G6PD deficiency)

55

Mafenide sodium (sulfamylon) characteristics

Painful application
Metabolic acidosis d/t carbonic anhydrase inhibition (decreased renal conversion of H2CO3 -> H2O and CO2)
Good eschar penetration, good for burns overlying cartilage
Broadest spectrum against pseudomonas and GNRs

56

Mupirocin

Good for MRSA, but very expensive

57

Signs of burn wound infection

-Peripheral edema
-2nd to 3rd degree burn conversion
-Hemorrhage into scar
-Erythema gangrenosum
-Green fat
-Black skin around wound
-Rapid eschar separation
-Focal discoloration

58

Best way to detect burn wound infection (and differentiate from colonization)

Biopsy of burn wound

59

Complications after burns

-Seizures
-Peripheral neuropathy (small vessel injury and demyelination)
-Ectopia (burned adnexa contraction, tx eyelid release)
-Eye injury (fluorescein stain, tx topical fluoroquinolone or gentamicin)
-Coreneal abrasion (tx topical abx)
-Symblepharon (eyelid stuck to conjunctiva, tx release with glass rod)
-Heterotopic ossification of tendons (tx PT, may need surgery)
-Fractures (Tx external fixation to allow for burn tx)
-Curling's ulcer
-Marjolin's ulcer
-Hypertrophic scar

60

Curling's ulcer

Gastric ulcer that occurs with burns

61

Marjolin's ulcer

Highly malignant squamous cell CA that arises in chronic non-healing burn wounds or unstable scars

62

Hypertrophic scar

-Usually occurs 3-4 months after injury 2/2 increased neovascularity
-More likely to be deep thermal injuries that take >3 weeks to heal, heal by contraction and epithelial spread, or heal across flexor surfaces

-Tx: steroid injection into lesion (best), silicone, compression; wait 1-2 yr before scar modification surgery

63

Erythema multiforme

least severe, self-limited, target lesions

64

SJS

more serious
<10% BSA

65

TEN

most severe form

66

Staph scalded skin syndrome

Caused by staphylococcus aureus

67

Skin epidermal-dermal separation

Seen in EM, SJS, TEN

68

TEN causes

Dilantin
Bactrim
PCN
Viruses

69

TEN tx

-Fluid resuscitation
-Supportive
-Prevent wound desiccation with homografts/xenografts wraps
-Topical abx
-IV abx if due to staphylococcus
-NO Steroids