Thermal Injuries

Question 1

Burns result in both _____ and ______ inflammatory responses

Answer 1

local, systemic

Question 2

A burn is damaged tissue from thermal energy that ______ and ______ protein leading to irreversible damage

Answer 2

denatures, coagulates

Question 3

Systemic responses to burns (usually in 20% BSA or greater)

Answer 3

• cardiovascular (fluid to interstitial space, shock)
• respiratory (bronchoconstriction - respiratory failure, ARDS)
• metabolic (high nutritional demands)
• Immunological (infection risk)

Question 4

5 Types of burns

Answer 4

• heat
• electrical
• friction
• chemical
• radiation

Question 5

Why is it important to get an accurate estimation of burn size

Answer 5

to guide therapy and possible transfer to burn center

Question 6

TBSA stands for

Answer 6

total % body surface area

Question 7

3 methods of burn size estimation

Answer 7

• lund-browder chart
• rule of Nines
• palm method

Question 8

Rule of 9s

Answer 8

Question 9

Which burn size estimation is best used in pediatric cases?

Answer 9

Lund-Browder chart (considers relative % of body surface area affected by growth

Question 10

Burns suspicious for physical abuse

Answer 10

• scald burns with sharp demarcations
• distinct shape of objects
• small circular burns (cigarette)
• burns on perineal area (dip in)

Question 11

Burn classifications

Answer 11

Question 12

Superficial burns

Answer 12

• epidermis only
• no blisters
• painful, dry, erythematous, blancing
• heals 3-5 days
• no scarring
• Tx: remove clothing/jewelry, cool burn, NSAIDs

Question 13

Sunburn

Answer 13

• involves UVA and UVB (UVB = more erythema)
• Ddx: consider drug induced phototoxic reactions like phytophotodermatitis

Question 14

Superficial partial thickness burns

Answer 14

• involves epidermis and papillary layer of dermis
• blisters
• pain, erythema, moist, weeping, blanches
• heals 1-3 weeks
• infection risk
• Tx: cool water, NSAIDs, clean, debridement, topical abx

Question 15

Commonly used topical Antimicrobials for burns

Answer 15

• bacitracin, neomycin (allergic rxns)
• silver sulfadiazine (not on face, sulfa allergy, pregnancy)
• Bismuth petroleum gauze (used in skin graft)
• mefanide acetate
• chlorhexidine

Question 16

Deep partial thickness burns

Answer 16

• involves epidermis and reticular layer of dermis (hair follicles and glands)
• blisters
• painful only to pressure
• waxy, dry, red yellow or pale, non-blanchable
• heals 2-9 weeks
• hypertrophic scarring expected, joint impairment
• Tx: don’t cool/submerge, pain control, tetanus update, excision/closure, burn center, ICU, nutritional/psychological support, contracture management

Question 17

Full thickness burn

Answer 17

• involves epi, dermis, hypodermis
• same management as deep partial
• pain control with opioids

Question 18

4th degree burn

Answer 18

• extends into fat, muscle, bone
• no feeling, non-blanchable
• permanent damage
• extensive tissue reconstruction and debridement

Question 19

Diagnostics for major burns

Answer 19

• CBC
• Electrolytes (hyperkalemia)
• Creatinine Kinase for rhabdomyolysis
• carboxyhemoglobin (CO poisoning)
• serum lactate (cyanide poisoning)
• Arterial blood gas
• chest x ray
• end tidal CO2 and pulse ox
• ECG/EKG
• blood typing for transfusion

Question 20

Escharotomy

Answer 20

indicated for deep partial and full thickness burns, performed for circumferential burns to alleviate risk of compartment syndromes

Question 21

ABCDE for burns

Answer 21

airway
breathing
circulation
disability
exposure

Question 22

Airway

Answer 22

• signs of smoke inhalation injury (need for intubation, leading cause of death in burn pts)
• give supp oxygen to keep sats at 90-96%
• emergency cricothyroidotomy
• succinylcholine can be used in first 72 hrs (risk of hyperkalemia after)

Question 23

Breathing

Answer 23

• s/s of breathing impairment: decreased mental status, tachypnea, hypoxia, accessory muscle use
• use bronchodilators for bronchospasms
• DONT use corticosteroids d/t infection risk

Question 24

Disability/Exposure

Answer 24

• neuro status
• monitor core body temp to avoid hypothermia
• tetanus immunizations
• topical abx

Question 25

Circulation

Answer 25

- burn shock characterized by myocardial depression and increased capillary permeability - fluid resuscitation crucial (not overly though) for burns >15% TBSA - parkland formula - monitor urine output

Question 26

what is the parkland formula for circulation management?

Answer 26

method for calculating initial fluid resuscitation

Question 27

Steps for chemical burns

Answer 27

1. ensure PPE and remove patient from area of exposure 2. remove clothing/jewelry 3. determine chem exposure and call poison control prn 4. brush dry chemicals off 5. irrigate with water (except dry lime, phenols, elemental metals (Na, K, CaO, Magnesium, Phosphorus)

Question 28

Common alkalotic chemical burn

Answer 28

wet cement

Question 29

How to remove dry lime (chemical burn)

Answer 29

brush off prior to irrigation (can react into strong alkali with water)

Question 30

how to remove elemental metals (chemical burn)

Answer 30

dry forceps and place in mineral oil (can combust or release hazardous byproducts with water)

Question 31

how to remove phenol (chemical burn)

Answer 31

wipe off with sponge soaked in 50% polyethylene glycol (not water soluble)

Question 32

high voltage electrical injury

Answer 32

- lower morbidity than low voltage - AC more damaging than DC - skin burns appear mild compared to internal tissues/organs

Question 33

Cold injuries

Answer 33

frostnip, frostbite, chilblains (pernio)

Question 34

Frostnip

Answer 34

localized paresthesia that resolves with rewarming (1st stage of frostbite)

Question 35

Chilblains (pernio)

Answer 35

localized inflammatory lesions from repetitive exposure to damp cold above freezing

Question 36

Describe Grade 1 frostbite

Answer 36

- frostnip - no cyanosis, usually heals quickly

Question 37

Grade 2 frostbite

Answer 37

- cyanosis to distal phalanx - nail damage or soft tissue amputation

Question 38

Grade 3 frostbite

Answer 38

- intermediate and proximal phalanx cyanosis - bone amputation

Question 39

first degree frostbite

Answer 39

- superficial - central pallor surrounded by erythema

Question 40

describe second degree frostbite

Answer 40

- large blisters with clear fluid surrounded by edema and erythema - blisters may form eschar - no tissue loss

Question 41

third degree frostbite

Answer 41

- smaller blisters, hemorrhage, more proximal than 2nd degree - black eschar in 1+ weeks

Question 42

fourth degree frostbite

Answer 42

- muscle and bone involved - complete tissue necrosis - mummification in 4-10 days

Question 43

Frostbite management

Answer 43

- remove wet clothing, splint, dont rub or expose to fire - immerse in heated water to thaw - thrombolysis for sever injury - tetanus update - surgical consult - bulky dressing, elevate, hydrotherapy, abx controversial

Question 44

4 stages of NFCI (non freezing cold injury)

Answer 44

1st: during cold exposure 2nd: following exposure 3rd: hyperemia 4th: following hyperemia

Question 45

NFCI Treatment

Answer 45

- address systemic hypothermia - allow gradual rewarming - replace fluid loss - update tetanus - amitriptyline

Question 46

Grade 4 frostbite

Answer 46

- carpal or tarsal bones involved - bone amputation

Question 47

Tear gas (chemical burn)

Answer 47

remove clothing, wash with water brushing down and away from face

Question 48

Hydrofluoric acid (chem burns)

Answer 48

- highly corrosive - can cause hypocalcemia and hypomagnesemia leading to cardiac arrhythmias - Tx: water irrigation, topical 2.5% calcium gluconate gel