Updated: 6/12/2019

Burns

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Questions
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Evidence
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Topic
Snapshot
  • A 42-year-old female is rescued from a burning building by firefighters and brought to the hospital. On examination, her pulse is 100/min, blood pressure is 130/60 mmHg, respirations are 34/min, and weight is 60 kg (132 lbs). She has second and third degree burns over her anterior and posterior chest and abdomen, bilateral arms and hands, and second degree burns over her face. She is coughing, spitting out carbonaceous sputum, has singed eyebrows and vibrissae (nostril hair) and a hoarse voice. Because of signs for inhalational burns, she is first intubated and ventilated. Total body surface area (BSA) involved is estimated to be 58.5%. She is given 100% oxygen, and IV lactated Ringer's (58.5% BSA x 60kg x 4ml = 14,040 ml) with 7 L administered in the first 8 hours of admission, and another 7 L in the next 16 hours. She is transferred emergently to a burn center because of facial and inhalational burns.
Introduction
  • Fourth leading cause of death in children
  • Types of burns include chemical (acid/alkali), electrical, radiation (UV, medical/therapeutic), thermal (scald, fire)
    • can be seasonal (e.g., fireworks)
    • can be associated with abuse
  • Most common causes
    • children: scald burns
    • adults: flame burns
  • Pathophysiology
    • three zones (from outermost to innermost): hyperemia, edema, ischemia
      • zone of hyperemia
        • vasodilation from inflammation
        • viable tissue (recovery within 7 days)
      • zone of stasis/edema
        • decreased perfusion with microvascular thrombosis
        • progressive tissue necrosis (death in 1-2 days without treatment)
        • zone where early treatment has most benefit
      • zone of ischemia
        • no blood flow
        • irreversible damage
Presentation

Classification (New)

Degree
(Traditional)
Site
Symptoms/Signs
  • Erythema/Superficial
  • 1st degree
  • Epidermis
  • + Pain
  • Blanchable
  • Superficial-partial thickness
  • 2nd degree
  • Into superficial dermis
  • + Pain
  • Blanchable
  • Blisters
  • Deep-partial thickness
  • 3rd degree
  • Into deep dermis
  • - Pain
  • NOT blanchable
  • Soft
  • Full thickness
  • 4th degree
  • Into underlying muscle/bone
  • - Pain
  • NOT blanchable
  • Hard


Evaluation
  • Remember the percent of surface area burned with: Head 9%, Chest 9%, Back 9%, Abdomen 9%, Lower back 9%, Arms 18%, Legs 36%Primary and secondary survey
    • brush off gross contaminate and remove all clothing
    • if chemical burn, best next step: irrigation
      • alkali burns penetrate more deeply / rapidly than acid burns 
  • Prognosis based on patient age, burn size, and evidence of inhalational injury
    • obvious skin wounds 
      • evaluate locations of burns
      • estimate involved body surface area (% BSA)
        • each "hand width" area burned is 1% BSA
        • use Rule of 9's for adults (see above)
        • use Lund-Browder chart for children < 10 years
        • this is only for superficial and deep thickness burns (2nd/3rd degree)
          • NOT for erythemas (1st degree)
      • with electrical burns, deep tissue destruction may not be visible
    • suggestions of inhalational injury
      • facial burns and singed nasal hairs
      • hoarseness, stridor, dyspnea
      • altered mental status, headache, coma
      • cherry red skin is NOT reliable (late, post-mortem finding)
  • Investigations
    • arterial blood gas and carboxyhemoglobin level
    • CBC / electrolytes / urinalysis
    • chest radiograph
    • electrocardiogram
Management
  • Special considerations in ABC resuscitation
    • if inhalational injury is suspected, best next step: immediate intubation
      • impending airway edema
      • best diagnostic test: bronchoscopy
        • CXR or ABG cannot rule out inhalational injury
    • if CO poisoning is suspected, best next step: 100% O2 by facemask
      • until carboxyhemoglobin level < 10%
    • if burn eschar encircles chest, best next step: escharotomy to relieve constriction 
  • Restoration of normal skin function: thermoregulation, fluid control, and infection prevention
    • thermoregulation
      • increase room temperature, cover patient with blankets, and use warmed fluids
    • fluid control 
      • use Parkland formula as baseline
        • 4 ml of Lactated Ringer's per kilogram per % BSA over first 24 hours
        • first half given over first 8 hours
        • second half given over next 16 hours
      • additional fluid required if electrical burn, inhalational injury, BSA > 80%, resuscitation delayed, or 4th degree burns are present
      • monitoring
        • clear mental status
        • vitals
          • mean arterial pressure > 70 mmHg
          • pulse < 120/min
        • urine output
          • children (< 12 years): > 1.0 ml/kg/hr
          • adults: > 0.5 ml/kg/hr
    • infection prevention
      • tetanus prophylaxis
        • all patients with > 10% BSA burn or burn worse than superficial thickness need Td
      • cleanse and cover with dry sterile dressing
      • mafenide acetate
        • a topical antibiotic with broad spectrum coverage
        • can penetrate thick eschar
      • topical silver sulfadiazine
        • do NOT use in pregnant patients, children < 2 months old
        • do NOT use around eyes
         
      • NO benefit in prophylactic PO/IV antibiotics or corticosteroids
  • Burn surgery
    • debridement to level of bleeding capillaries
    • apply split thickness skin grafts over excised areas 
    • escharotomy for circumferential burns
  • Other considerations
    • stress ulcer prophylaxis
      • H2 antagonists or proton pump inhibitors
    • nutrition
      • prepare additional supplements/tube feeds
      • basal metabolic rate increases by 2x - 3x if BSA% > 40%
  • Criteria for transfer to burn center
    • full thickness burn > 5% BSA
    • full or partial thickness burn over critical areas (face, hands, feet, genitals, perineum, major joints)
    • circumferential burns
    • chemical, electrical or lightning injury
    • electrical burns may have cardiac arrythmia or ventricular fibrillation, unexpected falls with fractures and dislocations
    • inhalational injury
    • preexisting medical problems
    • special psychosocial or rehabilitative care needs

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Questions (7)
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(M2.DM.17.4767) A 27-year-old male presents to the emergency department after being brought in from a house fire. The patient has extensive burns covering his body and is conscious but in severe pain. The patient has a past medical history notable for marijuana use. He is not currently on any medications. Physical exam is notable for extensive burns covering the patients back, chest, thighs, and legs. The patient's oropharynx reveals no signs of damage or extensive smoke inhalation. The patient is breathing on his own and has normal breath sounds bilaterally. His temperature is 99.5°F (37.5°C), pulse is 145/min, blood pressure is 100/70 mmHg, respirations are 27/min, and oxygen saturation is 93% on room air. Which of the following interventions is most likely to reduce mortality in this patient?

QID: 109093
1

IV fluids

53%

(19/36)

2

Oral antibiotics

11%

(4/36)

3

Topical antibiotics

3%

(1/36)

4

Normal saline soaked dressings

14%

(5/36)

5

Oxygen administration

19%

(7/36)

M 7 D

Select Answer to see Preferred Response

(M2.OR.17.4694) A 13-year-old male is brought by ambulance to the ED with bilateral foot pain. He reports making footprints on some freshly laid sidewalk cement the day before with his friends. He states that his jeans' heels were slightly soaked, and that he did not attempt to wash the cement off of them. On physical exam, there is marked tissue necrosis on both ankles extending down to the bone in some places (Figure A). Which chemical was this patient most likely exposed to?

QID: 107718
FIGURES:
1

Lime

35%

(6/17)

2

Ethylene glycol

6%

(1/17)

3

Ammonia

18%

(3/17)

4

Benzene

6%

(1/17)

5

Hydrochloric acid

35%

(6/17)

M 6 D

Select Answer to see Preferred Response

(M3.OR.17.3) A 45-year-old male comes into the trauma bay by EMS transport with a known history of gross contamination of an unknown dry/powder chemical from a research laboratory accident. Currently his vital signs are stable but he is in obvious discomfort with diffuse skin irritation. What should be done for this patient during the primary survey?

QID: 102757
1

Take a sample of the unknown substance and send it to the lab for stat identification

0%

(0/2)

2

Sedate and intubate the patient for concern of poor airway protection

0%

(0/2)

3

Dilute the unknown substance load by washing the patient off in a chemical burn shower

100%

(2/2)

4

Brush off the gross amount of unknown chemical and then remove all of the patient's clothes

0%

(0/2)

5

Cover the patient's skin burns with topical mineral oil

0%

(0/2)

M 5 D

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(M2.OR.16.4684) A 35-year-old man is brought to the emergency department from a kitchen fire. The patient was cooking when boiling oil splashed on his exposed skin. His temperature is 99.7°F (37.6°C), blood pressure is 127/82 mmHg, pulse is 120/min, respirations are 12/min, and oxygen saturation is 98% on room air. He has dry, nontender, and circumferential burns over his arms bilaterally, burns over the anterior portion of his chest and abdomen, and tender spot burns with blisters on his shins. A 1L bolus of normal saline is administered and the patient is given morphine and his pulse is subsequently 80/min. A Foley catheter is placed which drains 10 mL of urine. What is the best next step in management?

QID: 107350
1

Additional fluids and admission to the ICU

25%

(1/4)

2

Additional fluids and escharotomy

75%

(3/4)

3

Continuous observation

0%

(0/4)

4

Escharotomy

0%

(0/4)

5

Moist dressings and discharge

0%

(0/4)

M 7 E

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(M2.OR.16.4691) A 34-year-old woman is brought into the emergency department by emergency medical services after an electrical fire in her apartment. She is coughing with an O2 saturation of 98%, on 2L of nasal cannula. The patient's physical exam is significant for a burn on her right forearm that appears to be dry, white, and leathery in texture. Her pulses and sensations are intact in all extremities. The patient's vitals are HR 110, BP 110/80, T 99.2, RR 20. She has no evidence of soot in her mouth and admits to leaving the room as soon as the fire started. Which is the following is the best treatment for this patient?

QID: 107602
1

Bacitracin

25%

(1/4)

2

Pain relievers

0%

(0/4)

3

Mafenide acetate

25%

(1/4)

4

Excision and grafting

50%

(2/4)

5

Amputation

0%

(0/4)

M 6 E

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(M2.OR.15.4690) A 60-year-old patient comes into your clinic with a new concern. He states that about 20 years ago, he was shot in his right quadriceps while serving in the military. Since then, he has had a wound that partially heals, but has never closed completely. Now, the patient describes the wound as somewhat different. He states it is ulcerated with elevated edges and has been bleeding. You perform a full thickness biopsy of the lesion as shown in Figure A. What is the most likely diagnosis?

QID: 107583
FIGURES:
1

Basal cell carcinoma

40%

(2/5)

2

Squamous cell carcinoma

40%

(2/5)

3

Melanoma

0%

(0/5)

4

Actinic keratosis

20%

(1/5)

5

Seborrheic keratosis

0%

(0/5)

M 6 E

Select Answer to see Preferred Response

Evidence (9)
EXPERT COMMENTS (12)
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