1
Q
What is TBSA?
A
- Total Body Surface Area
2
Q
What is STSG?
A
- Split Thickness Skin Graft
3
Q
Are acid or alkali chemical burns more serious?
A
- ALKALI burns because the body cannot buffer the alkali, thus allowing them to burn for much longer.
4
Q
Why are electrical burns so dangerous?
A
- most of the destruction from electrical burns is internal because the route of least electrical resistance follows nerves, blood vessels, and fascia; injury is usually worse than external burns at entrance and exit sites would indicate; CARDIAC DYSRHYTHMIAS, myoglobinuria, acidosis, and renal failure are common.
5
Q
How is myoglobinuria treated?
A
HAM:
- Hydration with IV fluids
- Alkalization of urine with IV bicarbonate
- Mannitol diuresis
6
Q
What is a FIRST-degree burn?
A
- epidermis only
7
Q
What is a SECOND-degree burn?
A
- epidermis and varying levels of dermis
8
Q
What is a THIRD-degree burn?
A
- “full thickness” including the entire dermis
9
Q
What is a FOURTH-degree burn?
A
- burn injury into bone or muscle
10
Q
How do FIRST-degree burns present?
A
- painful, dry, red areas that do not form blisters (think of sunburn).
11
Q
How do SECOND-degree burns present?
A
painful, hypersensitive, swollen, mottled areas with BLISTERS and open weeping surfaces.
12
Q
How do THIRD-degree burns present?
A
- painless, insensate, swollen, dry, mottled white, and charred areas; often described as DRIED LEATHER.
13
Q
What is the major clinical difference between SECOND- and THIRD-degree burns?
A
- THIRD-degree burns are painless, and SECOND-degree burns are painful.
14
Q
By which measure is burn severity determined?
A
- depth of burn and TBSA affected by second and third degree burns.
15
Q
How is TBSA calculated?
A
- by the “rule of nines” in adults and a modified rule in children to account for the disproportionate size of the head and trunk.
16
Q
What is the “rule of nines”?
A
- each upper limb= 9%
- each lower limb= 18%
- anterior and posterior trunk= 18% each
- head and neck= 9%
- perineum and genitalia= 1%
17
Q
What is the “rule of the palm”?
A
- surface area of the patient’s palm is 1% of the TBSA (used for estimating size of small burns).
18
Q
What is the burn center referral criteria for SECOND-degree burns?
A
- greater than 20% of TBSA
* greater than 10% TBSA in children
19
Q
What is the burn center referral criteria for THIRD-degree burns?
A
- greater than 5% TBSA
- any burns involving the face, hands, feet, or perineum
- any burns with inhalation injury
- any burns with associated trauma
- any electrical burns
20
Q
What is the treatment of FIRST-degree burns?
A
- keep clean, Neosporin, pain meds
21
Q
What is the treatment of SECOND-degree burns?
A
- remove blisters; apply antibiotic ointment (Silvadene) and dressing; pain meds
22
Q
Do most SECOND-degree burns require skin grafting?
A
- NO, because the epidermis grows form hair follicles and from margins.
23
Q
What are some newer options for treating a SECOND-degree burn?
A
- Biobrane (silicone artificial epidermis- temporary)
2. Silverlon (silver ion dressings)
24
Q
What is the treatment of THIRD-degree burns?
A
- early excision of eschar (within first week postburn) and STSG (split thickness skin graft)
25
How can you decrease bleeding during excision?
- tourniquets as possible, topical epinephrine, topical thrombin.
26
What is a n autograft STSG?
- STSG from the patients own skin
27
What is an allograft STSG?
- STSG from a cadaver (temporary coverage)
28
What thickness is the STSG?
- 10/1000 to 15/1000 of an inch (down to the dermal layer)
29
What prophylaxis should the burn patient get in the ER?
- tetanus
30
What is used to evaluate the eyes after a third-degree burn?
- fluorescein (dye used to detect foreign bodies in the eyes).
31
What principles guide the initial assessment and resuscitation of the burn patient?
- ABCDEs, then urine output; check for eschar and compartment syndromes
32
What are the signs of smoke inhalation?
- smoke and soot in sputum/mouth/nose, nasal/facial hair burns, carboxyhemoglobin, throat/mouth erythema, history of loss of consciousness/explosion/fire in small enclosed area, dyspnea, low O2 saturation, confusion, headache, coma.
33
What diagnostic imaging is used for smoke inhalation?
- bronchoscopy
34
What lab value assesses smoke inhalation?
- carboxyhemoglobin level (greater than 60% is associated with a 50% mortality).
- treat with 100% O2 and time
35
How should the airway be managed in the burn patient with an inhalation injury?
- with a low threshold for intubation; oropharyngeal swelling may occlude the airway so that intubation is impossible; 100% oxygen should be administered immediately and continued until significant carboxyhemoglobin is ruled out.
36
What is burn shock?
- the loss of fluid from the intravascular space as a result of burn injury, which causes "leaking capillaries" that require crystalloid infusion
37
What is the parkland formula?
V= TBSA burn (%) x weight (kg) x 4
- used to estimate the volume (V) of cyrstalloid necessary for the initial resuscitation of the burn patient; half of the calculated volume is given in the FIRST 8 HOURS, the rest in the next 16 hours.
38
What burns qualify for the parkland formula?
- greater than 20% TBSA second and third-degree burns only
39
*** What is the Brooke formula for burn resuscitation?
- replace 2 cc for the 4 cc in the parkland formula
40
How is crystalloid given?
- through 2 large-bore peripheral venous catheters
41
Can you place an IV or central line through burned skin?
- YES
42
What is the adult urine output goal?
- 30-50 cc (titrate IVF)
43
Why is glucose-containing IVF contraindicated in burn patients in the first 24 hours postburn?
- patient's serum glucose will be elevated on its own because of the stress response
44
What fluid is used after the first 24 hours postburn?
- colloid; use D5W and 5% albumin at 0.5 cc/kg/% burn surface area
45
Why should D5W IV be administered after 24 hours postburn?
- because of the massive sodium load in the first 24 hours of lactated ringers infusion and because of the massive evaporation of H2O from the burn injury, the patient will need free water.
- AFTER 24 hours, the capillaries begin to work and then the patient can usually benefit from ALBUMIN and D5W
46
What is the minimum urine output for burn patients?
- adults= 30 cc
| - children= 1-2 cc/kg/hr
47
How is volume status monitored in the burn patient?
- URINE OUTPUT, blood pressure, heart rate, peripheral perfusion, and mental status
* Foley catheter is mandatory and may be supplemented by central venous pressure and pulmonary capillary wedge pressure monitoring.
48
Why do most severely burned patients require nasogastric decompression?
- patients with greater than 20% TBSA burns usually develop a paralytic ileus, which leads to vomiting, which increases aspiration risk and pneumonia.
49
What stress prophylaxis must be given to the burn patient?
- H2 blocker to prevent burn stress ulcer (curling's ulcer)
50
What are the signs of burn wound infection?
- increased WBC with left shift
- DISCOLORATION OF BURN ESCHAR (most common sign)
- green pigment
- necrotic skin lesion in unburned skin
- edema
- ecchymosis tissue below eschar
- hypotension
51
Is fever a good sign of infection in burn patients?
- NO!
52
What are the common organisms found in burn wound infections?
- staph aureus
- pseudomonas
- strep
- candida albicans
53
How is a burn wound infection diagnosed?
- send burned tissue in question to the laboratory for quantitative burn wound bacterial count
54
How are MINOR burns dressed?
- gentle cleaning with nonionic detergent and debridement of loose skin and broken blisters; the burn is dressed with a topical antibacterial (neomycin) and covered with a sterile dressing.
55
How are MAJOR burns dressed?
- cleansing and application of topical antibacterial agent
56
Why are SYSTEMIC IV antibiotics contraindicated in fresh burns?
- bacteria live in the eschar, which is avascular (the systemic antibiotic will not be delivered to the eschar_; thus apply topical antimicrobial agents.
57
Are prophylactic systemic antibiotics administered to burn patients or inhalational injury?
- NO
58
Circumferential, full-thickness burns to the extremities are at risk for what complication?
- distal neurovascular impairment
| * treat via escharotomy
59
What is the major infection complication (other than wound infection) in burn patients?
- PNEUMONIA, central line infection (change central lines prophylactically every 3 to 4 days)
60
Is tetanus prophylaxis required in the burn patient?
- YES, except in those actively immunized within the past year
61
From which burn would is water evaporation highest?
- third degree
62
Can infection convert a partial-thickness injury into a full-thickness injury?
- YES!
63
How is carbon monoxide inhalation overdose treated?
- 100% O2 (+/- hyperbaric O2)
64
Which electrolyte must be closely followed acutely after a burn?
- Na+
65
How are STSGs nourished in the first 24 hours?
- IMBIBITION (fed from wound bed exudate)
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