Burn Management

Question 1

Burns can cause?

Answer 1

Coagulative Necrosis

Question 2

If a burn is chemical or electrical in origin, what can it do to the body in addition to “heat transfer?”

Answer 2

Direct Injury to cell membranes

Question 3

What can cause a burn?

Answer 3

1. Flame
2. Scald
3. Contact
4. Chemical
5. Electricity

Question 4

What factors are taken into account for the depth of a burn?

Answer 4

1. Temperature
2. Time exposed
3. Specific Heat of the substance.

Question 5

When you are burned, what is released?

Answer 5

Inflammatory Mediators

Question 6

With a burn, there is an increased capillary permeability. What is the consequence of this?

Answer 6

• Lead proteins into interstitium

- Get edema into burned and non-burned skin

Question 7

T/F: There are large fluid loss due to fluid shifts in the body and also losses from exposed burned skin.

Answer 7

True

Question 8

Characteristics of Burn

Answer 8

1. Low metabolism/Cardiac Output
2. Decreased Temp
   Then!!!
3. Hypermetabolism
4. High Cardiac Output
5. Hyperglycemia
6. Increased Heat Production

Question 9

This occurs when too much fluid moves from the intravascular space (blood vessels) into the interstitial.

Answer 9

Third Spacing

Question 10

This is a type of burn that is localized to the epidermis (sunburn).

Answer 10

1st Degree Burn

Question 11

This is a type of burn that is injury to both the dermis and epidermis

Answer 11

2nd Degree Burn

Question 12

This type of burn is typically red, painful, blister, “wet” appearing. Regeneration usually occurs in 7-14 days from the hair follicles/sweat glands.

Answer 12

Superficial 2nd degree burn (Papillary Dermis)

Question 13

This type of burn is typically more pale/mottled, dry and decreased sensation.

Answer 13

Deep 2nd degree burn (Reticular Dermis)

Question 14

This is a type of burn that full covers the epidermis and dermis. It is commonly hard and leathery eschar. This is PAINLESS! (Goes into SQ fat)

Answer 14

Third Degree Burn

Question 15

This type of burn involves muscle, bone, etc.

Answer 15

Fourth Degree Burn

Question 16

When should you go to a burn center?

Answer 16

1. Partial Thickness >10% if less than 10 yo, or greater than 50 yo
2. Partial Thickness >20%
3. Face, Hands, Feet, Genital/Perineum, Joints
4. Full thickness >5%
5. Electrical Injury
6. Chemical Burn
7. Inhalation Injury
8. Comorbidities like CHF
9. Concomitant Trauma
10. Children
11. Special, emotional, social, or rehab needs

Question 17

What do you do when someone comes in with a burn? (ABCDE)

Answer 17

1. Airway – give O2, put on pulse ox, pre-emptively intubate as needed
2. Breathing - sounds and chest rise
3. Circulation
4. Disability - GCS < 8 = Intubate
5. Exposure - remove clothing

Question 18

Airway complications with housefires

Answer 18

1. Direct injury from heated air/smoke –> Edema
2. Edema from inflammatory response to burns
3. Edema from the resuscitation fluids

Question 19

What does progressive hoarseness indicate?

Answer 19

Impending Airway Obstruction

Question 20

When do you pre-emptively intubate anyone?

Answer 20

• Respiratory Distress
• Inhalation Injury (Bronch helps dx this)
• Large burns (due to edema)

Question 21

Things to do with circulation in a burn victim:

Answer 21

1. 2 large bore IV
2. Start burn resuscitation with Lactated Ringers
3. PLace patient on continuous EKG/monitor
4. Palpate or doppler extremity signals with circumferential Burns

Question 22

Initial Assessment of Burn victims after the ABCDE! (AMPLE)

Answer 22

A-Allergies
M-Medications (also ask about last tetanus)
P-PMH (CHF = careful with fluids)
L-Last meal
E-Events regarding the injury (how did it start, how long where you exposed, what type?)

Question 23

When figuring out the burn size, what is a good rule of thumb?

Answer 23

The size of the palm of the hand is roughly 1% or the Rule of 9s (will see the Rule of 9s later)

Question 24

What is the Parkland Formula?

Answer 24

4 x weight(kg) x %TBSA = ml to give in 1 day

– Titrate to UOP of 0.5 mL/kg/hr in adults and 1 mL/kg/hr in children

DO NOT GIVE COLLOID IN FIRST 24 HOURS

Question 25

What is the rule of 9s?

Answer 25

- Head and Neck = 9% - Upper extremity (Arms) = 9% - Each lower extremity (Legs) = 18% - Anterior Trunk = 18% - Posterior Trunk = 18% - Genitalia (perineum) = 1%

Question 26

Burn Wound Management

Answer 26

- Circumferential deep 2nd or 3rd degree extremity burn can compromise circulation - Assess for the 6 P's = Pain, Pallor, Pulselessness, Paresthesias, Paralysis, Poikilothermia - Directly Measure tissue pressure (30 mmHg is cutoff)

Question 27

How do you treat burn wounds?

Answer 27

Escharotomy (is a surgical procedure used to treat full thickness (third-degree) circumferential burns. Since full thickness burns are characterized by tough, leathery eschar, an escharotomy is used primarily to combat compartment syndrome)

Question 28

Why are burn patients susceptible to infection?

Answer 28

- Due to immunologic insult of large burns | - Dead tissue is easily colonized

Question 29

Treatment for Superficial 2nd degree?

Answer 29

Temporary pig skin

Question 30

Treatment for 3rd and most deep 2nd degree burns?

Answer 30

Early excision and grafting, except palm/soles/face/genitals.

Question 31

What are topical antimicrobials for burns?

Answer 31

1. Sulfamylon for ears (SE: metabolic acidosis via carbonic anhydrase inhibition) 2. Bacitracin for face (Few SE) 3. Silvadene for trunk, neck, extremities (SE: neutropenia, thrombocytopenia)

Question 32

Tell me about electrical burns

Answer 32

1. Most significant injury is within deep tissue 2. Edema can compromise circulation 3. Be ready to perform eschar-/fasciotomies 4. Explore & debride necrotic tissue 5. May have to re-explore questionable areas 6. EKG if heart was in conduction path 7. Follow serial CPK & urine myoglobin due to possibility of rhabdomyolysis

Question 33

Tell me about Chemical Burns

Answer 33

1. Speed is essential 2. ABCDE – remove all clothing 3. Irrigate with 15-20L of water (Brush off any dry powder before irrigation) 4. Alkalis generally cause worse damage 5. Do not attempt to counteract acid burns using alkali or alkali burns using acid

Question 34

Why is nutrition important in burn surgery victims?

Answer 34

Patients with major thermal injury develop a hypermetabolic state characterized by increased basal metabolic rate, increased oxygen consumption, negative nitrogen balance, and weight loss. Subsequently, these patients have increased caloric requirements to prevent delayed wound healing, decreased immune competence, and cellular dysfunction.

Question 35

In a burn patient, what is the goal of OR treatment?

Answer 35

Debridement of devitalized tissue

Question 36

What is a skin graft involving cadaver skin?

Answer 36

Allograft

Question 37

How does an allograft help?

Answer 37

It VASCULARIZES and engrafts and provides physiologic wound closure for 2 to 4 weeks, at which point it typically is rejected and must be replaced with either new allograft or preferably autograft from reharvested donor sites.

Question 38

What is a skin graft involving pig skin?

Answer 38

Xenograft

Question 39

How does a xenograft work?

Answer 39

Porcine xenograft can also be used as a cheaper alternative, but it will NOT vascularize and will not engraft. When widely meshed skin grafts are necessary, overlayed sheets of allograft can be used on top of the autografts to protect the wound bed as the meshed interstices epithelialize.