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WVSOM - Burns

Burns and Trauma

Role of skin Prevent heat loss, water loss, invasion of bacteria
Typical water loss of skin ~15mL/m2/hr
Water loss in full thickness burn ~200mL/m2/hr
Burns result in Loss of vascular integrity, increased capillary permeability, increased interstitial fluid volume, reduction in blood volume
Fluid loss results in Hypovolemia, hypotension, tachycardia, decreased CO, vasoconstriction, kidney ischemia
Fluid loss is __________ to the ______ and _______ of the burn Proportional, size, depth
Cause of burns in 3-14 year olds Flame burns
Cause of burns in 15-60 year olds Industrial accidents
Cause of burns in 60+ year olds Accidents
Cause of burns in < 3 year olds Skull burns
____% of burns occur at home; ____ are preventable 50, 1/2
Burn severity is dependent on 3 things Temperature of heat source, duration of application of heat, conduction of tissue
What affects conduction of tissue? Pigments, thickness, moisture, oils / secretions
First degree burn Involves the epidermis
Second degree burn Partial thickness; burn down into dermis; will have bulla (blister)
Third degree burn Full thickness; fat and into muscle
First degree burn clinical presentation Erythema, pain (~40 hours), minimal edema, dry; capacity to prevent infection remains intact
Causes of first degree burns Gas explosions, brief contact with hot liquids, prolonged sunlight exposure
Treatment of first degree burns Remove clothing, apply cool compress (helps with pain and burning EXCEPT when it involves large areas = likelihood of hypothermia), soothing lotion; ~10 days for skin to scale off
Clinical presentation of second degree burns Blisters (bulla), edema, mottled red / pink (underneath bulla), moist, painful
Causes of second degree burns Short exposure to flash heat, contact with hot liquid, periphery of deep flame burn
Treatment of second degree burns < 10% body surface area = cool compress, leave blisters intact, cleanse wound, occlusive dressing; > 10% body surface area = hospitalize
Occlusive dressing Absorptive, bulky, eliminate dead space (air will cause pain), give vascular support, produce splinting effect
Cause of third degree burns Flame injury, contact with hot object
Clinical presentation of third degree burns Dry, white / charred, leathery appearance, almost painless, involve the hypodermis, whole skin destruction
Treatment of third degree burns Remove dead tissue, cleanse burn area, initial excision and grafting if small (3-4 cm = grafting; < 3 cm = no grafting), tangential excision and wound closure if large
Priority is given to which areas during skin grafting Face, neck, hands, flexion creases
Types of skin grafts Allografts (human), homografts (cadaver), xenografts (pig), biologic and biosynthetic dressings
What are the ABCDEs of primary survey A - airway and c-spine control, B - breathing, C - circulation, D - disability, E - exposure
"A" in ABCDE of primary survey Upper airway very susceptible, indications subtle, may take 24-48 hours to develop, CO baseline, don't depend on x-ray
Related to airway, when should a patient be intubated and transferred to a burn unit? If there are facial burns, singed eyebrows and nasal hairs, carbonaceous deposits in oropharynx / sputum, confinement in burning building, impaired mentation, explosion to head / torso, CO levels > 10%
"B" in ABCDE of primary survey Look for pneumothorax, flail chest (indicate broken ribs), provide 100% O2 if not breathing
"C" in ABCDE of primary survey Evaluate pulses = BP (radial->femoral->carotid), place IV 16 gauge catheter in both antecubital veins
"D" in ABCDE of primary survey mini neurologic exam; perform AVPU (A - alert, V - voice, P - pain, U - unresponsive)
"E" in ABCDE of primary survey Undress patient; decrease exposure to chemicals, etc.
Time-frame for completing ABCDE of primary survey < 2 minutes
What should the fluid replacement be in a burn patient? 2-4mL IV solution/kg body weight/% BSA in 24 hours; 1/2 over first 8 hours; rest over next 16 hours; should be adjusted as needed
______ output should be maintained during fluid replacement Urine
Urine output of adult 30-50mL/hr
Urine output of child (< 30kg) 0.7-1mL/kg body weight/hr
Secondary survey A (allergies), M (medications), P (past history), L (last meal), E (event - what happened)
Besides AMPLE, the secondary survey should also include complete physical, associated injuries, extent and depth of burn (anterior surface of palm = 1%; rule of 9s)
Rule of 9s Equal % front and back = Adult: head - 4.5%, arms - 4.5%, torso - 18%, legs - 9%, genitals - 1%; child: head - 9%, arms - 4.5%, torso - 18%, legs - 7%, genitals - 1%
___________, ____________, and ________ can be used to assess peripheral circulation Capillary refill, cyanosis, doppler
A flow sheet should be maintained to keep track of (4) Vitals, fluid replacement, ventilator settings, blood gasses and lab
Why should blood be obtained in a burn victim? (7) CBC, type and cross match / screen, carboxyhemoglobin (unlikely that < 20% will present with symptoms), chemistry profile, prothrombin, electrolytes, ABG (arterial blood gas)
Evaluation and treatment of burn victim Chest x-ray; NPO x 48 hours; NG tube if > 25% BSA; narcotics, analgesics, sedatives in small, frequent doses; urinary catheter x 72 hours
Criteria for hospitalization Full thickness (third degree burn) > 2% BSA; partial thickness (second degree burn) > 10% BSA; serious lesions of face, feet, peritoneal, genital area; burns that cross flexion creases
Transfer to burn unit Full thickness > 5% BSA; partial thickness > 20% BSA (10% in < 10 or > 50); all 2nd / 3rd degree burns involving face, eyes, hands, peritoneum; burns associated w/ fractures / other injuries
Transfer to burn unit High voltage electrical burns; significant chemical burns; inhalation burns; lesser burns w/ pre-existing conditions
Complications associated with burns Infection, gastric distention, paralytic ileus, fecal impaction, curling ulcer, upper respiratory tract obstruction, intubation injury, pulmonary insufficiency, atelectasis (collapsed lung), pneumonia, decubiti (ulcers from pressure)
Chemical burns Alkali WORSE than acidic
What should you do for acidic chemical burns? Irrigate with neutral solution for 20-30 minutes (stops burn from progressing)
What should you do for alkali chemical burns? Irrigate for 8 hours!
What do electrical burns travel along? Nerves and vessels
Are electrical burns as damaging as they appear on the surface? NO, they are much worse
Amount of myoglobin present in urine after electrical burn > 100mL/hr
How do you treat an electrical burn patient with myoglobinuria? Give 25 grams of mannitol then 12.5 grams/L fluid
Osteopathic considerations for burn victims Rule of the artery is supreme (maintain circulation), decrease lymphatic congestion (lymph pump), prolonged bedrest (rib raising, lymphatic drainage)
Created by: JaneO