Burns Flashcards by Iseoluwa Ojo

DEFINITION
Burn injury is a major trauma resulting from the _________________ leading to _____________________ and resultant _________ fluid distribution and losses, inflammatory and immune disturbances that may result in mortality.

transfer of heat energy

disruption of tissue integrity

systemic

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THERMAL BURNS: EPIDEMIOLOGY
BURNS

Less than _____% of burn injuries are severe enough to present at the hospital, of this group only _____%
require admission, the rest can be managed on outpatient basis.

10; 10

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THERMAL BURNS: EPIDEMIOLOGY
BURNS

Scalds are usually common in children less than _________ occurring usually in the kitchen or bathroom. It may also result from child abuse.

From ___-____ yr., clothing fires are usually common, for the 15-60-year group ___________ and _________ are usually common, while in the age
group greater than 60 years is usually have associated comorbid medical factors.

3 years; 3-14

industrial accidents ; house fires

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The commonest etiological agent in this pediatric burn group was _______________ and most resulted from domestic accidents from cooking with open hearths and Kerosene stoves.

The commonest affected group was the _________ socioeconomic group, and the Zaria and Calabar studies reveal a high absconsion rate from the wards because of inability to continue treatment for financial reasons.

hot water scald

lowest

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All studies generally reveal a (male or female?) preponderance of 1.2: 1,
which is similar to studies from abroad.

Male

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Chemical burns usually result from ___________ . Like in the American literature the upper parts of
the body are usually affected with severe morbidity to the eyes nose, mouth and neck. In the
report from Lagos it constitutes less than _____% of all burns. The low incidence is due to the low level of ___________ .

assault

industrialization

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Chemical burns

Types of chemicals usually involved are inorganic acids such as
___________ used by battery chargers and alkali such as ____________ used by cottage industries in the production of soap.

sulphuric acid

sodium hydroxide

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PATHOLOGY OF BURNS
The morbidity and mortality of burns is usually determined by the ________ of burns, the ________
burnt, the ______ of the patient and other co-morbid factors such as controlled or uncontrolled medical
illness and inhalation injury.

depth; surface area

age

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DEPTH OF BURNS
This depends on three factors

The ________________ of heat i.e. Temperature ________ /_____ of chemical / _________ for electricity
i.e. potential difference

2.___________ of exposure to flame / contact of chemical or electricity

3 ____________ of the skin: Vascular areas of the body _____________ fast from the surface resulting in
(more or less?) severe burns on the surface.

source intensity; gradient; pH

Voltage; Duration; Vascularity

conduct heat; less

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Flash burns, from explosions and electrical arc injury, are _____
intensity source of _______ duration, which results in _________ of the epidermis with relative __________ of the dermis.

high; short; carbonization

preservation

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While _______ intensity burns e.g. falling into hot water results in _______ exposure and _________ burns.

low; longer; deeper

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BURNS: pathology

The pathology range from the acute inflammatory effects of _______ that is mainly epidermal to charring found in more severe flame burns.

sunburn

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Burns: Pathology

The earliest cellular effect seen is a reversible ___________________________________ . With progressive thermal injury there is irreversible ________________________________ . Progressive damage results in thermal _________ and finally ___________ .

clumping of nuclear chromatin

coagulation of cytoplasmic proteins

desiccation; carbonization

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Histologically the burn wound consists of three main zones

The ZONE OF COAGULATION. This contains ____________________
tissue
The ZONE OF STASIS is immediately below; consist of an area of ______________________ . This contains _________________ tissue
The next is the ZONE OF HYPEREMIA with _________________.
Characterize inflammation
The is followed by the zone of _______
In very severe burns the closest zone is a zone of __________.

irreversibly damaged

stagnant (not clotted) blood

reversibly damaged

an increased blood flow.; edema

charring

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Histologically the burn wound consists of three main zones

The ZONE OF ___________.
The ZONE OF ___________
The ZONE OF _____________

COAGULATION

STASIS

HYPEREMIA

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in severe burns the whole body becomes a zone of edema

T/F

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The zone of stasis is progressively converted to the zone of _______________ of tissue damage over _________ post burn; hence the burn appears to deepen. This (can or cannot ?) be prevented by the use of moist dressings but by the ___________ and application of ————————— or other biologic
dressing.

coagulation; 48 hours

early excision; cutaneous allograft

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DEPTH OF BURNS

Classically the depth of burning has been classified as

FIRST DEGREE: No _______ ,erythema or carbonization of epidermis heals in ————— -

SECOND DEGREE : Presents with _________ and when these are de-roofed a ________ wound is seen and
heals in __________ . If pressure is applied and there is ___________ it is superficial second degree, else it is deep second degree

THIRD DEGREE burns. There are _____________ but a white or brown or black bed indicating ______________________________ .

Blisters; 5-7 days

blisters; pink; 14-21days; blanching

no blisters

complete destruction of the dermis

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A more pragmatic classification that is only concerned with the ability of the wound to heal spontaneously, is functional classification

______________ which is likely to heal without surgical intervention and _________________ burns not likely to heal without intervention

PARTIAL THICKNESS

FULL THICKNESS

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PARTIAL THICKNESS:

Divided into 3

(1)__________ BURNS = ______ DEGREE BURN e.g. ____________

(2) _____________
_________________
= ___________ DEGREE

FULL THICKNESS: __________. = _________ DEGREE

EPIDERMAL; FIRST; Sun Burn

SUPERFICIAL DERMIS ; DEEP DERMAL; SECOND

all dermis; THIRD

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Clinically first degree burns appear as a ______________ in Caucasians but it is usually caused by __________ and is not common in black skinned, but if present is usually characterized by __________ and ___________ . Healing is usually complete in __________ .

painful erythema

sun burn; pain ; shininess

one week

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deep second degree burns usually heal with __________________.

hypertrophic scarring

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Full thickness or third degree burns are usually (wet or dry?) , pain_____, leathery white, brownish or frankly
charred. This burn heals from the margin and results in poor scars and contractures and best treated
surgically

dry; painless

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PATHOPHYSIOLOGY

Burns usually result in _____________ , which is the first stage of the healing process. This process consists of the __________ and the __________ reaction.

inflammation; cellular

humeral

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The ________ reaction in inflammation results in the activation of COAGULATION, COMPLEMENT BRADYKININ-KININ, PROSTAGLANDIN, XANTHINE OXIDASE systems, which act locally and HISTAMINE that acts systemically

Humeral

Burns Pathophysiology The cellular factors of the inflammatory phase are responsible for the prolonged __________________________. If severe and prolonged this may lead to MULTIPLE ORGAN FAILURE SYNDROME and death.

SYSTEMIC INFLAMMATORY RESPONSE SYNDROME (SIRS)

A lipoprotein factor produced from damage skin called ____________________ also contributes to perpetuation of SIRS.

CUTANEOUS BURN TOXIN (CBT)

Burns pathophysiology The presence of pain leads to the release of CORTISOL, ___________, _______________ in addition IL-1, and IL-2 also contributes to the effects of ________________ . These mediators affect all organ systems of the body.

GLUCAGON ; CATHECOLAMINES insulin resistance

Burn Pathophysiology CARDIVASCULAR _________ CARDIAC OUTPUT + __________ PERIPHERAL RESISTANCE POOR ____________ The combined effect of this is Hypovolemic SHOCK.

REDUCED; INCREASED MICROCIRCULATION

HEMATOPOIETIC (BURN ANAEMIA) 1. HEMOLYSIS: Damage to red blood cells _______________ , with shortened half-life of cells _________________ at the time of burning. 2. APLASIA: ________________ 3. IATROGENIC: Loss of blood from __________ and loss of blood from _____________________ 4. MICRO-ANGIOPATHIC: Damage to normal cells flowing through damaged burnt vessels. The gross effect of this is HYPOCHROMIC anemia.

underlying the burnt skin adjacent or close Bone Marrow suppression. dressings; repeated sampling for investigations.

Burns: Pathophysiology RENAL 1. The presence of SHOCK, ____________ from burnt muscles and ______________ from hemolysis results in ACUTE TUBULAR NECROSIS or severe cases FAILURE ACUTE CORTICAL NECROSIS. This may be worsened with the use of _______________ , such as gentamicin. The gross effect is ACUTE RENAL FAILURE.

MYOGLOBINURIA HEMOGLOBINURIA AMINOGLYCOSIDES

Burns: Pathophysiology GASTRO-INTESTINAL 1. In burn shock compensatory mechanism ____________________ , and this ISCHEMIA results in __________ 2. The ischemic process also results in weakened _____________ leading to CUSHINGS ULCERS or CURLINGS ULCER. These ulcers may bleed or perforate 3. In the first 16-hour’s post burn the GIT mucosa become _________ and allow ___________ of BACTERIAL, ENDOTOXIN and CANDIDA. These organisms may later localize in distant sites causing infection.

divert blood from the GIT ILEUS; mucosal resistance leaky; TRANSLOCATION

Gastro intestinal complications of burns _____________ of the patient prevents this complication.

Early feeding

Burns : Pathophysiology RESPIRATORY Hyperventilation leads to a mild ________________ . In inhalation injury, ________ respiratory failure occurs

respiratory alkalosis acidosis

Burns: Pathophysiology CENTRAL NERVOUS SYSTEM Hypoxia from shock leads to a reduced cerebral perfusion leading to ____________ .

confusion

Burns : Pathophysiology ENDOCRINE The endocrine system is stimulated to produce GLUCACON, CORTISOL, CATHECOLAMINES and T3 / T4. These hormones in combination with the cytokines cause an _________________. The whole effect on the endocrine system results in a NEGATIVE NITROGEN BALANCE and __________

INSULIN RESISTANCE MALNUTRITION

Burns : Pathophysiology IMMUNE SYSTEM 1. The LOSS OF __________ with ADSORPTION OF BACTERIA AND ENDOTOXIN from the burn wound leads to susceptibility to wound infection and ____________ The reduced polymorph nuclear leukocyte MIGRATION, the UPTAKE AND DESTRUCTION BACTERIA

INTERGUMENT septicemia

Burns : Pathophysiology IMMUNE DEPRESSION There is excessive LOSS of ____________ from the wound Abortive proliferation and production of IL-2 by lymphocytes, EXCESS PRODUCTION OF SOLUBLE IL-2 RECEPTORS REVERSAL OF CD4/CD8 LYMPHOCYTE RATIOS The presence of CUTANEOUS BURN TOXIN 10. The use of INVASIVE __________\ All these contribute to a global profound immune depression and susceptibility to invasive sepsis.

IMMUNOGLOBULINS CATHETERS

SURFACE AREA BURNT The surface area burnt is usually estimated either using the _________________ or the LUND AND BROWDER CHART

WALLACES RULE OF NINE

RULE OF NINE Parts of the body head/neck and upper limbs are _______%, anterior trunk posterior truck, lower limbs ______% and Perineum ____%

9; 18 1

SEVERITY OF BURNS CRITERIA FOR HOSPITAL ADMISSION (DEFINITION OF MAJOR BURN) 1. Patients with burn over _____% body surface in children or _____% body surface area in adults. 2. Patients with deep burn of equal or greater than ____% ___-thickness in any age. 3. Burns involving the ____,_______,_______, and _______ 4. If ________________ is present 5. All __________ burns 6. All _________ burns 7. Any patient with pre-morbid history of hypertension, diabetes or other controlled or uncontrolled medical illness. 8.Any patient less than ____ year-old or older than ____- years. 9.If outpatient treatment is impossible on account of distance, education or intelligence the patient should be admitted. 10. All ____________ burns irrespective of the size or age of the patient.

10; 15 ; 5; full head, neck, hands, feet and perineum. smoke inhalation injury chemical; electrical ; one-; 50 contaminated

A contaminated burn is any burn in which ________________________ e.g. raw eggs, engine oil, pap etc. has been applied.

any unorthodox material

Any burn presenting more than _________ after injury is no more a fresh burn wound.

24 hours

The goals of treatment are 1. TO ____________ 2. PREVENT ____________ 3. TO TREAT ___________ AS THE ARISE 4. ____________ i.e. PHYSICAL, PSYCHOLOGICAL AND ECONOMIC OUTPATIENT TREATMENT

PRESERVE LIFE COMPLICATIONS COMPLICATIONS REHABILITATE

OUTPATIENT TREATMENT They are given anti-tetanus booster prophylaxis of sub- cutaneous ______________ for immune individuals. For the non-immune individuals, they are given intramuscular ________ units of ___________________

0.5mls of tetanus toxoid 1500; anti-tetanus serum and anti-tetanus toxoid 0.5ml.

OUTPATIENT DEPARTMENT The wounds are cleaned with dilute hibitane ________ or dilute _________ or some other disinfectant such as Savlon. _________ impregnated with ___________ (paraffin gauze or Jelonet or sofratulle) is applied. Apply _____________ cream such as __________ , followed by enough layers of sterile gauze and the dressing is secured with gauze bandage.

1:1000; Savlon Gauze; petroleum jelly anti-microbial; Dermazine

OUTPATIENT TREATMENT _________ bandaging should be avoided, as it will not allow inflammatory edema

Crepe

OUTPATIENT TREATMENT The patient should be placed on oral broad spectrum antibiotic such as- __________ or __________ for those that are allergic to penicillin’s. The patient is instructed to return every ______ for dressings, for the first ________ and alternate day afterwards, or if the dressings become soaked or come off, or is malodorous or painful or if the patient develops a fever.

ampiclox or erythromycin day; 3 days

OUTPATIENT TREATMENT All patients who do not show satisfactory healing in __________ are admitted for grafting or treatment of infection.

2 weeks

In addition, __________ ______-thickness burn eschar of the extremity can lead to compartment syndrome and ischemia. In the chest and abdomen this may lead to restriction of respiration. Timely ______________ or ____________ will relive the ischemia and respiratory difficulty.

circumferential full bilateral escharotomy ; fasciotomy

An escharotomy is ?????? .

an incision made on the burnt skin (eschar) down to the subcutaneous tissue to relieve the tourniquet effect due to a burn eschar

EXAMINATION History of injury and ______ of the injury should be noted.

time

Explosions and burns sustained in a closed space are usually associated with inhalation injury. T/F

Other symptoms of inhalation injury are a _______ cough, ______ nasal vibrissae, ________ sputum, _______ and ________ burns.

brassy; singed carbonaceous head and neck

The diagnosis of inhalation injury is usually aided with ____________________.

fibreoptic bronchoscopy

FLUID RESUSCITATION The urine output should be aimed for ______ ml/kg/hour , the higher values are usually used in patients with _______ burns or deep burns with __________ . In children the acceptable output should be ____ml/kg/hour.

0.5- 1 ; electrical myoglobinuria; 1

Fluid resuscitation The urine load must not be produced under _____________ of _________ or ________ .

an osmotic load dextrose ; mannitol

The crystalloid only resuscitation fluids are now more popular Why?

it is being shown that colloids given in the first 16 hours leak out of the vascular space and worsen the edema.

The maximum limit of fluid calculation should be _____% BSA.

In most crystalloid based formulae, half of the calculated fluid should be completed at _________ post-burn and the remaining half given in the next ___________ . ____% of the calculated dose is given in the next 24 hours.

8 hours 16 hours; 50

Fluid Resuscitation Administer whole blood transfusion : for burns 40-50% BSA ___mls/kg/%BSA, for burns 51-60% BSA give ____mls/kg/%BSA for burns greater than 60% BSA give ____mls/kg/%BSA.

0.3 0.4 0.5

In the Muir and Barclay formula ____ rations are given in the first 12hours, ___hrly, ____ rations in the next 12hours, ___hrly and ____ ration in the last 12hours, ___hrly

3; 4 2; 6 1; 12

FORMULA PARKLAND =??

4ml/kg/%BSA

FORMULA: MUIR AND BARKLEY __________________ =1 RATION

(WEIGHTx %BSA)/2

PAIN MANAGEMENT Adequate pain management is given with __________ 0.2mg/kg 6 hourly or 0.05mg/kg/hr for patient controlled analgesia in the first 72 hours. Alternatively, 0.4-0.8mg/kg of ————- 3 to 6 may be used. After __________ convert to _________ and or non-steroidal anti-inflammatory drugs.

IV morphine ; pentazocine 72hours paracetamol

Pain Management For break through pain from therapeutic procedure e.g. _________ should receive morphine 0.1-0.15mg/kg or pentazocine 0.4mg/kg. These may be combined with IV diazepam® or dormicum®

dressings

Children may be given IM ketamine in 1mg/kg in addition to diazepam T/F

MANAGEMENT OF THE BURN WOUND This should commence after adequate resuscitation. It includes cleansing the wound daily in a __________, in a bath containing __________/________ solution, application of topical ________ ® daily for ___________ then alternate application of Dermazine®. An alternative topical agent is Mafenide Acetate (Sulfamylon®).

hydrotherapy weak hibitane / Savlon Dermazine; 2 weeks

Dermazine® is effective against Gram _________ bacteria, while Sulfamylon® is effective against Gram __________ and particularly Pseudomonas aeruginosa.

positive negatives

The side effects of this agent are that Sulfamylon® causes ______________ due to _______________________ . It is also painful to apply. On the other hand Dermazine® causes a ______________ that is reversible on discontinuation of therapy.

metabolic acidosis inhibition of carbonic anhydrase leukopenia

Wounds that are being prepared for grafting should be dressed with either paraffin gauze or __________ ® as this encourages the formation of healthy granulation tissue.

Sofratulle

METHODS OF DRESSING 1. EXPOSURE METHOD The wound is ___________ after the application of topical antimicrobials. The wound must be protected from insects under a mosquito net. The air environment must be ______ and not _______ . A protective crust is soon formed.

exposed to air dry dusty

METHODS OF DRESSING 2. CLOSED METHOD This done by the application of ___________ ———— based _________. A fluffy layer of __________ and a sterile layer of ___________ , that is retained by plaster or gauze bandage.

non-sticky paraffin based gauze sterile gauze absorbent cotton wool

Wound monitoring involves a daily wound inspection and a daily wound swab microscopy culture and sensitivity for first ___________ , then _____________ wound swab microscopy culture for the rest of the admission.

7 days; twice weekly

WOUND DEBRIDEMENT AND WOUND CLOSURE There are two methods the CONSERVATIVE and ACTIVE management. CONSERVATIVE: Management allows for __________________ under occlusive or exposure under topical antimicrobial. Any complications arising from the management are e.g. chronic unhealed burn wound, hypertrophic scars, keloids etc.

spontaneous healing

WOUND DEBRIDEMENT AND WOUND CLOSURE ACTIVE: This involves active ____________ of the wound and active closure with some form of _________________.

surgical debridement biologic dressings

Forms of biologic dressings There are three recognized surgical methods, i.e. list them

EPIFASCIAL EXCISION , Escharotomy, and Tangential excision

Forms of biologic dressings There are three recognized surgical methods, i.e. EPIFASCIAL EXCISION, which is excision to the _______________ . This type of excision is usually associated with (more or less?) hemorrhage and (good or bad?) graft take. However, the cosmetic deformity is gross on account of loss of ______________________.

deep fascia; less good all subcutaneous fat padding

Forms of biologic dressings The other method is escharotomy where the eschar is excised with scalpel. This management is associated with __________ hemorrhage and ______ graft take over the adipose tissue bed left by the ___________ . These methods are usually reserved for small burns.

considerable poor necrectomy

Forms of biologic dressings Tangential excision involves the removal of burn eschar , ____________ using a _____________ . It is associated with __________ hemorrhage and not more than _____ % of the body surface is excised at any one sitting.

layer by layer; dermatome considerable; 20

within _________ of excision i.e. within the shock phase it is called ACUTE EXCISION . If closed between ______ and __________ of injury, it is called EARLY EXCISION. Any excision beyond ___________ is called i.e. after complications begin to manifest is called LATE EXCISION.

five days one and two weeks two weeks

After excision the wound may be closed by many alternative methods, which _______ autografts, ________ allografts, porcine xenograft, cultured autogenous keratinocytes or skin substitutes.

Skin; cadaveric

PROPHYLAXIS FOR STRESS ULCERS For the patients who present early after burns i.e. less than ____________ has been shown to protect the gut mucosa and prevent translocation of intestinal bacteria.

12 hours oral feeding

PROPHYLAXIS FOR STRESS ULCERS However, patients presenting late, nil per Os and naso-gastric drainage is preferred because of the tendency to develop ______ . In all patients with surface extensive major burn _________ and ____________ is given.

ileus; antacids H2 receptor blocker

SEPSIS MONITORING The earliest sign in most septicemia patients is ______________ . This is later followed by _________ , __________ in the young and elderly patients, hyperthermia in most patients.

a loss of appetite hypotension; hypothermia

NUTRITION The metabolic demands of the burn injury demand that the patient be given a _____ calorie And ______ protein diet with increased dose of multi-vitamins.

High high

NUTRITION The caloric intake is calculated and is preferably given _______. However, the _________ routes for supplementation or a total parenteral nutrition is used if the enteral route is inadequate or contra-indicated.

enteral intravenous

NUTRITION The Nutritional Status is monitored by twice weekly ___________________ and a twice weekly ________ estimation in the first week and weekly thereafter.

weighing (kg)/height (meter) serum protein

PHYSIOTHERAPY Physiotherapy should be commenced as soon as possible after resuscitation. An attempt should be made to mobilize the patient within __________

48 hours.

Burns Flashcards

(89 cards)