(Quiz 1) Trauma and Burns: Burns to the Face, Trunk, and Extremities

Define Each Level of Burn Injury and How They Present: - 1st degree - 2nd degree superficial partial thickness - 2nd degree deep partial thickness - 3rd degree - 4th degree

1st (superficial; first): Epidermis only. Similar to sunburn; localized, painful, dry, blanching redness with no blisters 2nd (superficial partial thickness; second): All of the epidermis and some dermis. Painful, swollen, warm, mottled areas with blisters. 2nd (deep partial thickness; second): All of the epidermis and some dermis. Painless, warm, white, mottled areas with blisters that appear to have open weeping surfaces. The presence of pain is an easy way to differentiate superficial partial-thickness burns (with pain) from deep partial-thickness burns (without pain). 3rd (full thickness; third): All of the skin (epidermis and dermis). Painless, white, dry, leathery, and do not blanch with pressure. 4th: All of the skin and underlying bone, tendon, adipose, or muscle. Similar to third degree; disfiguring. PPT: 1st degree • Epidermis only • Red, moderately painful, blanching • Heals within a few days 2nd degree • Part of Dermis • Superficial — Blisters, red, moist in base — Painful — Should heal within 2 weeks • Deep — Beefy red to white, drier — Variable healing 3rd degree • Through Dermis • Dry, white, leathery • Burn itself is not painful but surrounding tissues often very painful 4th degree • Muscle/Bone

2nd degree superficial partial thickness vs. 2nd degree deep partial thickness Which is painful and which is painless?

2nd (superficial partial thickness; second): All of the epidermis and some dermis. Painful, swollen, warm, mottled areas with blisters. 2nd (deep partial thickness; second): All of the epidermis and some dermis. Painless, warm, white, mottled areas with blisters that appear to have open weeping surfaces. The presence of pain is an easy way to differentiate superficial partial-thickness burns (with pain) from deep partial-thickness burns (without pain). Superficial is painful because nerves are still there, unlike deep partial thickness.

What 2 Electrolyte Abnormalities Must Be Closely Monitored in Burn Patients?

Burn victims should be monitored for abnormalities in serum sodium and potassium. Hyponatremia & Hyperkalemia Hyponatremia can increase the risk of developing seizures in burn patients. Hyperkalemia can develop from the destruction of cells and tissues and can lead to cardiac conduction abnormalities.

+++++++++++++++++ Determining TBSA from Rule of Nines

Calculating the total body surface area (TBSA) affected by second- or third-degree burns will allow one to determine the severity of a patient's burn injuries. This can be approximated using the rule of nines. The body is divided into regions whose surface areas are multiples of nine: head = 9% each arm = 9% anterior torso = 18% posterior torso (back) = 18% each leg = 18%

++++++++++++++++++++++++++++ Types of burns: Chemical burns - Alkali burns vs. Acidic burns — what type of necrosis occurs in each?

Chemical burns: Alkali burns are more damaging than acidic burns owing to their ability to penetrate tissues more deeply; acidic burns cause coagulation necrosis whereas alkali burns cause liquefactive necrosis. Acid: Coagulative necrosis - like ceviche — acid from lime cooks meat. Base: Liquefactive necrosis Organic compounds: Fat solvent so dissolve cell membranes Chemical burns produce heat as well as cell destruction Management: IRRIGATE, IRRIGATE, IRRIGATE!!

What Procedure Should Be Done for a Patient with a Circumferential Chest Burn and Deteriorating Respiratory Status?

Chest escharotomy. Escharotomy is performed by incising the constricting eschar, thereby improving chest wall compliance and respiration. Unlike a fasciotomy, escharotomy only involves incisions through the burned soft tissues and not the deeper underlying structures. This procedure is painless as the nerve endings in the dermis are involved. Extremity escharotomies should also be considered in patients with full-thickness circumferential burns with evidence of compromised perfusion. What Are the Other Indications for Escharotomy? Circumferential deep burns and neurovascular compromise of the extremity (e.g., weak pulse, decreased capillary refill, motor weakness, and decreased sensation).

What is a circumferential burn? What Is the Significance of a Circumferential Burn in the Extremity? How About on the Chest?

Circumferential burns: full thickness burn affecting the entire circumference of a digit, extremity, or even the torso. Circumferential full thickness burns in the extremity significantly increase the risk of developing compartment syndrome. Burn patients with circumferential extremity full-thickness burns with evidence of compromised distal perfusion should undergo escharotomy. Circumferential burns of the chest can compromise respiratory efforts due to the inflexible eschar and underlying tissue edema which can prevent chest wall motion and, thus, limit ventilation. These patients should also be considered for escharotomy.

Tissue Remodeling: Type I vs. Type III Collagen

Early scar - higher content of type III collagen, increased ECM Scar re-modeling begins after re-epithelialization • Type III collagen gradually replaced by type I collagen • Increased collagen crosslinking • Water resorption • Scar peaks at 80% tensile strength at 60 days post-injury

Cataracts are a long-term complication of what type of burn?

Electrical

++++++++++++++++++++++++++++ Types of burns: Electrical burns

Electrical: Immediate life-threatening complication is cardiac arrhythmia; injuries are often out of proportion to the size of the external burn wound; patients may also develop muscle necrosis, posterior shoulder dislocations, myoglobinuria, and renal failure. Watch Out: Direct current (DC) electrocution (e.g., lightning) puts patients at risk for asystole, while alternating current (AC) electrocution (e.g., wall socket) puts patients at risk for ventricular fibrillation.

When is an escharotomy indicated for a burn patient?

Escharotomy is performed to release the burn eschar which is encumbering blood flow to distal extremities. This should be done if pulses are weak or absent — remove eschar to improve blood flow.

How Do You Manage Burn Wounds?

Following the institution of resuscitative measures, local treatment of burn wounds involves cleansing and debridement and application of antimicrobial agents and dressings. Serial tangential excision and debridement of the burn tissue is indicated. Skin grafting is performed after the wound bed is deemed clean. Skin grafts are contraindicated if there is evidence of infection. -Following the institution of resuscitative measures -cleansing and debridement and application of antimicrobial agents and dressings. -Serial tangential excision and debridement of the burn tissue -Skin grafting is performed after the wound bed is deemed clean. --Skin grafts are contraindicated if there is evidence of infection.

++++++++++++++++++++++++++++++++++++++++ Parkland formula for the amount of fluid needed in a burn patient How much of it is administered over what amount of time? What type of fluid should be used?

Parkland Formula: Total fluid volume = 4cc/kg x weight (kg) x TBSA (%) Use Lactated Ringers One-half of the total fluid volume should be administered in the first 8 hours from the time of injury and the second half in the subsequent 16 hours:

What Medication Should All Burn Patients Be Started on to Prevent Curling's Ulcers?

Proton pump inhibitors or H2 blockers

What is the most common pathogen that infects burn wounds?

Pseudomonas aeruginosa is a gram-negative bacillus and is considered to be the most common cause of infections in burn patients, followed by Staphylococcus aureus and Streptococcus pyogenes. Fungal infections tend to occur in burn patients during the later stages of recovery because by this time the majority of bacteria have been eliminated by the use of topical antibiotics. The most common cause of fungal infection in burn patients is by Candida albicans. The most common cause of viral infection in burn patients is herpes simplex virus. Infections in burn patients can be problematic for multiple reasons. They may delay wound healing, encourage scarring, and can result in burn wound sepsis with resultant bacteremia.

What are the main 3 topical antibiotics used for burns

Silver sulfadiazine (Silvadene): Commonly used topical burn agent; may result in granulocyte reduction (neutropenia and thrombocytopenia); poor deep tissue penetration and ineffective against Pseudomonas. Sulfamylon or mafenide acetate: Dispensed in a cream and a solution; it functions as a carbonic anhydrase inhibitor and may result in metabolic acidosis; deep tissue penetration and effective against Pseudomonas; may be painful in application. Silver nitrate: Poor deep tissue penetration and ineffective against Pseudomonas; brown staining of skin is common, and methemoglobinemia may rarely occur.

A 25-year-old man (weight 70 kg) arrives to the emergency department an hour after sustaining burn injuries in a house fire. He is awake but appears confused and disoriented. He complains of a severe headache. On initial exam, his temperature is 101.6 °F, blood pressure is 90/74 mmHg, heart rate is 120/min, respiratory rate is 26/min, and oxygen saturation is 89 %. He has blistering, painful burns to the face with singed nasal hairs, and carbonaceous sputum. The burns on his chest and back are painless, circumferential, white, dry, and leathery. The bilateral upper extremities are also burned with painful, swollen, mottled areas with blisters that appear to have open weeping surfaces. The remainder of his skin that is not burned has a cherry-red appearance. He also has sunken eyes, a dry tongue, and slow capillary refill. What Is the Diagnosis and Resulting or Associated Complications Affecting This Patient? What degrees are the burns?

The patient has sustained severe burn injuries to the face, trunk, and extremities. He has second-degree burns to the face and bilateral upper extremities and third-degree burns to the chest and back. - 2nd (superficial partial thickness; second): All of the epidermis and some dermis. Painful, swollen, warm, mottled areas with blisters. - 2nd (deep partial thickness; second): All of the epidermis and some dermis. Painless, warm, white, mottled areas with blisters that appear to have open weeping surfaces. - 3rd (full thickness; third): All of the skin (epidermis and dermis). Painless, white, dry, leathery, and do not blanch with pressure. Singed nasal hairs and carbonaceous sputum coupled with his low oxygen saturation are concerning for inhalational injuries which are life-threatening and should be addressed immediately by securing the airway via intubation and administration of 100% O2. The cherry-red appearance of his skin along with his confusion, disorientation, and history of being trapped in a house fire is concerning for carbon monoxide poisoning. Additionally, he is in hypovolemic shock secondary to the massive loss of fluid as a result of his burn injuries (burn shock).

Why Are Burn Patients at Increased Risk for Dehydration?

The skin acts as a protective barrier and plays an essential role in fluid and temperature regulation of the body. When the integrity of this protective layer is compromised, the skin becomes unable to regulate body temperature or prevent fluid from seeping out of the body. This can lead to hypovolemic shock if enough intravascular volume is lost.

++++++++++++++++++++++++++++ Types of burns: Thermal burns

Thermal: Most common cause of burn injuries is scalding, typically from hot water

What Is the Significance of a Second-Degree Burn That Progresses to a Third-Degree Burn While in the Hospital?

This is concerning for a burn wound sepsis. Other things to look for include a discolored burn, eschar with green pigment, black necrotic skin, skin separation, and signs of sepsis. Fever is not always reliable since the body's primary temperature regulator, the skin, is often compromised in burn victims (discussed in Pathophysiology). The diagnosis of burn wound sepsis is based upon the bacterial concentration per gram of tissue in the burn wound or eschar. The finding of >10^5 bacteria/g of tissue on quantitative analysis is highly suggestive of burn wound sepsis.

What criteria must be met to admit a burn patient to the burn unit?

When to go to Burn Center • Partial thickness > 10% (smaller in kids/elderly) • Sensitive areas (face, genitalia, joints, hands, feet) • Third degree burns • Chemical, Electrical, or Inhalation injury • Burn with Concomitant trauma • Bad co-morbidities • Social or emotional intervention (worried about domestic abuse) Textbook: Criteria for admission to a burn center: • 2nd- or 3rd-degree burns >10 % TBSA in patients <10 or >50 years of age (kids and older adults) • 2nd- and 3rd-degree burns >20 % TBSA in all patients • 2nd- and 3rd-degree burns involving the hands, face, feet, genitalia, perineum, or skin overlying major joints • Electrical and chemical burns • Concomitant inhalational injury • Significant preexisting medical conditions • Suspected child abuse or neglect