1. Chapter 11: Burns
Lisa Spiguel

2. 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

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

5. 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

6. 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

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

8. Zones of Injury

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

10. Burns

11. Superficial Thickness

12. Partial Thickness

13. Full Thickness

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

15. 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

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

17. 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

18. UW Protocol Table 11.3

19. 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.

20. 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

21. 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%

22. How much volume will you give this patient in the first 8 hours of resuscitation?mL mL mL mL

23. 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

24. 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: > mL/kg/hr
Avoid large volume crystalloid boluses, increase hourly rate 10%

25. 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%

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

27. Airway swelling following an inhalational injury is worst at which time following injury?
1- First 12 hours
hours
hours
hours

28. 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%

29. 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

30. 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

31. Escharotomity

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

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

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

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

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

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

38. 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

39. 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
cm thickness
Includes epidermis and part of dermis

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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)