Professional Documents
Culture Documents
Objectives
PART 1
Anatomy
PART 2
Physiologic
Overview Causes of Burns Estimating Burns (Depth & %) Categories & Zones
Anatomy
Adult skin surface 1.5-2.0 m2 (0.2-0.3 in newborns); largest organ Skin thickness 1-2 mm; peaks age 30-40; M> F Functions include:
protection
from external environment maintenance of fluid/electrolyte homeostasis Thermoregulation immunologic function sensation Metabolic organ (i.e., Vit D synthesis)
Causes of Burns
Usually caused by heat, electricity, chemicals, radiation, and friction Thermal burns are caused by steam, fire, hot objects or hot liquids.
Electrical burns are the result of direct contact with electricity or lightning Chemical burns occur when the skin comes in contact with household or industrial chemicals Radiation burns are caused by over-exposure to the sun, tanning booths, sun lamps, X-rays or radiation from cancer treatments Friction burns occur when skin rubs against a hard surface, e.g. carpet, gym floor, concrete or a treadmill
Effect of Heat
Temporal and quantitative 40-44C, enzymes malfunction, proteins denature and pumps fail > 44C, damage occurs faster than repair mechanisms can keep up with Damage continues even when the source is withdrawn
Effect of Electricity
Effects of current depend on several factors - Type of circuit - Voltage - Resistance of body - Amperage - Pathway of current - Duration of contact High voltage (>1000V) causes underlying tissue damage. Deep tissues act as insulators and continue to be injured. Resistance of various tissues from LH: nerve, vessels, muscle, skin, tendon, fat, bone Ohms Law- V=IR Damage more related to cross-sectional area which explains extremity injuries without trunk injuries.
Electrical Storms/Lightning
Burns are characteristically superficial and present as a spidery or arborescent pattern. Cardiopulmonary arrest is common following lightning injury. Coma and neurologic defects are also common but usually clear in a few hours or days. Watch for tympanic membrane rupture
World record for surviving lightning strikes is Roy C. Sullivan who was a park ranger from VA. Roy was struck 7 times from 19421977.
Electrical Pruning
Effect of Chemicals
Acids and alkalis cause injury via different mechanisms. Petroleum products can cause delipidation and depth of wound 2 tendency to adhere to skin Acids: coagulation necrosis
area of coagulation is formed and limits extension of injury exception is hydrofluoric acid, which produces a liquefaction necrosis similar to alkalis. Acid damaged skin can look tanned and smooth; do not mistake for a suntan.
In contrast to acids, whose tissue penetration is limited by the formation of a coagulum, alkalis can continue to penetrate very deeply into tissue Can cause severe precipitous airway edema or obstruction.
Inhalation Injury
Heat dispersed in upper airways leads to edema Cooled smoke and toxins carried distally Increased blood flow to bronchial arteries causes edema Increased lung neutrophils mediators of lung damage release proteases and oxygen free radicals (ROS) Exudate in upper airways formation of fibrin casts
Stage 3 bronchopneumonia
Early Staph pneumonia (frequently PCN resistant) Late - Pseudomonas
Inhalation Injury
Mild: < 5% TBSA Moderate: 5-15% TBSA Severe: > 15% (95% of burns seen) May require Burn Unit care because of potential for disability despite small TBSA (face,
hands, feet, perineum)
Initial assessment is often unreliable Ignore mild erythema when calculating fluid requirements Pink areas that blanch are usually superficial Deeper wounds are dark red, mottled or pale and waxy Insensate areas are usually deep (3rd degree or
greater)
Temperature and duration Thickness of skin (thin on eyelids, thick on back) Age (children and elderly have proportionally thinner skin in comparison to adults) Vascularity Agent oil vs water; acidic vs alkalotic Time to definitive care
Burn Zones
2.
3.
Zone of coagulation - A nonviable area of tissue at the epicenter of the burn Zone of ischemia or stasis - Surrounding tissues (both deep and peripheral) to the coagulated areas, which are not devitalized initially but, 2 microvascular insult, can progress irreversibly to necrosis over several days if not resuscitated properly Zone of hyperemia - Peripheral tissues that undergo vasodilatory changes due to neighboring inflammatory mediator release but are not injured thermally and remain viable
Zone of Hyperemia
Zone of Ischemia
Zone of Coagulation
Burns are divided into 4 categories, depending on the depth of the injury, as follows: First-degree burns are limited to the epidermis. A typical sunburn is a first-degree burn. Painful, but self-limiting. First-degree burns do not lead to scarring and require only local wound care.
burns
of injury extends into the dermis, with some residual dermis remaining viable
Partial
or full-thickness burns involve destruction of the entire dermis, leaving only subcutaneous tissue exposed.
Escharatomy Sites
Preferred sites for escharotomy incisions. Dotted lines indicate the escharotomy sites. Bold lines indicate areas where caution is required because vascular structures and nerves may be damaged by escharotomy incisions. (From Davis JH, Drucker WR, Foster RS, et al: Clinical Surgery. St. Louis, CV Mosby, 1987.)
Fourth-degree burn is usually associated with lethal injury. Extend beyond the subcutaneous tissue, involving the muscle, fascia, and bone. Occasionally termed transmural burns, these injuries often are associated with complete transection of an extremity.
PART 2
Physiologic
Pathophysiology of Burns
Cell damage and death causes vasoactive mediator release: Histamines Thromboxanes Cytokines Increasing capillary permeability causes edema, third spacing and dehydration Possible obstruction to circulation (compartment syndrome) and/or airway
Resuscitation Period
leak can be seen in those with delayed resuscitation 2 systemic release of O2 radicals upon reperfusion
Extravascular extravasation of fluid, lytes, colloid molecules Other variables affect resuscitation: preexisting fluid deficits, delay until treatment, inhalation injury, depth of wound Must reevaluate resuscitation progress and endpoints frequently; do not just use a formula
Resuscitation Guidelines
Postresuscitation Period
Day 3 until 95% wound closure Hyperdynamic, febrile, protein catabolic state Tachycardia can be normal in burn patients Blood pressure may be hard to obtain due to circumferential burns Release of more inflammatory mediators, cortisol, glucagon, catecholamines, bacteria from wound High risk of infection and pain Remove non-viable tissue or close wounds to avoid sepsis Nutritional support essential
Maintain and support body temperature with high ambient temps and humidity
Recovery Period
95% wound closure until 1 year post-injury Continued catabolism and risk of non-healing wound Anticipate septic events, treat complications, and continue nutritional support
Small cutaneous lesions may overlie extensive areas of damaged muscle myoglobin ARF. Monitor for at least 48 hours after injury for cardiopulmonary arrest May see vertebral compression fractures from tetanic contractions or other fractures from a fall. Visceral injury is rare but liver necrosis, GI perforation, focal pancreatic necrosis and gallbladder necrosis have been reported. Look for motor and sensory deficitsmotor nerves are affected more than sensory nerves. Thrombosis of nutrient vessels of the nerve trunks or spinal cord can cause late onset deficits. Early deficits are direct neuronal injury. Delayed hemorrhage can occur from affected vessels Cataracts may form up to 3 or more years after electrical injury Microwave radiation damages tissues via a heating effect. Subcutaneous fatty tissue is often spared given its lower water content.
Generalized edema found in burns > 30% TBSA Heat directly damages vessels and causes permeability + Heat activates complement histamine release and more permeability thrombosis and coagulation systems
Accelerated fluid loss 2 leaky capillaries Host resistance to infection Multisystem Organ Failure Infections in burns <20% TBSA are well tolerated. > 40% TBSA with infection has very low survival rate Initially CO, subsequent hypermetabolic state w/ doubling of CO in 24 48 hours
OR Pictures
Burn Questions
A 50 year-old man sustains a flame burn involving the entire upper left extremity, entire anterior trunk, genital area, and half of the left lower extremity. Approximately what percentage of the total body surface area is burned? a. 24% b. 28% c. 37% d. 45% e. 30%
According to American Burn Association criteria, which of the following patients should be referred to a burn center?
A. Second- and third-degree burns involving more than 20% of the total body surface area (TBSA) in patients younger than 10 or older than 50 years of age. B. Full-Thickness burns that involve 2% of the TBSA in patients of any age. C. Significant burns of the face, hands, feet, genitalia, perineum, or skin overlying major joints. D. Burn Injury in children with suspected or actual child abuse or neglect. E. Acute massive skin loss syndromes (e.g., StevensJohnson syndrome/toxic epidermal necrolysis, large traumatic de-gloving injuries)
All of the following are true regarding the Pathophysiology of thermal injury, except?
A. Increased capillary permeability is due to direct effect of heat and the liberation of vasoactive mediators. B. Increased pulmonary vascular resistance occurs during the immediate postburn period. C. Elevated thyronine (T3) and thyroxine (T4) levels. D. Elevated interleukin-6 (IL-6) level E. Decreased immoglobulin G (IgG) level
A 60-year-old, 80-kg man has sustained a second-degree burn to 40% TBSA with a significant inhalation injury. He was admitted to the burn unit 30 minutes after the accident. According to the Parkland formula, resuscitation was started with lactated Ringers solution at 800 ml/hr. Six hours later the patient was found to be oliguric. What should be the next step in resuscitation of this patient? A. Swan-Ganz catheter placement and measurement of pulmonary wedge pressure. B. Trial of small dose of furosemide C. Low does of dopamine (2-3 ug/kg/min). D. Increase in volume of the lactated Ringers solution infusion. E. Bolus of colloid solution
Which of the following statements is/are true regarding resuscitation of patients with burn injury during the first 24 hours?
a. Parkland formula uses a balanced electrolyte solution & the fluid requirement is calculated as 3 ml/kg body weight per %TBSA burned. b. Patients with 15% or more TBSA burn require intravenous fluid resuscitation. c. Adequate urine output implies hemodynamic stability and adequate organ perfusion. d. Crystalloid resuscitation restores cardiac output more rapidly than colloid alone. e. Late pulmonary morbidity and mortality are higher in colloidresuscitated patients.
Characteristics A. Limited eschar penetration, resistant organisms neutropenia, thrombocytopenia B. Painful application, hyperchloremic reactions good eschar penetration C. Hyponatremia, hypokalemia, hypocalcemia, methemoglobinemia
Which of the following statements is/are true regarding metabolism in the burn patient?
a. Postburn hypermetabolism is mediated by catecholamine release. b. IL-1 and IL-6 are elevated in burn injuries and enhance the hypermetabolic response by increasing oxygen consumption. c. Elevated core and skin temperature and lower core-to-skin heat transfer are manifested in postburn hypermetabolism. d. Increased blood flow to the muscles in the burned limb. e. The burn wound preferentially utilizes glucose by anaerobic glycolytic pathways despite increased blood flow to the wound.
Select the correct statements regarding nutrition in burn patients. a. The optimal calorie/nitrogen ratio varies between 150:1 & 160:1. b. Fat is the best source of non-protein calorie. c. Glutamine deficiency results in atrophy of gut mucosa d. Long-chain triglycerides for maintaining lean body mass. e. Overfeeding is associated with hyperventilation.
Which of the following statements is/are true for invasive burn wound infection?
a. Common in burns larger than 30% total body surface area. b. Characterized by conversion of a partialthickness burn to full-thickness burn. c. Definitive diagnosis can be made if quantitative culture of the biopsy recovers more than 105 organisms per gram on tissue. d. Incidence of Candida wound infection has increased owing to topical antimicrobial chemotherapy. e. Topical antimicrobial agents have markedly decreased the incidence of invasive
Which of the following statements is/are true regarding administration of antibiotics to burn patients? a. Prophylactic systemic antibiotics are indicated in patients with extensive burns. b. With invasive burn wound sepsis, systemic antibiotics should not be instituted before culture and sensitivity results are available. c. Positive wound cultures should be treated with systemic antibiotics. d. Antibiotics effective against anaerobic organisms are always indicated for burn wound sepsis. e. Subtherpeutic serum antibiotic levels are
Which of the following statements is/are true regarding burn wound excision?
A. Excision is indicated for deep partial-thickness and fullthickness burn wounds. B. Early excision and closure of burn wounds has been shown to reduce the incidence in invasive burn wound infection, shorten the hospital stay, reduce pain, and improve functional recovery. C. Excision should be performed after successful fluid resuscitation. D. Tangential excision involves sequential excision of the eschar down to bleeding, viable tissue. E. Excision of more than 10% of TBSA single procedure is associated with significantly morbidity.
Which of the following statements is/are true regarding burn wound closure?
A. Split-thickness autograft is contraindicated if wound culture is positive B-hemolytic streptococci. B. Xenograft is the most frequently used and effective biologic dressing when an autograft is not available. C. Allograft dressings promote bacterial proliferation. D. Cultured autologous keratinocyte sheets can be used for permanent wound coverage with good results.