| Question |
Answer |
| Depth dependent on depth of heat penetration, Rapid protein denaturation & cell damage, Dead skin tissue = eschar |
heat induced injury |
| First to third day after injury, Tissue damage caused by toxic mediators of inflammation- Increased permeability, Later wound conversion if excessive |
inflammatory mediator injury |
| Vascular thrombosis/vasoconstriction- Systemic hypovolemia, impairment of perfusion (constricting eschar or edema) produces the same effect- Restrictive eschar –if a chest burn they cant respire very well |
ischemia induced injury |
| – Ongoing inflammation = continued tissue damage (i.e. increased neutrophils, proteolytic activity, deactivation of growth factors |
delayed injury |
| what are the three zones of burn injury |
(1) Zone of Coagulation (2) Zone of Stasis (Injury) (3) Zone of Hyperemia |
| depression of cardiac output precedes what zone of burn injury |
(3) Zone of Hyperemia |
| tachycardia precedes what zones of burn injury |
(2) Zone of Stasis (Injury) (3) Zone of Hyperemia |
| Hemolysis > hemoglobinuria, Increase RBC lipid peroxidation > fragmented cells, Decrease RBC survival, Decrease hematopoiesis, Increase WBC? Activation of clotting and Depletion of factors > DIC |
hematologic response |
| Limited to the epidermis, patient has some blistering Heals in 7-10 days, pt heals w/out scarring mostly, tx w/ cool compress/anagesics, NSAIDs, ointment for comfort, rarely admitted |
superficial/first degree burn |
| Involves epidermis and superficial dermis, Typical blistered burn- Usually heals in 2-3 weeks- TX: topical anti-microbial and analgesics or possibly wound care products (Biobrane®, Dermagraft TC®, ionic silver release etc.) aloe vera, medihoney |
Partial thickness/superficial second degree |
| Involves through to deep dermis – few epithelial structures remain, Heals in >3 weeks, often with hypertrophic scar- Treat initially with topical antimicrobial; may require skin graft- Admitted for hydration and pain management (can use narcotics) |
deep partial thickness/ deep second degree |
| : Involves epidermis, dermis and subcutaneous fat- Treat initially with topical antimicrobial- Requires excision and 1° closure or skin grafting –has to be a cleaner type wound- Admit for resuscitation- Debridements can be chemical or I & D |
Full thickness/ third degree: |
| burn that involves deep structures—muscle and bone |
Full thickness/ fourth degree: |
| what dressings should you avoid when covering a burn wound |
wet dressing when covering the burn because it will eventually dry and it could take skin with it if you took it off |
| what is special about the IV solutions given to burn patients |
– Warm IV solutions because you don’t want to drop their temperature (body temp already goes down in a burn situation) |
| what burn patients may need IV fluid therapy (14g or 16g peripheral IV) central line if the patient is hard to stick |
– May be required in patients with 2° burn >20% or 3° burn >10% |
| – 4cc/kg/%TBSA burn of LR= Total volume in 24 hrs- First ? of total volume – give in the first 8hrs from time of burn- Remaining ? of total volume – give over the next 16 hrs |
parkland formula (2nd and 3rd degree burns) |
| FFP, albumin, dextran, hetastarch |
colloid fluids |
| Lactated Ringers, Normal Saline (typically this is what we use) |
crystalloid fluids |
| 250 mEq Na (Monafo), 180 mEq Na (Warden) |
hypertonic solutions |
| Urine output should be ___ cc/hr in adultsUrine output should be ____cc/kg/hr in children |
30-60 0.5-1.0 |
| what should the bp and MAP be maintained around when resuscitating a burn |
systolic> 90 and MAP 65 |
| Over-resuscitation-extra fluid goes into 3rd spacing instead of being reabsorbed into primary circulation diff breathing, labored breathing, crackles when listening to the lung, lactic acidosis, increasing hct and instability |
fluid creep |
| how do you tx fluid creep |
colloid resuscitation, hypertonic solutions, plasma exchange, heavy dose of diuretics with potassium |
| clinical signs of impaired circulation—cyanosis, impaired capillary refillingprogressive neurological signs (5 P’s = pallor, pain, paresthesia, pulseless, and poikilothermia)PAD and compartment syndrome |
circumferential extremity burns |
| cut into the eschar, until subQ fat— prevent compartment syndr- incision in mid-lateral/ mid-medial line of limb and across involved joints- only incise through depth of eschar to nl SubQ tissue- if goes down to musc do a fasciotomy after |
escharotomy |
| is anesthesia needed in an escharotomy |
no |
| – compartment syndrome to extremities, usually due to electrical injuryo needed if massive swelling is involved |
fasciotomy |
| – intra-abdominal compartment syndromeo massive fluid hydration for inhalation injurieso Possible use of peritoneal dialysis catheters if +FAST |
laparotomy |
| topical antimicrobial– leukopenia (reversible), poor penetration, slows epithelialization, under 3 mos. Kernicterus (RX) |
silvadene cream |
| topical antimicrobial–late allergy, early resistance |
bacitracin ointment |
| topical antimicrobial–(Mafenide acetate 15%) – carbonic anhydrase inhibition, systemic acidosis, pain on application (RX) |
sulfamylon cream |
| topical antimicrobial–? staining, leeching of electrolytes, methemeglobinemia |
cerium/silver nitrate |
| Signs & Symptoms include: Hoarseness, Stridor and/or wheezing, Carbonaceous sputum- Singed nasal hair, eyebrows or facial hair- Edema or inflammatory changes in upper airway |
inhalation injury |
| how do you treat an inhalation injury |
laryngo/bronchoscopy to examine for sgs of inhal injury, humidified O2 by mast, poss intubation, poss use systemic steroids, dont fluid overload |
| Slough of Mucosa-plugs which in turn clogs up the airway—have to suck out the mucus plugs with a bronchoscopy – Goblet cell injury increases >> decrease surfactant – Ciliated Epithelial Cells-Dysynchronous |
chemical injury to lower airways |
| what are the toxic carboxyhgb levels for adults and kids/pregnant women |
CarboxyHgb levels toxic if >15% in adults, >10% in kids & pregnant women (or teratogenicity) |
| Cherry Red color – in capillary/ blood tubes, no hyperventilation until late stage, PaO2 is normal, carotid body not affected until lactic acidosis develops, get ABG when pt is obtunded |
carbon monoxide poisoning |
| what is the CO2 level of mild CO poisoning – Headache, confusion, nausea |
10-20% |
| what is the CO2 level of moderate CO poisoning – Irritability, dizziness, fatigue, visual symptoms, impaired judgment |
20-40% |
| what is the CO2 level of severe CO poisoning – Hallucinations, ataxia, coma,convulsions, possible tachypnea |
40-60% |
| what is the CO2 level of fatal CO poisoning |
>60% |
| what percentage of TBSA do patients start having hyper metabolism |
Generally > 40% TBSA burn unless septic, > 40% always experience catabolism |
| The Greatest mortality in burns is due to |
complications |
| fibrinous slough, confusion, ileus, leukopenia, temp abnormalities, Exudate – changes quality/ quantity, Ulcerations, Cellulitis, Black spots, get biopsy and quantitative bacterial culture (10^5) to prove pathology |
sepsis with burns |
| what is the most common organism seen w/ sepsis with burns and what organism is becoming more common |
MC pseudomonas Resistant actinobacter increasing |
| how do you treat burn sepsis |
– Can use catheter or tube to keep an area apart—as a wicking device or can also be placed deeper into tissue to allow drainage to occur so the deep infection can work its way out |
| what type of burn coverage for a large burn would you use Autograft (self), Isograft (identical twin), Primary closure, Spontaneous – 2° healing |
permanent |
| what type of burn coverage for a large burn would you use ? Allograft (homograft)—another person, Xenograft (heterograft) pigskin, Bioengineered tissue eg.transcyte |
temporary |
| intergra®, alloderm, cultured epithelium, fetal tissues (animal/human, products) |
permanent biological burn coverage |