Chapter 11: Burns
Lisa Spiguel
Which of the below is not a criteria for transfer to a burn
center by the American Burn Association?
1. All burns > 10% of TBSA
2. Burns that involve the hands, feet, genitalia
3. Burns in patients with co-existing complex medical
comorbidities
4. Burns in patients with concomitant trauma
State of Florida mandates that hot water heaters in
multi-dwelling facilities to be set at which
temperature (ο F)?
1. 82
2. 95
3. 110
4. 120
Which of the following below is not a zone of injury
following a burn injury?
1- Zone of Coagulation
2- Zone of Liquefaction
3- Zone of Stasis
4- Zone of Hyperemia
Which Zone represents 3rd degree or full thickness
burns?
1- Zone of Coagulation
2- Zone of Liquefaction
3- Zone of Stasis
4- Zone of Hyperemia
What factors Transition one zone to a deeper zone?
1- Edema
2- Infection
3- Poor perfusion
4- All of the above
Zones of Injury
The following picture represents which type of burn?
1- Superficial
2- Superficial Partial thickness
3- Deep Partial thickness
4- Full thickness
Burns
Superficial Thickness
Partial Thickness
Full Thickness
Diffusion of nutrients to the healing tissues is called?
1- Imbibition
2- Inosculation
3- Granulation
4- Neovascularization
Burn Healing
• Full Thickness
– Heals from epithelialization from wound edges
• Partial Thickness
– Heals from re-epithelialization from epidermal
appendages
• Hair Follicles
• Sweat Glands
• Sebaceous Glands
Burn Healing
• Imbibition
– Osmotic nutrient and oxygen deliver
– Day 0-3
• Neovascularization
– Days 3+
• Epithelialization
– From epidermal appendages
• Contraction
Evaluation of a Burn Patient
•
•
•
•
•
•
ABCs – Primary Survey
Secondary Survey
Resuscitation
Estimate size and depth of burn
Concomitant Injuries
Diagnostic Studies/ Lab work
– Labs:paO2, pCO2, CO, CBC, BMP, Coags, +/- UA
– Diagnostic Studies based on concomitant trauma
• Wound Care
• Nutrition
UW Protocol Table 11.3
True or False:
An easy method of calculating a patient’s TBSA burn is
to use the palm of your hand, which constitutes 1%
TBSA.
A child has disproportionately a large TBSA designated
to which part of the body as compared to an adult?
1- Head
2- Feet
3- Legs
4- Torso
A 54 yo 70kg man is transferred to your burn center, as
shown in the picture. Estimate the TBSA involved?
1- 10%
2- 20%
3- 40%
4- 50%
How much volume will you give this patient in the first
8 hours of resuscitation?
1- 1800 mL
2- 2800 mL
3- 3800 mL
4- 4800 mL
Estimating Extent
• Rule of Nines
– Differs for adults and
Children
– Children have larger
head and smaller leg %
• Size of Patients palm
Calculating Fluid Requirement
• Parkland Formula: 4 cc/kg x % TBSA
• Fluid:
– Adults: LR (1st 24 hours)  D5 ½ NS
– Pediatrics: D5 0.45%NS
• Administer:
– First ½ in the first 8 hours
– Second ½ in the Second 16 hours
• Monitor MAP and UO
– MAP > 60 mmHg
– U/O:
• Adults: > 30 ml/hr, (concerned about Rhabdo – 100mL/hr)
• Pediatric: > 1.5 -2 mL/kg/hr
• Avoid large volume crystalloid boluses, increase hourly rate 10%
A 72 yo male was rescued from a house fire. On initial
evaluation he has stupor and confusion. What is his
likely carboxyhemoglobin level?
1- 5%
2- 10%
3- 20%
4- 30%
Carboxyhemoglobin T1/2 is?
1- 30 minutes
2- 1 hour
3- 2 hours
4- 4 hours
Airway swelling following an inhalational injury is worst
at which time following injury?
1- First 12 hours
2- 12-24 hours
3- 24-48 hours
4- 48-72 hours
Inhalation Injury
• Clinical Exam
• CarboxyHb levels
– Coughing, wheezing,
stridor
– Carbonaceous material on
face
– Singed facial hair
• Laryngoscopy
– Erythema
– Edema
– Carbonaceous sputum
below level of vocal cords
• Smokers < 20%
A 70 kg man is HD#2 following admission for a 35%
TBSA burn as demonstrated in the picture below. Over
the past 3 hours he his BPs are 90/50s, his u/o has
decreased to 5 mL/hr, and his Peak Airway pressures
are 40 mmHg. What is the next step in management?
1. Decrease his PEEP
2. Bolus 1 L of 0.9 NS
3. Start vasopressin
4. Check bladder pressures
Fluid Resuscitation Complications
• Poor tissue Healing
• Pulmonary Complications
– Edema/ARDS
– Effusions
• Extremity Compartment Syndrome
– Escharotomies
– Fasciotomies
• Abdominal Compartment HTN/Syndrome
– Bladder pressures > 25 mmHg
– Decompressive laparotomy
Escharotomity
Which of the following below is a side effect of silver
sulfadiazine (Silvadene)?
1. Neutropenia
2. Leukocytosis
3. Metabolic Acidosis
4. Metabolic Alkalosis
Which topical antimicrobial is best used to for ear
burns?
1.
2.
3.
4.
Silvadene
Sulfamylon
Silver Nitrate
Bacitracin
Which topical antimicrobial is contraindicated in
patients with sulfa allergy?
1.
2.
3.
4.
Silvadene
Sulfamylon
Silver Nitrate
Bacitracin
Which topical antimicrobial is associated with
methemoglobinemia?
1.
2.
3.
4.
Silvadene
Sulfamylon
Silver Nitrate
Bacitracin
Topical Antimicrobials
Side Effects
Neutropenia, Thrombocytopenia
Metabolic Acidosis
Painful
Methemoglobinemia
Electrolyte imbalances
What is the thickness of a split thickness skin graft?
1.
2.
3.
4.
0.001 cm
0.012 cm
0.12 cm
1.2 cm
Burn Excision
• Optimal timing is 3-4 days post injury
• Surgical Excision:
– Fascial excision: Excising involved tissue down to muscle fascia
– Tangential excision: Sequential excision of eschar until the wound bed
displays punctate bleeding
Autograft
• Use of patients skin as donor sites
• Full thickness
– Less wound contracture
– Limited donor sites (behind ear, groin, clavicle)
– Have to be closed by primary closure
• Split thickness
– 0.012-0.015 cm thickness
– Includes epidermis and part of dermis
Additional Options
• Allografts
• Xenografts
– Temporary biologic
– Porcine
dressing
– Similar to allograft process
– Meshed 1:1
• Epidermal Skin Substitutes
– Provides physiologic
– Cultured autologous
wound coverage for 2-4
keratinocytes
weeks
• Dermal Skin Substitutes
– Rejection occurs at 2-4
– Integra (inner matrix of type 1
weeks  removal and
collagen and chondroitin
autograft or re-allograft
sulfate)
– No allografts in pregnancy:
– Becomes vascularized in 2-3
fetal deaths from HLA
weeks then can by autografted
mismatch
Treatment of an alkali chemical burn is?
1.
2.
3.
4.
Copious irrigation with tap water for 30 minutes
Neutralization of the alkali agent
Intra-arterial calcium gluconate infusion
Both 1 and 2
Treatment of an acidic chemical burn is?
1.
2.
3.
4.
Copious irrigation with tap water for 30 minutes
Neutralization of the acidic agent
Intra-arterial calcium gluconate infusion
Both 1 and 3
Treatment of a hydrofluoric acid chemical burn is?
1.
2.
3.
4.
Copious irrigation with tap water for 30 minutes
Neutralization of the acidic agent
Intra-arterial calcium gluconate infusion
Both 1 and 3
What is the daily protein requirement for a 70 kg man
with a 35% TBSA partial thickness burn?
1. 75 gm/day
2. 175 gm/day
3. 250 gm/day
4. 425 gm/day
Nutritional Support
• Protein catabolism results in 1500 to 200 gm
of nitrogen loss/day
• Protein Requirement:
– 1gm/kg/day + (3 g/day x % TBSA)
• Caloric Requirement:
– 25 kcal/kg/day + (30 kcal/day x % TBSA)