Thermal Injuries

Question 1

What is the most effective way to stop the burning process when you are managing a burn patient?

Answer 1

Completely remove the patient’s clothing to stop the burning process

• don’t try to peel off adherent clothing though
• once clothing has been removed, cover the patient with warm, clean, dry linens to prevent hypothermia

Question 2

What are the factors that increase risk for upper airway obstruction in burn patients?

Answer 2

1. Burns to the face/head
2. Burns inside the mouth
3. Inhalation injury
4. Increasing burn size and depth
5. Associated trauma

**All of these can cause airway edema and obstruction

Question 3

What are the indications for early intubation in a burn patient? (9)

Answer 3

1. Signs of airway obstruction
2. Extent of the burn (TBA > 40-50%)
3. Extensive and deep facial burns
4. Burns inside the mouth
5. Significant edema or risk for edema
6. Difficulty swallowing
7. Signs of respiratory compromise: inability to clear secretions, respiratory fatigue, poor oxygenation or ventilation
8. Decreased LOC
9. Anticipated patient transfer of large burn with airway issue without qualified personnel to intubate en route

Question 4

Fill in the blank: A carboxyhemoglobin level > ___% in a patient who was involved in a fire also suggests inhalation injury.

Answer 4

10%

Question 5

What are the three causes of lower airway breathing concerns in a patient with burns?

Answer 5

1. Hypoxia
2. Carbon monoxide poisoning
3. Smoke inhalation injury

Question 6

What are the clinical features of carbon monoxide poisoning?

Answer 6

Patients with CO levels < 20% are usually asymptomatic.  
Higher CO levels cause:
1. N/V
2. Confusion
3. Coma
4. Death

Question 7

What is the affinity of Hgb for CO compared to O2? What can you do to help dissociate CO from Hgb?

Answer 7

Affinity of Hgb for CO is 240 times compared to O2.

• CO dissociates very slowly and the half life is 4 hours
• half life of HbCO can be reduced to 40 minutes by breathing 100% oxygen!! So make sure you put CO patients on 100% oxygen by non-rebreathing mask

Question 8

Can pulse oximetry be used to rule out carbon monoxide poisoning?

Answer 8

No - a pulse oximeter will still read as 100% O2 sat even though the patient has carbon monoxide poisoning since it isn’t able to distinguish the difference between carboxyhemoglobin and oxyhemoglobin

Question 9

What are 2 baseline tests you should obtain in a patient with smoke inhalation injury?

Answer 9

1. ABG

2. CXR

Question 10

What is the updated American Burn Association recommendations for fluid resuscitation in flame or scale burn injuries in adults as opposed to old Parkland Formula?

• when to give fluid bolus?
• what is the recommendations for fluid resuscitation in flame/scald burn injuries in children?

Answer 10

For adults: use 2 ml/kg/% TBSA for partial (superficial and deep) thickness and full thickness burns with Ringer’s Lactate over 24 hours

• Give 1/2 over first 8 hours and the next 1/2 over next 16 hours
• after this, adjust the rate of fluids given to target a urine-output of 0.5 ml/kg/hr for adults and 1 ml/kg/hr for children < 30 mg
• **This change was made from 4 ml/kg/%TBSA due to overresucitation with fluids
• Only bolus patients if they are hypotensive

For children: use 3 ml/kg/%TBSA

Question 11

What is the updated American Burn Association recommendations for fluid resuscitation in electrical injuries in adults as opposed to old Parkland Formula?
-what is the recommendations for fluid resuscitation in electrical burn injuries in children?

Answer 11

4 ml/kg/%TBSA given 1/2 over first 8 hours, then 1/2 over next 16 hours but titrate based on urine output
-this is for ALL ages!

Question 12

How do you estimate TBSA of burns?

Answer 12

Rule of 9s for partial and full thickness burns

• for adults, different body areas represent multiples of 9s
• for young children, can use the palmar surface of the patient’s hand (including the fingers) to represent approximately 1% of the patient’s body surface

Question 13

What are the classifications of burn depth?

Answer 13

1. Superficial thickness: erythema and pain only, no blisters. Heal well, do not require IV fluid replacement since epidermis remains intact. This is NOT included in TBSA calculation for burn involvement
2. Partial thickness: divided into superficial and deep. Superficial partial-thickness burns are moist, painfully hypersensitive, usually blistered, pink, blanch to touch. Deep partial-thickness burns are drier, less painful, usually blistered, red or mottled in appearance, do not blanch to touch
3. Full thickness: appear letathery, white, waxy, painless to touch, does not blanch, dry. No weeping

***The deeper the burn, the less pliable and eslastic it comes.

Question 14

A patient presents with a circumferential extremity burn. What steps should you take to maintain peripheral circulation?

Answer 14

1. Remove all jewelry/ID/allergy bands on the extremities
2. Assess peripheral pulses, CR, paresthesia/pain with passive stretching
3. May need to do escharotomy with surgical consultation (usually not needed within the first 6 hours of a burn injury)

Question 15

True or false: You should not apply cold water to a patient with extensive burns (>10% TBSA)

Answer 15

True! This will lead to hypothermia

Question 16

What is the role of prophylactic antibiotics in the early postburn period?

Answer 16

No evidence to support use of prophylactic antibiotics. Only use if signs of infection develop

Question 17

What type of burns do acids cause? What about alkali agents?

Answer 17

Acidic burns - coagulation necrosis

Alkali burns - liquefactive necrosis (more serious, alkali penetrates more deeply)

Question 18

What is the first step in managing a chemical burn?

Answer 18

Immediately remove all chemicals from skin, remove clothing and immediately flush away the chemical with large amounts of warmed water x 20-30 minutes at least with shower or hose. Alkali burns require longer irritation

Question 19

How long should you irrigate alkali burns to the eye?

Answer 19

Need continuous irrigation during the first 8 hours after the burn

Question 20

True or false: Electrical burns frequently are more serious than they appear on the body surface

Answer 20

True! Often the overlying skin can look normal but underneath there can be deep muscle necrosis
-can get injury to the digits, blood vessels (thrombosis) and nerves

Question 21

What is the immediate treatment of a patient with a significant electrical burn?

Answer 21

1. Establish an airway and ensure adequate oxygenation and ventilation
2. Place an IV line
3. ECG monitoring
4. Place an indwelling bladder catheter

Question 22

When should you do prolonged monitoring for an electrical injury?

Answer 22

1. Loss of consciousness
2. Have demonstrated injury from the burn
3. Exposure to high voltage (>1000 volts)
4. Cardiac rhythm abnormalities or arrhythmias on early evaluation

Question 23

How do you remove tar from skin in a tar burn?

Answer 23

Treatment overall includes rapid cooling of the tar and care to avoid further trauma while removing the tar
-use mineral oil to dissolve the tar (this is safe on injured skin)

Question 24

What are the criteria for transfer of patients to burn centers? (10)

Answer 24

1. Any full thickness burns
2. Partial thickness burns > 10%
3. Children with burns in hospitals not equipped to treat children
4. Burns in patients with preexisting medical disorders that could complicate management, prolong recovery or affect mortality (ie. diabetes, renal failure, etc.)
5. Any electrical injury
6. Any chemical burns
7. Burns to the face, hands, feet, genitals, perineum, major joints
8. Inhalation injury
9. Burn injury in patients who will require special social, emotional, or rehab interventions
10. Any patient with burns and concomitant trauma in which the burn injury poses the greatest risk of morbidity or mortality

Question 25

What are the two types of cold injury seen in trauma patients?

Answer 25

1. Frostbite | 2. Non-freezing injury

Question 26

What are the 4 categories of frostbite?

Answer 26

Frostbite: due to freezing of tissue, ice crystal formation causing cell membrane injury, microvascular occlusion, and subsequent tissue anoxia. Some tissue damage can also be due to reperfusion injury during rewarming 1. First-degree: Hyperemia and edema present WITHOUT skin necrosis 2. Second-degree: Large blisters/vesicles with hyperemia and edema with partial-thickness skin necrosis 3. Third-degree: Full thickness and subcutaneous tissue necrosis, commonly see hemorrhagic vesicle formation 4. Fourth-degree: full thickness skin necrosis including muscle and bone with later necrosis

Question 27

What is nonfreezing injury?

Answer 27

Due to microvascular endothelial damage, stasis and vascular occlusion - examples: trench foot or cold immersion foot (or hand) - usually result from long-term exposure to wet conditions and temperatures just above freezing - alternating arterial vasospasm and vasodilation occur with the affected tissue first cold and numb, then progress to hyperemia within 24-48 hours. With the hyperemia comes intense painful burning in addition to tissue damage (edema, blistering, redness, ecchymosis, ulcerations).

Question 28

What is the management of frostbite and nonfreezing injuries?

Answer 28

* **Do not attempt rewarming if there is a risk of refreezing 1. Remove cold, wet clothing and replace with warm blankets 2. Give the patient hot fluids by mouth if they're able to drink 3. Place the injured part in circulating water at a constant 40 degrees celcius until pink color and perfusion return (usually within 20-30 minutes) - either use a large whirlpool tank or place the injured limb into a bucket with warm water running in - do not rub or massage the area * *Rewarming can be ++ painful so use appropriate analgesia

Question 29

Why is it important to monitor a patient's cardiac status and peripheral perfusion during rewarming for a frostbite or nonfreezing cold injury?

Answer 29

Rewarming large areas can lead to reperfusion syndrome with resulting acidosis, hyperkalemia, local swelling and this could lead to arrhythmias

Question 30

What are the principles of wound care for frostbite?

Answer 30

1. Prevent infection 2. Do not open uninfected vesicles 3. Elevate the injured area 4. Protect the affected tissue by a tent or cradle 5. Avoid pressure to the injured tissue

Question 31

What are passive rewarming techniques?

Answer 31

Passive rewarming: placing the patient into an environment that reduces heat loss 1. Use dry clothing and warm blankets 2. Increase temp of the room 3. Overhead heat lamps 4. Bair huggers ***Used for mild hypothermia and relies on patient's intrinsic thermoregulatory mechanism to generate heat and raise body temperature

Question 32

What are methods of active rewarming?

Answer 32

Supplies heat energy to the patient and doesn't rely on patient to generate their own heat 1. Warmed IV fluids 2. Warmed packs to areas of high vascular flow such as the groin and axilla 3. Circulatory bypass (ECMO) ***Used for moderate and severe hypothermia

Question 33

In which patients with frostbite is rewarming not needed/unlikely to be effective?

Answer 33

If the patient presents several days after the frostbite has occurred with black, clearly dead toes/fingers/hands/feet

Question 34

What is the definition of hypothermia?

Answer 34

Any core temp < 36 degrees celcius | -severe hypothermia is any core temp < 32 degrees celcius