Thermal, Chemical, and Electrical Injuries Flashcards
(153 cards)
1
Q
Initially, burn depth is based on two extrinsic factors: intensity of
heat and duration ofcontact
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2
Q
cellular and matrix proteins are irreversibly damaged
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3
Q
Appropriate resuscitation and local wound care are central to limiting
reversible tissue loss and are the goal ofinitial burn care
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4
Q
burn shock
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Burns greater than 20% of total body surface area (TBSA) cause a system-wide inflammatory response
5
Q
Burns greater than 20% of total body surface area (TBSA) cause a system-wide inflammatory response higher blood viscosity
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6
Q
. Maximal fluid shifts occur around
12 hours after burn
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7
Q
Within 24 hours after a large burn, capillary integrity in nonburned tissue returns to near normal and transudation ofcolloids
out ofthe vascular space diminishes
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8
Q
Water continues to collect in the interstitial space
even after restoration ofcapillary integrity and further perpetuates
global tissue edema.
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9
Q
Burn shock results from loss of intravascular volume, cardiac
dysfunction, and vascular changes.
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10
Q
Prior to initiation of resuscitation when capillary leak predominates increased systemic vascular resistance predominates
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11
Q
the systemic vascular resistance drops before resuscitation
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F after resuscitation
12
Q
cytokine release and current intravascular volume status affect preload
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F affect preload, contractility, and afterload
13
Q
kidney is damage why?
A
from hypoperfusion, and
acute kidney injury can be perpetuated by increased blood viscosity from elevated hematocrit and myoglobinuria from deeper tissue
damage.
14
Q
In the event ofsuspected inhalation Consultation to otolaryngologist may be indicated for serial fiber optic laryngoscopic examinations
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15
Q
What benefit of escharotomies?
A
with circumferential torso burns escharotomies to improve their thoracic compliance and promote adequate ventilation-breathing
with circumferential extremity restore circulation
distally
16
Q
the International Society for Burn Injuries advocate descriptive terminology-superficial, partial-thickness, full-thickness instead of first, second, and third degree
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17
Q
, ICD-10
codes quantify burn depth in degrees instead of descriptive terms.
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18
Q
Superficial (first-degree) burns features
A
affect the epidermis only. These
are dry, erythematous, blanch with pressure, and painful without blistering or ulceration of the skin
19
Q
Superficial partial-thickness burns
are whiter, have varying degrees of sensation and edema
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F deep partial-thickness burns often do
not demonstrate blanching or capillary refill
20
Q
New technologies have been used to assist in assessing burn
wound depth.
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Ultrasound, laser Doppler, and fluorescein
21
Q
The Lund-Browder chart is the oldest but historically most accurate method of assessing burn size
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22
Q
Assessing burn size methods
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The Lund-Browder chart
The rule of nines
the pa/mar method utilizes
Computer-based applications such as the SAGE diagram.
mobile applications
23
Q
Obese patients
have a relatively larger proportion ofskin on their trunks
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24
Q
There are currently no consensus guidelines from major burn
organizations to guide burn size estimation
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25
Blisters should be unroofed, and broad-spectrum topical antimicrobials should be placed over the wound
depending on its depth and extent
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Systemic antibiotics have no role
in treated uninfected burns.
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criteria for outpatients management
Superficial partial-thickness burns or small full-thickness burns
One, the ability to provide adequate local wound care at home
adequate analgesia does not interfere with wound care
adequate oral intake and thus nutritional support and hydration.
compliance with therapeutic instructions to prevent stiffness across joints or loss of range of motion.
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As per ABA criteria, burns greater than 20% or greater than 10%
in a child should be admitted to the ICU
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The historic prognostic indicator for burn
mortality is the Baux score
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What is the Baux score: ?
the patient's age plus TBSA is equal to the
likelihood of mortality.
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What is the difference in case of inhalational injury
Twenty percent is added for inhalational injuries
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The revised
Baux score and associated nomogram are more accurate reflections
of current mortality rates
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Over resuscitation consequences
leads to excess edema formation and its sequelae: compartment syndromes of the extremities and abdomen, as well as organ dysfunction
including worsening respiratory function
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Treatment of abdominal compartment syndrome
systemic paralysis
and ultimately decompressive laparotomy
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Balanced, isotonic crystalloid solutions such as lactated Ringer
solution are preferred, as they limit diffusion into the interstitial space
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Normal salin can be given
F Normal saline is generally avoided because it provides excess chloride
load and can perpetuate a metabolic acidosis
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There is no evidence to support
the use of colloid over or in addition to crystalloid in the first 24hours after a burn injury,
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colloids have a narrow role in acute burn resuscitation and are limited to instances when
the volume of resuscitation is exceeding predicted levels
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to maintain 0.5 to 1.0 mL of urine output per kilogram per hour
and mean arterial pressure greater than 65 mm Hg
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patients with chronic kidney disease or congestive heart failure, need special treatment like?
benefit from other
methods of goal-directed therapy such as provided with a SwanGanz or other cardiac monitoring device
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What is the role of vasopressor ?
Initiation of vasopressor or
inotropic support may be indicated, especially in the setting of fluid
resuscitation exceeding predicted amounts
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ascorbic acid at a dose of 66 mg/kg/h for 24 hours decreased overall volume requirements for resuscitation. vitamin C acts as an oxidative scavenger
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First-line agents are opioid-based analgesics such as morphine or
fentanyl.
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Oral administration has, in general, a longer duration of effect and thus
is preferred if possible
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Background pain can often be treated with a
sustained-release opioid analgesic such as OxyContin or MS Contin
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Breakthrough or procedural pain can be treated with more acute
agents such as morphine sulfate immediate release or oxycodone
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Nonsteroidal anti-inflammatory drugs have a role in burn pain control but are associated with bleeding risks
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Sedation, in the form of anxiolysis, should be used in burn patients
as a procedural or background adjunct to analgesia
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Ketamine is a useful alternative that does not
contribute to hemodynamic depression but may cause transient
hypertension
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Benzodiazepine can be used safely for for burn patients
F benzodiazepine use has been associated with longer ICU stays
and worse outcomes,
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The goal
of dressings in burned patients
prevent wound desiccation, limit further
trauma, and control microbial growth.
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Topical antimicrobials are the
standard of care for all burn wounds
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The traditional dressing of daily silver sulfadiazine and gauze
is always reasonable,
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Indication of silver sulfadiazine
For an evolving burn wound
if there is a need for the removal of eschar, pseudoscalar, or necrotic burn
tissue by daily mechanical debridement
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Silver-releasing dressings dressings have sustained activity for up to 7 days after placement. This has the advantage of limiting multiple painful debridements
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Neurovascular checks are indicated for any
partial-thickness or full-thickness near-circumferential burn of the
extremities
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fasciotomies are always should don with escharotomies
F
1- severe burns that have a large volume of resuscitation
2- crush or electrical injuries,
3- distal vascular examinations do not improve
after adequate escharotomies,
4- muscle bulging through the fascia,
5-compartment pressures are elevated
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Initiation of early
enteral feeding is a central component of burn care with the goal of
full caloric support within 24 hours after admission
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Enteral nutrition is superior to parenteral nutrition, with gastric feeds
preferred over small bowel feeding.
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If gastric feeding intolerance occurs, the tube should be
advanced to a post pyloric position
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Hemodynamically unstable
patients requiring increasing amounts of vasopressor support may
require reduction of enteral feeds to trophic levels to prevent intestinal ischemia.
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Is there a role for growth hormone in burned patients?
oxandrolone, a testosterone analog, between 40% and 70% TBSA. demonstrated decreased muscle loss and
improved donor site wound healing compared with controls
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Beta-blockers can mediate the cholinergic response and also help
blunt hypermetabolism by decreasing the resting heart rate
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Burn patients are hypercoagulable and are at an overall higher risk
for deep vein thrombosis
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unfractionated heparin is prefered over low molecular weight heparin
F There is no clear benefit for either unfractionated heparin or low-molecular-weight heparin
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critically ill burn patients are at risk for stress gastritis or
upper gastrointestinal stress ulcers (Curling ulcer)
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inhalation injury is the most critical
determination for survival
F After the size of the burn
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Upper airway inhalation injury is defined
by injury to the supraglottic airway from breathing in hot air.
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chemical pneumonitis result from supraglottic inhalation
F Subglottic inhalation injury is characterized by inhaling the toxic
products of combustion and results in a chemical pneumonitis similar to acute respiratory distress syndrome
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Subglottic inhalation daignosis
Diagnosis is confirmed
by bronchoscopy, and findings may not be immediately evident on
chest X-ray.
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The treatment is also supportive with mechanical ventilation until the acute lung injury resolves, in this case usually over
5 to 10 days.
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The high-flow percussive ventilator is a useful adjunct
that works by recruiting alveoli with low pressures
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When the percussive ventilator is
used, inhaled heparin and acetylcysteine are helpful to avoid airway
desiccation and bleeding.
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Supraglotic airway edema resolves, usually in 48
to 72 hours while in subglottic oedema resolve in 5-10 days
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Carbon monoxide can be detect on pulse oximetery
F not detectible by pulse oximetry
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Carboxyhemoglobin level elevated ?
initiated with inhaled oxygen either by nonrebreather mask or endotracheal tube. Application of 100% oxygen
can reduce the half-life of carbon monoxide in the circulation from
4 hours to 40 to 60 minutes
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low FiO2 should be attempted to
prevent oxidative damage to the pulmonary parenchyma.
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The most common sites for infection in burn patients
the respiratory tract, the burn wound, and imparted devices such as central
line-associated bloodstream infections and catheter-associated urinary
tract infections
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Superficial partial-thickness thermal injuries that will heal in less
than 3 weeks should be managed nonoperatively.
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Mixed or indeterminate
depth burns should be followed closely for 5 to 7 days to allow possible healing to occur
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patients in deep full thickness burn or Deep partial-thickness
with early (<14 days) excision had improvements in mortality (4%
versus 11% ) and faster wound closure
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ultra-early excision within 72 hours
after injury may lead to better results overall
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if grafting is being considered. If
complete excision will expose critical, ungraftable structures, leaving
questionable tissue in place for 2 or 3 days is a reasonable temporizing step
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tangential excision can excise normal tissue
F Benefits to this method are that it preserves as much
healthy tissue as possible results in better functional and aesthetic outcomes.
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Blood loss with tangential excision more than pre facial excision
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blood loss during tangential
excision, especially when removing large areas of burn or when operating more than a week after injury.
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How you can decrease the blood loss in tangential excision ?
Preoperative injection of dilute
epinephrine solution or extremity tourniquets are useful to decrease
blood loss during excision
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but may make assessment of the underlying wound bed more difficult
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Tangential excision may not be suitable
for a hemodynamically unstable patient or in cases where the burn is third-degree and extends into the subcutaneous tissue and can't tolerate long time operation
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s prefascial excision. In this
method, the surgeon removes all of the skin and subcutaneous tissue
to the level of the deep investing fascia.
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prefascial excisionis quick and
reliable, with less blood loss than with tangential excisio
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Prefascial
excision is indicated only in critically ill patients who would not tolerate long operations or large volume blood loss
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Pediatric and
gerhitric patients have thinner reticular dermis
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Unmeshed, sheet grafts should be considered when best longterm functional and aesthetic outcomes are the priority.
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sheet grafts useful for primary grafting of the face, hands and feet
and should be standard care for most burns in children
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interstices in the mesh must heal by contraction
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Full-thickness grafts have little role in acute burn surgical management
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Full-thickness grafts are best reserved for subsequent reconstruction of areas such as the eyelids or the palmar surface of the hand
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Benefit of frozen cadaveric allograft
It encourages angiogenesis within the wound bed
and can limit evaporative losses for larger burns that must be closed
in a staged fashion
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Allografts limmitations
expensive, ,
must be maintained frozen in an approved skin bank. As the patient
regains immunocompetence, the allogenic skin will reject, which
can occur from 10 to 30 days after placement.
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Integra can also be used to
bridge across and cover areas of questionable vascularity such as bone
lacking periosteum or tendons denuded ofparatenon
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Integra limitation
easily become infected ifthe burn wound
was inadequate debrided and take a prolonged time, usually around
3 weeks, to become revascularized. They are all expensive.
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Cultured epidermal autografts and spray on keratinocytes limitation
they are very expensive, and
outcomes are practitioner dependent
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Joints should be immobilized both one
joint above and below the area ofgrafting.after dressing
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inadequate dressings may
lead to shearing during the graft
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Methods ofdressings
foam bolsters, tie-over
bolsters, negative pressure wound therapy dressings, and compressive
therapy for extremities
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There is no demonstrated superior technique of dressing
from one to the other.
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The acid or base denatures cutaneous proteins with acids
forming coagulation necrosis and bases with liquefactive necrosis
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Chemical Burns treated by dilution,
specifically, the treatment is to irrigate the contact area with regular
tap water for a minimum of 15 minutes.
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Acids and bases can
be neutralized with an opposing reagent
f Acids and bases should
not be neutralized with an opposing reagent because this could
create an exothermic reaction that could add thermal damage to
the already existing chemical damage
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hydrofluoric acid, should not be neutralized
F
One exception to this rule is
hydrofluoric acid, which should be neutralized with calcium gluconate or calcium chloride
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Bases tend to create more significant
injury than acids
T because ofdeeper penetration from ongoing liquefactive injury.
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The depth ofchemical injuries may not be readily
apparent on the initial evaluation
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Chemical peeling treatment decisions are usually delayed for 5 to
7 days.
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Electrical burns can be the most devastating type ofburn injury
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electrical burns can be difficult to diagnose the exact extent of the injury
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These types of burns are also often
associated with other traumatic injuries or secondary flash or blast
injuries from the superheated air surrounding the electrical current
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the amount of heat generated directly proportional to the resistance encountered
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Bone has the highest resistance, followed by fat, tendon, skin, muscle, blood vessels, and nerve.
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Areas with low cross-section and high bony content, such as the wrist
and ankles, are particularly susceptible to severe injury.
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Creatine kinases are drawn for
quantification of muscle damage
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Peripheral nerve releases including carpal tunnel and Guyon canal should be included in surgical management if
contact points involve the hand or extremity
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Ice crystal formation in frost bite alter matrix organization
F Ice crystal formation
in the intracellular and extracellular spaces kills cells but does not
alter matrix organization
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Rewarming of the effected site should don first
F Systemic hypothermia should be addressed first followed by rapid rewarming in a water bath with a temperature between 40 and 42°C for 30 minutes in the affected areas.
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nonsteroidal anti-inflammatory drugs such as ibuprofen can help prevent ongoing inflammatory damage in frostbite
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If the injury
is less than 24 hours old, angiography with either catheter directed or
systemic thrombolytic administration may decrease need for digital
amputation
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Facial burn injury should be managed operatively initially in case of full-thickness injuries.
F Facial burn injury should be managed nonoperatively initially even
if they appear to be full-thickness injuries.
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facial burns should be reevaluated at approximately 10 to
14 days and any nonhealing areas excised and grafted
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If severe lid burns exist, eyelid releases or temporary
tarsorrhaphies may be indicated to protect the cornea from further
damage from exposure
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Isolated burns of the neck are best managed, like other isolated
injuries, by early excision and sheet grafting
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patients with
a very large TBSA burn, facial burns, and inhalation injury, the
neck should be grafted early with a meshed graft to allow early
tracheostomy
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A tracheostomy should not be placed
through ungrafted burned areas because of the unacceptably high
risk of mediastinitis.
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most
palmar hand burns heal reasonably well.
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Dorsal hand burns have
best outcomes with early excision and grafting
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Kirschner wires may be placed toimmobilize theinterphalangeal and
metacarpophalangeal joints with the hand in a position of safety to
prevent tightening of the collateral ligaments
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Age and body habitus affect burn size estimation
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The
Parkland (4 cc xweight [kg] x %TBSA) and ABA consensus formula
(2 cc x weight [kg] x % TBSA for adults) are two common methods
used to estimate the total amount of fluids needed during the first
24hours
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Glucose should be added
when resuscitating smaller children
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patients
with greater than 30% TBSA are treated with ascorbate as an adjunct
during the first 24 hours after burn injury.
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Silver-releasing dressings suitable for superficial partial-thickness
wounds that meet criteria for outpatient management. This is particularly true for pediatric scald burns.
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Curreri formula
Adult : 25 kcal x weight (kg)+ 40 kcal x %TBSA
Children : 60 kcal x weight (kg)+ 35 kcal x %TBSA
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Gastroparesis is common, and prokinetic agents such as metoclopramide and erythromycin are helpful in promoting gastric
emptying
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Hepatic
dysfunction may develop with long-term or higher dosages, so liver
function tests should be followed and the drug stopped if elevations
occur. Oxandrolone should be used cautiously in children less than
4 years of age.
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Chemical thromboprophylaxis is generally
indicated but must be balanced against bleeding risk from wounds or
after surgery and adjusted for the hypermetabolic state
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critically ill burn patients are at risk for stress gastritis or
upper gastrointestinal stress ulcers (Curling ulcer). Prophylaxis with
an H2 blocker or a PPI is recommended, although intragastric continuous feeds are protective as well
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After treatment of CO poisoning, low FiO2 should be attempted to
prevent oxidative damage to the pulmonary parenchyma.
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Changes in clinical condition such as
worsening or new-onset hyper- or hypothermia, tachycardia, hypotension, insulin resistance, leukocytosis or leukopenia, rising lactates, or
base deficits should prompt a head to toe examination of the patient
for signs of secondary infection and a culture of any suspicious areas.
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Burn wound infections are treated with topical antimicrobial and broad-spectrum intravenous antibiotics targeting gram-positive organisms and pseudomonas if it appears the infection has spread
outside of the burn wound and into the surrounding soft tissues
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The interstices ofthe
mesh graft allow serum or small amounts ofbleeding to escape which
may improve mesh graft take rates when compared to sheet grafts.
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In an electrical burn, electricity travels along the path of least
resistance which in human tissue corresponds directly with the water
content of that tissue
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Creatine kinases are drawn for
quantification of muscle damage
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in frost bite Surgery should be delayed until full tissue demarcation
has occurred, which can take anywhere from 3 weeks to 3 months I
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Half-normal
saline is not used in acute burn resuscitation because it is hypotonic and would lead to increased volume ofresuscitation
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