- What are the three causes of burns? How should all burns be managed
initially?
Burns may be thermal, chemical, or electrical. Initial management of all burns includes lots of
intravenous fluids (first choice: lactated Ringer solution; back-up choice: normal saline),
removal of all clothes and other smoldering items on the body, copious irrigation of chemical
burns, and, of course, the ABCs (airway, breathing, circulation). You should have a low
threshold for intubation. In the setting of burns related to a fire, give 100% oxygen until
significant carboxyhemoglobin from carbon monoxide inhalation is ruled out. - What are the important sequelae of electrical burns?
Because most of the tissue destruction due to electrical burns is internal, sequelae include
muscle necrosis, myoglobinuria, acidosis, and renal failure. Use large amounts of intravenous
hydration to prevent renal shutdown. The immediate life-threatening risk with electricity
exposure and burns (including lightning and a child who puts his or her finger in an electrical
outlet) is cardiac arrhythmias. Get an electrocardiogram (EKG). - How are chemical burns managed? Which is worse—acid or alkali burns?
All chemical burns should be treated with copious irrigation from the nearest source (e.g., tap
water), because the sooner you dilute the chemical, the less damage will be done. Alkali
burns are worse than acidic burns, because alkaline substances penetrate more deeply. - What is burned skin prone to develop?
Burned skin is much more prone to infection, usually by Staphylococcus aureus or
Pseudomonas aeruginosa. With pseudomonal infection, look for a fruity smell and/or bluegreen appearance. Prophylactic antibiotics are given topically only. Give a tetanus booster to all
burn patients unless they have recently received one (within the past 5 years). - How is burn severity classified? Describe the management of each class.
Burn depth terminology no longer includes the use of “first-, second-, and third-degree” burns.
Burn severity is now classified as superficial, superficial partial thickness, deep partial
thickness, and full thickness burns.
Superficial burns are erythematous without blister formation, involve only the epidermis,
and pain is localized.
Superficial partial thickness burns are painful, warm, and moist with blister formation and
involve the epidermis and superficial papillary dermis.
Deep partial thickness burns reveal skin that is mottled, waxy, and white in appearance
with ruptured blisters. Pain sensation is absent, but pressure sensation is intact.
Full thickness burns involve both the epidermis and dermis, and have a white to gray
leathery appearance and do not blanch with pressure. - Define hypothermia. How is it managed? What are the complications?
Hypothermia is defined as a body temperature < 95F (35C), usually accompanied by mental
status changes and generalized neurologic deficits. If the patient is conscious, you can use
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slow rewarming with blankets. If the patient is unconscious, consider gastric and bladder
lavage with warm water as well as warm intravenous fluids.
Monitor the EKG for arrhythmias, which are common in hypothermic patients. You may see
the classic J wave—a small, positive deflection following the QRS complex (Fig. 9-1). Also
monitor electrolytes, renal function, and acid-base status. - Distinguish between frostnip and frostbite. How are they managed?
In frostnip, a mild form of cold injury, the affected skin is cold and painful. In frostbite, a
more severe form of cold injury, the skin is cold and numb. Treat both with warming of the
affected areas, using warm water (not scalding hot) and generalized warming (e.g., blankets). - True or false: You should not give up resuscitation efforts until the patient is
fully warmed in the setting of hypothermic cardiac arrest.
True. An old saying in medicine claims that the patient is not considered dead “until warm
and dead.” Hypothermia can slow body function to a remarkable degree, and there are case
reports of resuscitation hours after initial attempts in the field once the body was warmed. - Define hyperthermia. What causes it? How is it managed?
Hyperthermia is defined as a body temperature greater than 104F. The three primary
causes are infections, medications, and heat stroke. If heat stroke is the cause, look for a
history of prolonged heat exposure and a high temperature (> 104F), without clues to other
culprits. Treat with immediate cooling (e.g., wet blankets, ice, cold water). The immediate
threats to life are convulsions (treat with diazepam) and cardiovascular collapse. Always rule
out infection and medications (especially those with anticholinergic activity such as
antihistamines, antipsychotics, and antidepressants) as the cause. - What are the two classic examples of hyperthermia due to medication?
Malignant hyperthermia is an idiosyncratic, genetically related reaction to general anesthesia,
usually caused by succinylcholine or halothane exposure. Treat with dantrolene.
Neuroleptic malignant syndrome is thought to be related to malignant hyperthermia and is
an idiosyncratic, genetically related reaction to an antipsychotic. Look for extremely high
levels of creatine phosphokinase and mental status changes in a patient taking antipsychotics.