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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
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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
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What populations have highest death rate from burns?
children and eldery (trouble getting away)
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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
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Rule of 9s:
- Head= 9
- Arms= 18
- Back= 18
- legs= 36
- perineum=1
- (can also use palm to estimate injury = palm is 1%)
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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
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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
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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
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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
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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
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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
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Hydrofluoric acid burns
spread calcium on wound
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Powder burns
wipe away before irrigation
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Tar burns
cool, then wipe away with lipophilic solvent
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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
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Lightning
cardiopulmonary arrest secondary to electrical paralysis of brainstem
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1st week of burn-
early excision of burned areas
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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)
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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
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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
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When are skin grafts contraindicated?
skin grafts contraindicated if culture is positive for beta-hemolytic strep or bacteria >105
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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
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Split thickness grafts-
should be 12-15 mm (include epidermis and part of the dermis)
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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
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Xenografts (porcine)
- 1) not as good as homografts
- 2) last 2 weeks
- 3) these do not vascularize
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Dermal substitutes
not as good as homografts or xenografts
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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
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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
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Where do you use meshed grafts:
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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
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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
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How can burn scar hypopigmentation and irregularities be improved?
dermal abrasion and thin split-thickness grafts
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2nd-5th week of burn treatment:
- 1) specialized areas addressed
- 2) allograft replaced with autograft
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Face burns:
- 1) topical antibiotics for 2 weeks
- 2) full thickness grafts for unhealed areas (nonmeshed)
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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.
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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
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Repair of genital burns
- 1) antibiotics for 2 weeks
- 2) graft unhealed areas (can use meshed)
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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
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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
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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
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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
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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
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What is burn wound sepsis usually due to?
pseudomonas
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What is the most common viral infection of burn wounds?
HSV
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What bacteria count do you need to have to count as a wound infection?
<105 organisms is not a burn wound infection
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What is the best way to detect burn wound infection (and differentiate from colonization)
biopsy of wound
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Complications after burns (on the following slides)
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Seizures
- 1) usually iatrogenic and related to Na concentration
- 2) can also be benzodiazepine withdrawal
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Peripheral neuropathy
secondary to small vessel injury and demyelination
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Ectopia
- 1) from contraction of burned adnexa
- 2) tx: eyelid release
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Eyes
- 1) fluorescein staining to find injury
- 2) Tx: topical fluoroquinolone or gentamycin
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Corneal abrasion
Tx: topical antibiotics
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symblepharon
- 1) eyelid stuck to conjunctiva
- 2) tx: release with glass rod
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heterotopic ossification of tendons
tx: physical therapy; may need surgery
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fractures
tx: often get external fixation to allow for treatment of burns
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Curling's ulcer
gastric ulcer that occurs with burns
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Marjolin's ulcer
highly malignant squamous cell Ca that arises in chronic nonhealing burn wounds or unstable scars
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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
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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
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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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