Chapter 17 - Burns

Question 1

What is a first degreen burn?

Answer 1

sunburn- epidermis only

Question 2

What is are the two types of second degree burns?

Answer 2

superficial dermis (papillary)- painful to touch; blebs and blisters; hair follicles intact; blanches
-Deep dermis (reticular) - Decreased sensation; loss of hair follicles (need graft)

Question 3

What are 3rd degree burns?

Answer 3

Leathery feeling (charred parchment); down to subcutaneous fat

Question 4

What are 4th degree burns?

Answer 4

Down to bone, into adjacent adipose or muscle tissue

Question 5

What are admission criteria for 2nd and 3rd degree burns?

Answer 5

• > 10% BSA in pts 50yo
• > 20% in all other pts
• burns to significant portions of hands, face feet, cock and balls, perineum, or skin on joints
• 3rd degree in >5% any age

Question 6

Other than the criteria for 2nd and 3rd degree burns, what are some criteria for burn admission?

Answer 6

electrical and chemical
concomitant inhalation injury
trauma
social/emotional issues
child abuse or neglect

Question 7

Why are kids and elderly highest mortality

Answer 7

bitches cant get away

Question 8

what are most common types of burns?

Answer 8

scalds

Question 9

what are the most common types of burns to cum to hospital and get admitted?

Answer 9

flamers

Question 10

What is the rule of 9’s?

Answer 10

• Head 9
• arms 9/9
• chest 18
• back 18
• legs 18/18
• Taint, cock and balls, lady junk 1%

Question 11

What is the parkland formula?

Answer 11

For burns >20% give 4cc/kg x %burn in first 24 hours; give have in the first 8 (LR)
-can grossly underestimate in inhalation injury, etoh, electrical, post escharotomy

Question 12

Indications for escharotomy?

Answer 12

• circumferential burns
• low temperature, weak pulse, low cap refill, low pain sensation, decreased neuro function in extremity
• problems ventilating with chest torso burns

Question 13

Lung injury from smoke caused by what?

Answer 13

carbonaceous materials and smoke, not heat

Question 14

What are the risk factors for airway injury? What are the signs and symptoms of possible airway injury?

Answer 14

Risks: etoh, trauma, closed space, rapid combustion, delayed extrication

signs: facial burns, wheezing, carbonaceous sputum

Question 15

What are the indications for intubation in smoke lung injury?

Answer 15

upper airway stridor or obstruction, worsening hypoxemia

Question 16

What is the most common infection in burn patients?

Answer 16

Pneumonia. Also most common cause of death

Question 17

What do you do with acid and alkali burns?

Answer 17

copious water irrigation.

• alkalis produce deeper burns than acid due to liquefaction necrosis
• acud burns produce coagulation necrosis

Question 18

What do you do with hydrofluoric acid burns?

Answer 18

spread calcium on wound

Question 19

What do you do with powder burns?

Answer 19

wipe away before irrigation

Question 20

What do you do with tar burns?

Answer 20

cool, then wipe away with a lipophilic solvent

Question 21

What do you do with electrical burns?

Answer 21

• cardiac monitoring
• can cause rhabdo and compartment syndrome
• polyneuritis
• polyneuritis
• intestinal/gallbladder perf, pancreatic nec.
• liver necrosis

Question 22

How do smiting lightning bolts kill you?

Answer 22

cardiopulmonary arrest secondary to electrical paralysis of brainstem

Question 23

In the first week of early excision burns

• what happens to CO
• what is caloric need
• protein need

Answer 23

• CO decreased for 24-48h then increases
• 25kcal/day + 30kcal x %burn
• protein 1g/kg + 3g x %burn
• need glucose- obligatory
• excise in first 72 hours- viability based on color, texture, punctate bleeding after removal

Question 24

When is skin graft contraindicated (bacteria)?

Answer 24

beta hemolytic strep + or bacteria >10^5

Question 25

What is best type of skin graft?

Answer 25

split thickness/full thickness - decrease infection, desiccation, protein loss, pain, water loss, heat loss, rbc loss - increases granulation and improves survival

Question 26

how thick should stsg be?

Answer 26

12-15mm- include epidermis include epidermis and part of dermis

Question 27

homografts used when?

Answer 27

temporizing- last 2-4wks

Question 28

how long do xenografts last?

Answer 28

2 wks, do not vascularize

Question 29

when do you fraft wounds to face, palms, soles, dick, balls, lady junk?

Answer 29

defer for first week

Question 30

For each burn wound incision, how much blood loss, skin excised, time in OR?

Answer 30

<2 hrs in OR

Question 31

What are reasons to delay autografting?

Answer 31

``` infection not enough skin septic unstable do not want to create more blood loss with donor sites ```

Question 32

Most common reason for skin graft loss?

Answer 32

seroma or hematoma formation under graft | -apply pressure dressing to skin graft

Question 33

why are stsg good compared to ftsg?

Answer 33

more likely to survive | not as thick, so easier for imbibition and subsequent neovascularization

Question 34

why are ftsg good compared to stsg?

Answer 34

less wound contraction | good for palms and back of hands

Question 35

How can burn scar hypopigmentation and irregularities be improved?

Answer 35

dermal abration thin split thickness grafts

Question 36

Weeks to five what to do with the face?

Answer 36

Topical antibiotics for two weeks, full thickness grafts for unhealed areas – nonmeshed

Question 37

What to do with hand burns for weeks 2-5?

Answer 37

– Superficial – ROM exercises, splint in functional position if too much edema – deep – immobilize for seven days after operation, then physical therapy. May need wire fixation if joints unstable or open. Treat with full thickness graft

Question 38

What to do with palm burns for weeks 2 to 5?

Answer 38

Try to preserve specialized Palmer attachments. Splinted hand in extension for one week. Graft in week two with full thickness non-meshed autograft graft

Question 39

How do you prevent burn wound infections?

Answer 39

Apply Neosporin immediately after burns | no role for prophylactic IV antibiotics

Question 40

What are the most common bacteria in burn infections?

Answer 40

Pseudomonas is most common organism in Burn infection, followed by Staphylococcus, E coli, and Enterobacter

Question 41

What are side effects of Silvadene? What allergy cat it not be used with?

Answer 41

Can cause neutropenia and thrombocytopenia. Cannot use with sulfa allergy Ineffective against Pseudomonas and GNRs Can cause methemoglobinemia

Question 42

What are the side effects of silver nitrate?

Answer 42

Can cause electrolyte imbalances – hyponatremia, hypochloremia, hypocalcemia and hypokalemia -Discoloration -Limited eschar penetration Ineffective against some Pseudomonas species and GPCs

Question 43

What are the problems with Sulfamylon?

Answer 43

Painful application - Metabolic acidosis due to carbonic anhydrase inhibition - Good eschar penetration; good for burns overlying cartilage - Broadest spectrum against pseudomonas and GNRs

Question 44

What are signs of burn wound infection?

Answer 44

Peripheral edema, second to third degree burn conversion, hemorrhage into scar, Erythema gangrenosum, Green fat, black skin around wound, rapid eschar separation

Question 45

What is burn wound sepsis usually caused by?

Answer 45

Pseudomonas

Question 46

What is the most common viral infection in burn wounds?

Answer 46

Hsv

Question 47

What is the best way to detect burn wound infection?

Answer 47

Biopsy the wound

Question 48

What are seizures after burns usually caused by?

Answer 48

Usually iatrogenic and related to sodium concentration; can also be benzodiazepine withdrawal

Question 49

What is peripheral neuropathy after burns caused by?

Answer 49

Secondary to small vessel injury and demyelination

Question 50

What is Ectapia caused by after Burns?

Answer 50

Burned adnexa. Treatment is eyelid release.

Question 51

What is a symblepharon after a burn?

Answer 51

Eyelid stuck to conjunctiva. Treat with Eyelid release with a glass rod

Question 52

What is a curlings ulcer?

Answer 52

Gastric ulcer that occurs with Burns

Question 53

What is a marjolin's ulcer?

Answer 53

Hey highly malignant squamous cell carcinoma that arises in chronic nonhealing burn wounds or unstable scars

Question 54

What is a hypertrophic scar, and when does it occur?

Answer 54

- Usually occurs 3 to 4 months after injury secondary to increased neo vascularity - More likely to be deep thermal injuries that take more than three weeks to heal - Wait 1 to 2 years before scar modification - Treat with grafting, steroids, silicone, compression

Question 55

What is toxic epidermal necrolysis Caused by?

Answer 55

Caused by a variety of drugs including Dilantin, Bactrim, penicillin and viruses - Epidermal dermal separation - Treatment is supportive. Need to prevent wound desiccation with topical antimicrobials and xenograft

Question 56

What is seen with Stevens Johnson syndrome?

Answer 56

Subepidermal bullae, epidermal cell necrosis, dermal edema | -Hypersensitivity reaction