Surgery - Derm (CMPP)

At what total body surface area does burn shock occur

>20%

Burn shock

significant metabolic changes occur, resulting in loss of intravascular volume, resulting in hemoconcentration

What are possible complications of fluid resuscitation of burns

Cerebral edema

Compartment syndrome

Pulmonary edema

1st Degree Burns

Affects the outer layer of skin (epidermis)

Skin looks red, dry, and painful with no blisters

2nd Degree Burns

Involves the epidermis and part of the dermis

Symptoms include intense pain, redness, swelling, and fluid-filled blisters

3rd Degree Burns

Destroys both the epidermis and dermis, reaching the fat layer underneath

The burn area looks white, leathery, brown, or charred and often causes little to no pain due to destroyed nerve endings

4th Degree Burns

Deepest burn destroying all skin layers and extending deep into underlying fascia, muscles, tendons, or bone.

Surface appears dry, blackened, charred and it painless

What is involved in the surgical evaluation and treatment of burns

Systematic wound assessment,

Early excision of dead tissue, and

Definitive wound closure using skin grafts or flaps

What is considered “early excision” for dead tissue from burns

2 days

Rule of 9s

A quick way to assess TBSA of a burn on an adult patient

• Head = 9%

• Left Arm = 9%

• Right Arm = 9%

• Chest = 9%

• Abdomen = 9%

• Upper Back = 9%

• Lower Back = 9%

• Anterior Left Leg = 9%

• Posterior Left Leg = 9%

• Anterior Right Leg = 9 %

• Posterior Right Leg = 9%

• Groin = 1%

Palmar Method

A burn estimation technique that considers the palm of the patient’s hand to be 1% of their TBSA

How is Rule of 9s modified for infants

Head → 9% to 18%

Legs → 18% for one leg to 14%

What fluid is used for burn fluid resuscitation

Lactated Ringer’s (LR) solution

Parkland Forumla

A calculation for the fluids for burns

Volume of Solution (LR) for 24 hrs = 4 mL x TBSA of burn (%) x weight (kg)

First half of the volume is given in 8 hours, then second half is given in 16 hours

Cleveland Clinic Burn Guide

A guide to assessing the TBSA of a burn

what secondary injuries should be checked for in burn patients

airway compromise,

carbon monoxide poisoning,

associated traumatic injuries requiring priority stabilization

tight, circumferential burns that restrict blood flow

What procedures can be performed for burns

Escharotomy/Fasciotomy:

Early Excision

Autografting and Closures:

Contracture Release:

Escharotomy

Make emergency incisions through tight, burned skin (eschar) to relieve compartment syndrome and restore perfusion

Autografting and Closures

Apply split-thickness skin grafts or temporary biological/synthetic dressings to close the wound bed and promote healing

Contracture Release

Perform later reconstructive procedures to release tight scar bands and recover functional range of motion

Cellulitis

Skin becomes infected with a bacterial pathogen

Presenation of Cellulitis

pain,

redness,

erythema of the affected skin

What pathogens typically responsible for cellulitis

Staphylococcus aureus,

Streptococcus pyogenes,

MRSA,

Pasteurella multocida

Patients with cellulitis also need to be assessed for

necrotizing soft tissue infections (NSTAs)

What are typical indicators to treat cellulitis inpatient

Fever

Leukocytosis

Outpatient Treatment for Cellulitis

Cephalexin or Augmentin x 5-10 days (up tp 14)

PCN Allergy → Clindamycin

MRSA Suspect → TMP-SMX or Doxycycline

Inpatient Treatment for Cellulitis

IV Cefazolin, Ceftriaxone, or Clindamycin x 5-10 days (up tp 14)

MRSA → IV Vancomycin or Clindamycin

Treatment for Cutaneous Abscess

Incision and drainage

Consider Abx

When should Abx be given after an I&D

immunocompromised,

DM,

fever,

tachycardia,

large abscess (over 2cm)

high-risk location (face, groin, perianal)

What condition is often called “flesh-eating bacteria”

Necrotizing soft tissue infections (NSTI)

Necrotizing soft tissue infections (NSTI)

Rapidly progressing, life-threatening bacterial infections that cause widespread destruction of the skin, subcutaneous fat, and deep fascia

Red Flags for Necrotizing soft tissue infections (NSTI)

Pain out of proportion

Redness, swelling, and warmth that spread visibly over the course of hours as compared to days

Development of a dusky, purplish, or bluish skin color, accompanied by bulla or areas of black skin necrosis

Cracking or popping sensation felt under the skin, caused by gas produced by invading bacteria

High fever,

tachycardia,

severe chills,

confusion,

hypotension (septic shock)

What are the types of NSTIs

Type I (Polymicrobial):

Type II (Monomicrobial):

Type III:

Anatomical Variants:

Most Common Type of Necrotizing soft tissue infections

Type 1

Cause of Type I Necrotizing soft tissue infections

a mix of aerobic and anaerobic bacteria but usually involves C. perfringens

Who typically gets Type I Necrotizing soft tissue infections

Olders Adults

DM

CKD

Obese

Cause of Type II Necrotizing soft tissue infections

by a single organism, most famously Group A Streptococcus or Staphylococcus aureus

Who is more at risk for Type II Necrotizing soft tissue infections

Trauma

Surgery

IVDA

Cause of Type III Necrotizing soft tissue infections

specific marine bacteria, most notably Vibrio vulnificus.

How are Type III Necrotizing soft tissue infections acquired

exposure of an open wound to warm, coastal seawater

handling raw or eating contaminated shellfish

What some anatomical variant necrotizing soft tissue infections

Fourneir’s Gangrene (Perineum and Genitals)

Ludwig’s Angina (Floor of Mouth and neck)

What should be done immediately for suspected necrotizing soft tissue infections

begin simultaneously in a hospital setting without waiting for laboratory or imaging results to confirm it

What is the general managment plan for necrotizing soft tissue infections

Immediate Surgical Debridement:

Broad-Spectrum Intravenous Antibiotics:

Aggressive Resuscitation

Adjuvant Therapies

What is typically the Abx regimn for empric necrotizing soft tissue infections

Piperacillin-Tazobactam (Zosyn) or Carbapenem (Broad Coverage)

Vancomycin (MRSA cover)

Clindamycin (Shuts down toxins by Strep and Staph)

What goes into the Aggressive Resuscitation for necrotizing soft tissue infection

substantial IV fluid resuscitation,

vasopressors to maintain blood pressure,

close monitoring in the ICU

What adjuvant therapies can be used for necrotizing soft tissue infections

hyperbaric oxygen therapy (HBOT) to inhibit anaerobic bacteria and promote healing,

Intravenous Immunoglobulin (IVIG) to help neutralize circulating bacterial toxins

What are the most important prognositc factors for necrotizing soft tissue infections

Early clinical recognition

immediate surgical consultation

Fournier’s gangrene

Type of necrotizing soft tissue infection occurring in the perineal, genital, and perianal region

Who is more likely to get Fournier’s gangrene

Men

What type of necrotizing soft tissue infection does Fournier’s tend to be

type 1 NSTI – almost always polymicrobial

Treatment of Fournier’s gangrene

Early wide debridement

broad-spectrum antibiotics

removal of the scrotum is not uncommon

May need penile degloving

Plastic surgery consultation for future reconstruction

Fournier’s gangrene