Term
| Explain the Phases of Burn Care |
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Definition
PHASE I: Initial eval and resuscitation (0-72hrs)
-Clear identify all injuries
-Perform an accurate individualized fluid resuscitation
-Ensure effective decompression of extremities and torso
PHASE II: Initial excision and biologic closure (days 1-7)
-Accuratel ID all wounds requiring Sx
-Excise the bulk of all full-thickness wounds
-Effect definitive or temporary biologic closure of wounds created by excision
PHASE III: Definitive wound closure (wks 1-6)
-Replace temporary wound membranes with permanent coverage
-Close physiologically small, but fxnally critical areas
-Separate pt from intensive care support
PHASE IV: Rehab and reconstruction (Day 1 - Yr 2)
-Initiate early ranging, splinting and antideformity positioning
-Progress to active strength and endurance training
-Initiate scar mgmt program
-Foster reintegration with family and community |
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Term
| Geriatric Considerations with Burns (Part I) |
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Definition
-Injury mechanisms more often involve compromised mobility or dexterity
-Injury mech more commonly involve abuse/neglect
-Injuries may reflect an inability to safely live alone because of compromised fxn
-Injuries occur during syncopal episodes
-Resuscitation should be carefully considered if burns are very large
-Pts may have advanced directives, spouses and families, or heath care proxies who should be consulted ASAP |
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Term
| Geriatric Considerations with Burns (Part II) |
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Definition
-Older adults often do not have the physiologic reserve of the young
-Pulmonary fxn may be compromised by smoking
-Occult or overt coronary artery or peripheral vascular Dz may exist
-Muscle strength, including of respiratory muscles, may be reduced
-Renal fxn may be compromised with greater sensitivity to nephrotoxins or HoTN
-Skin is thinner so burns are relatively deeper and donor site healing less reliable
-Older adults may live alone or have a spouse who cannot reasonably meet D/C needs
-D/C planning may be very involved and must be started early |
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Term
| Acute Burn Transfer Advice |
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Definition
-The airway must be adequately controlled prior to transport
-Pt with serious burns should be transported with an NG tube, bladder cath, and two IVs
-Fluid resuscitation should generally begin prior to transfer if transport will exceed 1hr
-Initial infusion for adults: RL at 2-4mL/kg/%TBSA, 1st 1/2 in 1st 8hrs
-Make every effort to keep pts warm. Cover wounds with clean, dry sheet
-VS should be monitored. PulseOx ideal |
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Term
| Burn-Specific Secondary Survey Highlights: HEENT |
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Definition
-Globes should be examined and corneal epithelium stained with fluorescein before adnexal swelling makes exam difficult. Tarsorrhaphy is not usually indicated acutely
-Corneal epithelial loss can be overt, giving a clouded appearance in the cornea. Topical ophthalmic ABXs constitue optimal Tx
-Intraocular HTN should be excluded in pts with large burns including the face
-Signs of airway involvement include perioral and intraoral burns or carbonaceous material and progressive hoarseness
-Hot liquid can be aspirated in conjunction with a facial scald injury and result in acute airway compromise requiring urgent intubation
-ET tube security is crucial and is best maintained with an umbilical tape harness, rather than adhesive tape, on a burned face |
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Term
| Burn-Specific Secondary Survey Highlights: Neck |
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Definition
-Radiographic eval is driven by the mechanism of injury
-Rarely, in pts with very deep burns, neck escharotomies are needed to facilitate venous drainage of the head |
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Term
| Burn-Specific Secondary Survey Highlights: Cardiac |
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Definition
-The cardiac rhythm should be monitored for 24-72hrs in those with high-voltage electrical injuries
-If intravascular volume and oxygenation are adequately supported, significant arrhythmias are unusual in otherwise healthy pts |
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Term
| Burn-Specific Secondary Survey Highlights: Pulmonary |
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Definition
-Optimize chest wall compliance by performing liberal chest escharotomies PRN
-Severe inhalation injury may lead to slough of endobronchial mucosa and thick endobronchial secretions that can occlude the ET tube, so one should be prepared for sudden ET tube occlusions |
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Term
| Burn-Specific Secondary Survey Highlights: Vascular |
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Definition
-The perfusion of burned extremities should be vigilantly monitored by serial exams. Indications for escharotomy include decreased temp, increased consistency, slowed cap refill and diminished Doppler flow in digits.
-Fasciotomy is indicated after electrical or deep thermal injury when distal flow is compromised on clinical exam. Compartment pressures can be helpful, but clinically worrisome extremities should be decompressed regardless of compartment pressure readings. |
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Term
| Burn-Specific Secondary Survey Highlights: Abdomen |
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Definition
-NG tubes should be in place and their fxn verified, especially before air transport in unpressurized choppers
-An inappropriate resuscitative volume requirement may be a sign of an occult intra-abdomen injury
-Torso escharotomies may be required to facilitate ventilation in the presence of deep circumferential abdominal wall burns
-Immediate ulcer prophylaxis with histamine receptor blockers and antacids is indicated in all pts with serious burns |
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Term
| Burn-Specific Secondary Survey Highlights: Genitourinary |
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Definition
-Bladder cath facilitates using UO as a resuscitation endpoint and is appropriate in all pts who require a fluid resuscitation
-It is important to ensure that the foreskin is reduced over the bladder cath after insertion, as progressive swelling may otherwise result in paraphimosis |
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Term
| Burn-Specific Secondary Survey Highlights: Neurologic |
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Definition
-An early neuro eval is important, as the pts sensorium is often progressively compromised by meds or hemodynamic instability during the hours after injury. This may require CT scans in those with a mech of injury consistent with head trauma
-Pain and anxiety meds should be administered within the bounds of safety
-Pts who require neuromuscular blockade for transport should also receive adequate sedation and analgesia |
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Term
| Burn-Specific Secondary Survey Highlights: Extremities |
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Definition
-Extremities that are at risk for ischemia, particularly those with circumferential thermal burns or those with electrical injury, should be dressed so they can be frequently examined
-Tense extremities should be decompressed promptly by escharotomy and/or fasciotomy when clinical exam reveals increasing consistency, decreased temp, and diminished Doppler flow in digits
-The need for escharotomy usually becomes evident during the early hours of resuscitation. Therefore, most escharotomies can be delayed until transport has been effected if transport times will not extend beyond 6 hrs after injury
-Burned extremities should be elevated and splinted in a position of fxn |
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Term
| Burn-Specific Secondary Survey Highlights: Wound |
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Definition
-Wounds, although often underestimated in depth and overestimated in size on initial exam, should be evaluated for size, depth, and the presence of circumferential components
-Burn wounds are proportionately tetanus prone, and tetanus immune statue should be determined and appropriately supplemented |
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Term
| Burn-Specific Secondary Survey Highlights: Laboratory |
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Definition
-ABG analysis is important when airway compromise or inhalation injuries is present
-A normal admission carboxyhemoglobin concentration does not eliminate the possibility of a significant exposure as the half-life of carboxyhemoglobin is 30-40min in those effectively ventilated with 100% O2
-Baseline Hgb and lytes can be helpful later during resuscitation |
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Term
| Burn-Specific Secondary Survey Highlights: Radiography |
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Definition
| -The radiographic eval is driven by the mech of injury and the need to document placement of lines and tubes |
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Term
| Typical Resuscitation Targets |
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Definition
-Sensorium: Arouseable and comfortable
-Temp: Warm centrally and peripherally
-Systolic BP: MAP >60mmHg
-Pulse: 80-180/min (age dependent), easily palpable peripherally
-UO: 0.5-1mL/kg/hr (glucose neg)
-Base Deficit: <2 |
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Term
| A Consensus Resuscitation Formula |
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Definition
FIRST 24 HR
-LR: 2-4mL/kg/%TBSA/24hr (1st 1/2 in 1st 8hr)
-Colloid: Many advise 5% albumin at 1 X maintenance rate if burn is >40% TBSA
SECOND 24 HR
-Crystalloid: To maintain UO, commonly requiring ~1.5 X maintenance rate. If silver nitrate is used, Na+ leaching will mandate continued isotonic crystalloid. If another topical agent is used, free water requirement is significant. Serum Na+ should be monitored closely. Nutritional support should begin, ideally by the enteral route
-Colloid: 5% albumin in LR to maintain serum albumin at or above 2.0g/dl.
0-30%: none
30-50%: 0.3mL/kg/% TBSA/24hr
50-70%: 0.4mL/kg/% TBSA/24hr
70-100%: 0.5mL/kg/% TBSA/24hr |
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Term
| Initial Wound Eval: Size, Depth, Circumferential Components |
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Definition
BURN WOUND SIZE
-Lund-Browder Chart
-Rule of Nines
-Palmar Surface of Pt's Hand |
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Term
| Initial Wound Eval: Size, Depth, Circumferential Components |
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Definition
BURN WOUND DEPTH
-First Degree: Red, dry and painful and are often deeper than they appear, sloughing the next day
-Second Degree: Red, wet and very painful. There is an enormous variability in the depth, ability to heal, and propensity to hypertrophic scar formation
-Third Degree: Leathery in consistency, dry, insensate, and waxy. These wounds will NOT heal
-Fourth Degree: Involve underlying SubQ tissue, tendon or bone |
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Term
| Characteristics of an Idealized Skin Substitute |
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Definition
-Inexpensive
-Has a long shelf-life with refrigeration
-May be used off-the-shelf on any pt
-Nonantigenic, nonallergenic
-Durable and easy to work with mechanically
-Flexible and contours to irregular surfaces well
-Physiologic vapor barrier
-Excellent bacterial barrier
-Easy to secure in position
-Vascularizes rapidly
-Grows with a child
-Can be applied in one operation
-Does not become hypertrophic
-Does not need surfacing with split-thickness autograft |
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Term
| Mgmt of Progressive Respiratory Failure (Part I) |
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Definition
-Address bronchospasm with nebulized B2-agonists
-Address poor chest wall compliance secondary to overlying eschar with escharotomies
-Address endobronchial secretions with frequent SXN and toilet bronchoscopy PRN
-Ensure ventilator synchrony with adequate opiate and benzodiazepine infusions. Neuromuscular blockade may be required on occasion
-Reset endpoint of ventilation to a physiologic pH (7.2 or more). Allow a gradual-onset hypercapnia as long as there is no head injury |
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Term
| Mgmt of Progressive Respiratory Failure (Part II) |
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Definition
-Reset endpoint of oxygenation to an arterial Sat of at least 90%, typically associated with a PaO2 of 60 or greater
-Optimize PEEP. This is usually done bedside trial
-Optimize PIP. This is best doen by using pressure-control mode targeting a Vt of 6-7mL/kg, as long as total inflating pressures (PIP + PEEP) can be kept under 40 cmH2O. In some pts with compromised chest wall compliance from eschar, violating this pressure cap does not result in transpleural pressures in an injurious range
-In those few pts in whom these measures are not sufficient, consider the use of innovative adjuncts, such as inhaled nitric oxide or extracorporeal support |
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Term
| Rapid Eval of Deteriorating Intubated Burn Pts: 5 Problems to Consider |
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Definition
When there is a sudden deterioration of the intubated pt, there are 5 possibilities to immediately consider:
1. Mechanical problem with Vent
2. Tube obstruction
3. Tube displacement out of the trachea
4. Tube displacement into R Mainstem bronchus
5. PTX |
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Term
| Rapid Eval of Deteriorating Intubated Burn Pts: Initial Eval (Part I) |
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Definition
-Disconnect the pt from vent and bag at 100%. This eliminates and treats the possibility of mech problems with the system. If this is not a solution:
-Bag vent the pt. If ventilation doesn't go in, you have an obstructed tube. Try to clear or SXN the tube. If it cannot be quickly cleared-->extubate, mask ventilate, and reintubate. If the tube was not occluded:
-Bag vent the pt. If the tube is not obstructed, you may have displacement out of the airway or down the R mainstem. If you hear gurgling in the hypopharynx, you probably have a tube displaced or a cuff leak. If the former, extubate, mask vent and reintubate. If the latter, inflate the cuff. If the tube seems to be in the airway: |
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Term
| Rapid Eval of Deteriorating Intubated Burn Pts: Initial Eval (Part II) |
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Definition
-Bag vent the pt. Auscultate the axillas. If the R-sided sounds are much louder than the L sounds you probably have a R mainstem intubation. This can confirmed by inspection of tube depth at the alveolar ridge or direct laryngoscopy showing a deep insertion [don't do that]. Back the tube out and reassess. If neither of these is the cause:
-Bag vent the pt while auscultating both sides of the chest. Unilateral BS are consistent with a PTX. This can be tough to differentiate from a mainstem intubation in some situations, but is often accompanied by hemodynamic deterioration or hyperresonance. Inspection of the tube via direct laryngoscopy will reveal proper placement and depth of insertion. If you suspect a PTX and don't have time for a CXR, place a small cath in the 2nd interspace, MCL and later place a chest tube. |
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Term
| Considerations for Weaning and Extubating of Pts with Serious Burns (Part I) |
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Definition
-Sensorium: The pt must be alert enough to guard the airway
-Airway Patency: Upper airway edema must be resolved to the degree that there is an audible airleak around a properly sized ET with cuff deflated at moderate inflating pressures (~20cmH2O). Consider 24hr course of steroids.
-Muscle Strength: Strength must be adequate for ventilation. An indirect measure of this is a Vt of 6-10mL/kg with CPAP of 5cmH2O and a MIP <-20cmH2O. A rapid, shallow breathing index (f/Vt) <105 |
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Term
| Considerations for Weaning and Extubating of Pts with Serious Burns (Part II) |
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Definition
-Pulmonary Toilet: Pts recovering from inhalation injury often have reduced ciliary clearance in the face of increased secretion from PNA and tracheobronchitis. They must be alear enough to cough and cooperate with SXN. Frequent CPT will greatly help airway clearance
-Compliance: Combined chest wall and lung compliance must be high enough that the work of spontaneous breathing is not excessive. Indirect measures of the area measured Static compliance of at least 50mL/cmH2O and Vt of at least 10mL/kg with moderate inflating pressure (<20cmH2O)
-Gas Exchange: An intrapulmonary shunt <20%, indicated by a PaO2/FiO2 ratio >200 |
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Term
| Systemic Approach to Burn ICU Ward Rounds |
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Definition
-Big picture
-Recent events
-Neuro issues and plans
-Pain and anxiety issues and plans
-Hemodynamic issues and plans
-Pulmonary issues and plans
-GI issues and plans
-Nutrition issues and plans
-Infectious issues and plans
-HEENT issues and plans
-GU issues and plans
-Renal issues and plans
-Vascular issues and plans
-Wound issues and plans
-Rehab issues and plans
- Psychiatric issues and plans
-Family issues and plans
-Lab and X-ray issues and plans
-Care coordination and consultation issues and plans
-Other issues and plans
-Long-term care and follow-up issues and plans
-Documentation issues and plans |
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Term
| Key Objectives of a Pain and Anxiety Mgmt Protocol |
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Definition
VENTILATED ACUTE:
-Tube security
-Covering background and procedural needs
-Opiate and Benzo synergy
-Planning for extubation
NONVENTILATED ACUTE:
-Avoidance of respiratory depression
-Covering background and procedural needs
-Opiate and Benzo syndergy
CHRONIC ACUTE:
-Participation in rehab efforts
-Covering background and procedural needs
-Perioperative comfort
RECONSTRUCTIVE:
-Perioperative comfort |
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Term
| The Harris-Benedict Equation for Estimated Basal Metabolic Rate (BMR) |
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Definition
Calculated BMR can be multiplied by an injury or activity factor (commonly in burns from 1.5-1.7) to provide estimated caloric needs
-Women: BMR = 655 + (4.35 X lbs) + (4.7 X inches) - (4.7 X Yrs)
-Men: BMR = 66 + (6.23 X lbs) + (12.7 X inches) - (6.8 X Yrs) |
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Term
| Common Complications Seen in Pts with Serious Burns: Neurologic |
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Definition
-Transient Delirium: occurs in up to 30% of pts. Usually resolves with supportive therapy. Anoxia, metabolic disturbance, and structural lesions should be considered
-Seizures: Can complicate hyponatremia with cerebral edema or abrupt Benzo withdrawal
-Peripheral nerve injuries: Can occur from direct thermal injury or compression from compartment syndrome, constricting eschar, or tight splints in sedated pts
-Delayed peripheral nerve and spinal cord deficits can develop wks after high-voltage injury secondary to small vessel thrombosis or demyelination |
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Term
| Common Complications Seen in Pts with Serious Burns: Psychiatric |
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Definition
| -PTSD: Occurs in up to 30% of burn pts. It can be exacerbated by inadequate pain and anxiety mgmt |
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Term
| Common Complications Seen in Pts with Serious Burns: Cardiovascular |
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Definition
-Endocarditis: presents with fever and recurrent bacteremia, sometimes accompanied by a new murmur
-Suppurative thrombophlebitis: presents with fever and bacteremia, often without signs of local infxn. Dx may require US or exploration of prior peripheral IV sites or cutdowns
-HTN: may occur most commonly in preadolescent boys and is best managed with Beta-blockers, once adequate pain and anxiety mgmt are ensured
-Venous thromboembolic complications: Are infrequent in young. They are common enough in postpubertal and adult pts to justify prophylaxis. Careful venous cannulation and use of the smallest catheter that can meet the pt's needs will further reduce this complication
-CV and art cath insertion complications: Can be minimized by proper technique |
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Term
| Common Complications Seen in Pts with Serious Burns: Pulmonary |
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Definition
-CO intoxication: Managed with effective ventilation with 100% O2 for 6hr. Hyperbaric O2 Tx is appropriate in selected pts
-PNA: May occur with or without inhalation injury and is treated with pulmonary toilet and ABX
-Respiratory failure: may occur early postinjury secondary to inhalation injury or late secondary to sepsis or PNA |
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Term
| Common Complications Seen in Pts with Serious Burns: Hematologic |
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Definition
-Neutropenia and thrombocytopenia: Accompany sepsis and should trigger investigation for infectious complications
-DIC: Is commonly secondary to sepsis and should prompt empiric Tx and search for septic foci
-Immunologic deficits: Are common in serious burns. Prompt wound closure is the best Tx |
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Term
| Common Complications Seen in Pts with Serious Burns: Otolaryngolic |
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Definition
-Auricular chondritis: Results from bacterial invasion of relatively avascular cartilage beneath ear burns, causing rapid destruction of the framework of the ear. It can be prevented by topical mafenide acetate
-Sinusitis and OM: Can be caused by obstruction of the Eustachian tube by NT or gastric tubes. It is treated by relocation of tubes, ABX, topical decongestants and occasional surgical drainage
-Complications of ET intubation: include nasal alar and septal necrosis, vocal cord erosions and ulcerations, tracheal stenosis, and tracheoesophageal and tracheoinominate artery fistulae. The occurrence of such complications is minimized by proper tube position and size and attention to cuff pressures |
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Term
| Common Complications Seen in Pts with Serious Burns: Enteric (Part I) |
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Definition
-Hepatic Dysfxn: can be secondary to splanchnic ischemia during resuscitation and presents as transaminase elevation. Late hepatic failure is usually secondary to sepsis and presents with elevated cholestatic chemistries and progressive synthetic failure
-Pancreatitis: Can be secondary to splanchnic ischemia and begins with amylase and lipase elevation progressing through hemorrhagic pancreatitis
-Acalculus Cholecystitis: Can present as sepsis with rising cholestatic chemistries without localized signs in critically ill pts. Serial PE and US are generally diagnostic. Bedside percutaneous cholecystectomy is useful in instable pts |
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Term
| Common Complications Seen in Pts with Serious Burns: Enteric (Part II) |
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Definition
-Gastric and Duodenal Ulcers: Are caused by splanchnic ischemia during the early hours after injury. This can result in life-threatening bleeding or perf. The risk is reduced by effective resuscitation and routine histamine receptor blockers and/or antacids
-Intestinal ischemia: Is caused by splanchnic ischemia and can progress to infarction. It is prevented by effective resuscitation. It can occur later due to fulminant sepsis
-Small Bowel Overfeeding with Perf: Can occur if postpyloric feeds are administered by pumps despite an unappreciated ileus. Prevention requires frequent abdominal exam.
-C diff: Presents with severe diarrhea and systemic toxicity. Burn pts exposed to ABX are at risk. Empiric Tx with enteral metronidazole or vancomycin is justified |
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Term
| Common Complications Seen in Pts with Serious Burns: Ophthalmic |
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Definition
-Ectropia: Caused by contractile forces of facial and eyelid burns; risks globe exposure and dessication. Tarsorrhaphy is infrequently helpful as contractile forces can cause these sutures to pull through the lids. Lid release is a more definitive and effective Tx
-Corneal Ulceration: Complicates corneal burns or corneal exposure and dessication. Superinfxn can lead to corneal perf and loss of vision. This dreaded complication can be minimized by vigilant globe lubrication and prompt correction of ectropia
-Symblepharon: Are adhesions of the lid to the denuded conjunctiva following chemical burns or corneal epithelial defects complicating TEN. These can be minimized by daily exam and adhesion disruption |
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Term
| Common Complications Seen in Pts with Serious Burns: Renal |
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Definition
Early acute renal failure: Follows inadequate perfusion during resuscitation, myoglobinuria, or abdominal compartment syndrome
-Late renal failure: Complicates sepsis and multiorgan failure of the use of nephrotoxic agents |
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Term
| Common Complications Seen in Pts with Serious Burns: Endocrine |
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Definition
| -Acute adrenal insufficiency: Presents with variable degrees of HoTN, fever, hyponatremia, and hyperkalemia |
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Term
| Common Complications Seen in Pts with Serious Burns: Genitourinary |
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Definition
-UTI: Common complications of bladder cath. They can be minimized by placing only when necessary
-Nephrolithiasis: Infrequent, but can be seen in immobilized burn pts. Typical pain, hematuria, or frequent infxn should prompt investigation
-Candida cystitis: Can be treated with antifungals administered systemically or by irrigation. If infections are recurrent, the upper tracts should be screened with US |
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Term
| Common Complications Seen in Pts with Serious Burns: Musculoskeletal |
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Definition
-Exposed burned bone: May require complex flap closure. However, in most situations, debridement of exposed necrotic bone with a powered bit facilitates granulation tissue coming up through nutrient vessels, which supports subsequent autografting. Negative-pressure dressings seem to speed granulation in most settings.
-Fractured and burned extremities: Best immobilized with external fixators while overlying burns are grafted. Burn pts with fractures in unburned extremities are often best managed with prompt internal fixation
-Hypertrophic scar formation: Major cause of long-term fxnal and cosmetic morbidity. It can cause deformity during protracted acute hospitalization and may require acute release to ensure optimal recovery. Later mgmt tools include compression garments, massage, steroid injxn, topical silicone, tuneable dye laser, Z-plasty, and incisional release Sx |
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Term
|
Definition
BURN IMPETIGO
-Loss of epithelium from previously epithelialized surface
-Not related to local trauma
BURN-RELATED SURGICAL WOUND INFXN
-Infxn in a surgically created wound which has not yet epithelialized
-Includes loss of any overlying graft or membrane
BURN WOUND CELLULITIS
-Infxn occurs in uninjured skin surrounding a wound
-Signs of local infxn progress beyond what is expected from burn-related inflammation
INVASIVE BURN WOUND INFXN
-Infxn occurs in unexcised burn and invades viable underlying tissue
-Dx may be supported by histologic exam or quantitative cultures |
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Term
| Unique Initial Priorities of Nonburn Problems Appropriate for Burn Unit Care: Electrical Injuries |
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Definition
-Cardiac rhythm should be monitored in high (>1000V) and selected intermediate (220-1000V) voltage exposure for 12-24hr
-Low and intermediate voltage exposures can cause locally destructive injuries, but commonly result in systemic sequelae
-Delayed neurologic and ocular sequelae can occur after high voltage injury, so neurologic and ocular exams should be documented during initial assessment
-Extremities in the path of high voltage current should be monitored for compartment syndrome and be decompressed promptly when it develops
-Bladder caths should be placed in all pts suffering high voltage exposure to document and help manage pidmenturia |
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Term
| Unique Initial Priorities of Nonburn Problems Appropriate for Burn Unit Care: Chemical Burns |
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Definition
-Irrigate cutaneous wounds with tap water for at least 30min for acidic exposure
-If alkaline exposure, irrigate until wound does not have a soapy feel of pH is normalized
-Irrigate the globe with isotonic crystalloid. Blepharospasm may require ocular anesthetic administration
-Concentrated hydrofluoric acid exposures may be complicated by life-threatening hypocalcemia. Serum calcium must be closely monitored and supplemented. Subeschar infiltration of 10% calcium gluconate solution may be appropriate after exposure to highly concentrated or anhydrous solutions
-Dilute hydrofluoric acid exposures are treated with topical 2.5% calcium gluconate gel until pain is resolved. Hands may be placed into a glove filled with gel |
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Term
| Unique Initial Priorities of Nonburn Problems Appropriate for Burn Unit Care: Tar Burns |
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Definition
-Tars should be cooled with tap water irrigation initially
-Wounds can be dressed with lipophilic solvent topical agents to facilitate removal |
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Term
| Unique Initial Priorities of Nonburn Problems Appropriate for Burn Unit Care: Toxic Epidermal Necrolysis |
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Definition
-TEN is a diffuse cutaneous and visceral epidermal slough at the dermal-epidermal jxn, usually associated with an antecedent flu-like syndrome and often with drug administration
-The severity of cutaneous, mucous membrane, and conjunctival involvement varies widely. Typically, visceral slough follows days behind cutaneous involvement
-Differentiation from drug eruptions, viral exanthems, or SSS can occasionally be difficult on exam. Skin Bx may be helpful in equivocal cases
-Tx involves prevention of wound dessication and infxn, Tx of septic complications, and support of failing organ systems, while awaiting re-epithelialization
-Early ophthalmologic care is important to optimal long-term outcome
-Those with severe oropharyngeal or tracheobronchial involvement may require intubation for airway protection and enteral tube feedings for nutritional support |
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Term
| Unique Initial Priorities of Nonburn Problems Appropriate for Burn Unit Care: Purpura Fulminans |
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Definition
-Typically a complication of meningococcal sepsis
-Probably secondary to transient Protein C deficiency. Fresh frozen plasma or activated protein C should be considered early
-Frequently accompanied by organ failure
-Tx involves mgmt of organ failure and excision and grafting of wounds to prevent wound sepsis
-Can be associated with adrenal infarction or hemorrhage and acute adrenal insufficiency
-Long-term morbidity secondary to major amputation and epiphyseal arrest is common |
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Term
| Unique Initial Priorities of Nonburn Problems Appropriate for Burn Unit Care: Staphylococcal Scalded Skin Syndrome |
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Definition
-SSS is a rxn to staphylococcal exotoxin which results in epithelial separation at the granular layer
-May be related only to colonization, rather than frank infxn
-Most common in infants and young children
-Superficial wounds heal quickly if infxn and dessication do not occur
-Mucous membrane and conjunctival involvement is not seen. This is a key point of physical exam and diagnostic differentiation
-Empiric anti-staphylococcal ABXs should be administered while a focus of infxn is eliminated |
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Term
| Unique Initial Priorities of Nonburn Problems Appropriate for Burn Unit Care: Soft Tissue Infxn |
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Definition
-Essential first steps are suspicion, exploration of suspicious compartments, and aggressive excision of nonviable or infected tissue
-ABXs are important, but are adjuncts to therapy
-Hyperbaric O2 can be considered as an adjunct to anerobic soft tissue infxns, but Sx is cornerstone of mgmt |
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Term
| Unique Initial Priorities of Nonburn Problems Appropriate for Burn Unit Care: Soft Tissue Trauma |
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Definition
-Large soft tissue wounds or degloving injuries are well managed in the burn unit
-Careful trauma-specific secondary survey is important
-Tertiary survey evaluation for missed injuries is imporant |
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Term
| Unique Initial Priorities of Nonburn Problems Appropriate for Burn Unit Care: Injuries of Abuse |
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Definition
-Should be considered in all injured pts, not only children. Burns are common in domestic violence
-Suspicious injuries must be filed with the appropriate state agency
-Important points of exam include uniformity of burn depth, absence of splash marks, sharply defined wound margins, porcelain contact sparing, flexor sparing, stocking or glove patterns, dorsal location of contact burns of the hand, and localized very deep contact burns
-Important points of Hx include unusual or conflicting stories, prior injuries and delayed presentation |
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Term
| Considerations in OutPt Burn Care: Pt |
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Definition
-The airway must not be at risk
-Fluid resuscitation is NOT required
-The pt can eat and drink
-Community and family support is adequate for monitoring, wound care, and transportation
-The pt and family must understand the care plan
-There is no suspicion of abuse
-The wound unequivocally does not require Sx |
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Term
| Considerations in OutPt Burn Care: Techniques |
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Definition
-Teach the pt and the family
-Set up a clear communication plan
-Make a clear and simple wound cleansing and topical care plan
-Make a clear and simple wound cleansing and topical care plan
-Ensure that community support services are in place
-Communicate specific return and hospitalization conditions
-Set up follow-up clinic visits
-St up long-term f/u plans |
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