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Questions and Answers
What are the main causes of burn injuries?
What are the main causes of burn injuries?
What does the Wallace rule of nines measure?
What does the Wallace rule of nines measure?
Which type of burn is caused by alkalis?
Which type of burn is caused by alkalis?
What is the primary physiological effect in the first 24 hours postburn?
What is the primary physiological effect in the first 24 hours postburn?
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Which layer of skin is primarily affected by thermal burns?
Which layer of skin is primarily affected by thermal burns?
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Early management of which type of injury is crucial following severe burns?
Early management of which type of injury is crucial following severe burns?
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What is the Parkland formula used for in burn treatment?
What is the Parkland formula used for in burn treatment?
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Which skin layer has the greatest thickness variation?
Which skin layer has the greatest thickness variation?
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What is the primary purpose of performing an ABCDEF primary survey in burn injuries?
What is the primary purpose of performing an ABCDEF primary survey in burn injuries?
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Which criterion does NOT indicate the need for hospital admission for burn injuries?
Which criterion does NOT indicate the need for hospital admission for burn injuries?
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What percentage of body surface area (BSA) is designated for the head and neck in the Wallace rule of nines for adults?
What percentage of body surface area (BSA) is designated for the head and neck in the Wallace rule of nines for adults?
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What characterizes a second-degree burn?
What characterizes a second-degree burn?
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For children up to 1 year old, how is body surface area (BSA) distributed for the legs according to the Wallace rule?
For children up to 1 year old, how is body surface area (BSA) distributed for the legs according to the Wallace rule?
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What is NOT typically considered a serious associated injury in the context of burn assessments?
What is NOT typically considered a serious associated injury in the context of burn assessments?
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Which type of burn involves the destruction of both the epidermis and dermis?
Which type of burn involves the destruction of both the epidermis and dermis?
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What is the appropriate pre-hospital action if a patient has a significant electrical burn?
What is the appropriate pre-hospital action if a patient has a significant electrical burn?
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What characterizes a fourth-degree burn?
What characterizes a fourth-degree burn?
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The Parkland formula for fluid resuscitation recommends how much fluid to administer in the first 24 hours for burn patients?
The Parkland formula for fluid resuscitation recommends how much fluid to administer in the first 24 hours for burn patients?
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What is the best indicator of tissue perfusion during fluid resuscitation?
What is the best indicator of tissue perfusion during fluid resuscitation?
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What is the daily maintenance fluid requirement for children weighing 25 kg?
What is the daily maintenance fluid requirement for children weighing 25 kg?
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Which sign is NOT typically associated with significant inhalational injury?
Which sign is NOT typically associated with significant inhalational injury?
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What alteration in fluid resuscitation is warranted after high-voltage electrical injuries?
What alteration in fluid resuscitation is warranted after high-voltage electrical injuries?
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What components are found in Hartmann’s solution used for fluid resuscitation?
What components are found in Hartmann’s solution used for fluid resuscitation?
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What is a significant indicator of inhalation injury present after exposure?
What is a significant indicator of inhalation injury present after exposure?
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What is the first line of treatment for a patient with inhalational injury?
What is the first line of treatment for a patient with inhalational injury?
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When is endotracheal intubation necessary for patients with inhalational injury?
When is endotracheal intubation necessary for patients with inhalational injury?
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What complication is likely to occur when the burn surface area is 25% or more?
What complication is likely to occur when the burn surface area is 25% or more?
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What is the purpose of escharotomy in burn treatment?
What is the purpose of escharotomy in burn treatment?
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What is recommended for nutritional support in burn patients?
What is recommended for nutritional support in burn patients?
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What should be done during the local management of burns?
What should be done during the local management of burns?
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Which procedure is typically recommended after postburn day 3 for full thickness burns?
Which procedure is typically recommended after postburn day 3 for full thickness burns?
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When can fasciotomies be necessary in burn treatment?
When can fasciotomies be necessary in burn treatment?
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What is tangential excision aimed at achieving?
What is tangential excision aimed at achieving?
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Which type of skin graft consists of the full thickness of both the epidermis and dermis?
Which type of skin graft consists of the full thickness of both the epidermis and dermis?
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Which agent is most commonly used for local wound care in burn patients?
Which agent is most commonly used for local wound care in burn patients?
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What special consideration exists when using Sulfamylon for burn treatment?
What special consideration exists when using Sulfamylon for burn treatment?
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How is background pain best managed in burn patients?
How is background pain best managed in burn patients?
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What is a potential side effect of using Silver sulfadiazine?
What is a potential side effect of using Silver sulfadiazine?
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What is the primary disadvantage of using silver nitrate in burn treatment?
What is the primary disadvantage of using silver nitrate in burn treatment?
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What factor necessitates the use of skin substitutes in extensive burn cases?
What factor necessitates the use of skin substitutes in extensive burn cases?
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Study Notes
Burn Injury Overview
- A burn is a traumatic lesion caused by thermal, chemical, mechanical, or electrical agents.
- Burns affect all ages and can cause long-lasting physical and psychological scars.
- The skin surface area is approximately 1.5 - 2.0 m2 in adults.
- The dermis is about 10 times thicker than the epidermis.
Burn Injury Causes
- Thermal Burns: Most common cause, including scald, flash, flame, and contact burns.
- Chemical Burns: Caused by alkalis, acids, organic compounds, and phosphorus.
- Electrical Burns: Caused by low voltage (up to 1,000 V).
- Radiation Injury: Another cause of burns.
Burn Injury Pathophysiology
- Thermal injury causes coagulation necrosis of skin and underlying tissues.
- Burn injury has deleterious effects on all organ systems.
- Hemodynamic effects in the first 24 hours post-burn include decreased blood volume, increased blood viscosity, and depressed cardiac output.
- Perform an ABCDEF primary survey to assess the patient: airway, breathing, circulation, neurological disability, exposure.
Hospital Admission Criteria for Burns
- Second- and third-degree burns greater than 10% TBSA in patients under 10 or over 50 years of age.
- Second-degree burns greater than 20% TBSA in other ages.
- Third-degree burns greater than 5% TBSA in any age.
- Significant burns of the face, hands, feet, genitalia, or perineum.
- Significant electrical/lightning injuries.
- Significant chemical burns.
- Associated inhalation injury, concomitant mechanical trauma, or significant preexisting medical illnesses.
- Burns requiring special social, emotional, or long-term rehabilitative support, including cases of suspected or actual child abuse.
Burn Assessment
- Extent: Determine the surface area affected using the "Wallace Rule of Nine”.
- Adult BSA: Head and neck (9%), each arm (9%), anterior trunk (18%), posterior trunk (18%), each leg (18%), perineum (1%).
- Child BSA (up to 1 year): Head and neck (18%), each arm (9%), anterior trunk (18%), posterior trunk (18%), each leg (13.5%), perineum (1%).
- For each additional year of age up to 10, subtract 1% from head and neck and add 0.5% to each leg.
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Depth: Initially discern between erythema and actual skin damage.
- First-degree burn: Superficial burn involving only the epidermis, heals in less than 7 days.
- Second-degree burn: Involves the epidermis and upper dermal layer; characterized by redness, blistering, and pain.
- Third-degree burn: Involves the epidermis and dermis; presents as white, leathery, charred, and painless due to nerve destruction.
- Fourth-degree burn: Involves skin, muscle, and bone.
Fluid Resuscitation
- Required for adults with burns >15% TBSA and children with burns >10% TBSA.
- Use the Parkland Formula: 4 ml/kg/% burn of Hartmann's solution in the first 24 hours after the burn.
- 50% of the fluid is given in the first 8 hours after injury.
- The remaining 50% is given in the next 16 hours.
- Hartmann's solution contains: Na+ 131 mmol/l, Cl− 111 mmol/l, Lactate 29 mmol/l, K+ 5 mmol/l, Ca2+ 2 mmol/l.
- Monitor urine output (aim for 0.5-1 ml/kg/h in adults, 1-1.5 ml/kg/h in children), pulse, blood pressure, capillary refill, core-peripheral temperature gradient, respiratory rate, and urine osmolality.
- Serial blood lactate and base excess measures also indicate resuscitation adequacy.
Fluid Resuscitation Considerations for Children
- Children have proportionally greater surface area than adults.
- Children have reduced physiological reserves.
- Children require additional maintenance fluid containing dextrose.
- Daily maintenance fluid requirement: 100 ml/kg for the first 10 kg body weight, 50 ml/kg for the next 10 kg body weight, 20 ml/kg for the remainder of the body weight.
- Administer maintenance fluid enterally when possible.
Inhalation Injury
- Inhalation injury refers to chemical tracheobronchitis and acute pneumonitis caused by the inhalation of smoke and irritants.
- In severe cases, it can progress to adult respiratory distress syndrome (ARDS).
Signs of Significant Inhalation Injury
- Singed nasal hair.
- Significant facial burns.
- Carbonaceous sputum.
- Hoarseness.
- Stridor.
- Carboxyhemoglobin levels >15% at 3 hours post-exposure are strong evidence of smoke inhalation.
Evaluation of Inhalation Injury
- Obtain chest X-ray and arterial blood gases.
- Perform fiberoptic bronchoscopy at the bedside.
- Xenon ventilation/perfusion scanning can be used to diagnose inhalation injury.
Treatment of Inhalation Injury
- Primarily supportive with oxygen therapy.
- Administer 100% oxygen immediately.
- Endotracheal intubation may be necessary.
- Hyperbaric oxygen therapy is used in some cases.
Other Important Considerations
- Routine tetanus prophylaxis is required in burned patients.
- Prophylactic systemic antibiotics are not recommended. Administer antibiotics if features of infection are present.
- Insert a nasogastric tube and prescribe antacids for patients with deep burns >25% of TBSA.
- Regularly monitor hematocrit, electrolytes, and renal function tests.
- Provide high-calorie and high-protein diet with Vitamin A, C, Iron, and Zinc supplements.
- Offer psychological support.
- Rehabilitation and physiotherapy with early splinting of burned extremities and joints to prevent contractures.
Burn Wound Decompression
- Deep dermal and full-thickness burns are inelastic.
- Circumferential burns can cause distal limb ischemia.
- Extensive chest burns (or abdominal burns in children) can impair ventilation.
- Constriction worsens with fluid resuscitation.
Escharotomy
- Relieves constriction of the burned area.
- Usually performed with electrocautery.
- Begins and ends in unburnt or superficially burnt skin.
- Limb escharotomies are made in midaxial lines, avoiding the ulnar nerve at the elbow and peroneal nerve at the knee.
- Chest escharotomies are made along the mid-axillary lines to the subcostal region, joined by a chevron incision across the upper abdomen. This creates a mobile breastplate.
Fasciotomy
- Required for burns involving muscle or high-voltage electrical injuries.
Local Management of Burn Wounds
- Initial care involves debridement of necrotic tissue, open blisters, environmental protection, and edema reduction.
- Consider enzymatic debridement.
- Early excision of burn tissue provides better functional and aesthetic outcomes.
- Post-excision wounds are typically covered with meshed split-thickness autografts.
- Start staged excision on post-burn day 3 for full-thickness burns.
Types of Burn Wound Excision
- Tangential excision: Sequential removal of eschar and necrotic tissue layers until viable, bleeding tissue is reached.
- Fascial excision: Excision of burned tissue and subcutaneous tissue down to the muscle fascia.
- VersaJet (water-jet powered): Useful for excising concave surfaces of the hand and feet, eyelids, ear, and nose.
Coverage of Skin Defect After Excision
-
Skin Graft: Segment of tissue transferred from a donor site to a recipient site without its blood supply.
- Full-thickness skin graft: Consists of epidermis and full dermis thickness.
- Split-thickness skin graft: Consists of epidermis and variable dermis, depending on thickness (thin, intermediate, thick).
- Skin Substitutes: Used for extensive burns when available donor sites are limited, acting as a temporary skin replacement until autografts can be applied.
Pain Control in Burn Patients
- Background Pain: Best managed with longer-acting agents like morphine.
- Procedural Pain: Occurs during wound care and therapy; shorter-acting agents are suitable, including benzodiazepines.
- Avoid NSAIDs.
Topical Agents for Burn Wound Care
-
Silver Sulfadiazine (1% Silvadene): Most commonly used agent; effective against most Gram-positive and Gram-negative organisms.
- The “pseudoeschar” formed can confuse the inexperienced.
- Leukopenia can occur.
-
Sulfamylon (Mafenide acetate): Has superior eschar penetration; suitable for ears, noses, and electrical burns.
- Causes intense pain on application.
- Associated with metabolic acidosis.
-
Silver Nitrate (0.5%): Effective against Pseudomonas colonization.
- Produces black stains.
- Can cause hyponatremia and methemoglobinemia.
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Description
Test your knowledge on the causes, types, and management of burn injuries. This quiz covers essential topics such as the Wallace rule of nines, the primary effects of burns, and the critical aspects of early treatment. Enhance your understanding of burn assessments and the physiology involved in burn care.