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CHAPTER 7
Trauma
21. Which of the following qualifies as pneumothorax as a
tension pneumothorax?
A. Distended neck veins
B. Tracheal deviation
C. Hypotension
D. Subcutaneous emphysema
Patients who have an abnormal voice, abnormal breathing
sounds, tachypnea, or altered mental status require further
airway evaluation. Blood, vomit, the tongue, teeth, foreign
objects, and soft tissue swelling can cause airway obstruction;
suctioning affords immediate relief in many patients. In the
comatose patient, the tongue may fall backward and obstruct
the hypopharynx; this can be relieved by either a chin lift or
jaw thrust. An oral airway or a nasal trumpet is also helpful
in maintaining airway patency, although the former is usually
not tolerated by an awake patient. Establishing a definitive
airway (ie, endotracheal intubation) is indicated in patients
with apnea; inability to protect the airway due to altered
mental status; impending airway compromise due to inhalation injury, hematoma, facial bleeding, soft tissue swelling,
or aspiration; and inability to maintain oxygenation. Altered
mental status is the most common indication for intubation.
Agitation or obtundation, often attributed to intoxication or
drug use, may actually be due to hypoxia. But the timing of
endotracheal intubation may be critical in the hypovolemic
patient because positive airway pressure may further compromise cardiac function and precipitate cardiac arrest; thus,
circulation may take priority over airway. (See Schwartz 11th
ed., Ch. 7, p. 184.)
Answer: C
Tension pneumothorax is presumed in any patient manifesting respiratory distress and hypotension in combination with
any of the following physical signs: tracheal deviation away
from the affected side, lack of or decreased breath sounds
on the affected side, and subcutaneous emphysema on the
affected side. Patients may have distended neck veins due to
impedance of venous return, but the neck veins may be flat
due to concurrent systemic hypovolemia. Tension pneumo-
thorax and simple pneumothorax have similar signs, symptoms, and examination findings, but hypotension qualifies
the pneumothorax as a tension pneumothorax. Although
immediate needle thoracostomy decompression with a
14-gauge angiocatheter may be indicated in the field, tube
thoracostomy in the midaxillary line should be performed
immediately in the emergency department (ED) before
a chest radiograph is obtained. (See Schwartz 11th ed.,
Ch. 7, p. 186.)
22. Which of the following does NOT describe flail chest?
A. Fracture of greater than at least three ribs on both
sides of the chest.
B. Three of more ribs fractured in at least two locations
C. Paradoxical movement of a free floating segment of
chest wall
D. High likelihood of associated pulmonary contusion
Answer: A
Flail chest occurs when three or more contiguous ribs are
fractured in at least two locations. Paradoxical movement
of this free-floating segment of chest wall is usually evident
in patients with spontaneous ventilation, due to the negative
intrapleural pressure of inspiration. The additional work of
breathing and chest wall pain caused by the flail segment is
rarely sufficient to compromise ventilation. Instead, it is the
decreased compliance and increased shunt fraction caused by
the associated pulmonary contusion that is the source of acute
respiratory failure. Pulmonary contusions often progress during the first 12 hours. Resultant hypoventilation and hypoxemia may require intubation and mechanical ventilation. The
patient’s initial chest radiograph often underestimates the
extent of the pulmonary parenchymal damage; close monitoring and frequent clinical reevaluation are warranted. (See
Schwartz 11th ed., Ch. 7, p. 186.)
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23. Which of the following describes a type I tracheobronchial injury?
A. Occurring within 3 cm of the mainstem bronchus
B. Likely to cause a pneumothorax
C. A distal bronchial injury
D. Occurring within 2 cm of the carina
24. Which of the following is NOT one of the four injuries
that should be identified during the “circulation” section
of the primary survey?
A. Massive hemothorax
B. Extremity vascular injury
C. Cardiac tamponade
D. Massive hemoperitoneum
25. For motor vehicle collisions, which of the following variables are NOT among those strongly associated with lifethreatening injuries?
A. Head on impact
B. Death of another occupant in the vehicle
C. Extrication time >20 minutes
D. Change in velocity of >20 MPH
E. Lack of restraint use
Answer: D
Major air leak occurs from tracheobronchial injuries. Type I
injuries are those occurring within 2 cm of the carina. These
may not be associated with a pneumothorax due to the envelopment in the mediastinal pleura. Type II injuries are more
distal injuries within the tracheobronchial tree and hence
manifest with a pneumothorax. Bronchoscopy confirms the
extent of the injury and its location, and directs management.
(See Schwartz 11th ed., Ch. 7, p. 187.)
Answer: B
During the circulation section of the primary survey, four lifethreatening injuries must be identified promptly: (a) massive
hemothorax, (b) cardiac tamponade, (c) massive hemoperitoneum, and (d) mechanically unstable pelvic fractures with
bleeding. Critical tools used to differentiate these in the multisystem trauma patient are the chest and pelvis radiographs,
and extended focused abdominal sonography for trauma
(eFAST). Identification of one of these injuries during the
primary surgery necessitates immediate intervention. (See
Schwartz 11th ed., Ch. 7, p. 188.)
Answer: A
Patients who have sustained blunt trauma can be separated
into categories according to their risk for multiple injuries:
those sustaining high-energy transfer injuries and those sustaining low-energy transfer injuries. Injuries involving highenergy transfer include auto-pedestrian accidents, motor
vehicle collisions in which the car’s change of velocity (ΔV)
exceeds 20 mph or in which the patient has been ejected,
motorcycle collisions, and falls from heights >20 ft. In fact,
for motor vehicle collisions the variables strongly associated with life-threatening injuries, and hence reflective
of the magnitude of the mechanism, are death of another
occupant in the vehicle, extrication time of >20 minutes,
ΔV >20 mph, lack of restraint use, and lateral impact. Low-
energy trauma, such as being struck with a club or falling from
a bicycle, usually does not result in widely distributed injuries. However, potentially lethal injuries of internal organs can
occur because the net energy transfer to any given location
may be substantial. (See Schwartz 11th ed., Ch. 7, p. 196.)
CHAPTER 7
Trauma
26. When performing diagnostic peritoneal lavage (DPL)
to rule out diaphragm injury, the appropriate laboratory
cutoff values to use are:
A. RBC >7500/mL, WBC >350/mL, Amylase >10 IU/L,
AP >1.5 IU/L, Bilirubin >0.01 mg/dL
B. RBC >15000/mL, WBC >750/mL, Amylase >15
IU/L, AP >2.5 IU/L, Bilirubin >0.05 mg/dL
C. RBC >10000/mL, WBC >500/mL, Amylase >19
IU/L, AP >2.0 IU/L, Bilirubin >0.01 mg/dL
D. RBC >12500/mL, WBC >1000/mL, Amylase >12
IU/L, AP >1.5 IU/L, Bilirubin >0.10 mg/dL
Answer: C
Penetrating thoracoabdominal wounds may cause occult
injury to the diaphragm. Patients with gunshot or stab
wounds to the left lower chest should be evaluated with diagnostic laparoscopy or DPL to exclude diaphragmatic injury.
In general, penetrating right diaphragm injury is ignored
unless there is a major underlying liver injury with a risk of
biliopleural fistula. Diagnostic laparoscopy may be preferred
in patients with a positive chest radiograph (hemothorax or
pneumothorax) or in those who would not tolerate a DPL. For
patients undergoing DPL evaluation, laboratory value cutoffs
to rule out diaphragm injury are different from traditional
values formerly used for abdominal stab wounds (Table 7-3).
An RBC count of >10,000/μL is considered a positive finding and an indication for abdominal evaluation; patients with
a DPL RBC count between 1000/μL and 10,000/μL should
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CHAPTER 7
Trauma
27. Focused assessment with sonography in trauma (FAST)
examination is sensitive for detecting what volume of
intraperitoneal fluid?
A. >100 cc
B. >250 cc
C. >500 cc
D. >1000 cc
undergo laparoscopy or thoracoscopy. (See Schwartz 11th
ed., Ch. 7, p. 202.)
TABLE 7-3 Criteria for “positive” finding on diagnostic
peritoneal lavage
Abdominal
Trauma
Red blood cell count >100,000/mL >10,000/mL
White blood cell count >500/mL >500/mL
Amylase level >19 IU/L >19 IU/L
Alkaline phosphatase level >2 IU/L >2 IU/L
Bilirubin level >0.01 mg/dL >0.01 mg/dL
Thoracoabdominal
Stab Wounds
Answer: B
Blunt abdominal trauma is now evaluated initially by FAST
examination, and this has supplanted diagnostic peritoneal
lavage (DPL) (Fig. 7-3). FAST is not 100% sensitive, however,
so diagnostic peritoneal aspiration is warranted in hemodynamically unstable patients without a defined source of blood
loss to rule out abdominal hemorrhage. FAST is used to identify free intraperitoneal fluid in Morrison’s pouch, the left
upper quadrant, and the pelvis. Although this method is sensitive for detecting intraperitoneal fluid of >250 mL, it does
not reliably determine the source of hemorrhage nor grade
solid organ injuries. Patients with fluid on FAST examination,
considered a “positive FAST,” who do not have immediate
indications for laparotomy (hemodynamically stable, no evidence of peritonitis) undergo CT scanning to quantify their
injuries. (See Schwartz 11th ed., Ch. 7, p. 202.)
Hemodynamically
stable
No
FAST +
DPA
FIG. 7-3. Algorithm for the initial evaluation of a patient with suspected blunt abdominal trauma. CT = computed
tomography; DPA = diagnostic peritoneal aspiration; FAST = focused abdominal sonography for trauma; Hct = hematocrit.
No
Yes
Equivocal
Peritonitis?
Yes
Laparotomy
No
No
28. What approach is most appropriate for accessing the
proximal left subclavian artery?
A. Left anterolateral thoracotomy
B. Left anterolateral thoracotomy with superior sternal
extension and supraclavicular incision
C. Median sternotomy
D. Median sternotomy with supraclavicular extension
Indications for CT:
FAST +
Yes
Candidate for
nonoperative
management
or
patient with
cirrhosis
-Altered mental status
No No
-Confounding injury
-Gross hematuria
-Pelvic fracture
-Abdominal tenderness
-Unexplained Hct <35%
Yes
Yes
Abdominal CT
Repeat FAST
in 30 minutes
Answer: D
A method advocated for access to the proximal left subclavian artery is through a fourth interspace anterolateral thoracotomy, superior sternal extension, and left supraclavicular
incision (“trap door” thoracotomy). Although the trap door
procedure is appropriate after resuscitative thoracotomy, the
proximal left subclavian artery can be accessed more easily via a sternotomy with a supraclavicular extension. If
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29. A left medial visceral rotation is appropriate for exposing
injuries to all of the following EXCEPT:
A. Inferior vena cava (IVC).
B. Celiac axis.
C. Proximal superior mesenteric artery (SMA).
D. Left renal artery.
the left subclavian artery is injured outside the thoracic outlet, vascular control can be obtained via the sternotomy and
definitive repair done through the supraclavicular incision.
Emergent median sternotomy is optimal for anterior stab
wounds to the heart. Typically, these patients have pericardial tamponade and may undergo placement of a pericardial
drain before a semiurgent median sternotomy is performed.
Patients in extremis, however, should undergo anterolateral
thoracotomy. (See Schwartz 11th ed., Ch. 7, p. 210.)
Answer: A
Supracolic injuries (aorta, celiac axis, proximal SMA, and left
renal arteries) are best approached via a left medial visceral
rotation. This is done by incising the lateral peritoneal reflection (white line of Toldt) beginning at the distal descending
colon and extending the incision along the colonic splenic
flexure, around the posterior aspect of the spleen, and behind
the gastric fundus, ending at the esophagus. The left colon,
spleen, pancreas, and stomach are then rotated toward the
midline. The authors prefer to leave the kidney in situ when
mobilizing the viscera because this exaggerates the separation
of the renal vessels from the SMA. The operative approach
for SMA injuries is based on the level of injury. Fullen zone
I SMA injuries, located posterior to the pancreas, are best
exposed by a left medial visceral rotation. Fullen zone II SMA
injuries, extending from the pancreatic edge to the middle
colic branch, on the other hand, are approached via the lesser
sac along the inferior edge of the pancreas at the base of the
transverse mesocolon; the pancreatic body may be divided
to gain proximal vascular access. More distal SMA injuries,
Fullen zones III and IV, are approached directly within the
mesentery. A venous injury behind the pancreas, from the
junction of the superior mesenteric, splenic, and portal veins,
is accessed by dividing the neck of the pancreas. IVC injuries
are approached by a right medial visceral rotation. Proximal
control is obtained just above the iliac bifurcation with direct
pressure via a sponge stick; the injury is identified by cephalad dissection along the anterior surface of the IVC. A Satinsky clamp can be used to control anterior caval wounds. (See
Schwartz 11th ed., Ch. 7, p. 212.)
CHAPTER 7
Trauma
30. Which of the following criteria should trigger angiography to control bleeding attributable to liver injury in a
hemodynamically stable patient?
A. Drop in Hgb of >2.0 g/dL
B. Alkaline phosphatase >250 IU/L
C. Transfusion of 4U RBC in 6 hours, or 6U over 24 hours
D. Persistent right upper quadrant pain
Answer: C
Nonoperative management of solid organ injuries is pursued
in hemodynamically stable patients who do not have overt
peritonitis or other indications for laparotomy. Patients with
>grade II injuries should be admitted to the surgical intensive
care unit (SICU) with frequent hemodynamic monitoring,
determination of hemoglobin, and abdominal examination.
The only absolute contraindication to nonoperative management is hemodynamic instability from intraperitoneal
hemorrhage. Factors such as high injury grade, large hemoperitoneum, contrast extravasation, or pseudoaneurysms may
predict complications or failure of nonoperative management.
Angioembolization and endoscopic retrograde cholangiopancreatography (ERCP) are useful adjuncts that can improve the
success rate of nonoperative management. The indication for
angiography to control hepatic hemorrhage is transfusion of
4 units of RBCs in 6 hours or 6 units of RBCs in 24 hours
attributable to the liver. (See Schwartz 11th ed., Ch. 7, p. 225.)
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31. What is the most commonly missed type of gastric
CHAPTER 7
injury?
A. Pre-pyloric injury
B. Lesser curve injury
C. Injury at the gastroesophageal (GE) junction
D. Posterior wound of a through and through penetrat-
ing injury
Trauma
32. During the initial phases of shock resuscitation, what is
an appropriate goal hemoglobin level?
A. 8.0 g/dL
B. 10 g/dL
C. 7 g/dL
D. 12 g/dL
Answer: D
The most commonly missed gastric injury is the posterior
wound of a through and through penetrating injury. Injuries also can be overlooked if the wound is located within the
mesentery of the lesser curvature or high in the fundus. To
delineate a questionable injury, the stomach can be digitally
occluded at the pylorus while methylene blue-colored saline
is instilled via a nasogastric (NG) tube. Alternatively, air can
be introduced via the NG tube with the abdomen filled with
saline. Little controversy exists regarding the repair of injuries
to the stomach or small bowel because of a rich blood supply.
Gastric wounds can be oversewn with a running single-layer
suture line or closed with a stapler. If a single-layer closure is
chosen, full-thickness bites should be taken to ensure hemostasis from the well-vascularized gastric wall. Partial gastrectomy
may be required for destructive injuries, with resections of the
distal antrum or pylorus reconstructed using a Billroth procedure. Patients with injuries that damage both Latarjet nerves
or vagi should undergo a drainage procedure. (See Schwartz
11th ed., Ch. 7, p. 228.)
Answer: B
The period of acute resuscitation, typically lasting for the first
12 to 24 hours after injury, combines several key principles:
optimizing tissue perfusion, ensuring normothermia, and
restoring coagulation status. There are a multitude of management algorithms aimed at accomplishing these goals, the
majority of which involve goal-directed resuscitation with
initial volume loading to attain adequate preload, followed by
judicious use of inotropic agents or vasopressors. Although
the optimal hemoglobin level remains debated, during shock
resuscitation a hemoglobin level of >10 g/dL is generally
accepted to optimize hemostasis and ensure adequate oxygen
delivery. After the first 24 hours of resuscitation, a more judicious transfusion trigger of a hemoglobin level of <7 g/dL in
the euvolemic patient limits the adverse inflammatory effects
of stored RBCs. (See Schwartz 11th ed., Ch. 7, p. 237.)
33. Which of the following is a physiologic change of pregnancy that may influence evaluation of an injured pregnant patient?
A. Increased resting heart rate by 10 to 15 beats per
minute
B. Increased resting blood pressure during the first
2 trimesters
C. Decreased maternal intravascular volume
D. Decreased tidal volume and minute ventilation
Answer: A
Pregnancy results in physiologic changes that may impact
postinjury evaluation. Heart rate increases by 10 to 15 beats
per minute during the first trimester and remains elevated
until delivery. Blood pressure diminishes during the first 2 trimesters due to a decrease in systemic vascular resistance and
rises again slightly during the third trimester (mean values:
first = 105/60, second = 102/55, third = 108/67). Intravascular volume is increased by up to 8 L, which results in a relative anemia but also a relative hypervolemia. Consequently,
a pregnant woman may lose 35% of her blood volume before
exhibiting signs of shock. Pregnant patients have an increase
in tidal volume and minute ventilation but a decreased functional residual capacity; this results in a diminished PCO2 and
respiratory alkalosis. Also, pregnant patients may desaturate
more rapidly, particularly in the supine position and during
intubation. (See Schwartz 11th ed., Ch. 7, p. 240.)
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34. Which of the following is true regarding trauma in geriatric patients?
A. Admission Glasgow Coma Score (GCS) score after
severe head injury is a good predictor of outcome.
B. Rib fractures are associated with pulmonary contu-
sion in 35% of patients, and complicated by pneumonia in 10% to 30% of patients.
C. Approximately 10% of patients older than 65 years
will sustain a rib fracture from a fall <6 ft.
D. Chronologic age older than 65 years is associated
with higher morbidity and mortality after trauma.
Answer: B
Mortality in patients with severe head injury more than doubles after the age of 55 years. Moreover, 25% of patients with
a normal GCS score of 15 had intracranial bleeding, with an
associated mortality of 50%. Just as there is no absolute age
that predicts outcome, admission GCS score is a poor predictor of individual outcome. Therefore, the majority of trauma
centers advocate an initial aggressive approach with reevaluation at the 72-hour mark to determine subsequent care. Secondly, one of the most common sequelae of blunt thoracic
trauma is rib fractures. In fact, in one study, 50% of patients
older than 65 years sustained rib fractures from a fall of <6 ft,
compared with only 1% of patients younger than 65 years.
Concurrent pulmonary contusion is noted in up to 35% of
patients, and pneumonia complicates the injuries in 10% to
30% of patients with rib fractures. (See Schwartz 11th ed.,
Ch. 7, p. 243.)
CHAPTER 7
Trauma
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CHAPTER 8
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Burns
1. A 22-year-old man is brought to the emergency room
after a house fire. He has burns around his mouth and his
voice is hoarse, but breathing is unlabored. What would
be the most appropriate next step in management?
A. Immediate endotracheal intubation
B. Examination of oral cavity and pharynx, with fiber-
optic laryngoscope if available
C. Place on supplemental oxygen
D. Placement of two large-bore IV catheters with fluid
resuscitation
2. What percentage burn does a patient have who has suffered partial-thickness burns to their anterior right leg
and anterior chest and abdomen as well as superficial
burns to their right arm?
A. 18%
B. 27%
C. 36%
D. 45%
Answer: B
Initial evaluation of the burned patient should follow the
same initial priorities of all trauma patients and involves four
crucial assessments: airway management, evaluation of other
injuries, estimation of burn size, and diagnosis of carboxyhemoglobin (CO) and cyanide poisoning. With direct thermal injury to the upper airway or smoke inhalation, rapid
and severe airway edema is potentially lethal. Anticipating
the need for intubation and establishing an early airway are
critical. Signs of impending respiratory compromise include
a hoarse voice, wheezing, or stridor; subjective dyspnea is a
particularly concerning symptom and should trigger prompt
elective endotracheal intubation. Perioral burns and singed
nasal hairs alone do not indicate an upper airway injury,
but are signs that the oral cavity and pharynx should be further evaluated for mucosal injury. Orotracheal intubation is
the preferred method for securing the airway. Nasotracheal
intubation may be useful for patients with associated facial
trauma when experienced providers are present, but it should
be avoided if oral intubation is safe and easy. (See Schwartz
11th ed., p. 251.)
Answer: C
Most burn resuscitation formulas estimate fluid requirements based on burn size measured as a percentage of total
body surface area (TBSA) (%TBSA). The “rule of nines” is a
crude but quick and effective method of estimating burn size
(Fig. 8-1). In adults, the anterior and posterior trunk each
account for 18%, each lower extremity is 18%, each upper
extremity is 9%, and the head is 9%. In children under 3 years
of age, the head accounts for a larger relative surface area and
should be taken into account when estimating burn size. For
smaller or odd-shaped burns, the “rule of the palm” where the
palmar surface of the hand, including the digits, is 1% TBSA
is useful. Diagrams such as the Lund and Browder chart give
a more accurate accounting of the true burn size in children
and adults. The importance of an accurate burn size assessment cannot be overemphasized. Superficial or first-degree
burns should not be included when calculating burn size, and
thorough cleaning of soot and debris is mandatory to avoid
confusing soiled skin with burns. Examination of referral
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CHAPTER 8
Burns
9%
18%
data suggests that physicians inexperienced with burns tend
to overestimate the size of small burns and underestimate the
size of large burns, with potentially detrimental effects on
pretransfer resuscitation. (See Schwartz 11th ed., p. 253.)
4.5% 4.5%
9%
18%
1%
18%
9%
1%
18%
FIG. 8-1. The “rule of nines” can be used as a quick reference for estimating a patient’s burn size by dividing the
body into regions to which total body surface area is allocated in multiples of 9.
3. A 40-year-old woman is admitted to the burn unit after
an industrial fire at a plastics manufacturing plant with
burns to the face and arms. Her electrocardiogram
(ECG) shows S-T elevation, and initial chemistry panel
and arterial blood gas reveal an anion-gap metabolic acidosis with normal arterial carboxyhemoglobin. What is
the most appropriate next step?
A. Correction of acidosis by adding sodium bicarbonate
to IV fluids
B. Administration of 100% oxygen and hydroxocobalamin
C. Transthoracic echocardiogram
D. Blood culture with intravenous antibiotics
Answer: B
Hydrogen cyanide toxicity may also be a component of an
overwhelming smoke inhalation injury. Cyanide inhibits cytochrome oxidase, which is required for oxidative phosphorylation. Afflicted patients may have a persistent, severe lactic
acidosis, neurologic symptoms, pulmonary edema, or cardiac
sequelae (ST elevation on electrocardiogram). Classic signs
of cyanide poisoning—including bitter almond breath and
cherry-red skin changes—are rare and should not be used as
the sole diagnostic criteria. Treatment consists of sodium thiosulfate, hydroxocobalamin, and 100% oxygen. Sodium thiosulfate works as a substrate for the metabolism of cyanide into a
nontoxic derivative, but it works slowly and is not effective for
acute therapy. Hydroxocobalamin—a vitamin B12 precursor—
quickly complexes with cyanide, is excreted by the kidney,
and is recommended for immediate therapy. In the majority of patients, lactic acidosis will resolve with ventilation,
and sodium thiosulfate treatment becomes unnecessary. (See
Schwartz 11th ed., p. 256.)
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4. In order to assess the special concerns associated with
electrical burns:
A. All extremity compartments should be evaluated and
a baseline ECG should be obtained.
B. A full neurologic assessment including ophthal-
mologic is required to evaluate acute intraocular
pathology.
C. A Foley catheter should be placed to allow for titra-
tion of fluid administration.
D. Workup should include an echocardiogram to evalu-
ate ventricular wall motion.
5. What is the zone of coagulation and what is the appropriate treatment?
A. The most severely burned portion is typically in the
center of the wound, which will require excision and
grafting.
B. The most severely burned portion is typically in the
center of the wound, which will likely heal without
surgical intervention if adequate perfusion is maintained and infection is prevented.
C. It has variable degrees of vasoconstriction and resul-
tant ischemia, which will require excision and grafting.
D. It is hyperemic and extremely painful to touch, but
will not require surgical excision or grafting.
Answer: A
Electrical burns make up 3% of US hospital admissions but
have special concerns, including cardiac arrhythmia and compartment syndrome with concurrent rhabdomyolysis. A baseline ECG is recommended in all patients with an electrical
injury, and a normal ECG in a low-voltage injury (<1000 V)
may preclude hospital admission. Because compartment syndrome and rhabdomyolysis are common in high-voltage electrical injuries, vigilance must be maintained for neurologic or
vascular compromise, and fasciotomies should be performed
even in cases of moderate clinical suspicion. For patients with
rhabdomyolysis, a Foley catheter and monitoring of electrolytes may be aid in renal function monitoring, but fluid
administration and urine output is not prioritized as highly in
electrical when compared to external burns. Long-term neurologic symptoms and cataract development are not uncommon
with high-voltage electrical injuries, and neurologic and ophthalmologic consultation should be obtained to define baseline patient function. However, acute intraocular pathology is
unlikely to be uncovered. (See Schwartz 11th ed., p. 252.)
Answer: A
The zone of coagulation is the most severely burned portion and is typically in the center of the wound. As the name
implies, the affected tissue is coagulated and sometimes
frankly necrotic, much like a full-thickness burn, and will
need excision and grafting. Peripheral to that is a zone of
stasis, with variable degrees of vasoconstriction and resultant ischemia, much like a second-degree burn. Appropriate resuscitation and wound care may prevent conversion to
a deeper wound, but infection or suboptimal perfusion may
result in an increase in burn depth. This is clinically relevant
because many superficial partial-thickness burns will heal
with nonoperative management, and the majority of deep
partial-thickness burns benefit from excision and skin grafting. The outermost area of a burn is called the zone of hyperemia, which will heal with minimal or no scarring and is most
like a superficial partial-thickness burn or first-degree burn.
(See Schwartz 11th ed., p. 253.)
CHAPTER 8
Burns
6. Which of the following describes a partial-thickness,
second-degree burn?
A. Leathery, painless, and nonblanching
B. Painful but do not blister
C. Dermal involvement and are extremely painful with
weeping and blisters
D. Will need excision and grafting
Answer: C
Based on the original burn depth classification by Dupuytren
in 1832, 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. Fifth-degree burns (through muscle to bone)
and sixth-degree burns (charring bone) were also described
although are less common. Partial-thickness burns are 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 leathery, painless, and
nonblanching. Jackson described three zones of tissue injury
following burn injury. (See Schwartz 11th ed., p. 253.)
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