CHAPTER 17- BURNS.txt

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CHAPTER 17- BURNS.txt
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2012-01-07 18:11:21
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  1. Burn Classification:
    • 1st degree- sunburn (epidermis)
    • 2nd degree-
    • Superficial dermis (papillary)- painful to touch; blebs + blisters; hair follicles intact; blanches
    • Deep dermis (reticular)- decreased sensation; loss of hair follicles (need skin grafts)
    • 3rd degree- leathery feeling (chared parchment); down to subcutaneous fat
    • 4th degree- down to bone, into adjacent adipose or muscle tissue
  2. Admission criteria:
    • 1) 2nd and 3rd degree burns >10% BSA in patients aged <10 or >50 years
    • 2) 2nd and 3rd degree burns >20% BSA in all other patients
    • 3) 2nd and 3rd degree burns to significant portions of hands, feet, face, genitalia, perineum, or skin overlying major joints
    • 4) 3rd degree burns >5% in any age group
    • 5) electrical and chemical burns
    • 6) concomitant inhalational injury, mechanical traumas, preexisting medical conditions
    • 7) injuries in patients with special social, emotional, or long-term rehabilitation needs
    • 8) suspected child abuse or neglect
  3. What populations have highest death rate from burns?
    children and eldery (trouble getting away)
  4. What type of burn is most common and what type is more likely to come to hospital?
    • Scald burns- most common
    • Flame burns- more likely to come to hospital and be admitted
  5. Rule of 9s:
    • Head= 9
    • Arms= 18
    • Back= 18
    • legs= 36
    • perineum=1
    • (can also use palm to estimate injury = palm is 1%)
  6. Parkland formula
    • 1) For burns >20%- give 4cc/kg x % burn in first 24hrs ; give 1/2 in first 8 hours
    • 2) use lactated ringer's (LR) solution in first 24 hours
    • - its important to use LR in first 24 hours- colloid (albumin) in first 24 hours has been shown to increase pulmonary/respiratory complications --> can use colloid after 24 hours.
    • 3) urine output best measure of resuscitation (0.5-1cc/kg/hr in adults; 2-4 cc/kg/h in children <6 months)
    • 4) parkland formula can grossly underestimate volume requirements with inhalational injury, EtOH, electrical injury, post escharotomy
  7. Escharotomy indications:
    • 1) perform within 4-6 hours
    • 2) circumferential burns
    • 3) If compartment syndrome is suspected:
    • - low temp
    • - weak pulse
    • - decreased capillary refill
    • - decreased pain sensation
    • - decreased neurologic function in extremity
    • 4) problems ventilating patient with significant chest torso burns
  8. Risk factors for burn injuries:
    • 1) alcohol/drug use
    • 2) age (very young/very old)
    • 3) smoking
    • 4) low socioeconomic status
    • 5) occupation
    • 6) violence
    • 7) epilepsy
  9. What % of burns are a result of child abuse?
    What are important point of H+P that suggest abuse/neglect
    - 15%

    • History:
    • 1) delayed presentation of medical care
    • 2) conflicting histories
    • 3) previous injuries

    • Suspicious Burn Patterns:
    • - sharply demarcated margins
    • - uniform depth
    • - absence of splash marks
    • - stocking or glove patterns
    • - flexor sparing
    • - dorsal location of contact injury of the hands
    • - very deep localized contact injury
  10. Lung Injury:
    1) caused by carbonaceous materials and smoke, not heat

    • 2) Risk factors for airway injury:
    • 1- EtOH
    • 2- trauma
    • 3- closed space
    • 4- rapid combustion
    • 5- extremeties of age
    • 6- delayed extraction

    • 3) signs and symptoms of possible airway injury- facial burns, wheezing, carbonaceous sputum
    • 4) Indications for intubation- upper airway stridor/obstruction, worsening hypoxemia, can occur with massive volume resuscitation
    • 5) Pneumonia is the most common infection in burn wound patients. Also, the most common cause of death after inhalational injury
  11. Acid and alkali burns
    • 1) copious water irrigation
    • 2) Alkalis produce deeper burns than acid due to liquefaction necrosis
    • 3) Acid burns produce coagulation necrosis
  12. Hydrofluoric acid burns
    spread calcium on wound
  13. Powder burns
    wipe away before irrigation
  14. Tar burns
    cool, then wipe away with lipophilic solvent
  15. Electric burns
    • 1) cardiac monitoring
    • 2) can cause rhabdomyolysis and compartment syndrome
    • 3) Other complications-
    • 1- polyneuritis
    • 2- quadraplegia
    • 3- transverse myelitis
    • 4- cataracts
    • 5- liver necrosis
    • 6- intestinal perforation
    • 7- gallbladder perforation
  16. Lightning
    cardiopulmonary arrest secondary to electrical paralysis of brainstem
  17. 1st week of burn-
    early excision of burned areas
  18. Cardiac output in severely burned patients:
    1) first have decreased cardiac output for 24-48 hours, then have increased cardiac output (ebb and flow phases following burn)
  19. Caloric need:
    Protein need:
    Glucose:
    Caloric need: 25 kcal/kg/day + (30 kcal x %burn)

    Protein need: 1g/kg/day + (3kcal x % burn)

    Glucose: best source of nonprotein calories in patients with burns. Burn wounds use glucose in an obligatory fashion
  20. When should you try to excise burn wounds:
    • 1) <72 hours
    • 2) used for deep 2nd and 3rd degree burns
    • 3) viability is based on color, texture, punctate bleeding after removal
  21. When are skin grafts contraindicated?
    skin grafts contraindicated if culture is positive for beta-hemolytic strep or bacteria >105
  22. Autografts [split thickness (STSG) or full-thickness (FTSG)]
    • 1) are the best
    • 2) Decreased: infection, desiccation, protein loss, pain, water loss, heat loss, and RBC loss
    • 3) increased graulation tissue and improved survival
  23. Split thickness grafts-
    should be 12-15 mm (include epidermis and part of the dermis)
  24. Homografts
    • 1) allografts; cadaveric skin
    • 2) not as good at autografts
    • 3) can be a good temporizing material; last 2-4 weeks
    • 4) allografts vascularize and are eventually rejected at which time they must be replaced
  25. Xenografts (porcine)
    • 1) not as good as homografts
    • 2) last 2 weeks
    • 3) these do not vascularize
  26. Dermal substitutes
    not as good as homografts or xenografts
  27. When should wounds to face, palms, soles, and genitals be fixed?
    wounds to face, palms, soles, and genitals should be deferred for the 1st week
  28. For each burn wound incision:
    • 1) < 1L blood loss
    • 2) < 20% of skin excised
    • 3) < 2 hours in OR
    • or
    • 4) patients can get extremely sick if too much time is spent in OR
  29. Where do you use meshed grafts:
    • back
    • flank
    • trunk
    • arms
    • legs
  30. Reasons to delay autografting:
    • 1) infection
    • 2) not enough skin
    • 3) patient septic or unstable
    • 4) do not want to create any more donor sites with concomitant blood loss
  31. Most common reason for skin graft loss:
    What type of graft is most likely to survive?
    Which type of grafts has less wound contracture?
    • 1) seroma or hematoma formation under graft
    • 2) need to apply presure dressing (cotton balls) to skin graft to prevent seroma and hematoma buildup underneath the graft
    • 3) STSGs- are more likely to survive- graft not as thick so easier for imbibition and subsequent revascularization to occur
    • 4) FTSGs- have less wound contraction- good for areas such as the palms and back of hands
  32. How can burn scar hypopigmentation and irregularities be improved?
    dermal abrasion and thin split-thickness grafts
  33. 2nd-5th week of burn treatment:
    • 1) specialized areas addressed
    • 2) allograft replaced with autograft
  34. Face burns:
    • 1) topical antibiotics for 2 weeks
    • 2) full thickness grafts for unhealed areas (nonmeshed)
  35. Treatment of hand burns:
    • Superficial-
    • ROM exercises, splint in functional position if too much edema

    • Deep-
    • 1) Treat with full-thickness grafts.
    • 2) Immobilize for 7 days after operation, then physical therapy.
    • 3) May need wire fixation of joints if unstable or open.
  36. repair of burns on palms
    • 1) try to preserve specialized palmar attachments
    • 2) splint hand in extension for 1 week
    • 3) graft in week 2 with full-thickness non-meshed skin graft
  37. Repair of genital burns
    • 1) antibiotics for 2 weeks
    • 2) graft unhealed areas (can use meshed)
  38. Burn wound infections:
    • 1) usually apply bacitracin or neosporin immediately after burns
    • 2) no role for prophylactic IV antibiotics
    • 3) Pseudomonas is most common organism in burn wound infection, followed by staphylococcus, E. coli, and enterobacter
    • 4) more common in burns >30% BSA
    • 5) topical agents have decreased incidence of burn wound bacterial infections
    • 6) candida infections have increased incidence secondary to topical antimicrobial
    • 7) granulocyte chemotaxis and cell-mediated immunity are impaired in burn patients
  39. Silvadene (silver sulfadiazine)
    • 1) can cause neutropenia and thrombocytopenia
    • 2) do not use in patients with sulfa allergy
    • 3) limited eschar penetration
    • 4) ineffective against some pseudomonas species and other GNRs; effective for candida
    • 5) methemoglobinemia- contraindicated in patients with G6PD deficiency
  40. Silver nitrate
    • 1) can cause electrolyte imbalances-->
    • 1- dec Na & dec Cl
    • 2- dec Ca & dec K

    • 2) discoloration
    • 3) limited eschar penetration
    • 4) ineffective against some pseudomonas species and GPCs
  41. Sulfamylon (mafenide sodium)
    • 1) painful application
    • 2) metabolic acidosis due to carbonic anhydrase inhibiton (decreased renal conversion of H2CO3--> H2O and CO2)- can cause hypersensitivity reactions
    • 3) good eschar penetration; good for burns overlying cartilage
    • 4) broadest spectrum against pseudomonas and GNRs
  42. Signs of burn wound infection
    • 1) peripheral edema
    • 2) 2nd to 3rd degree burn conversion
    • 3) hemorrhage into scar
    • 4) erythema gangrenosum
    • 5) green fat
    • 6) black skin around wound
    • 7) rapid eschar separation
    • 8) focal discoloration
  43. What is burn wound sepsis usually due to?
    pseudomonas
  44. What is the most common viral infection of burn wounds?
    HSV
  45. What bacteria count do you need to have to count as a wound infection?
    <105 organisms is not a burn wound infection
  46. What is the best way to detect burn wound infection (and differentiate from colonization)
    biopsy of wound
  47. Complications after burns (on the following slides)
  48. Seizures
    • 1) usually iatrogenic and related to Na concentration
    • 2) can also be benzodiazepine withdrawal
  49. Peripheral neuropathy
    secondary to small vessel injury and demyelination
  50. Ectopia
    • 1) from contraction of burned adnexa
    • 2) tx: eyelid release
  51. Eyes
    • 1) fluorescein staining to find injury
    • 2) Tx: topical fluoroquinolone or gentamycin
  52. Corneal abrasion
    Tx: topical antibiotics
  53. symblepharon
    • 1) eyelid stuck to conjunctiva
    • 2) tx: release with glass rod
  54. heterotopic ossification of tendons
    tx: physical therapy; may need surgery
  55. fractures
    tx: often get external fixation to allow for treatment of burns
  56. Curling's ulcer
    gastric ulcer that occurs with burns
  57. Marjolin's ulcer
    highly malignant squamous cell Ca that arises in chronic nonhealing burn wounds or unstable scars
  58. hypertrophic scar
    • 1) usually occurs 3-4 months after injury secondary to increased neovascularity
    • 2) more likely to be deep thermal injuries that take >3 weeks to heal, heal by contraction and epithelial spread, or heal across flexor surfaces
    • 3) wait 1-2 years before scar modification
    • 4) Tx:
    • 1- grafting
    • 2- steroids
    • 3- silicone
    • 4- compression
  59. Toxic epiderman necrolysis (TEN)
    • 1) variant of erythema multiforme major and staphylococcal scalded skin syndrome
    • 2) epidermal-dermal separation seen
    • 3) caused by a variety of drugs (dilantin, bactrim, penicillin) and viruses
    • 4) Tx: supportive; need to prevent wound desiccation with topical antimicrobials and xenografts
    • 5) antibiotics if due to staph aureus
    • 6) NO STEROIDS
  60. Steven-Johnson syndrome (erythema multiforme)
    • 1) less severe form of TEN
    • 2) hypersensitivity reaction:
    • 1- subepidermal bullae
    • 2- epidermal cell necrosis
    • 3- dermal edema
    • 3) caused by a variety of drugs (dilantin, bactrim, penicillin) and viruses
    • 4) Tx: supportive; need to prevent wound desiccation with topical antimicrobials and xenografts
    • 5) NO STEROIDS

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