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65 Cards in this Set
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Acute upper airway edema:
_-_% of hospitalized burn pts c/ inhalation injury - Mild pharyngeal edema esp. in supraglottic structures -> edematous tissues prolapse + obliterate the aryepiglotic folds, arytenoid eminences, interarytenoid areas |
Acute upper airway edema:
-20-35% of hospitalized burn pts c/ inhalation injury - Mild pharyngeal edema esp. in supraglottic structures -> edematous tissues prolapse + obliterate the aryepiglotic folds, arytenoid eminences, interarytenoid areas |
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patient presents c/ skin mass.
-Path: peripheral palisading nuclei, stromal retraction +/- collagenase production -What is this? What is the tx? |
Basal cell ca:
-4:1 more common than SCC (#1 cancer in US) -Path: PERIPHERAL PALISADING NUCLEI, stromal retraction -Ulcerative, deep invasion, occasionally dark -Regional adenopathy for clinically (+) nodes -MORPHEAFORM type = most agressive. makes COLLAGENASE -Tx: resect c/ 0.3-0.5 cm margins -Chemo, XRT may be of limited benefit for inoperable dz or mmets; neuro; lymphatic; or vascular invasion |
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What paralytic should be avoided in the OR for burn pts?
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SUCCINYLCHOLINE:
-Depolarization of cell membrane -> K release -> T wave changes -> wide QRS -> V fib -Burn pts already have high risk of hyperkalemia 2/2 myonecrosis -Tx: Ca gluconate -> D50 + 10U insulin, HCO3-, kayexalate, dialysis, etc. |
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#1 infection in pts c/ severe burn injuries = _
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PNEUMONIA = #1 infection in pts c/ severe burn injuries
-2/2 inhalation injury, decreased immunity, pulm edema 2/2 fluid resuscitation, mechanical ventilation -up to 60-70% of pts c/ severe burns |
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RFs for burn infection
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Burn wound infections:
-Common in burns >30% BSA -Impaired granulocyte chemotaxis, cell-mediated immunity in burn pts -Infection diagnosed by bx, defined as >10^5 organisms/gm tissue -Pseudomonas> Staph, E. coli, Enterobacter -HSV = #1 viral burn wound infection -Signs: periph edema, 2nd -> 3rd deg conversion, hemorrhage into scar, erythema gangrenosum, green fat, black skin around wound, rapid eschar separation, focal discoloration If infection is present, start abx, excise wound, place porcine allograft (not autograft) |
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Burn wound sepsis is diagnosed by _
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Detected (and differentiated from colonization) by BIOPSY
Burn wound infection: >10^5 organisms/gram of tissue -Pseudomonas = #1 cause of burn wound sepsis -HSV = #1 viral burn wound infection -Signs: periph edema, 2nd -> 3rd deg conversion, hemorrhage into scar, erythema gangrenosum, green fat, black skin around wound, rapid eschar separation, focal discoloration |
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Burn wound infection is diagnosed, defined by …
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Burn wound infections:
->10^5 organisms/gram of tissue -Detected (and differentiated from colonization) by BIOPSY -Pseudomonas = #1 cause of burn wound infection and sepsis > Staph, E. coli, Enterobacter -HSV = #1 viral burn wound infection -Signs: periph edema, 2nd -> 3rd deg conversion, hemorrhage into scar, erythema gangrenosum, green fat, black skin around wound, rapid eschar separation, focal discoloration If infection is present, start abx, excise wound, place porcine allograft (not autograft) |
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what is T1/2 of CO?
100% O2 reduces the T1/2 to _ hrs |
CO poisoning:
-100% O2 reduces T1/2 of CO2 from 5 hrs -> 1 hr |
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Pt c/ circumferential 2nd deg burn to arm, decreased perfusion to hand.
Next step? |
Escharotomy indications;
-Circumferential burns -Decreased temp/ pulse/ capillary refill/ pain sensation/ neuro function in extremity => may need fasciotomy if compartment syn suspected -Difficult ventilation in significant chest/torso burns from decreased chest compliance (2/2 burn, then edema from fluids) |
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what are the the biggest RFs for melanoma (non-modifiable RFs)?
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10% risk: dysplastic, atypical, or large congenital nevi
100% risk: familial BK mole syndrome Others: xeroderma pigmentosum. fair complexion, sunburns, hx skin ca, hx XRT |
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Pt c/ circumferential 2nd deg burn to arm, decreased perfusion to hand -> escharotomy done, but perfusion still not adequate.
-Next step? |
For deep burns, escharotomy may not be sufficient to restore perfusion => FASCIOTOMY
-In arm, dorsal AND ventral compartments |
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Patient presents c/ painful mass on end of her finger
-Must consider _ -Tx would be ... |
Glomus cell tumor:
-painful subungal tumor, of blood vessels + nerves. -Benign -from glomic end organ (most common = END OF FINGER) -Tx: shell out |
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what is the tx for hydrofluoric acid burn?
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Hydrofluoric acid burn => treat with topical calcium
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Keloids:
-etiology -inheritance -4 therapies |
Keloids: autosomal D, dark skin
-collagen beyond original scar -failure of collagen breakdown, increased collagen production -Tx: XRT, steroids, silicone, pressure garments |
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__ cells:
-antigen recognition -involved in contact hypersensitivity |
Langerhans cells:
-antigen recognition -involved in contact hypersensitivity |
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what type of skin cancer is caused by chronic nonhealing wounds, burn wounds?
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Marjolin's ulcer = highly malignant sq cell ca that arises in chronic nonhealing wounds or unstable scars
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Localized invasive melanoma is stage _ or _, depending on thickness
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Localized invasive melanoma is stage 1 or 2, depending on thickness
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T1b, T2, T3, T4 melanomas require _ and _ during surgery
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T1b, T2, T3, T4 melanomas require lymphatic mapping and SLN bx during surgery
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Stage _ melanoma warrants high-dose interferon alpha
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Stage 3 melanoma warrants high-dose interferon alpha
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Pt c/ recurrent melanoma or multi-nodal disease (esp >4 metastatic nodes) needs _
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RADIATION TX:
-recurrent melanoma -multi-nodal disease (esp >4 metastatic nodes) |
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Melanoma: in addition to TNM, 4 (-) prognostic factors are:
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Melanoma: in addition to TNM, 4 (-) prognostic factors are:
1. Male sex 2. ulceration of primary melanoma 3. Mitotic rate >1 mm2 4. location on head, trunk |
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Melanoma tumor thickness IN SITU =>
_-cm excision margin |
Melanoma tumor thickness IN SITU ->
0.5-1 cm excision margin |
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Melanoma tumor thickness 0-1 cm =>
_-cm excision margin |
Melanoma tumor thickness 0-1 cm =>
1-cm excision margin |
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Melanoma tumor thickness 1-2 cm =>
_-cm excision margin |
Melanoma tumor thickness 1-2 cm =>
2-cm excision margin (1 cm in anatomically restricted areas) |
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Melanoma tumor thickness 2-4 cm =>
_-cm excision margin |
Melanoma tumor thickness 2-4 cm =>
2-cm excision margin |
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Melanoma tumor thickness >4 cm =>
_-cm excision margin |
Melanoma tumor thickness >4 cm =>
at least 2-cm excision margin |
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melanoma has worse prognosis if located on these 4 areas...
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melanoma: worse prognosis if located on BANS:
Back Arms Neck Scalp |
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melanoma: Breslow depth
<0.75 mm => _% cure 0.75-1.65 mm 1.65-4 mm >4 mm => _% distant mets |
melanoma: Breslow depth
<0.75 mm => 90% cure 0.75-1.65 mm 1.65-4 mm >4 mm => 80% distant mets |
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Patient presents c/ new blue/black skin lesion.
-Must r/o _, which comprises _% of melanoma -Prognosis is ... |
Melanoma types:
-Nodular (10-15%): worst, early mets. vertical growth c/ blue/black borders -Superficial spreading (70%): from nevus/sun exposed areas -Acral lentiginous (<5%): very aggressive, palms/soles of Af Americans -Lentigo maligna (5%): least agressive, minimal invasion, elevated nodules. |
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__ = #1 melanoma
Affects __ type areas of skin |
Melanoma types:
-Nodular (10-15%): worst, early mets. vertical growth c/ blue/black borders -Superficial spreading (70%): from nevus/sun exposed areas -Acral lentiginous (<5%): very aggressive, palms/soles of Af Americans -Lentigo maligna (5%): least agressive, minimal invasion, elevated nodules. |
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What is the typical presentation of acral lentiginous melanoma?
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Melanoma types:
-Nodular (10-15%): worst, early mets. vertical growth c/ blue/black borders -Superficial spreading (70%): from nevus/sun exposed areas -Acral lentiginous (<5%): very aggressive, palms/soles of Af Americans -Lentigo maligna (5%): least agressive, minimal invasion, elevated nodules. |
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Lentigo maligna = _% of melanoma.
looks like _ prognosis is _ |
Melanoma types:
-Nodular (10-15%): worst, early mets. vertical growth c/ blue/black borders -Superficial spreading (70%): from nevus/sun exposed areas -Acral lentiginous (<5%): very aggressive, palms/soles of Af Americans -Lentigo maligna (5%): least agressive, minimal invasion, elevated nodules. |
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A 35 yo female presents with a 1.73 cm irrigular left leg skin pigmentation. A biopsy reveals nodular melanoma. The mass is excised with a 2cm margin. No clinical lymphadenopathy is detected. What would be the next step in management?
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Routine CTs or bone scans are not indicated if basic evaluation (H&P, CXR, LDH) is not suggestive of metastasis. Elective lymphadenectomy with out evidence of metastasis is not known to be beneficial. It is reasonable to consider SLNB in patients with melanoma greater than 1.5 cm. Immuno and chemotherpy is appropriate only for confirmed metastasis
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patient presents c/ reddish purple papulo-nodule.
Path specimen stains (+) for enolase, neurofilament protein -What kind of cancer is this? |
Merkel cells:
-sensory mechanoreceptors -Merkel cell ca: red/purple papulo-nodule = neuroendocrine tumor. stain for neuron-specific enolase, neurofilament protein |
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12 hrs into resuscitation, pt c/ severe burns stops making urine. CVP is 18, pt found to have myoglobin-induced ATN.
Tx is _ |
Oliguria in burn pt:
1. ATN 2/2 myoglobinuria Parkland formula can grossly underestimate fluid requirements in inhalational injury, EtOH, electrical injury, and s/p escharotomy (for burns >20% BSA, 0.5-1 cc/Kg/kr in adults, 2-4 cc/Kg/hr in babies <6 mo, give 1/2 in 1st 8 hrs) Need to place central line in that case to get CVP |
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13 hrs into resuscitation, pt c/ severe burns stops making urine.
Top 2 reasons on differential… |
Tx for myoglobin-induced ATN in burn pt:
Fluid resuscitation, HCO3- drip to prevent precipitation of myoglobin |
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which melanoma has the worst prognosis?
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Nodular melanoma has the worse prognosis. Among the 4 major types above, nodular melanoma is the only type that has only vertical growth phase (VGP). Other types go through two phases - radial growth phase (RGP) followed by deeper invasion into the dermis by VGP
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What is the Parkland Formula?
What is its shortcoming? |
Parkland formula: for burns >20% BSA
-4 cc/Kg x % burn in 1st 24 hrs. Give 1/2 in 1st 8 hrs -Use LR in 1st 24 hrs -UOP = best measure of resuscitation (0.5-1 cc/Kg/kr in adults, 2-4 cc/Kg/hr in babies <6 mo) -Can grossly underestimate fluid requirements ith inhalational injury, EtOH, electrical injury, and s/p escharotomy |
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What pts should not get silvadene?
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Silvadene = silver sulfadiazene
-SE: NEUTROPENIA, thrombocytopenia -Do not use in pts c/ SULFUR ALLERGY -Limited eschar penetration -Ineffective against some Pseudomonas species, other GNRs -Effective for CANDIDA |
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Which topical burn therapy causes neutropenia, thrombocytopenia?
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Silvadene = silver sulfadiazene
-SE: NEUTROPENIA, thrombocytopenia -Do not use in pts c/ SULFUR ALLERGY -Limited eschar penetration -Ineffective against some Pseudomonas species, other GNRs -Effective for CANDIDA |
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Pts c/ G6PD deficiency can't get topical burn therapy _
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Silver nitrate
-SE: discoloration, leeches NaCl -> HYPO-Na, HYPO-Cl, hypo-Ca, hypo-K -Limited eschar penetration -Ineffective against some pseudomonas species, GPCs -Methemoglobinemia: contraindicated in pts c/ G6PD deficiency |
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Which topical burn therapy causes electrolyte disturbances?
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Silver nitrate
-SE: discoloration, leeches NaCl -> HYPO-Na, HYPO-Cl, hypo-Ca, hypo-K -Limited eschar penetration -Ineffective against some pseudomonas species, GPCs -Methemoglobinemia: contraindicated in pts c/ G6PD deficiency |
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How do skin grafts survive in 1st 48 hrs?
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Skin grafts:
-Hours 0-48: Imbibition = osmotic exchange of nutrients -Day 3 onward: neovascularization -#1 cause of graft loss = seroma/hematoma formation underneath graft STSGs (epidermis = partial dermis) are more likey than full-tickness to survive b/c easier for imbibition and neovasculariation Full-thickness skin grafts contract less => better for palms, backs of hands |
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Most common cause of skin graft loss is _
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Skin grafts:
-Hours 0-48: Imbibition = osmotic exchange of nutrients -Day 3 onward: neovascularization -#1 cause of graft loss = SEROMA/HEMATOMA formation underneath graft STSGs (epidermis = partial dermis) are more likey than full-tickness to survive b/c easier for imbibition and neovasculariation Full-thickness skin grafts contract less => better for palms, backs of hands |
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STSG: supplied by _ days 0-3, then _ days 3-7
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STSG: supplied by imbibition (osmotic) days 0-3, then neovascularization days 3-7
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Burn pt has metabolic acidosis.
Must consider topical burn tx _ |
Sulfamylon = mafenide sodium
-PAINFUL application -Inhibits carbonic anhydrase (decreases renal conversion of H2CO3 -> H2O + CO2) -> METABOLIC ACIDOSIS -Hypersensitivity reactions -GOOD ESCHAR PENETRATION => good for burns over cartilage -Broadest spectrum against Pseudomonas, GNRs |
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Which topical burn therapy causes hypersensitivity reactions?
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Sulfamylon = mafenide sodium
-PAINFUL application -Inhibits carbonic anhydrase (decreases renal conversion of H2CO3 -> H2O + CO2) -> METABOLIC ACIDOSIS -Hypersensitivity reactions -GOOD ESCHAR PENETRATION => good for burns over cartilage -Broadest spectrum against Pseudomonas, GNRs |
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Which topical burn therapy has best eschar penetration and broadest coverage against Pseudomonas, GNRs?
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Sulfamylon = mafenide sodium
-PAINFUL application -Inhibits carbonic anhydrase (decreases renal conversion of H2CO3 -> H2O + CO2) -> METABOLIC ACIDOSIS -Hypersensitivity reactions -GOOD ESCHAR PENETRATION => good for burns over cartilage -Broadest spectrum against Pseudomonas, GNRs |
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A 40 year old man sustained 40% TBSA burns to his front trunk and lower extremities. After application of a topical burn cream, the patient developed a metabolic acidosis. The agent used to treat the burn was most likely:
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Sulfamylon inhibits carbonic anhydrase resulting in metabolic acidosis.
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what tumor is associated with Tuberous Sclerosis?
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Tuberous sclerosis => angiomyolipoma
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Predominant cell types in wound healing:
-Day 0-2: _ -Day 3-4: _ -Day 5+: _ |
Predominant cell types in wound healing:
-Day 0-2: PMNs -Day 3-4: Macrophages -Day 5+: fibroblasts |
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On days 0-2 of wound healing, #1 cell type = _
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On days 0-2 of wound healing, #1 cell type = PMNs
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At days 3-4 of wound healing, predominant cell type = _
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At days 3-4 of wound healing, predominant cell type = MACROPHAGES
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Predominant cell type from day 5 onward of wound healing = _
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Predominant cell type from day 5 onward of wound healing = FIBROBLASTS
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Type _ = predomindant type of collagen in the body
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Type 1 = predomindant type of collagen in the body
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Type _ = predomindant type of collagen being synthesized in 1st 48 hrs of wound healing
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Type 3 = predomindant type of collagen being synthesized in 1st 48 hrs of wound healing
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Max amount of collagen in a wound is at what time period?
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2-3 WEEKS: max amount of collagen in a wound
-After that point, collagen amount stays the same, but cross-linking improves strength |
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Most important cell type for wound healing = _
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Most important cell type for wound healing = MACROPHAGES
-Cytokines -Growth factors |
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Predominant type of collagen in cartilage = _
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Predominant type of collagen in cartilage = Type 2
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Max tensile strength in a wound is at time point _
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8 WEEKS: max tensile strength in a wound
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Vitamin _ prevents the negative effects of steroids on wound healing
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Vitamin A prevents the negative effects of steroids on wound healing
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Peripheral nerves regenerate at _mm/day
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Peripheral nerves regenerate at 1 mm/day
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_ = most important factor in healing of wounds by secondary intention
-This depends on _ |
epithelial integrity = most important factor in healing of wounds by secondary intention
(keeping epithelium intact over wound avoids leakage of proteins, serum => avoid infection) Epithelial cells migrate primarily from hair follicle beds, also from wound edges and sweat glands |
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_ = most important factor in healing of wounds by primary intention
-This is provided by the process of _ |
tensile strength of wound ( = most important factor in healing of wounds by primary intention
-Tensile strength is created by collagen cross-linking -Sutures hold wound together until the cross-linking occurs |
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Keloids can be treated c/ 3 things…
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Keloids can be treated c/:
steroids, silicone injections, XRT -unlike hypertrophic scar tissue, keloids are not confined to the orginal scar area |
