Review of Critical Care Medicine

Exposure treatment is done for burns of the –
a)Upper limb (JIPMER 87)
b)Lower limbs
c)Thorax
d)Abdomen
e)Head & neck

Circumferential (encircling) burns of the trunk are generally unsuited for exposure because all of the burned surfaces cannot be adequately exposed to the air at one time.

Granulating surfaces should never be exposed.

Rule of nine to estimate surface area of a burnt patient was introduced by – (AIIMS 84)
a) Mortiz kaposi b) Alexander wallace
c) Joseph lister d) Thomas barclay

Deep skin burns is treated with – (AIIMS 91)
a)Split thickness graft
b)Full thickness graft
c)Amniotic membrane
d)Synthetic skin derivatives

In burns heat loss is by/ due to – (PGI 80,
a)Dilatation of veins DELHI 80,92)
b)Shock
c)Exposed area by evaporation
d)None of the above

The cold water treatment of burns has the disadvantage that it increase the chances of –
a) Pain b) Exudation (PGI 81, AIIMS 83)
c) Infection d) None of the above

Pus in burns form in – (PGI 79, DELHI 89)
a) 2-3 Days b) 3-5 days
c) 2-3 weeks d) 4

One of folowing is not seen in severe burns -(Al 96)
a) Hypovolemia b) Sepsis
c) Duodenal ulcer d) Hyperthemia

Undue restlessness in a patient during the immediate post burn period is often a manifestitation of-(Karp
a) Hypoxia b) Hypovolemia 95)
c) Hyperkalemia d) Anxiety

Sabiston:- First-degree burns are, by definition, injuries confined to the epidermis. These burns are painful and erythematous, blanch to the touch, and have an intact epidermal barrier. Examples include sunburn or a minor scald from a kitchen accident. First-degree burns do not result in scarring, and treatment is aimed at comfort with the use of topical soothing salves, with or without aloe, and oral nonsteroidal anti-inflammatory agents.

Second-degree burns are divided into two types: superficial and deep. All second-degree burns have some degree of dermal damage, and the distinction is based on the depth of injury into this structure. Superficial dermal burns are erythematous and painful, blanch to touch, and often blister. Examples include scald injuries from overheated bathtub water and flash flame burns from open carburetors. These wounds spontaneously re-epithelialize from retained epidermal structures in the rete ridges, hair follicles, and sweat glands in 7 to 14 days. After healing, these burns may result in some slight skin discoloration over the long term. Deep dermal burns into the reticular dermis appear more pale and mottled, do not blanch to touch, but remain painful to pinprick. These burns heal in 14 to 35 days by re-epithelialization from hair follicles and sweat gland keratinocytes, often with severe scarring as a result of the loss of dermis

Third-degree burns are full thickness through the epidermis and dermis and are characterized by a hard, leathery eschar that is painless and black, white, or cherry red. No epidermal or dermal appendages remain; thus, these wounds must heal by re-epithelialization from the wound edges. Deep dermal and full-thickness burns require excision with skin grafting to heal the wounds in timely fashion.

Fourth-degree burns involve other organs beneath the skin, such as muscle, bone, and brain.

Schwartz:- Burn wounds are commonly classified as superficial (first degree), partial thickness (second degree), full thickness (third degree), and fourth-degree burns, which affect underlying soft tissue. Partial-thickness burns are then classified as either superficial or deep partial thickness burns by depth of involved dermis. Clinically, first-degree burns are painful but do not blister, second-degree burns have dermal involvement and are extremely painful with weeping and blisters, and third-degree burns are hard, painless, and nonblanching

Because full-thickness grafts are impractical for most burn wounds, split-thickness sheet autografts harvested with a power dermatome make the most durable wound coverings and have a decent cosmetic appearance.

Schwartz:- Thighs make convenient anatomic donor sites, which are easily harvested and relatively hidden from an aesthetic standpoint. The thicker skin of the back is useful in older patients, who have thinner skin elsewhere and may have difficulty healing donor sites. The buttocks are an excellent donor site in infants and toddlers.

The scalp is also an excellent donor site; the skin is thick and there are many hair follicles so it heals quickly. It has the added advantage of being completely hidden once hair regrows.

Areas of cosmetic importance such as the face, neck, and hands should be grafted with nonmeshed sheet grafts to ensure optimal appearance.

All requires hospitalization except – (Al 91)
a)5% Burns in children
b)10% Scalds in children
c)Electrocution
d)15% Deep burns in adults

Indications for specialist referral in burns –
a)> 20% superficial burn in adult (PGI 04)
b)Only palms
c)Scalds on head and face
d)10% burns in infants
e)10% deep burns in adult

A burn patient is referred when – (PGI 04)
a)10% superficial burn in child
b)Scald in face
c)25% superficial burn in adult
d)25% deep burn in adult
e)Burn in palm

Improvements in burn care originated in specialized units specifically dedicated to the care of burned patients. These units consist of experienced personnel with resources to maximize outcome from these devastating injuries ( Box 22-1 ). Because of these specialized resources, burned patients are best treated in such places. Patients with the following criteria are referred to a designated burn center:

In 3’rd degree burns, all are seen except – (PGI 99)
a)Vesicles are absent
b)Painful
c)Leathery skin
d)Reddish due to Hb Infiltration

Late deaths in burns is due to – (PGI 99)
a) Sepsis b) Hypovolemia
c) Contractures d) Neurogenic

Burns with vesiculation, destruction of the epidermis and upper dermis is – (PGI 99)
a) 1″ degree b) 2nd degree
c) 3rd degree d) 4th degree

True about burns – (PGI 2000)
a)Hyperglycemia is seen in early burns
b)Child with burns should have damp dressing
c)Chemical powder burns should be kept dry
d)3rd degree burns are painfull

Metabolic derangements in severe burns are all except- (PGI 2000)
a)cortico steroid secretion
b)Hyperglycaemia
c)secretion of HCl
d)Neutrophil dysfunction

Superficial burns; true is/are – (PGI 01)
a)Always requires skin grafting
b)Dry & inelastic
c)Blister formation
d)Painless
e)Can be healed within 7 to 10 days

Schwartz:- Clinically, first-degree burns are painful but do not blister, second-degree burns have dermal involvement and are extremely painful with weeping and blisters, and third-degree burns are hard, painless, and nonblanching

Love and Bailey:-Superficial burns These have the ability to heal themselves by epithelialisation alone. Epidermal burns look red, are painful, blisters are not present, and they heal rapidly without sequelae. Superficial dermal burns are blistered and painful; they should heal by epithelialisation within 14 days without scarring, but some­times leave long-term pigmentation changes.burns heal in 14 to 35 days

Hence superficial burns include first degree as well as second degree superficial ones with superficial dermis involvement.

True statement about burn resuscitation -(PGI 03)
a)Colloid preferred in initial 24 hrs
b)Colloid preferred if burnt area is > 15 % of total BSA
c)Half of the calculated fluid given in initial 8 hrs.
d)Diuretics should be given to all pt of electric burn.

The ideal temperature of water to cool the burnt surface is – (UPSC 02)
a) 15° b) 10°
c) 8° d) 6°

The best guide to adequate tissue perfusion in the fluid management of a patient with burns, is to ensure a minimum hourly urine output of- (Karn a) 10-30 ml b) 30-50 ml 04)
c) 50-70 ml d) 70-100 ml

Bailey:- Fluid resuscitation:- It is important at an early stage to secure large-bore intra­venous lines. Samples are taken for haemoglobin, urea and electrolytes, and blood cross-matching. Blood gases and blood analysis for carbon monoxide or cyanide poisoning are required in the unconscious patient. Having estimated the percentage burned surface area and measured the body weight, initial fluid resuscitation can be planned. The simplest formula (for adults) is: 3—4 ml/kg body weight/% burn/in the first 24 hours.Half of this volume is given in the first 8 hours and the rest in the next 16 hours. Timings begin from the time of the burn, not the start of resuscitation. Hartmann solution is preferred, but other isotonic fluids may be used. Metabolic fluid requirements are also needed. Formulae are only a guide and the adequacy of fluid resuscitation is monitored by regular clinical assessment. A urinary catheter is essential. Urine output is the best guide to adequate tissue perfusion; in an adult one should aim for 30—50 ml/hour.

Schwartz:- As in any critically ill patient, the target MAP is 60 mmHg to ensure optimal end-organ perfusion. Goals for urine output should be 30 mL/h in adults and 1 to 1.5 mL/kg per hour in pediatric patients. Because blood pressure and urine output may not correlate perfectly with true tissue perfusion, the search continues for other adjunctive parameters that may more accurately reflect adequate resuscitation. Some centers have found serum lactate to be a better predictor of mortality in severe burns; others have found that base deficit may be a better predictor of eventual organ dysfunction and mortality. Burned patients with normal blood pressures and serum lactate levels may still have compromised gastric mucosal blood flow. However, continuous measurement of gastric mucosal pH is logistically difficult and has not been widely implemented.

A third degree cirumferential burn in the arm and forearm region, which of the following is most important for monitoring – (U.P.P.GM.E.E. 04)
a)Blood gases
b)Carboxy-oxygen level
c)Macroglobiunria cryoglobinuria
d)Peripheral pulse and circulation

In 3″ degree burns, all are seen except –
a)Vesicles are absent (UPPGMEE 04)
b)Painful
c)Leathery skin
d)Reddish due to Hb infiltration

IV rules for burns – (MAHE 05)
a)% body surface area X weight in pounds X 4 = Volume in ml
b)% body surface area X weight in Kgs X 4 = Volume in Lts
c)% body surface area X weight in Kgs X 5 = Volume in ml
d)% body surface area X weight in Kgs X 4 = Volume in ml

Ans. is ‘d’ i.e., % body surface area X weight in Kgs [Ref : Bailey & Love 24th/e p. 272] X 4 = Volume in ml

A myriad of formulas exist for calculating fluid needs during burn resuscitation, suggesting that no one formula benefits all patients. The most commonly used formula, the Parkland or Baxter formula, consists of 3 to 4 mL/kg per percent burned of lactated Ringer’s, of which half is given during the first 8 hours postburn, and the remaining half over the subsequent 16 hours. The concept behind the continuous fluid needs are simple. The burn (and/or inhalation injury) drives an inflammatory response that leads to capillary leak; as the plasma leaks into the extravascular space, crystalloid administration maintains the intravascular volume. Therefore, if a patient receives a large fluid bolus in a prehospital setting or emergency department, that fluid has likely leaked into the interstitium and the patient will still require ongoing burn resuscitation, according to the estimates.

In a patient with the burn wound extending into the superficial epidermis without involving the dermis would present with all of the following EXCEPT –
a)Healing of the wound (SGPGI 05) spontaneously without scar formation
b)Anaesthesia at the site of burns
c)Blister formation
d)Painful

What is the most important aspect of management of burn injury in the first 24 hours ? (UPSC 07)
a) Fluid resuscitation b) Dressing
c) Escharotomy d) Antibiotics

The initial colonization of a burn is by which micro organisms – (JIPMER 80, UPSC 87)
a) Proteus b) Pseudomonas
c) Staphylococcus d) E. coli

Cardiac arrest, ECG changes occurs in – (UP 07)
a) Thermal burn b) Electrical burn
c) Cold burn d) Ionising radiation injury

Stress ulcers seen in burns are – (PGI 2000)
a) Curling’s ulcer b) Cushing’s ulcer
c) Meleney’s ulcer d) Rodent ulcer

‘Sterile needle test’ helps in differentiating –
a)Healing proces (JIPMER 81, AIIMS 86 )
b)Depth of burns
c)Degenerative proces
d)Infection

Which of the following is not true of Curling’s ulcer – (KA RNAT 96)
a)Seen in burned patients
b)Are solitary penetrating ulcer
c)Are shallow multiple erosions
d)Has also been described in children after head injury or craniotomy

An intern was doing saphenous cannulation for a burns pareint. Then the jpatient developed sudden onset of pain along the medial border of the correponding foot. Which nerve must have been accidentally ligated – (AIIMS 2K)
a) Sural nerve b) Deep peroneal nerve
c) Saphenous nerve d) Genicular nerve

Head & neck involvement in burns in infant is –
a) 9% b) 18% (PGI 2000)
c) 27% d) 32%

its 21%

An adult whose both lower limbs are charred along with genitalia has – – – -burns -(PGI 80, AIIMS 84)
a) 18% b) 19%
c) 36% d) 37%

Calculate the percentage of burns on the head, neck and face in a child of one year – (Al.. 88)
a) 10% b) 16%
c) 13% d) 15%…..NONE

Children have a relatively larger proportion of body surface area in their head and neck, which is compensated for by a relatively smaller surface area in the lower extremities. Infants have 21% of TBSA in the head and neck and 13% in each leg, which incrementally approaches the adult proportions with increasing age. The Berkow formula is used to accurately determine burn size in children

Sabiston                                                                                                       Schwartz                                                                                                               Love & Bailey

Schwartz has made the Rule of 9 depiction wrong by giving front and back of lower limb 18% each while its only 9% only.

Determination of burn size estimates the extent of injury. Burn size is generally assessed by the so-called rule of nines .In adults, each upper extremity and the head and neck are 9% of TBSA, the lower extremities and the anterior and posterior aspects of the trunk are 18% each, and the perineum and genitalia are assumed to be 1% of TBSA. Another method of estimating smaller burns is to consider the area of the open hand (including the palm and extended fingers) of the patient to be approximately 1% of TBSA and then transpose that measurement visually onto the wound for a determination of its size. This method is helpful when evaluating splash burns and other burns of mixed distribution.

Rule of Nines

Assessment of the burn area
An approximate clinical rule in wide use is the ‘rule of nines’ which acts as a rough guide to body surface area (Fig. 14.1). The examining doctor should assess the total area involved and how much of the area is partial thickness and how much full thickness. As a general rule, an adult with more than 20 per cent of the body surface involved or a child with more than 10 per cent of body surface area involved will require intravenous fluid replacement. However, an intravenous access line may be necessary for adequate analgesia for much smaller areas of burn and many children in particular will require fluid replacement because of vomiting. For smaller percentages than the above, it is necessary to maintain an adequate oral intake of fluid. The prognosis depends upon the percentage body surface area burned. A rough guide is that if the age and percentage add together to a score of 100 then the burn is likely to be fatal. A child may therefore survive a large burn, but even a small burn in an elderly patient is potentially fatal.
Intravenous access in a burnt child may be difficult. Both rectal and intraosseous infusion (into the upper third of the tibia) offer useful alternatives

Generalised diffuse peritonitis has been compared to second and third degree burns of- (AIMS 84)
a) 13% b) 30 %
c) 45% d) 60 %