Chapter 11: Burns Lisa Spiguel

Which of the below is not a criteria for transfer to a burn center by the American Burn Association? All burns > 10% of TBSA Burns that involve the hands, feet, genitalia Burns in patients with co-existing complex medical comorbidities Burns in patients with concomitant trauma

State of Florida mandates that hot water heaters in multi-dwelling facilities to be set at which temperature (ο F)? 82 95 110 120

Which of the following below is not a zone of injury following a burn injury? 1- Zone of Coagulation 2- Zone of Liquefaction 3- Zone of Stasis 4- Zone of Hyperemia

Which Zone represents 3rd degree or full thickness burns? 1- Zone of Coagulation 2- Zone of Liquefaction 3- Zone of Stasis 4- Zone of Hyperemia

What factors Transition one zone to a deeper zone? 1- Edema 2- Infection 3- Poor perfusion 4- All of the above

Zones of Injury

The following picture represents which type of burn? 1- Superficial 2- Superficial Partial thickness 3- Deep Partial thickness 4- Full thickness

Burns

Superficial Thickness

Partial Thickness

Full Thickness

Diffusion of nutrients to the healing tissues is called? 1- Imbibition 2- Inosculation 3- Granulation 4- Neovascularization

Burn Healing Full Thickness Partial Thickness Heals from epithelialization from wound edges Partial Thickness Heals from re-epithelialization from epidermal appendages Hair Follicles Sweat Glands Sebaceous Glands

Burn Healing Imbibition Neovascularization Epithelialization Osmotic nutrient and oxygen deliver Day 0-3 Neovascularization Days 3+ Epithelialization From epidermal appendages Contraction

Evaluation of a Burn Patient ABCs – Primary Survey Secondary Survey Resuscitation Estimate size and depth of burn Concomitant Injuries Diagnostic Studies/ Lab work Labs:paO2, pCO2, CO, CBC, BMP, Coags, +/- UA Diagnostic Studies based on concomitant trauma Wound Care Nutrition

UW Protocol Table 11.3

True or False: An easy method of calculating a patient’s TBSA burn is to use the palm of your hand, which constitutes 1% TBSA.

A child has disproportionately a large TBSA designated to which part of the body as compared to an adult? 1- Head 2- Feet 3- Legs 4- Torso

A 54 yo 70kg man is transferred to your burn center, as shown in the picture. Estimate the TBSA involved? 1- 10% 2- 20% 3- 40% 4- 50%

How much volume will you give this patient in the first 8 hours of resuscitation? 1- 1800 mL 2- 2800 mL 3- 3800 mL 4- 4800 mL

Estimating Extent Rule of Nines Size of Patients palm Differs for adults and Children Children have larger head and smaller leg % Size of Patients palm

Calculating Fluid Requirement Parkland Formula: 4 cc/kg x % TBSA Fluid: Adults: LR (1st 24 hours)  D5 ½ NS Pediatrics: D5 0.45%NS Administer: First ½ in the first 8 hours Second ½ in the Second 16 hours Monitor MAP and UO MAP > 60 mmHg U/O: Adults: > 30 ml/hr, (concerned about Rhabdo – 100mL/hr) Pediatric: > 1.5 -2 mL/kg/hr Avoid large volume crystalloid boluses, increase hourly rate 10%

A 72 yo male was rescued from a house fire A 72 yo male was rescued from a house fire. On initial evaluation he has stupor and confusion. What is his likely carboxyhemoglobin level? 1- 5% 2- 10% 3- 20% 4- 30%

Carboxyhemoglobin T1/2 is? 1- 30 minutes 2- 1 hour 3- 2 hours 4- 4 hours

Airway swelling following an inhalational injury is worst at which time following injury? 1- First 12 hours 2- 12-24 hours 3- 24-48 hours 4- 48-72 hours

Inhalation Injury Clinical Exam Laryngoscopy CarboxyHb levels Coughing, wheezing, stridor Carbonaceous material on face Singed facial hair Laryngoscopy Erythema Edema Carbonaceous sputum below level of vocal cords CarboxyHb levels Smokers < 20%

A 70 kg man is HD#2 following admission for a 35% TBSA burn as demonstrated in the picture below. Over the past 3 hours he his BPs are 90/50s, his u/o has decreased to 5 mL/hr, and his Peak Airway pressures are 40 mmHg. What is the next step in management? Decrease his PEEP Bolus 1 L of 0.9 NS Start vasopressin Check bladder pressures

Fluid Resuscitation Complications Poor tissue Healing Pulmonary Complications Edema/ARDS Effusions Extremity Compartment Syndrome Escharotomies Fasciotomies Abdominal Compartment HTN/Syndrome Bladder pressures > 25 mmHg Decompressive laparotomy

Escharotomity

Which of the following below is a side effect of silver sulfadiazine (Silvadene)? Neutropenia Leukocytosis Metabolic Acidosis Metabolic Alkalosis

Which topical antimicrobial is best used to for ear burns? Silvadene Sulfamylon Silver Nitrate Bacitracin

Which topical antimicrobial is contraindicated in patients with sulfa allergy? Silvadene Sulfamylon Silver Nitrate Bacitracin

Which topical antimicrobial is associated with methemoglobinemia? Silvadene Sulfamylon Silver Nitrate Bacitracin

Topical Antimicrobials Side Effects Neutropenia, Thrombocytopenia Metabolic Acidosis Painful Methemoglobinemia Electrolyte imbalances

What is the thickness of a split thickness skin graft? 0.001 cm 0.012 cm 0.12 cm 1.2 cm

Burn Excision Optimal timing is 3-4 days post injury Surgical Excision: Fascial excision: Excising involved tissue down to muscle fascia Tangential excision: Sequential excision of eschar until the wound bed displays punctate bleeding

Autograft Use of patients skin as donor sites Full thickness Less wound contracture Limited donor sites (behind ear, groin, clavicle) Have to be closed by primary closure Split thickness 0.012-0.015 cm thickness Includes epidermis and part of dermis

Additional Options Allografts Xenografts Epidermal Skin Substitutes Temporary biologic dressing Meshed 1:1 Provides physiologic wound coverage for 2-4 weeks Rejection occurs at 2-4 weeks  removal and autograft or re-allograft No allografts in pregnancy: fetal deaths from HLA mismatch Xenografts Porcine Similar to allograft process Epidermal Skin Substitutes Cultured autologous keratinocytes Dermal Skin Substitutes Integra (inner matrix of type 1 collagen and chondroitin sulfate) Becomes vascularized in 2-3 weeks then can by autografted

Treatment of an alkali chemical burn is? Copious irrigation with tap water for 30 minutes Neutralization of the alkali agent Intra-arterial calcium gluconate infusion Both 1 and 2

Treatment of an acidic chemical burn is? Copious irrigation with tap water for 30 minutes Neutralization of the acidic agent Intra-arterial calcium gluconate infusion Both 1 and 3

Treatment of a hydrofluoric acid chemical burn is? Copious irrigation with tap water for 30 minutes Neutralization of the acidic agent Intra-arterial calcium gluconate infusion Both 1 and 3

What is the daily protein requirement for a 70 kg man with a 35% TBSA partial thickness burn? 75 gm/day 175 gm/day 250 gm/day 425 gm/day

Nutritional Support Protein catabolism results in 1500 to 200 gm of nitrogen loss/day Protein Requirement: 1gm/kg/day + (3 g/day x % TBSA) Caloric Requirement: 25 kcal/kg/day + (30 kcal/day x % TBSA)