BURNS

63. The intravenous fluid that a 60 kg., 30-year-old wo an with an !0" #urn should #e given in the first $% hours following #urn in&ury is' (. )*.$ liters of +" glu,ose in la,tated Ringer-s. B. )%.% liters of la,tated Ringer-s. .. *.6 liters of hy/ertoni, salt solution 0sodiu 4. 5.$ liters of +" al#u in solution. 1. +.+ liters of the /entafra,tion ,o /onent of hydro6yethyl star,h. (nswer' B ,on,entration $00 12. /er liter3.

47S.USS78N' The ,onsensus range for esti ating fluid needs of #urn /atients in the first $% hours is $ to % l. of a /hysiologi, ,rystalloid solution /er kilogra #ody weight /er /er,ent of #ody surfa,e #urned. 7n this /atient that would #e *.6 to )*.$ liters of la,tated Ringer-s solution. The early elevation of ,ir,ulating levels of ,ate,hola ines and glu,o,orti,oids following #urn in&ury indu,es gly,ogenolysis, whi,h results in elevated ,ir,ulating #lood glu,ose levels. 9lu,ose should not #e ad inistered in the resus,itation fluids, sin,e the resulting e6aggeration of hy/ergly,e ia ,ould indu,e os oti, diuresis. 7n the first $% hours ,olloid-,ontaining solution is not ,o only used, #ut if it is used even the 1vans for ula re,o ends only ) l. /er kg. #ody weight /er /er,ent of #ody surfa,e #urned. :oreover, /atients in one study who re,eived ,olloid-,ontaining fluids ,ontinued to gain weight during the first 3 /ostin&ury days, retained ore sodiu , and had less urine out/ut than /atients who re,eived only ,rystalloid fluids in the first $% hours. ;y/ertoni, salt solution is also not ,o only used for #urn /atient resus,itation #e,ause of the re,ently des,ri#ed and sur/risingly fre2uent o,,urren,e of a,ute renal failure and in,reased ortality asso,iated with its use. 7f hy/ertoni, salt is used, the a ount infused should #e less than * liters, to avoid e6,essive elevation of the seru sodiu ,on,entration 0i.e., a#ove )60 12. /er liter3. The re,o ended li it of hydro6yethyl star,h infusion is ,urrently )+00 l. /er day. (lthough a )0" /entastar,h for of hydro6yethyl star,h has #een used to e6/and the /las a volu e of #urn /atients at the end of the first $% hours, even as little as +00 l. of that solution has #een re/orted to /rolong #oth /rothro #in and /las a thro #o/lastin ti e.

6%. 7ndi,ations for es,haroto y of a ,ir,u ferentially #urned right lower li # in,lude all

of the following e6,e/t' (. <rogressively severe dee/ tissue /ain. B. .oolness of the un#urned skin of the toes of the right foot. .. ( /ressure of %0 . ;g in the anterior ,o /art ent of the distal right leg.

4. 1de a of the un#urned skin of the right foot. 1. (#sen,e of /ulsatile flow in the /osterior ti#ial artery. (nswer' B4

47S.USS78N' The #lood flow to distal and underlying un#urned tissue in a li # ,an #e ,o /ro ised #y vas,ular ,o /ression due to ede a for ation #eneath the unyielding es,har of a full-thi,kness ,ir,u ferential #urn. The ost relia#ly noninvasive eans of onitoring ade2ua,y of the ,ir,ulation in a ,ir,u ferentially #urned li # is serial e6a ination using the ultrasoni, flow eter. The a#sen,e or /rogressive di inution of /ulsatile flow in the /osterior ti#ial artery in the lower li # or the /al ar ar,h arteries in the u//er li # indi,ates a need for es,haroto y. 4elayed ,a/illary refilling, ,yanosis of the digits, and /rogressively severe /aresthesias, /arti,ularly dee/ tissue /ain, are all ,lini,al signs that ay indi,ate vas,ular ,o /ro ise and should #e onitored if an ultrasoni, flow eter is not availa#le. <ersistent dee/ tissue /ain and /rogressively severe /aresthesias are the ost relia#le of the nons/e,ifi, ,lini,al signs. ( us,le ,o /art ent /ressure that e6,eeds 30 . ;g, whi,h is greater than nor al ,a/illary /ressure, has also #een used as an indi,ation for es,haroto y in #urn /atients. 1de a and ,oolness to the tou,h of distal un#urned tissue ,o only a,,o /any ther al in&ury and are not useful in assessing the need for es,haroto y.

6+. =hi,h of the following is>are true a#out inhalation in&ury in #urn /atients? (. ( ,hest 6-ray o#tained within $% hours of in&ury is an a,,urate eans of diagnosis.

B. 7ts /resen,e ,hara,teristi,ally ne,essitates ad inistration of resus,itation fluids in e6,ess of esti ated volu e. .. =hen oderate or severe, it e6erts a ,o or#id effe,t that is related to #oth e6tent of #urn and the age of the /atient. 4. 7t in,reases the /revalen,e of #ron,ho/neu onia. 1. <ro/hyla,ti, high-fre2uen,y ventilation redu,es the o,,urren,e of /neu onia and the

ortality in #urn /atients with inhalation in&ury. (nswer' B.41

47S.USS78N' 16tensive infla atory ,hanges are evoked in the airway following the inhalation of s oke and other irritating /rodu,ts of in,o /lete ,o #ustion. .lini,al signs are nons/e,ifi, and ay #e delayed. .hest 6-rays are also unrelia#le in dete,ting even severe inhalation in&ury. .hest 6-rays taken within $% hours of in&ury were found to #e falsely negative in *$" of )06 /atients with inhalation in&ury. @i#ero/ti, #ron,hos,o/i, e6a ination is the ost relia#le single eans of diagnosing inhalation in&ury of the large airways, #ut in /atients who inhaled finely /arti,ulate s oke the large airways ay show little if any infla atory ,hange. The distan,e s oke /arti,les travel #efore de/osition in the airways is inversely related to /arti,le siAe. =hen the s oke /arti,le ass edian dia eter is less than 0.+ ., de/osition o,,urs in the ter inal #ron,hioles and alveoli. 7n su,h /atients, inhalation in&ury is #est identified #y /rolonged retention of 6enon )33 as assessed #y a ventilation /erfusion lung s,an. ;istori,ally, fluid restri,tion was re,o ended for /atients with inhalation in&ury, #ut in re,ent years it has #e,o e o#vious that su,h /atients ty/i,ally re2uire ore resus,itation fluid than the volu e esti ated #y ,o only used for ulas. 1de a of the s all airways and o,,lusion due to endo#ron,hial sloughing and ins/issation /redis/ose #urn /atients to develo/ /neu onia. 7n one study, %6" of #urn /atients with inhalation in&ury develo/ed /neu onia and 6*" of the /neu onias o,,urred in the first /ost#urn week. The ,o or#id effe,t of oderate to severe inhalation in&ury is related to #oth age and #urn siAe and in,reases ortality #y a a6i u of $0" a#ove that /redi,ted on the #asis of age and #urn siAe in /atients whose #urn in&ury alone would #e asso,iated with a 5+" likelihood of death. 7n /atients with only ild inhalation in&ury there is little if any in,rease in ortality a#ove that /redi,ted on the #asis of age and #urn siAe alone. <ro/hyla,ti, use of high-fre2uen,y /er,ussive ventilation ini iAes airway ,olla/se and atele,tati, ,hanges, as a ,onse2uen,e of whi,h the in,iden,e of /neu onia is redu,ed and survival is signifi,antly in,reased.

66. (de2ua,y of fluid resus,itation in #urn /atients is indi,ated #y whi,h of the following? (. Urine out/ut of %+ l. /er hr. in a 50-kg. 30-year-old ++" of the total #ody surfa,e. B. ;ourly urine out/ut of 5 the total #ody surfa,e. an with fla e #urns involving

l. in a 5-kg. )+- onth-old ,hild with #urns involving %0" of . ;g.

.. ( /ul onary ,a/illary wedge /ressure of )5 to $0

4. ;ourly out/ut of %0 l. of /ort wineB,olored urine in an !0-kg. high-voltage ele,tri, in&ury of the right ar and left leg. 1. ( urinary sodiu (nswer' (B. ,on,entration of % 12. /er liter.

ale who has severe

47S.USS78N' The goal of #urn /atient resus,itation is the aintenan,e of vital organ fun,tion at the least i ediate or delayed /hysiologi, ,ost. @luid resus,itation of #urn /atients does not need to #e a test of a6i u renal fun,tion. (de2ua,y of volu e re/la,e ent and of renal #lood flow are indi,ated #y an hourly urine out/ut of 30 to +0 l. in adults and ) l. /er kg. /er hr. in ,hildren weighing less than 30 kg. 7n /atients with e6tensive us,le da age ,aused #y high-voltage ele,tri, in&ury, heavy loads of he o,hro agens give the urine the a//earan,e of /ort wine. Su,h /atients are /rone to develo/ a,ute renal failure unless #risk urine out/ut is aintained until the /ig ent ,on,entration is redu,ed to insignifi,ant levels. @luid should #e infused into su,h /atients at the rate needed to a,hieve an hourly urine out/ut of 5+ to )00 l., #ut if the /atient does not res/ond to in,reased fluid in/ut with an in,rease in urine volu e and ,learing of the he e /ig ents, a diureti, should #e given. ( /ul onary ,a/illary wedge /ressure of )5 to $0 . ;g is indi,ative of an ade2uate ,ir,ulating #lood volu e, #ut a urinary sodiu ,on,entration of less than $0 12. /er liter is ,onsistent with an intravas,ular volu e defi,it.

65. .o on ele,trolyte ,hanges during and after resus,itation in a /atient with a #urn of 6+" of the total #ody surfa,e in,lude' (. ( seru sodiu fluid thera/y. ,on,entration of )$! 12. /er liter following %! hours of resus,itation

B. ( seru sodiu ,on,entration of )+$ 12. /er liter on the fifth /ost#urn day in a 5+kg. ale with a 5+" #urn who has re,eived only ,al,ulated aintenan,e fluids ea,h day following su,,essful resus,itation. .. ( seru /otassiu ,on,entration of +.5 12. /er liter as a ,onse2uen,e of the destru,tion of red ,ells and other tissues in a /atient with high-voltage ele,tri,al in&ury. 4. ;y/okale ia due to the kaliureti, effe,t of 0.+" silver nitrate soaks. 1. ;y/o,al,e ia with a low ioniAed ,al,iu level on the third /ost#urn day as a ,onse2uen,e of dilution and hy/oal#u ine ia. (nswer' (B.

47S.USS78N' (t the end of the first %! hours of resus,itation, when la,tated Ringer-s solution is used in the first $% hours and ,olloid-,ontaining fluid and ele,trolyte-free fluid in the se,ond $% hours, odest hy/onatre ia 0seru sodiu ,on,entration of )$! to )30 12. /er liter3 is ,o only o#served #ut re2uires no treat ent. The total #ody salt load is a,tually in,reased, and a//ro/riate fluid anage ent /er its the in,reased eva/orative water loss to ,orre,t that i #alan,e. The ost ,o on /ostresus,itation fluid and ele,trolyte distur#an,e is hy/ernatre ia asso,iated with dehydration due to inade2uate re/la,e ent of insensi#le water loss. The hourly insensi#le water loss, whi,h far e6,eeds aintenan,e fluid re2uire ents in unin&ured /atients, ,an #e ,al,ulated thus' 7nsensi#le water loss 0in area 0s2. .3 l.>hr.3C0$+ D " of #ody surfa,e #urned3 E total #ody surfa,e

The release of /otassiu fro red ,ells and other tissues in&ured #y the #urn or #y ele,tri,al ,urrent ,an ,ause usually odest hy/erkale ia. 7f a,idosis o,,urs, the hy/erkale ia ay #e e6aggerated to sy /to ati, levels that re2uire treat ent. ;y/okale ia ,an #e indu,ed following resus,itation #y the kaliureti, effe,t of sulfa ylon #urn ,rea , #ut the hy/okale ia asso,iated with 0.+" silver nitrate soak treat ent is due to transes,har lea,hing of /otassiu . ;y/o,al,e ia is fre2uently asso,iated with hy/oal#u ine ia as a ,onse2uen,e of he odilution #y the resus,itation fluid and the ,ytokine-indu,ed re/rogra ing of he/ati, /rotein synthesis. 7n su,h ,ases ioniAed ,al,iu levels are ,o only nor al.

6!. The ,lini,al and histologi, signs of invasive #urn wound infe,tion in,lude whi,h of the following? (. @o,al dark red or dark #rown dis,oloration of the es,har. B. 4elayed se/aration of the es,har. .. .onversion of an area of /artial-thi,kness #urn to full-thi,kness ne,rosis. 4. The /resen,e of i,ro-organis s in the un#urned su#,utaneous tissue in a #urn wound #io/sy s/e,i en. 1. <erineural and /erivas,ular i,ro#ial igration through the es,har with /roliferation of i,ro-organis s in the su#es,har s/a,e. (nswer' (.4

47S.USS78N' 7t is essential to e6a ine the entire #urn wound at the ti e of the daily ,leansing to identify invasive #urn wound infe,tion at the earliest /ossi#le ti e. The a//earan,e of fo,al areas of dark red or dark #rown dis,oloration are the ost ,o on ,hanges indi,ative of #urn wound infe,tion, #ut si ilar ,hanges ay #e ,aused #y he orrhage due to lo,al trau a or a,eration. (,,elerated se/aration of the es,har is often /rodu,ed #y #urn wound infe,tions, #ut delayed se/aration of the es,har is indi,ative of effe,tive ,ontrol of the i,ro#ial /o/ulation in the #urn wound. .onversion of an area of /artial-thi,kness #urn to full-thi,kness ne,rosis is the ost relia#le ,lini,al sign of invasive #urn wound infe,tion. 7dentifi,ation of su,h a ,hange andates histologi, e6a ination of a #urn wound #io/sy, whi,h is the only relia#le eans of differentiating the ,oloniAation of nonvia#le tissue fro the invasion of via#le tissue. 7dentifi,ation of i,ro-organis s in the un#urned via#le tissue of a #urn wound #io/sy ,onfir s the diagnosis of invasive #urn wound infe,tion. :i,ro#ial igration along the skin a//endages, ter inal nerve radi,les, and thro #osed ,a/illaries in the es,har and heavy growth of i,ro-organis s in the su#es,har s/a,e are anifestations of the ,oloniAation of nonvia#le tissue and re/resent the e,hanis s #y whi,h es,har se/aration o,,urs.

6*. The treat ent of invasive #urn wound infe,tion

ay in,lude whi,h of the following? /eni,illin sus/ended in

(. Su#es,har infusion of half the daily dose of a #road-s/e,tru ) liter of nor al saline. B. Use of 0.+" silver nitrate soaks for to/i,al thera/y. .. S/e,ifi, syste i, anti#ioti, thera/y. 4. 16,ision and i ediate autografting.

1. ( /utation when the infe,tion has e6tended to involve underlying (nswer' (.1

us,le.

47S.USS78N' The <seudo onas organis s that ost ,o only ,ause invasive #a,terial #urn wound infe,tion are ty/i,ally sensitive to high ,on,entrations of #roads/e,tru /eni,illins. =hen the diagnosis of invasive <seudo onas #urn wound infe,tion has #een ade, one half of the daily dose of a #road-s/e,tru /eni,illin, ty/i,ally /i/era,illin, sus/ended in ) liter of nor al saline, should #e infused into the su#es,har tissues #eneath the infe,ted wound. ( nu #er $0 s/inal needle should #e used for the infusion, to ini iAe the nu #er of in&e,tion sites. @ollowing a se,ond su#es,har infusion of the #road-s/e,tru /eni,illin &ust /rior to o/eration, the infe,ted tissue should

#e e6,ised. The e6,ised wounds should not #e autografted #ut ,overed with a #iologi, dressing or a dressing soaked with an anti i,ro#ial solution su,h as +" afenide a,etate. The /atient is returned to the o/erating roo in $% to %! hours to e6a ine the e6,ised wound and assess the ade2ua,y of the dF#ride ent. The fre2uen,y of /erily /hati, and /erivas,ular /roliferation of invading <seudo onas organis s is asso,iated with a risk of etastati, s/read to re ote organs or tissues. .onse2uently, syste i, anti i,ro#ial thera/y should #e instituted #ased on the sensitivity /atterns of the resident i,ro#ial flora and ad&usted as ne,essary on the #asis of the /atient-s ,ulture and sensitivity results. ( /utation is fre2uently ne,essary to ,ontrol invasive #urn wound infe,tion when a /hy,o y,oti, infe,tion on a li # has traversed the investing fas,ia and involves signifi,ant a ounts of the su#fas,ial tissue.

50. The treat ent of /atients with high-voltage ele,tri, in&ury differs fro with ,onventional ther al in&ury with res/e,t to the need for' (. @as,ioto y. B. ;e odialysis. .. ( /utation. 4. <ulse o6i etry. 1. <rehos/ital ,ardio/ul onary resus,itation. (nswer' (B.1

that of /atients

47S.USS78N' Both lightning in&ury and ,onta,t with ele,tri, ,urrent ,an indu,e ,ardio/ul onary arrest due to either asystole or fi#rillation. .ardio/ul onary resus,itation ust #e initiated at the site of in&ury if ,ardia, arrest is /resent. .ardia, arrhyth ias ay also o,,ur following resus,itation, ne,essitating ele,tro,ardiogra/hi, 01.93 onitoring for at least %! hours following in&ury in /atients with a history of loss of ,ons,iousness or an a#nor al 1.9. Tissue da age and tissue destru,tion #eneath the investing fas,ia ,an result in the for ation of ede a that in,reases us,le ,o /art ent /ressure to a level that ne,essitates fas,ioto y 0G 30 . ;g3. The ,urrent flow in a li # in ,onta,t with high-voltage ,urrent ,an #e so great as to da age even the /eriosseous us,les and ake a /utation ne,essary. Hi#eration of he o,hro ogens as a ,onse2uen,e of dee/ tissue in&ury is asso,iated with an in,reased in,iden,e of a,ute renal failure ne,essitating he odialysis. 1le,tri, in&ury does not influen,e the need for onitoring #y /ulse o6i etry, and in fa,t the destru,tion of dee/ tissue in a li # ay /re,lude a//li,ation of the /ulse o6i eter to that e6tre ity.

5). Thera/euti, interventions needed for s/e,ifi, ,he i,al agents in,lude whi,h of the following? (. <rolonged saline irrigation of eyes in&ured #y ,on,entrated sodiu s,leral lens with an irrigating sidear . B. (d inistration of an e eti, agent as i .. 7ntra-arterial infusion of ,al,iu to hydrofluori, a,id in&ury. hydro6ide using a

ediate treat ent following lye ingestion.

glu,onate for relief of refra,tory dee/ tissue /ain due

4. Use of /ro/ylene gly,ol to re ove residual /henol following water lavage. 1. (//li,ation of +" ,o//er sulfate solution soaks to areas of e #edded /arti,les of white /hos/horus. (nswer' (.4

47S.USS78N' (n eye in&ured #y a strong ,he i,al agent ust #e irrigated i ediately at the site of the a,,ident to ini iAe ,orneal da age. <rolonged irrigation for )$ to 5$ hours is re,o ended for eyes in&ured #y a strong alkali solution. 7rrigation is diffi,ult #e,ause of #le/haros/as unless a odified s,leral ,onta,t lens with an irrigating sidear is used. 1 eti,s should #e avoided in the early treat ent of /atients following ,he i,al ingestion sin,e additional in&ury of the eso/hagus, oro/haryn6, and u//er airway ay #e ,aused as the ,he i,al is regurgitated. The intra-arterial infusion of ,al,iu glu,onate has #een re/orted to li it tissue da age and relieve /ain, #ut lo,al e6,ision of the involved tissue ay #e ne,essary for definitive ,ontrol of /ain and re oval of the in&ured tissue. 1ven though /henol is only slightly solu#le in water, initial water lavage of #urns ,aused #y /henol should #e ,arried out. @ollowing that initial lavage, the involved area should #e washed with a li/o/hili, solvent su,h as /olyethylene gly,ol, /ro/ylene gly,ol, or gly,erol to re ove the residual /henol. ( dilute 0.+" to )" solution of ,o//er sulfate ,an #e used as a wash to fa,ilitate identifi,ation and i /ede the ignition of e #edded /hos/horus /arti,les. 7f e6,essive a ounts of ,o//er sulfate are a#sor#ed through the in&ured tissues, intravas,ular he olysis ,an o,,ur and ay ,ause renal failure. .onse2uently, one should avoid the use of ore ,on,entrated solutions of ,o//er sulfate and should never a//ly the ,o//er sulfate solution as a soak. The i /ortant /rin,i/le of treat ent is to /revent ignition of the /arti,les #y /reventing their e6/osure to air, and that ,an #e done ost safely #y a//lying an o,,lusive dressing soaked with saline or water.

5$. .hara,teristi,s of the hy/er eta#oli, res/onse to #urn in&ury in,lude' (. 1levation of ,ore te /erature, skin te /erature, and ,ore-to-skin heat transfer. B. ( #ient te /erature de/enden,y of .. ( eta#oli, rate.

arked in,rease of #lood flow to the #urn wound.

4. ( ,urvilinear relationshi/ to the e6tent of #urn. 1. 86idation of stored li/id as the (nswer' (.1 a&or sour,e of eta#oli, energy.

47S.USS78N' (t ther al neutral and higher te /eratures, the ,ore te /erature, skin te /erature, and ,ore-to-skin heat transfer in #urn /atients re ain elevated, #ut eta#oli, rate ,an #e di inished in /atients with #urns of ore than +0" of the #ody surfa,e #y aintaining the a #ient te /erature a#ove 30 C. Blocking evaporative water loss by application of an impermeable membrane is not attended by a consistent diminution in metabolic rate, indicating that the burn patient is not externally cold but is internally warm. The hypermetabolism in burn patients is temperature sensitive but not temperature dependent. Even though earlier measurements described a curvilinear relationship between metabolic rate and extent of burn, recent measurements have shown that metabolic rate increases in linear fashion and rises to levels of twice normal in patients with burns of 7 ! and more of the total body surface. "ipid stores are the ma#or source of metabolic fuel that is oxidi$ed for energy, and not lean body mass, which undergoes proteolysis to provide the amino acids necessary for protein synthesis and wound healing as well as gluconeogenic processes that provide fuel for tissues re%uiring glucose. Blood flow to a burned limb is markedly increased as compared with flow in an unburned limb of the same patient, and the flow increase is directed to the wound per se, not the underlying muscles.

7&. ' &()year)old mountain climber who struck his head in a fall lay in the snow overnight before he could be rescued and brought to the hospital. *pon admission he is semicomatose and not shivering, with a pulse rate of +, beats per minute and a blood pressure of ,-. - mm. /g. /is rectal temperature as measured by a standard thermometer is reported as &+ C. 'll the digits on both feet appear to be fro$en.

Treatment for this patient should include0 '. 'dministration of inotropic and chronotropic vasoactive agents. B. 1ntra)arterial infusion of vasodilating agents. C. 1nfusion of lactated 2inger3s solution warmed to +- C. 4. 1mmersion in a circulating water bath heated to +- C. E. Excision of damaged tissue within +, hours after thawing. 'nswer0 C4

415C*551670 ' standard clinical thermometer will not measure body temperatures below &+ C. This patient3s clinical condition8depressed mental status, bradycardia, and hypotension8indicates that the patient is likely suffering from severe hypothermia and, so, re%uires prompt active rewarming by immersion in a water bath at +- C. or the use of partial cardiopulmonary bypass, if available, and the administration of resuscitation fluid warmed to +- C. 9asoactive agents do not treat the basic pathology in hypothermic patients and are typically ineffective. 9asodilating agents will be of little if any value in the treatment of the fro$en tissue in the feet since histologic studies have indicated that the vasculature in free$e)in#ured tissue is dilated, not constricted. 5ince assessment of tissue viability immediately after thawing is difficult and often erroneous, one should await clear demarcation of dead tissue before undertaking surgical excision of damaged tissue.

7+. 9alid points in the management of burns on special areas include0

a. The large ma#ority of genital burns are best managed by immediate excision and autografting b. 'll digits with deep dermal and full)thickness burns should be immobili$ed with six weeks of axial :irschner wire fixation c. 4eep thermal burns of the central face are best managed with immediate excision and autografting d. Burns of the external ear are commonly complicated by acute suppurative chondritis if

topical mafenide acetate is not applied 'nswer0 d

Because of the thickness and deep appendages of the skin of the central face, relatively deep burns of these areas fre%uently heal. This is fortunate, because it is difficult to achieve a favorable result with primary excision and grafting of the central face. ;anagement of the burned hand is dictated by the depth of in#ury. 5uperficial burns are managed with elevation, topical antimicrobials, and full passive range of motion for each #oint twice daily. 4eep, partial and full)thickness in#uries are best managed by excision and sheet grafting as soon as practical. /ands are immobili$ed in a functional position for seven days after surgery before passive and active therapy is resumed. <ourth degree hand burns, which involve the underlying extensor mechanism, #oint capsules or bone are significantly more difficult management problems and are managed by staged sheet autografting and often benefit from temporary axial :irschner wire fixation of open and unstable interphalangeal or metacarpophalangeal #oints. Burns of the external ear are treated with twice daily cleansing and application of mafenide acetate. 4eep burns of the external ear are commonly complicated by acute suppurative chondritis if topical mafenide acetate is not applied. 1n general, the practice for deep genital burns is to manage these limited surface area in#uries with topical therapy for a period of two to three weeks unless the wounds are remarkably deep. *nhealed in#uries are debrided and grafted with sheet autograft at this time, with generally excellent cosmetic and functional results.

7 . The hypermetabolic response seen in patients with large burns, who are successfully resuscitated, is thought to be driven by which of the following factors=

a. 4eficient gastrointestinal barrier function b. Bacterial contamination of the burn wound c. Evaporative heat loss d. Changes in hypothalamic function 'nswer0 a, b, c, d

The physiologic challenge of a burn in excess of (-! of the body surface fre%uently

results in an initial decrease in cardiac output and metabolic rate. 5ubse%uently, effected by a complex cascade of mediators, a hypermetabolic response is seen with a near doubling of cardiac output and resting energy expenditure over the next (+ to +, hours in those who are successfully resuscitated. The magnitude of this response peaks in those with in#uries of >-! or more of the body surface at as high as twice the normal basal metabolic rate. The etiology of the hypermetabolic response is not entirely understood but is assumed to involve a combination of factors including a change in hypothalamic function with coincident increases in glucagon, cortisol and catecholamine secretion, deficient gastrointestinal barrier function with translocation of bacteria and their byproducts, bacterial contamination of the burn wound with systemic release of similar products from this source, and some element of enhanced heat loss via transeschar evaporation of fluid. 'n important element of successful management of patients who have sustained large in#uries is support of this response through the provision of ade%uate %uantity and %uality of substrate.

7>. ?hich of the following statement@sA is.are true concerning inhalation in#ury=

a. The physiology of these in#uries include upper airway obstruction secondary to progressive edema, reactive bronchospasm from aerosoli$ed irritants, and microatelectasis from loss of surfactant and alveolar edema b. Endotracheal intubation is indicated immediately in all patients with suspected inhalation in#ury c. 4istal airway in#uries are usually caused by heat in#ury d. Beak inspiratory pressures of C +- cm of water are indicated to maintain functional residual capacity 'nswer0 a

The pathophysiology of inhalation in#ury is complex and varies with the aerosoli$ed toxins particular to the circumstances of individual in#uries. /owever, these in#uries routinely demonstrate the following0 DA upper airway obstruction secondary to progressive edemaE (A reactive bronchospasm from aerosoli$ed irritantsE &A small airway occlusion initially from edema and subse%uently from sloughed endotracheal debris and loss of ciliary clearance mechanismsE +A microatelectasis from the loss of surfactant and alveolar edemaE and A interstitial and alveolar edema secondary to loss of capillary integrity. The physiologic conse%uences of these aberrations are upper and lower airway

obstruction, increased airway resistance, decreased compliance, and an increase in the dead space to tidal volume ratio and intrapulmonary shunting. *pper airway obstruction is best managed with prompt endotracheal intubation which is maintained for +, to 7( hours and elevation the head. 1n e%uivocal cases, bronchoscopy is performed and patients with significant airway edema are intubated using the bronchoscope as a stylet. 'lthough severe steam inhalation can result in direct heat in#ury to the distal tracheobronchial tree, more distal airway in#uries are usually caused by aerosoli$ed toxins rather than thermal in#ury, as the upper airway is a highly effective heat sink. 'lthough moderate inflating pressures will help expand recruitable segments, peak inspiratory pressures in excess of +- cm /(6 should be avoided because they are associated with both overt barotrauma as well as more subtle overpressure in#uries to the pulmonary microvasculature and alveoli which themselves exacerbate respiratory failure. /igh inflating pressures are also ineffective in recruiting additional lung, because the compliance decrements are not homogeneous and high pressures simply over distended more compliant segments.

77. ?hich of the following statement@sA is.are true concerning the initial fluid resuscitation of a burn patient=

a. 2igid adherence to the ;odified Brooke formula is advised b. 1n general, children re%uire less fluid than that predicted by standard formulae c. Batients with inhalation in#uries re%uire less fluid than predicted by standard formulae d. 4extrose should not be given as the primary resuscitative fluid for any age group e. ;ost resuscitative formulae withhold colloid solutions until (+ hours post)in#ury 'nswer0 e

The large number of fluid resuscitation formulae in common use is attributed to the fact that no formula accurately predicts fluid re%uirements in every patient. 7o formula can replace a physician at the bedside repeatedly evaluating the patientFs physiology through the resuscitative period. ' reasonable consensus formula is the ;odified Brooke formula, however, regardless of the formula chosen to initiate resuscitation, subse%uent fluid administration is best guided by regular assessment of the resuscitation end points, rather than prediction of any formula. 9asoactive mediators released from the in#ured tissue result in diffuse capillary leaks seen shortly after ma#or burn in#ury with resulting

extravasation of both crystalloid and colloid for the first D, to (+ hours after burn. The pathophysiology explains the enormous volume re%uirements seen in such patients and is the reason that most resuscitative formulae withhold colloid until (+ hours post)in#ury. Children have been found to commonly re%uire fluid in excess of that predicted by several formulae. These re%uirements are generated if one uses a urine output of DG( cc.kg.hour as a resuscitation end point. These needs are real in infants and very young children whose renal concentrating abilities are not completely mature. /owever, in toddlers and older children whose concentrating abilities are more mature, targeting urine flow of -. GD cc.kg.hour results in overall fluid re%uirements closer to that of an adult and less overall edema. Batients with inhalation in#ury have demonstrated to have overall volume re%uirements greater than that predicted by standard formulae, possibly secondary to release of vasoactive mediators from in#ured burned parenchyma. 4uring the first (+ hours, 2ingerFs lactate is the primary resuscitative fluid. Because children less than D- kg can develop hypoglycemia if glucose is not administered, 2ingerFs lactate or half normal saline with ! dextrose at a maintenance rate is given along with the reduced amount of 2ingerFs lactate. 4extrose containing fluids should not be given as a primary resuscitative fluid in adults, as hyperglycemia and osmotic diuresis will result.

7,. ?hich of the following statement@sA is.are true concerning techni%ues of burn excision, and temporary and definitive wound closure=

a. Techni%ues to conserve blood include subeschar in#ection of dilute epinephrine solution, exsanguination of the extremity and inflation of a pneumatic tourni%uet b. <resh or cryopreserved human allograft is usually re#ected within ( to + weeks c. ' common use for human allograft is as a physiologic cover for selected clean superficial wounds as they epitheliali$e d. ' donor site can only serve as a single source for autograft 'nswer0 a, b

' common argument against the policy of early burn wound excision is the prodigious blood loss which has been associated with these procedures. /owever, modern blood conserving practices as well as earlier excision of wounds have diminished this concern. Tangential excision of the torso, neck and head are done after subeschar in#ection of dilute epinephrine solutions. Tangential excisions of the extremities are done after

exsanguination and inflation of a pneumatic tourni%uet. 6nce necrotic eschar is excised to a bed of viable tissue, immediate biologic closure is mandatory. 1deally, immediate autografting is performed. ?hen donor sites are insufficient for this purpose, a temporary biologic cover must be chosen while awaiting healing of donor sites for further use. 5uch covers should prevent desiccation and provide a vapor and bacterial barrier over the excised wound. <resh or cryopreserved human allograft is most appropriate for this use. 6nce placed on a viable wound bed, it will vasculari$e and provide physiologic wound closure until re#ected ( to + weeks later at which time or before, it is replaced with reharvested autograft. ' second common use for biologic dressings is a physiologic cover for selected clean superficial wounds as they epitheliali$e, which minimi$es the pain associated with open partial thickness burns. 'llograft, screened for malignant and infectious diseases, a precarious resource, is however, not commonly used as a biologic dressing in these circumstances. <or this purpose, reconstituted porcine xenograft should be used.

7H. ?hich of the following statement@sA is.are true concerning topical antimicrobials in common use in the *nited 5tates today=

a. 6f the common topical antimicrobials, only mafenide acetate is painful upon application b. The use of -. ! silver nitrate is associated with trans)eschar leeching of sodium and potassium from the wound c. 5ilver sulfadia$ine has the best eschar penetration d. 5ilver sulfadia$ine, mafenide acetate, and -. ! silver nitrate all have a broad spectrum activity, however, only silver nitrate has anti)fungal activity 'nswer0 a, b, d T/2EE C6;;67 T6B1C'" ;E41C'T1675 *5E4 17 T/E *71TE4 5T'TE5

'gent Characteristics 5ilver sulfadia$ine Bainless on application <air to poor eschar penetration 7o metabolic side effects

Broad antibacterial spectrum ;afenide acetate Bainful on application Excellent eschar penetration Carbonic anhydrase inhibitor Broad)spectrum antibacterial -. ! 5ilver nitrate Bainless on application Boor eschar penetration "eeches electrolytes Broad)spectrum antibacterial and antifungal

,-. The anthropometric changes observed as a patient progresses from infancy to adulthood include which of the following statement@sA=

a. The ma#or anthropometric changes involve the head and torso b. ' decrease in the relative si$e of the head from D,! to H! of the bodyFs surface area occurs c. The total surface area of the legs increases from D+ to D,! d. The upper extremities increase to D(! of the body surface area 'nswer0 b, c

'n accurate assessment of burn si$e can be made early and is important to the initial management as resuscitative fluid administration is primarily determined by overall burn si$e. Burn si$e in children is best estimated with an age)specific chart, because the childFs body proportions change with growth. The ma#or anthropometric change involves the head and legs. The infantFs head represents D,! of the total body surface and legs D+!. 1n older adolescents and adults, the head represents H! of the body surface and the legs D,!. Each upper extremity in the adult is usually considered to represent H! of the total body surface area.

,D. 'rguments in favor of early wound excision include which of the following statement@sA=

a. Enhanced survival is seen in patients with large burn in#uries b. /ospital stays can be shortened with this techni%ue c. Early burn excision results in fewer painful dressing changes d. ' decrease in duration and intensity of the hypermetabolic response is observed 'nswer0 a, b, c, d

Early removal of extensive areas of devitali$ed tissue with immediate biologic closure of the resulting wounds is the core surgical ob#ective of the first burn week. The policy of early excision is now widely practiced in the *nited 5tates and is carried out as an excision of the entire wound coincident with fluid resuscitation, or more commonly, by staged excision of all deep partial and full thickness components of the wound @less the face, palms, soles, and genitalsA over the first three to seven days after in#ury. The increasing popularity of early excision is based upon several documented and perceived advantages over the traditional approach of allowing eschar to be li%uefied by bacterial proteases until separation occurs, leaving a bed of granulation tissue which is subse%uently autografted. 4ocumented advantages include improved survival in patients with in#uries involving more than &-G+-! of the body surface, truncated hospital stays, lowered cost, and fewer painful dressing changes. 'lthough not proven, conventional wisdom suggests that a decrease in the duration and intensity of the hypermetabolic response, improved immunologic function and less hypertrophic scarring result from early excision.

,(. ?hich of the following are accepted ad#uncts in the management of hypertrophic scar=

a. "ocal steroid in#ection b. Compression garments c. Topical silicone

d. 2elease or excision with autografting e. Topical platelet)derived growth factor 'nswer0 a, b, c, d

/ypertrophic scar formation is a ma#or source of long)term morbidity after burns. 'll healed and grafted burns become hypervascular shortly after successful epitheliali$ation. ?ounds destined to become hypertrophic develop a second surge of neovasculari$ation between H and D& weeks. ?ounds that are most commonly associated with hypertrophy are deep dermal burns that heal in three or more weeks and full thickness wounds that heal by contraction and epithelial spread from wound edges. Current tools used in the prevention of hypertrophic scars include compression garments, topical silicone sheets, steroid in#ections, and release or excision and autografting.

,&. ?hich of the following statement@sA is.are true concerning carbon monoxide and cyanide exposure=

a. ' normal oxygen saturation by standard transmission pulse oximetry precludes the possibility of significant carboxyhemoglobinemia b. ;ost patients with cyanide exposure re%uire administration of sodium thiosulfate c. The half)life of carbon monoxide is reduced by a factor of oxygen with ventilation with D--!

d. Even if fire victims are well ventilated with high concentrations of oxygen by emergency response personnel from the time of extrication, carboxyhemoglobin values are fre%uently greater than D-! on initial evaluation 'nswer0 c

Both carbon monoxide and cyanide are commonly inhaled by victims of closed space fires. Batients with significant amounts of carboxyhemoglobin suffer from a marked reduction in their ability to deliver oxygen to peripheral tissues despite a normal arterial partial pressure of oxygen. 1ts (. hour half)life is reduced by a factor of by ventilation with D--! oxygen. <ire victims who are well ventilated with high concentrations of oxygen by emergency response personnel from the time of extrication commonly have

normal carboxyhemoglobin values @I !A on initial evaluation despite significant exposure to carbon monoxide at the time of in#ury. Carboxyhemoglobin is not sensed by standard transmission pulse oximetry, so a normal oxygen saturation on such a monitor does not preclude the possibility of significant carboxy)hemoglobinemia. /ydrogen cyanide, which is commonly present in the smoke of structural fires, interferes with oxidative metabolism at the cellular level resulting in lactic acidosis. ?ith proper ventilation and fluid resuscitation, the cyanide)induced acidosis corrects in most cases and specific treatment with sodium thiosulfate is not generally re%uired.

,+. 9alid points concerning the initial physical examination in a burn patient include which of the following statement@sA=

a. Batients should be examined in a warm environment to prevent hypothermia b. 'll corneal in#uries are obvious on initial physical examination c. 1nhalation in#ury is suggested by the presence of singed facial hair and nasal vibrissae, carbonaceous sputum, and a hoarse voice d. Blistering in or around the mouth may suggest hot li%uid aspiration in small children 'nswer0 a, c, d

'n organi$ed approach to serious burn in#uries facilitates achieving the optimal outcome and begins with a systematic initial evaluation that includes a primary survey, effective vascular and airway access, and a systematic secondary survey. ;any burn patients have sustained concurrent in#uries and the initial evaluation should therefore be approached as any multiple trauma patient. 'fter evaluating and securing the airway, while maintaining control of the cervical spine, breathing mechanics are assessed, a rough estimate is made of circulating volume, the level of consciousness is documented, and the patient is completely exposed. This should be done in a warm environment to avoid hypothermia. The burn specific secondary survey includes a complete history, vital signs, a detailed physical examination and laboratory and radiologic studies appropriate for the mechanism of in#ury. The patientFs neurologic status should be carefully documented early during the evaluation, because many patients will become progressively obtunded secondary to the administration of analgesics and sedatives and from intravascular volume depletion. The corneal epithelium and globes should be examined prior to the development of adnexal edema which will render ade%uate examination more difficult. ;a#or corneal epithelial burns are obvious by the opa%ue

appearance that results. ;ore subtle defects are apparent only after staining with topical fluorescein. *pper airway in#uries are suspected by the presence of a hoarse voice, burns to the lips or tongue, singed facial hair and nasal vibrissae, or carbonaceous sputum. /ot li%uid aspiration may complicate facial scald burns with small children, and should be suspected if there is blistering in or around the mouth.

, . The systemic response to a significant burn includes accelerated fluid losses. ?hich of the following statement@sA is.are true concerning tissue edema following a burn=

a. Edema in tissue immediately surrounding the burn is secondary to local disruption of the capillary bed b. Edema in tissue immediately surrounding the burn is secondary to the local release of vasoactive mediators such as prostaglandins, thromboxane '(, and reactive oxygen radicals c. Tissue edema following a burn occurs only in the tissues at or immediately ad#acent to the burn d. Bulmonary changes following a burn occur only secondary to excessive fluid administration 'nswer0 b

The systemic response to burning is driven by the loss of the skinFs barrier functions with accelerated fluid losses and decreased host resistance to infection, release of mediators from the in#ured tissue with secondary interstitial edema and organ dysfunction and from bacterial overgrowth within the eschar with the resulting systemic se%uelae. Edema in tissue immediately surrounding the burn occurs secondary to local release of vasoactive mediators, such as prostaglandins, thromboxane '( and reactive oxygen radicals. ?hen burn si$e exceeds (-! to &-! of the body surface, clinically significant interstitial edema is seen in distant soft tissue secondary to a combination of wound released mediators and hypoproteinemia. These distant microvascular effects also have the ability to interfere with the function of organ systems not directly in#ured by the burning process, explaining the fre%uent occurrence of pulmonary and other organ dysfunction in patients with large burns.

,>. ' patient sustains a high voltage electrical in#ury to the upper extremity. ?hich of the following statement@sA is.are true concerning peripheral perfusion to the in#ured arm=

a. Evidence of peripheral ischemia would be evident within the first few hours after in#ury b. Bhysical signs of diminished blood flow include a progressive increase in the extremityFs consistency and a decrease in distal temperature c. ' bedside escharotomy is an appropriate treatment d. 'n immediate fasciotomy performed in the operating room may be necessary 'nswer0 b, d

2egular assessment and documentation of peripheral perfusion is crucial during the first post)in#ury days. Blood flow can be compromised by constricting circumferential eschar as subeschar tissues become progressively edematous or by progressive intracompartmental edema in patients with electrical or deep thermal burns. Both are detected by the development of a progressive increase in the extremityFs consistency and a decrease in its distal temperature. Bulsatile doppler signals in the lower pressure distal vasculature, such as the plantar arch and digital vessels, should be documented hourly. The loss of pulsatile doppler signals is consistent with an increase in tissue pressure if intravascular volume is ade%uate. 'lthough lesser voltages may cause local destructive in#uries without systemic se%uelae, patients exposed to higher voltage @C D--- voltsA, present with a combination of deep tissue in#uries secondary to the passage of current, locally destructive entrance and exit wounds, and other local and systemic effects. Compartmental pressure elevation, secondary to edema of in#ured muscle, can result in additional ischemic in#ury if compartments are not promptly released by fasciotomy. JJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJ

47@@7.UHT (7R=(I

(nesthesia :.JK<art 0) $ ,o ents Ha#els' (N1ST;1S7(

).=hi,h of the following is a ,ontraindi,ation for using a laryngeal

ask airway ?

a3 when inhalational anaesthesia is re2uired #3 large o#stru,tive lesion in the oro/haryn6 ,3 :aintaining airway during diffi,ult intu#ation d3 1 ergen,y anage ent of airway in failed intu#ation

e3 #ron,hos,o/y in the awake /atient

$.7n a lower Seg ent .aesarean Se,tion whi,h of the following te,hni2ues of anesthesia is least desira#le ? a3 S/inal anesthesia #3 .audal anesthesia ,3 .o #ined S/inal 1/idural anesthesia d3 e/idural anesthesia e3 9eneral anesthesia

3.=hi,h of the following is likely to 41.R1(S1 the an anestheti, ? a3 ;y/erther ia #3 ;y/ernatrae ia ,3 BenAodiaAe/ines d3 ;y/er,a/nia e3 Thyroto6i,osis

ini u

alveolar ,on,entration of

1L<H(N(T78NS

.ontra,t (ll M 16/and (ll

:.J 0) (NS=1R The .orre,t (nswer is B The Haryngeal :ask (irway is an alternative airway devi,e used for anesthesia and airway su//ort. 7t ,onsists of an inflata#le sili,one ask and ru##er ,onne,ting tu#e. 7t is inserted #lindly into the /haryn6, for ing a low-/ressure seal around the laryngeal inlet and /er itting gentle /ositive /ressure ventilation. The Haryngeal :ask (irway is an a//ro/riate airway ,hoi,e when #e used #ut endotra,heal intu#ation is not ne,essary. ask ventilation ,an

.ontraindi,ations' Non-fasted /atients :or#idly o#ese /atients 8#stru,tive or a#nor al lesions of the oro/haryn6

7t ay #e used as a res,ue airway and fi#ero/ti, ,onduit when intu#ation is diffi,ult, haAardous or unsu,,essful. (nd it ,an #e used for #ron,hos,o/y in the awake or aslee/ /atient.

:.J 0$ (NS=1R The .orre,t (nswer is B .audal anaesthesia is un/o/ular #e,ause of the risk of introdu,ing needle /assing through the other-s sa,ru and re,tu and into fetal /resenting /arts.

:.J 03 (NS=1R The .orre,t (nswer is . The ini u alveolar ,on,entration 0:(.3 is the ,on,entration of anestheti, at ) at os/here of /ressure that /rodu,es i o#ility in +0" of /atients e6/osed to a no6ious sti ulus.7t is inversely related to /oten,y.

@a,tors =hi,h (ffe,t :(.

7n,rease :(. ;y/erther ia ;y/ernatrae ia Sy /athoadrenal sti ulation .hroni, al,ohol a#use 7n,reases in a #ient /ressure ;y/er,a/nia 4e,reasing age Thyroto6i,osis

4e,rease :(. Nitrous o6ide ;y/othyroid> y6oede a ;y/o,a/nia ;y/other ia-de,rease is roughly linear ;y/onatrae ia 7n,reasing age ;y/o6ae ia ;y/otension (nae ia

<regnan,y .NS de/ressant drugs - o/ioids, #enAodiaAe/ines, a&or tran2uiliAers, T.(-s agnesiu , ethyl do/a, ,lonidine

8ther drugs - lithiu , lido,aine, (,ute al,ohol a#use