CHAPTER 17- BURNS.txt

• 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

• 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

children and eldery (trouble getting away)

• Scald burns- most common
• Flame burns- more likely to come to hospital and be admitted

• Head= 9
• Arms= 18
• Back= 18
• legs= 36
• perineum=1
• (can also use palm to estimate injury = palm is 1%)

• 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

• 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

• 1) alcohol/drug use
• 2) age (very young/very old)
• 3) smoking
• 4) low socioeconomic status
• 5) occupation
• 6) violence
• 7) epilepsy

- 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

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

• 1) copious water irrigation
• 2) Alkalis produce deeper burns than acid due to liquefaction necrosis
• 3) Acid burns produce coagulation necrosis

spread calcium on wound

wipe away before irrigation

cool, then wipe away with lipophilic solvent

• 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

cardiopulmonary arrest secondary to electrical paralysis of brainstem

early excision of burned areas

1) first have decreased cardiac output for 24-48 hours, then have increased cardiac output (ebb and flow phases following burn)

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

• 1) <72 hours
• 2) used for deep 2nd and 3rd degree burns
• 3) viability is based on color, texture, punctate bleeding after removal

skin grafts contraindicated if culture is positive for beta-hemolytic strep or bacteria >10⁵

• 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

should be 12-15 mm (include epidermis and part of the dermis)

• 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

• 1) not as good as homografts
• 2) last 2 weeks
• 3) these do not vascularize

not as good as homografts or xenografts

wounds to face, palms, soles, and genitals should be deferred for the 1st week

• 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

• back
• flank
• trunk
• arms
• legs

• 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

• 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

dermal abrasion and thin split-thickness grafts

• 1) specialized areas addressed
• 2) allograft replaced with autograft

• 1) topical antibiotics for 2 weeks
• 2) full thickness grafts for unhealed areas (nonmeshed)

• 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.

• 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

• 1) antibiotics for 2 weeks
• 2) graft unhealed areas (can use meshed)

• 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

• 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

• 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

• 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

• 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

pseudomonas

HSV

<10⁵ organisms is not a burn wound infection

biopsy of wound

• 1) usually iatrogenic and related to Na concentration
• 2) can also be benzodiazepine withdrawal

secondary to small vessel injury and demyelination

• 1) from contraction of burned adnexa
• 2) tx: eyelid release

• 1) fluorescein staining to find injury
• 2) Tx: topical fluoroquinolone or gentamycin

Tx: topical antibiotics

• 1) eyelid stuck to conjunctiva
• 2) tx: release with glass rod

tx: physical therapy; may need surgery

tx: often get external fixation to allow for treatment of burns

gastric ulcer that occurs with burns

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

• 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

• 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

• 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