CHAPTER 23
Burns
Test Taking Tips
Count on using the Parkland formula to calculate the volume of fluids that you need to give to your burn patient. Don’t forget that the start time of volume resuscitation is at time of burn, not at time of arrival to the hospital.
Review topical antimicrobials such as silver nitrate or sulfamylon and their side effects and what they have best coverage for.
CLASSIFICATION
What are the 5 different causal categories for burns?
1. Flame: damage from superheated, oxidized air
2. Scald: damage from contact with hot liquids
3. Contact: damage from contact with hot or cold solid materials
4. Chemical: contact with noxious chemicals
5. Electrical: conduction of electrical current through tissues
What is a 1st-degree burn?
Injury localized to the epidermis
What is a superficial 2nd-degree burn?
Injury to the epidermis and superficial dermis
What is a deep 2nd-degree burn?
Injury through the epidermis and into the deep dermis
What is a 3rd-degree burn?
Full-thickness injury through the epidermis and dermis into the subcutaneous fat
What is a 4th-degree burn?
Injury through the skin and subcutaneous fat into underlying muscle or bone
Identify the depth of the burn:
A painful, erythematous burn with an intact epidermal barrier that blanches to the touch?
1st degree
Painful burn with blebs and blisters; hair follicles intact; blanches to the touch?
Superficial 2nd degree
Sensation decreased; loss of hair follicles?
Deep 2nd degree
Leathery feeling, no sensation?
3rd degree
FIGURE 23-1. Illustration of the zones of injury after burn. Factors likely to affect the zone of stasis determine the extension of injury from the original zone of coagulation. (Reproduced from Felliciano DV, Mattox, Moore EE. Trauma. 6th ed. http://www.accesssurgery.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.)
PATHOPHYSIOLOGY
What are the 3 zones of injury from a burn?
Zone of coagulation, zone of stasis, zone of hyperemia
Define the zone of coagulation:
Irreversibly damaged necrotic area of a burn where cells have been disrupted
Define the zone of stasis:
Area associated with vascular damage and leakage that is immediately adjacent to the necrotic zone with a moderate degree of insult and decreased tissue perfusion that can either survive or progress to coagulative necrosis
Zone of hyperemia:
Area of vasodilation from inflammation surrounding the burn with viable tissue where the healing process begins
EVALUATION OF BURN WOUNDS
How can you differentiate a superficial 2nd-degree from a deep 2nd-degree burn?
Superficial 2nd-degree burn will blanch to the touch, whereas deep 2nd-degree burn will not
Where does a superficial 2nd-degree burn re-epithelialize from?
Rete ridges; hair follicles; sweat glands (7–14 days)
Where does a deep 2nd-degree burn re-epithelialize from?
Hair follicles; sweat gland keratinocytes (14–35 days)
Where does a 3rd-degree burn re-epithelialize from?
Wound edges
FIGURE 23-2. Table for estimating extent of burns. In adults, a reasonable system for calculating the percentage of body surface burned is the “rule of nines”: Each arm equals 9%, the head equals 9%, the anterior and posterior trunk each equal 18%, and each leg equals 18%; the sum of these percentages is 99%. (Reproduced from Doherty GM. Current Diagnosis and Treatment: Surgery. 13th ed. http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.)
According to the rules of nines, what percentage of total body surface area (TBSA) do these regions represent in an adult?
Each upper extremity?
9% TBSA
Head and neck?
9% TBSA
Each lower extremity?
18% TBSA
Anterior torso?
18% TBSA
Posterior torso?
18% TBSA
Perineum and genitalia?
1% TBSA
What percentage of TBSA does the open hand (palm with fingers extended) of the patient account for?
1%; this area can be visually transposed onto the burn for an estimation of size.
What percentage do the head and neck account for in the TBSA of an infant?
21%
What percentage does each leg account for in the TBSA of an infant?
13%
FLUID RESUSCITATION
What formula estimates the amount of fluid needed for the resuscitation of a burn patient?
Parkland Formula: give 4 mL/kg × % burn in first 24 hours
Give ½ in first 8 hours, the rest in next 16 hours
Use for burns ≥20%
Use lactated Ringer solution
What is the best measure of adequate resuscitation?
Urine output
Adults: 0.5 to 1.0 mL/kg/h
Children <6 months: 2 to 4 mL/kg/h
How do you calculate the Galveston formula for maintenance fluid in the first 24 hours for a pediatric burn patient?
5000 mL/TBSA burned (in m2) + 1500 mL/m2 total area
Table 23-1 Resuscitation Formulas
TREATMENT OF BURNS
What is the treatment for a 1st-degree burn?
Topical soothing salves; oral nonsteroidal anti-inflammatory agents
What is the treatment for a superficial 2nd-degree burn?
Clean wound with antiseptic soap to remove dead skin and foreign material
Unroof blisters
Apply topical antibiotic and dress wound
What is the treatment for a deep 2nd- and 3rd-degree burns?
Initially treat like superficial 2nd-degree burns
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