First Aid For Surgery - Burns

Front 1

Most common cause of burn injuries

Back 1

Scalding! Remember: incidence of burns is higher during winter months

Front 2

Criteria to refer to burn center

Back 2

(1) Partial-thickness burns >10% BSA in Pt <10 or >50yo; (2) Partial-thickness burns >20% BSA in patients of other ages; (3) Partial or full-thickness burns involving face, hands, feets, genitals, perineum, or skin over major joints; (4) Full-thickness burns >5% BSA at any age; (5) Significant electrical or chemical burns; (6) Lesser burn injury + inhalation injury, trauma, or medHx

Front 3

Treatment outline for burn patient

Back 3

(1) ABCs; intubate if needed; start 1L LR bolus in adults, 20ml/kg in children in ED; (2) If CO suspected, administer 100% O2 via NRB; (3) Assess area of burn; (4) All burn patients need IV morphine; add cold saline soaks for analgesia if burns are <25% BSA (watch for hypothermia); (5) Cover burns with silver sulfadiazine/clean sheet and then warm blankets; (6) Elevate burned area to minimize edema; (7) ABG, carboxyhemoglobin levels; (8) Continue fluids per Parkland formula, EKG, Foley catheter, NG tube for extensive burns, GI prophylaxis for Curling's ulcers

Front 4

Most common cause of burn injuries

Back 4

Scalding! Remember: incidence of burns is higher during winter months

Front 5

Criteria to refer to burn center

Back 5

(1) Partial-thickness burns >10% BSA in Pt <10 or >50yo; (2) Partial-thickness burns >20% BSA in patients of other ages; (3) Partial or full-thickness burns involving face, hands, feet, genitals, perineum, or skin over major joints; (4) Full-thickness burns >5% BSA at any age; (5) Significant electrical or chemical burns; (6) Lesser burn injury + inhalation injury, trauma, or medHx

Front 6

Treatment outline for burn patient

Back 6

(1) ABCs; intubate if needed; start 1L LR bolus in adults, 20ml/kg in children in ED; (2) If CO suspected, administer 100% O2 via NRB; (3) Assess area of burn; (4) All burn patients need IV morphine; add cold saline soaks for analgesia if burns are <25% BSA (watch for hypothermia); (5) Cover burns with silver sulfadiazine/clean sheet and then warm blankets; (6) Elevate burned area to minimize edema; (7) ABG, carboxyhemoglobin levels; (8) Continue fluids per Parkland formula, EKG, Foley catheter, NG tube for extensive burns, GI prophylaxis for Curling's ulcers

Front 7

Typical scenario: An adult male is brought to the ED with second-degree burns on his chest and abdominal wall, anterior right leg, and perineum. What percentage TBSA does he have?

Back 7

Think: Rule of Nines says 18% for anterior torso, 9% for anterior leg, and 1% for perineum = 28%.

Front 8

Typical scenario: How much fluid should a 60-kg female with a 25% TBSA burn receive during the first 24 hours?

Back 8

Think: Parkland formula. At 4 mL/kg/%, 4 × 60 × 25 = 6000 mL required over the next 24 hours, at a rate of 375 mL/hr for the first 8 hours, and 188 mL/hr for the next 16 hours.

Front 9

What is the Parkland formula?

Back 9

For the first 24h: (1) LR at rate of 4ml/kg/%BSA burn. (2) Give half of 24hr requirement in first 8hr, the remainder over the next 16hrs

Front 10

What is adequate UOP in burn patients?

Back 10

Resuscitation is adequate when UOP is 30-50cc/hr in adults and 1 cc/kg/hr in children <30kg; Adjust fluids when urine output is more than

Front 11

Why is there a high rate of infections in burn patients?

Back 11

The risk of infection of burned tissue is increased because the wound is protein rich and moist, and is thus a good culture medium. The neoeschar and lack of vascularity limit antibiotic delivery.

Front 12

Cardiac changes in burn patients

Back 12

Hypovolemia and hemoconcentration can lead to an elevated hematocrit and decreased left ventricular end-diastolic volume that result in decreased cardiac output and low-flow state.

Front 13

Curling ulcer

Back 13

Burn patients are susceptible to Curling’s ulcer, which is due to lack of the normal mucosal barrier.

Front 14

Escharotomy

Back 14

Operation for circumferential burns of extremities (including penis) or thorax when there is impaired circulation or ventilation; no anesthesia is needed

Front 15

Fasciotomy

Back 15

Operation used when escharotomy fails. If compartment syndrome persists, incision of fascia is required

Front 16

MC compartment requiring fasciotomy

Back 16

Anterior tibial compartment. Electrical injury is more likely than other types of burn injury to necessitate fasciotomy because deep tissue edema may be extensive, causing compartment syndrome.

Front 17

Infections in burn patients

Back 17

(1) Infection of a burn wound causes an increase in depth (thus converts a 2nd-degree burn to 3rd degree); (2) Biopsy of wound is most definitive way to diagnose burn wound infection; (3) Burn patients are very prone to pneumonia and catheter-related infections

Front 18

Treatment of burn infections

Back 18

(1) Topical antimicrobials and systemic antibiotics; (2) For pseudomonas or pediatric infections, infuse subeschar piperacillin, plan for emergent debridement; (3) For candidal infections, start antifungals and if treatment fails, start systemic therapy with amphotericin B

Front 19

Effects of Carbon monoxide poisoning

Back 19

Impairs tissue oxygenation by decreasing oxygen carrying capacity of blood, shifting oxygen-hemoglobin dissociation curve to the left, binding myoglobin and terminal cytochrome oxidase.

Front 20

Mechanism of electrical burn

Back 20

(1) Tissue damage via conversion to thermal energy; (2) Damage occurs in skin and underlying tissues along the course of current; (3) Skin at point of contact is often severely charred

Front 21

S&S of electrical burn

Back 21

(1) Charring at point of contact; (2) Myoglobinuria w/ muscle damage; (3) Hyperkalemia with tissue necrosis; (4) High-voltage injury may cause cardiac arrest; (5) Neuropathy; (6) Compartment syndrome: swelling of injured extremity with pain, paresthesia, pallor, pulselessness, and poikilothermia

Front 22

5 Ps of compartment syndrome:

Back 22

(1) Pain; (2) Paresthesia; (3) Pallor; (4) Pulselessness; (5) Poikilothermia

Front 23

Nutrition of burn patients

Back 23

(1) Enteral route preferred, TPN if necessary though; (2) Early feeding recommended; (3) High calorie (30–35 Kcal/kg/day) and high protein (1.5–2 g/kg/day) requirements

Front 24

Burn Scar Cancer

Back 24

(1) Rare long-term complication of burn scars - called Marjolin's Ulcer; (2) Usually squamous cell carcinoma - mets via lymph nodes; (3) Dx by biopsy; (4) Rx: wide excision