أسئلة الخامسة جراحة ثالثة الدلتا

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Questions and Answers

What is the underlying process that defines a burn?

  • Liquefactive necrosis of the epidermis
  • Coagulative destruction of tissues (correct)
  • Ischemic infarction of dermal layers
  • Fibrotic replacement of subcutaneous fat

Which type of burn is caused by contact with electricity?

  • Chemical burn
  • Electrical burn (correct)
  • Thermal injury
  • Contact burn

According to the Rule of Nines, what percentage of the total body surface area (TBSA) does the chest and abdomen represent in an adult?

  • 9%
  • 18%
  • 36% (correct)
  • 27%

A patient has burns covering 30% of their body. According to burn severity grades, how would this burn be classified?

<p>Major (D)</p> Signup and view all the answers

Which of the following best describes a superficial burn?

<p>Affects only the epidermis, similar to a sunburn (D)</p> Signup and view all the answers

How long does a superficial partial thickness burn typically take to heal?

<p>10-14 days (D)</p> Signup and view all the answers

What is the primary method of epithelial regain in full thickness burns?

<p>Epithelial migration from healthy margins around the burn area (A)</p> Signup and view all the answers

Why is skin grafting typically required for full thickness burns?

<p>To accelerate the healing process due to complete destruction of the epidermis and dermis (A)</p> Signup and view all the answers

Which of the following is NOT apart of the pathophysiology of burns?

<p>Decreased fluid loss (B)</p> Signup and view all the answers

What is the zone of stasis in a burn injury?

<p>Intermediate area of potentially reversible damage (A)</p> Signup and view all the answers

What is the most common cause of death in the early stages (within 4-7 days) following a major burn injury?

<p>Infection (C)</p> Signup and view all the answers

What is the immediate treatment for constricting eschar in circumferential burns?

<p>Escharotomy (B)</p> Signup and view all the answers

What is a Marjolin's ulcer?

<p>Malignant transformation in a burn scar (C)</p> Signup and view all the answers

After ensuring breathing and circulation, what is the next immediate step in the initial management of a burn victim?

<p>Cool the burn area with running water (D)</p> Signup and view all the answers

Why is intramuscular (IM) administration of pain medication generally avoided in the initial management of burn patients?

<p>Poor absorption due to altered tissue perfusion (C)</p> Signup and view all the answers

In the context of burn management, what is the purpose of using a Foley catheter?

<p>To monitor urine output (D)</p> Signup and view all the answers

According to the fluid resuscitation guidelines, what type of intravenous fluids are typically administered in the first 24 hours post-burn?

<p>Crystalloids only (e.g., Saline or Ringer's Lactate) (A)</p> Signup and view all the answers

According to the Parkland formula, how is the total amount of Ringer's Lactate to be administered in the first 24 hours calculated?

<p>$4 \text{ ml/kg} \times \text{Weight (kg)} \times \text{% TBSA}$ (C)</p> Signup and view all the answers

What is a key difference between the exposure method and the occlusive method in local burn wound care?

<p>The exposure method promotes a dry wound environment, while the occlusive method maintains a moist environment. (B)</p> Signup and view all the answers

In which of the following situations would the exposure method of local burn wound care be most appropriate?

<p>Burns on the neck and face (C)</p> Signup and view all the answers

What is the purpose of tangential excision in surgical burn treatment?

<p>To remove the burned dermis (C)</p> Signup and view all the answers

When is the optimal timing for surgical excision and grafting of burn wounds, relative to bacterial contamination?

<p>3-5 days before bacterial contamination (B)</p> Signup and view all the answers

A patient presents with a burn that involves the epidermis and the first layer of the dermis with erythema. Which type of burn does this describe?

<p>Superficial partial thickness burn (A)</p> Signup and view all the answers

What systemic complication of burns is most directly related to loss of fluids?

<p>Hypovolemic shock (C)</p> Signup and view all the answers

What is the purpose of chemoprophylaxis in initial burn management?

<p>To prevent infection with tetanus toxoid, antibiotics &amp; local antiseptics (A)</p> Signup and view all the answers

What is the appropriate management for minor burns that can be treated on an outpatient basis?

<p>Dressing, antibiotics prophylaxis, and analgesics (B)</p> Signup and view all the answers

What is NOT an advantage of the occlusive method for local care of a burn wound?

<p>Increased bacterial inhibition due to dry air exposure (A)</p> Signup and view all the answers

What are the hot gases inhalation under inhalation burns?

<p>Hot gases (A)</p> Signup and view all the answers

Which of the following best explains the primary mechanism by which burns cause tissue damage?

<p>Coagulative necrosis due to protein denaturation by heat. (B)</p> Signup and view all the answers

A patient presents with a burn characterized by blisters and significant pain, involving both the epidermis and a portion of the dermis. Which classification of burn is most consistent with these findings?

<p>Superficial partial thickness burn. (B)</p> Signup and view all the answers

A patient has a burn that extends through the epidermis and dermis, with visible eschar formation. After eschar separation, granulation tissue is evident. What is the most appropriate next step in management?

<p>Proceed with skin grafting. (A)</p> Signup and view all the answers

According to the 'Rule of Nines' in adults, what percentage of total body surface area (TBSA) is represented by the entire back?

<p>18% (C)</p> Signup and view all the answers

A patient has full thickness burns covering 40% of their total body surface area (TBSA). Which systemic response is LEAST likely to occur during the acute phase?

<p>Increased cardiac output. (B)</p> Signup and view all the answers

What is the primary rationale for avoiding intramuscular (IM) injections in the initial resuscitation of a patient with extensive burns?

<p>Unpredictable absorption due to fluid shifts and poor perfusion. (D)</p> Signup and view all the answers

According to the Parkland formula, how would the estimated fluid requirement be calculated for a 70 kg patient with burns covering 50% of their total body surface area (TBSA) in the first 24 hours?

<p>$4 \text{ mL} \times 70 \text{ kg} \times 50 = 14000 \text{ mL}$ (A)</p> Signup and view all the answers

In the context of burn wound management, what is the primary purpose of tangential excision?

<p>To selectively remove thin layers of burned dermis until viable tissue is reached. (D)</p> Signup and view all the answers

A patient with circumferential full thickness burns on the chest develops respiratory distress. What is the MOST appropriate immediate intervention?

<p>Perform immediate escharotomy. (C)</p> Signup and view all the answers

What is the MOST concerning long-term complication associated with a non-healing burn wound?

<p>Marjolin's ulcer. (D)</p> Signup and view all the answers

Which of the following is the MOST critical factor in determining the need for transfer to a specialized burn center?

<p>Burn depth and percentage of total body surface area (TBSA) affected. (C)</p> Signup and view all the answers

During the acute phase of burn management, which of the following is the MOST important strategy to prevent bacterial colonization and subsequent infection?

<p>Maintaining strict aseptic technique during wound care. (D)</p> Signup and view all the answers

A patient with a significant burn injury develops acute oliguria. What is the MOST likely underlying cause in the first 48 hours post-burn?

<p>Pre-renal azotemia due to hypovolemia. (A)</p> Signup and view all the answers

Which of the following is the MOST significant advantage of using the exposure method in local burn wound care?

<p>Inhibition of bacterial growth due to dry air. (A)</p> Signup and view all the answers

In the management of inhalation burns, what is the rationale for considering early bronchoscopy?

<p>To assess the extent of airway damage and guide management. (D)</p> Signup and view all the answers

A patient with extensive burns develops Curling's ulcer. What is the underlying mechanism leading to the formation of this type of ulcer?

<p>Ischemia of the gastrointestinal tract due to hypovolemia and stress. (C)</p> Signup and view all the answers

Which of the following best describes the zone of stasis in a burn wound, according to Jackson's burn zones?

<p>The intermediate zone of potentially reversible tissue damage. (C)</p> Signup and view all the answers

What is the MOST appropriate initial step in managing a patient with suspected inhalation injury from a fire?

<p>Administer 100% humidified oxygen. (A)</p> Signup and view all the answers

A patient with extensive burns develops septic shock five days post-injury. What is the MOST likely source of infection in this scenario?

<p>Burn wound infection. (D)</p> Signup and view all the answers

Which of the following is the MOST appropriate method for providing analgesia in the acute management of a patient with severe burns?

<p>Intravenous (IV) opioids titrated to effect. (D)</p> Signup and view all the answers

Which of the following is a key advantage of using silver sulfadiazine in local burn wound care?

<p>It has broad-spectrum antimicrobial activity and penetrates eschar. (B)</p> Signup and view all the answers

A patient with a burn injury is being resuscitated with intravenous fluids. What clinical parameter is the MOST important to monitor to ensure adequate fluid resuscitation?

<p>Urine output. (B)</p> Signup and view all the answers

Which of the following systemic complications is MOST directly associated with the loss of skin integrity and barrier function in burn patients?

<p>Hypothermia. (D)</p> Signup and view all the answers

Why is tetanus prophylaxis a routine component of initial burn management?

<p>Due to the increased risk of Clostridium tetani infection in devitalized tissue. (B)</p> Signup and view all the answers

What is the key difference between the exposure method and the occlusive method in local burn wound care, concerning bacterial control?

<p>Exposure promotes drying which inhibits bacteria, occlusive supports moist environment. (C)</p> Signup and view all the answers

What is the most concerning risk associated with hot gases inhalation under inhalation burns?

<p>They can cause acute asphyxia, edema, and respiratory failure. (B)</p> Signup and view all the answers

What is the primary advantage of using crystalloids over colloids for initial fluid resuscitation in burn patients?

<p>Crystalloids are less expensive and readily available compared to colloids. (A)</p> Signup and view all the answers

Which of the following factors primarily dictate the choice between using crystalloids alone versus a combination of crystalloids and colloids in burn resuscitation?

<p>Severity of the burn and patient's response to initial resuscitation. (B)</p> Signup and view all the answers

Flashcards

Burn definition

Coagulative destruction of tissues.

Contact burn

Scalds caused by contact with boiled liquids.

Chemical Burns

Burns caused by acids or alkalis.

Wallace's Rule of Nines

Used in adults to estimate the total body surface area (TBSA) affected by burns.

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Head & neck % in burns

According to Wallace's rule of 9, the head and neck of an adult represent 9% of TBSA (4.5% front and 4.5% back).

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Major burn

Burn is major if it covers more than 25% of the body's surface area.

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Superficial burn

Burn limited to the epidermis; like a sunburn.

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Superficial Partial Thickness Burn

Burns involving the epidermis and first layer of the dermis.

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Deep partial thickness

Burns involving the epidermis and second layer of the dermis.

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Full Thickness Burn

Burns involving epidermis and dermis completely.

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Pathophysiology of burns

Bacterial colonization.

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Zone of coagulation

Central area with the most damage.

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Zone of stasis

Intermediate zone with impaired circulation.

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Neurogenic shock after a burn

Immediately from pain.

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Hypovolemic shock after burns

First 48 hours due to fluid loss.

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Curling's ulcer

After a burn, acute ulcer of stomach and duodenum

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Early Infection post-burn

Infection is the most likely cause of death within 4-7 days after the burn.

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Escharotomy

To relieve pressure from swelling.

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Scar formation

Hypertrophic scar or keloid.

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Marjolin's ulcer

Malignant transformation.

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Cooling the burn

Initial management of burns.

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Pain killer route

Avoid IM injection because of poor absorption.

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Parkland formula

2 ml/ percent area burnt/kg weight.

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Type of Fluids

Crystalloids (saline or Ringer's lactate).

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Constricting eschar

only that are released immediately.

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Topical antimicrobials

Application of silver nitrate or silver sulfadiazine.

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Occlusive Method

Use of sterile dressing.

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Timing

3-5 days before skin contamination.

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Thermal Injury

Destruction of tissues caused by flame burns.

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Electrical Burns

Tissue damage resulting from contact with electricity

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Cold Injury

Tissue damage caused by prolonged exposure to extreme cold.

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Burn Percentage Estimation

Measurement in adults for estimating the percentage of total body surface area affected by a thermal burn.

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Chest & abdomen % in burns

The front of the chest and abdomen each account for 18% TBSA.

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Upper limb % in burns

The upper limb accounts for 9% TBSA

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Lower Limb % in burns

Each lower limb accounts for 18% TBSA.

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Perineum % in burns

The perineum accounts for 1% TBSA.

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Intermediate burn

A burn that covers 15-25% of the body surface area.

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Fourth Degree Burn

A burn that involves underlying tissues such as tendon, muscle and bone.

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Zone of Hyperemia

Outermost region with increased blood flow due to inflammatory.

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Inhalation Injury

Lung injury from smoke inhalation, atelectasis, pneumonia, and respiratory failure.

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Renal Failure after a burn

Oliguria and acute renal failure due to prolonged hypovolemia.

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Causes Death in Burn

Acute airway blockage in head & neck burns.

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IV Cannulation

IV cannula rapidly before veins get collapsed.

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Checking UOP

Foley's catheter to check UOP.

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Fluid Therapy Timing

First 48 hours & then continued according.

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Fluid Amount

In the 1st 24 hours is 2 ml/percent area burnt/kg weight.

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Study Notes

  • Burn is the coagulative destruction of tissues

Types of Burns

  • Physical burns include contact burns (scalds from boiled liquids), thermal injury (flame burns), exposure to irradiation, electrical burns (contact with electricity), and cold injury (frost bite)
  • Chemical burns are caused by acids, alkalis, and corrosives/caustics
  • Inhalation burns come from hot gases

Classification of Burn by Area Affected (Adult Wallace's Rule of 9)

  • Head & neck: 9% (4.5% front & 4.5% back)
  • Chest & abdomen: 36% (18% front & 18% back)
  • Upper limb: 9% (4.5% front & 4.5% back)
  • Lower limb: 18% (9% front & 9% back)
  • Perineum: 1%
  • Major burn: more than 25% of body
  • Intermediate burn: 15-25% of body
  • Minor burn: less than 15% of body

Classification of Burn by Depth of Tissue

  • Superficial burn (1st degree): involves the epidermis only, like a sunburn, and heals rapidly within 5-10 days
  • Partial thickness burn (2nd degree), Superficial: involves the epidermis and 1st layer of dermis, causes erythema, and heals rapidly within 10-14 days
  • Partial thickness burn (2nd degree), Deep: involves the epidermis and 2nd layer of dermis, heals within 3-6 weeks from remnants of hair follicle & sweat glands, may become full thickness if infected
  • Full thickness burn (3rd degree): involves the epidermis and dermis completely, epithelial regain by epithelial migration is slow, requires skin graft after eschar separation in the 3rd week
  • Fourth degree burn: involves underlying tissues like tendon, muscle & bone

Pathophysiology

  • Protein denaturation occurs because of very high temperatures
  • Increased capillary permeability
  • Excessive loss of water
  • Bacterial colonization

Burn Zones (Jackson's Zones)

  • Central inner zone: zone of coagulation
  • Intermediate zone: zone of stasis
  • Outer zone: zone of hyperemia

Systemic Complications

  • Inhalation injury: can cause asphyxia, pneumonia, atelectasis, emboli, edema, emphysema, and respiratory failure
  • Neurogenic shock: occurs immediately due to pain
  • Hypovolemic shock: occurs in the first 48 hours due to fluid loss
  • Renal failure: can be acute due to prolonged hypovolemia, resulting in oliguria
  • CVS: anemia
  • Endocrine changes: increased ADH, cortisol, and catecholamines
  • Septic shock: due to infection
  • GIT: acute ulcer development in the stomach and duodenum (Curling's ulcer) & ileus
  • Multiple organ failure: due to respiratory failure and sepsis

Local Complications - Early

  • Infection (1st cause of death): within 4-7 days, can cause septicemia & septic shock and is prevented by antibiotics & proper wound care
  • Constricting eschar: deep circumferential burns in chest & limbs, treated by escharotomy
  • Edema in face & neck burns: causes suffocation, treated by tracheostomy

Local Complications - Delayed

  • Contracture around joints
  • Scar formation (hypertrophic scar/keloid)
  • Malignant transformation (Marjolin's ulcer)

Causes of Death in Burn

  • Hypovolemia & shock
  • Renal failure
  • Pulmonary oedema & ARDS
  • Septicemia
  • Multiorgan failure
  • Acute airway block in head & neck burns

Management - Initial (1st Aid)

  • Clothing should be removed
  • Cooling the part by running water for 20 minutes
  • Cleaning the part to remove dust & mud
  • Chemoprophylaxis: tetanus toxoid, antibiotics & local antiseptics
  • Covering with dressings
  • Comforting the patient with sedation & pain killer (IV 50 mg pethidine, not IM due to poor absorption)

Management - Minor Burns (Outpatient)

  • Dressing
  • Antibiotics prophylaxis
  • Analgesics

Management - Moderate & Major Burns (Burn Unit Hospitalization)

  • Insert a wide bore IV cannula rapidly before veins get collapsed
  • Foley's catheter to check UOP
  • Fluid therapy
  • Local care of the burn wound

Fluid Therapy (Depends on Percent of Burn & Weight of Patient)

  • In the first 24 hours, give 2 ml/percent area burnt/kg weight (half in first 8 hours, the rest in the next 16). Give half the calculated amount on the 2nd day
  • Use only crystalloids (saline or Ringer's lactate) or half crystalloids and half colloids (dextran)
  • Caloric daily needs are supplemented by 2000 ml of glucose 5%

Fluid Therapy Formulas

  • Evan's formula (1st day): 1 ml/kg/% burn normal saline + 1 ml/kg/% burn colloid + 2000 ml glucose, (2nd day): 0.5 ml/kg/% burn normal saline + 0.5 ml/kg/% burn colloid + 2000 ml glucose
  • Modified Brook's formula (1st day): 2-3 ml/kg/% burn Ringer's lactate + 2000 ml glucose, (2nd day): 1 ml/kg/% burn Ringer's lactate + 0.5 ml/kg/% burn colloid + 2000 ml glucose
  • Parkland's formula: 4 ml/kg Ringer's lactate x percent area per day

Local Care of Burn Wound

  • Constricting eschar: only constricting eschars are released immediately
  • Deep burns: need fasciotomy to save limbs
  • Topical antimicrobials: silver nitrate & silver sulphadiazine
  • Good cleansing: conservative debridement & remove loose skin
  • Exposure method: isolate the patient in a complete aseptic room and use complete aseptic techniques, this is indicated in neck, face, perineum & side of trunk and has advantages such as inhibiting bacteria and increased comfort for patients
  • Occlusive method: Clean the wound by aseptic solution, apply silver sulphadiazine ointment, and cover with vaseline gauze that is changed every 2-3 days. Indicated in circumferential burns, hands, and limbs. Advantages ↓ fluid loss evaporation, ↓ edema of tissues & ↓ pain

Surgical Treatment

  • Timing: 3-5 days before bacterial contamination
  • Procedure: tangential excision of dermis with immediate grafting or grafting delayed until granulation tissue is present

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