5) Burns Flashcards
(duration to burn a child) A.120 degrees
B.125 degrees 2 minutes
C.140 degrees 6 seconds
D.150 degrees 2 seconds
A.10 minutes
B.2 minutes
C.6 seconds
D.2 seconds
4 dif/ burns:
thermal, electrical, chem, radiation,
skin tolerates up to ? degrees
111F
Heat gradient
H → L heat will go
Extent of burn injury related to amount of
heat energy transferred to skin (Heat gradient)
Factors of burn severity:
Duration, Exposure, temp, surface
agent’s temperature relation to potential damage.
greater the agent’s temp, the greater its potential to cause damage.
Jacksons Theory of Thermal Burns 3 burn zones:
1st Zone of Coagulation 2nd Zone of Stasis 3rd Zone of Hyperemia
(Jacksons Theory) Zone of Coagulation:
Area of burn nearest to the heat source (most damage & tissue necrosis)Most damaged area
Zone of Hyperemia:
surrounding Area of erythema, damage with more RBC coming to area b/c/& cap/s more permeable (increased blood supply) trying to get phagocytes to inside for healing process
Sig burns have sig swelling from shift of fluid
Zone of Stasis / “Ischemia”:
Less damaged area adjacent to the Zone of Coagulation (treatable & posible reversible damage)
Thermal burn phases:
Emergent, Fluid-shift, Hypermetabolic, & Resolution phase
(Thermal burn phases) Emergent phase:
Vtach, cells anaerobic Body’s initial reaction to burn; pain response (afferent nerves damage> Nor/Epi release > tachycardia ; unless on beta blockers
(Thermal burn phases) Fluid-shift phase:
2nd phase; can last up to 24 hours; larger than 15 to 20%(BSA) of total body surface area
vasodilates & capillaries more permeable for phagocytosis
(Thermal burn phases) Hypermetabolic phase:
3rd phase Days or weeks depending on burn severity; increase in body’s demands for nutrients; begins process of repairing damaged tissue (needs Glucose, amino acids, carbohydrates, O2 to support damage)
(Thermal burn phases) Resolution phase:
4th phase Scar tissue laid down and remodeled; rehabilitate and return to normal function (weeks to months) new collagen & usually doesnt remodel to original state & makes escar (burn keloid) bc overgrowth
“pressure” of electric flow
Voltage
“energy” or amount of flow in given time
Current; measured in amperes
Ohm’s law:
relationship between current (I), resistance (R), voltage (V)
Electricity follows path of
least resistance w/ entry & exit wound: Nerves & blood vessels
Lightning can still strike you if proximity up to:
up to 50yrds can strike you
Chemical burns:
biochemical makeup of cell membranes; destroy cells
Direct current (DC):
Alternating current (AC):
= electrons flow in one direction > grab on can’t let go
= reverses flow in short intervals (60 cycles change electrons’’ flow) can let go
Lightning shock pathway to heart can & b/c:
= PSNS & SNS attach heart “defib w/o defibrillator” put in dysrhythmia or arrest
Denature:
take away natural state (from chem burns)
Alkalotic vs acidotic burns severity
Alkalotic burns > Acidotic burns
Lightning strikes frequency & strike proximity
~100times a sec around world & up to 50yrds can strike you
Chemical burns effect:
Denature biochemical makeup of cell membranes; destroy cells
best way to wash eyes
Morgan lens ((hard lens/contacts hooked up to water)
Radiation burns:
Factors:
= from nuclear sources Damages cells mischapping them & replicating thus cancer
= duration, Distance, shielding
(Rad) S/S of Exposure:
First sign:
Lethal Dose Exposure:
Organ shutdown:
= SLUDGEM PSNS S/S
= slight nausea & fatigue
= Emesis & malaise, Epistaxis, mouth, gums, & rectum (Vomiting usually lethal exposure
= Death
Geiger Counter:
Dosimeter:
= Radiation emission measured w/ Dosimeter
= Cumulative exposure recorded
1 Types of Radiation:
2 Radioactive Particles:
3 Alpha:
4 Beta:
5 Ionizing Rays:
6 Gamma:
7 X-Rays:
8 Atomic:
1= Radioactive Particles & Ionizing Rays
2= Alpha &Beta:
3= least worry & deflected w/ newspaper
4= flys further w/o skin penetration
5= Gamma & X-Rays
6= worst, several ft of concrete & lead
7= penetrates skin
8= nuclear reactor
(Radiation) Duration:
Distance:
Shielding:
= Radiation exposure accumulative danger
= Rad/ strength lessens quickly as distance from source increases
= More material between you & rad/ source, < exposure experienced
Light Burns:
Inhalation Burns:
Toxic inhalation:
Cyanide & carbon monoxide are released via:
= Intense light from arc welder, industrial laser (Ultraviolet keratitis)
= Inhaled gases, heated air, flames, steam; airway & resp/ injury
= Synthetic resins & plastics release toxic gases as they burn
= fake wood & such burning thus Toxic inhalation
Stridor w/ inhalation burns:
Bad Airway burns might might need:
= AKA “crowing” larynx last defense against heat then swells 2/3s so intubate asap bc only worsens (Press chest & follow bubbles)
= Might need to nasal endotracheal intubation w/ BAAM & Endotrol tube (ET w/ trigger) BAAM> High=inhale &Low=exhale
1 (Burn depth) 3rd degree:
2 feeling & appearance:
1= full thickness burn down to SCT may involve M. bone & organs
2= leather, looks Charred, dark brown or white, hard to touch “painless”
(Burn depth) Degrees:
= 1st/Superficial, 2nd/partial, 3rd/full/complete
(Burn depth) 1st degree:
= Epidermis only, red skin, pain & tender, NO blister(can lose temp/reg)
(Moderate criteria) Superficial:
Partial thickness burns:
Full thickness burns:
= BSA >50%
= BSA <30%
= BSA <10%
(Burn depth) 2nd degree:
= Partial, EPi & Dermis burned: intense pain, fluid shift comes up thus blisters, RED to WHITE, moist & mottled w/ shifts
(Critical Criteria) 3rd & 2nd Degree criteria:
Any 2nd or 3rd degree burns involving:
Burn types that’re critical & Rx:
= 3rd>10% & 2nd>30%
= Face, Hands, Genitalia, Circumferential, Feet, (Dipping), Airway
= Chem, high voltage, Burns w/ major trauma go trauma center 1st then burn center
(Wallace Rule of 9s) used only for:
Adult %s:
infants (0-1):
Form:
= burns >10%
= 1 genitals, 9 head thoracic & ABDMN, distal anterior (applies to other areas) arm 4 ½
= head 18, arm 9, legs 13.5, 18 front thoracic & ABDMN
= # of child -1 > take away from head then give to each leg (Applicable up 10y/o) For every year beyond age 1, subtract 1 from head / that # & add it evenly between the 2 legs.
Rule of palm:
use of PT hand = 1% of BSA (burns <10%)
Burn worries:
= Hypothermia, Hypovol/, Electrolyte imbalance /HyperK, Infection
(Burn worries) Hypothermia:
Burn may disrupt body’s ability to reg/ core temp, If burn is extensive, uncontrolled body heat loss induces rapid, severe hypothermia.
(Burn worries) Hypovolemia:
Tissue destruction reduces/eliminates skin’s ability to contain fluid w/in, Inability of damaged blood vessels to retain plasma causes fluid & electrolyte shift into burned tissue & Takes 4-6hrs to dev/
(Burn worries) Electrolyte imbalance:
Body’s ability to reg Na,K,& electrolytes is overwhelmed, Careful electrocardiogram (ECG) monitoring and fluid resuscitation help prevent hyperkalemic
Succholyine depolarzing makes hyperK worse
(Burn worries) Infection:
natural body bacteria can kill & become opertunicle & Most persistent killer of burn victims & Does not appear for several days following acute injury, Pathogens pose hazard to life when they grow to massive numbers
Eschar:
= Burn destroys dermal cells; Skin constricts over wound site, increasing pressure of edema beneath & restricting flow of blood (compartment syndrome) May be severe enough to occlude all blood flow into distal extremity
(Burn worry) late stage Organ failure:
= can go into rhabdo from myglobins; Burn process releases material from damaged or dying body cells into bloodstream, May cause kidney failure, liver failure, arrhythmias, possible cardiac arrest.
Escharotomy =
= release pressure w/ cutting burn to relief fluid pressure
Special pop of burns:
PT’s cope less b/c:
= GERI, Pedi, & PTs ill/injured have >dif coping w/ burn injuries
= Fluid retention, <fluid reserves, <able to combat infection, More apt to have underlying diseases
!!!Parkland Burn Form for:
form:
= (BSA >20% only 2 & 3 degree burns)
= 4 mL x BSA x Weight (kg) = ½ 1st 8 Hrs & ½ next 16Hrs
Dry dressing for burns:
Wet dressing for burns:
= >10%
= <10%
(Parkland Burn Form) EX: 32yo male found with 10% BSA 1st degree burns, 10% BSA 2nd degree burns, and 10% BSA 3rd degree burns. The patient is 110 pounds.
1. 4 mL x BSA x Weight (kg)
2. Total mL / 2 = (Amount to give for:
3. How many mL’s per hr?
4. How many gtts/min using a 10 gtt/mL IV drip set?
5. Know w/ formula:
- 4mL X 20 (2nd + 3rd degree burns) X 50 (kg) = 4000 mL
- 4000 mL / 2 = 2000 mL (Amount to give 1st 8 hours then next 16Hrs)
- 2000 mL / 8 = 250 mL per/hour for 1st 8 hrs
- 42 gtts/min
- Pick closest option choice for gtts & Vol calculated. Use biggest bores& macro drips
1 CO monitors: carboxy, carbmino, methemo
2 Cyanide A&P:
3 (Cyanokit): Dynamics:
4 (Cyanokit) Indications:
5 (Cyanokit) Contras:
6 (Cyanokit)Adverse Effects:
7 (Cyanokit)Adult Dose:
8 (Cyanokit) Pediatric Dose:
1= carboxy, carbmino, methemo
2= cytochrome oxidase blocks cells from using O2
3= Hydroxocobalamin “vitamin B12”; Binds w/ cyanide to form nontoxic cyanocobalamin, preventing its toxic effects.
4= Suspected cyanide poisoning
5= Known hypersensitivity to medication
6= HyperBP, Anaphylaxis, Angioedema, N/V/D, Red urine (may last 2-5 weeks)
7= (Use fluid to dilute w/ 100mLs) 5G IV/IO over 15 minutes May repeat a 2nd 5G for a max cumulative dose of 10Gs
8= 70 mg/kg IV/IO (max 5 grams) over 15 mis
1 (Morphine)
2 Pharmacodynamics:
3 Indications:
4 Contraindications:
5 Adverse Effects:
6 Adult Dose:
7 Pediatric Dose:
8 Keep on standby:
1 = not same as Morphine Sulfate
2= Narcotic (opioid) Schedule II Narcotic releases histamine allergy
3= Moderate to severe pain
4= SBP<90 & Known hypersensitivity
5= HypoBP, Syncope Tachy/BradyC, Resp/Depres, Apnea, N/V
6= 2-10 mg or 0.1 mg/kg to max dose (max 20 mg) IV, IO, IM, SQ & PO
7= 0.1 mg/kg IV/IO (slow) or IM up to 10 mg
8= Narcan is an antagonist
1(Fentanyl) know:
2 Pharmacodynamics:
3 Indications:
4 Contraindications:
5 Adverse Effects:
6 Adult & Pediatric Dose same:
7 Antidote:
1= quicker but shorter duration than Morp (100 mcg=10 mg Morp)
2= , Schedule II Narcotic (opioid), sig/ more potent than morphine
3= Moderate to severe pain, Anesthetic
4= Known hypersensitivity to med, SBP <90
5= HypoBP, N/V, Cramps, CHEST WALL RIGIDITY, Resp/depress
6= 1mcg/kg to max of 100 mcg (IV/IO/IM/IN) may repeat PRN in 5-10 minutes w/ Max of 1 mL per nostril if administered IN
7= Narcan is an antagonist
1 (Ketamine) know:
2 Pharmacodynamics:
3 Indications:
4 Contraindications:
5 Adverse Effects:
6 Adult & Pedi Pain Dose:
7 Dissociation dose:
1= retrograde amnesia, Raises BP,
2= + sympathetic response, Sedative-hypnotic & analgesic med
3= Moderate to severe pain & SFI/RSI
4= History of hypersensitivity to med, Hypertension
5= Severe hallucinations and/or nightmares
6= 0.2 mg/kg/1-2min IV/IO w/ a max single dose of 20 mg
7= 0.5 mg/kg IN/IM
Caring for chem/ burn, its keen to know if its acid or an alkali b/c:
If carbon monoxide is present should also suspect the presence of:
= Alkalis continue to destroy cell membranes via liquefaction necrosis
= Cyanide
1 Children for the Rules of Nines, the head is awarded:
2 Children for the Rules of Nines, each leg is awarded:
3 Children for the Rules of Nines, each arm is awarded:
4 Children for the Rules of Nines, the anterior trunk is awarded:
5 Children for the Rules of Nines, the posterior trunk is awarded:
1= 18 % of body surface area.
2= 13.5% of body surface area.
3= 9% of body surface area.
4= 18% of body surface area.
5= 18% of body surface area.
1 Adults for the Rules of Nines, the head is awarded:
2 Adults for the Rules of Nines, the genitalia is awarded:
3 Adults for the Rules of Nines, the posterior trunk is awarded:
4 Adult for the Rules of Nines, each arm is awarded:
5 Adults for the Rules of Nines, each leg is awarded:
6 Adults for the Rules of Nines, the anterior trunk is awarded:
1= 9 % of body surface area.
2= 1 % of body surface area.
3= 9 % of body surface area.
4= 18 % of body surface area.
5= 18 % of body surface area.
6= 18 % of body surface area.
Burn injury in an enclosed space, always consider the possibility of:
Supraglottic structures are useful w/ burns b/c:
= Inhalation Burns
= B/c very moist mucosa lines the airway Supraglottic airways may absorb heat and prevent lower airway burns
Fluid resuscitation is an important part of treating serious burns. The formula for the amount of IV fluid needed to be infused includes:
4 mL × patient weight (kg) × BSA burned
True or false) A burn is a progressive process:
Burns resulting from exposure to heat are called:
= True
= Thermal Burns
When estimating size of a small burn, best method to use is the:
Using “rule of nines” for total BSA burned, dif/ w/ infants & adults:
= Rule of palms (up to about 10% BSA)
= Lower EXTRMs of infant need to be increased by 4.5%
The following burn patterns is usually seen with child abuse:
“Stocking burns” to lower legs, Circumferential burns on buttocks, Multiple circular burns of the same size to the arms and legs
1 Resp/ arrest from electrical burn is a result of:
2 The “pressure” of the electric flow is known as:
3 PTs in cardiac arrest b/c electrical current have high survival rate if:
4 human body relation w/ current:
5 Electrical injuries’ usually damage:
1= immobilization of M.s from prolong exposure to electrical current
2= Voltage
3= Prehospital intervention is prompt
4= Body offers resistance to the flow of electricity
5= does lots of damage to muscle tissue & other tissues
1 One of the chief functions of the skin is:
2 The skin is comprised of 3 layers:
3 Layer that serves as stratum of insulation vs trauma & heat loss is:
4 Layer that contains blood vessels, glands, & nerve endings is:
5 Full-thickness burns can involve injury to:
6 The integumentary system relation to NS:
1= Temp regulation
2= Epidermis, Dermis, & Subcutaneous Tissue
3= Subcutaneous Tissue
4= Dermis
5= blood vessels, nerves, M. T., bone, & sometimes internal organs.
6= is not part of the nervous system
Effects of heat can cause structural proteins to break down. Term for this altering of the usual substance of something is:
Denaturing
Reddened skin, edema, blisters, & pain is which burn class:
2nd degree burn to an adult’s upper & lower back represents:
PT w/ 2nd degree burn to chest & back will benefit
= Partial Thickness
= approximately 18% total BSA
= from burn center care
Area nearest the heat source that suffers the most damage is called the zone of:
Coagulation
Burn injuries should be assigned a higher priority when they affect:
You should increase the severity of a burn patient by 1Lvl w/:
= Pediatric PTs
= pediatric & elderly patients
Fluid shift phase of the burn process major sign:
During a burn, loss of plasma protein will what:
= Massive edema due to the fluid shift
= reduce body’s ability to draw fluids from uninjured Ts back into vascular compartment
The presence of blisters differentiates:
A sunburn, resulting in red, painful skin, is EX of:
A superficial, or first-degree burn, involves:
= between a superficial and partial-thickness burn
= a 1st degree burn.
= only the epidermis
The stage of the burn process characterized by catecholamine and pain-mediated reaction is called the:
Emergent Phase
The most persistent killer of burn victims is:
Burn injuries carry an increased danger of:
= Infection
= infection
Rad/ only sig/ hazard if inhaled/ingests contaminated material is:
Neutron radiation is:
= Alpha
= uncommon outside of nuclear power reactors & Bombs
T. or F.) Dry lime burn should 1st be flushed w/ water & then dried off
False
When caring for a patient with a full-thickness burn, remember that:
PTs who’re candidates for immediate transport to a burn center:
= margins are frequently partial-thickness burns thus quite painful
= Sig/ burns to: face, feet, hands, or perineal area
Ketamine) Dynamics:
Indications:
Contra:
Sedation Dose:
Pain dose:
= Dissociative anesthetic. NMDA Receptor Antagonist Anesthetic
= Sedation, SFI/RSI, Analgesic
= Hypersensitivity
= Sedation: 1-2 mg/kg Onset: 30-60 secs, Duration: 10-20 mins
= Pain: 0.2 mg/kg IV/IO (max single dose 20 mg), 0.5 mg/kg IM/IN (if no IV/IO)
Methylene Blue) Dynamics:
Indications:
Contra:
Dose:
= Water soluable thiazine dye helps metHb to hemoglobin conversion
= Methemoglobinemia (metHb), Nitrate OD/poisoning
= Hypersensitivity
= 1 mg/kg IV/IO over 5-30 minutes.
Morphine) Dynamics:
indications:
Contra:
Analgesia:
STEMI:
NSTEMI-ACS:
= Narcotic (Schedule II Opioid) Analgesia & sedation via binding to opiate receptor
= Ischemic chest pain not relieved by Nitroglycerin
= Hypersensitivity. Uncorrected hypotension (<90 SBP)
= 2-10 mg up to max 20 mg.
= 2-4mg slow IV/O, may admin 2nd dose 2-8mg IV/IO q5-15 mins
= 0.1 mg/kg slow IV/IO or IM up to 10 mg
Rocuronium) Dynamics
Indications:
Contra:
Dose:
= Nondepolarizing neuromuscular blocker. Binds to ACh receptors
=DSI/RSI
= Hypersensitivity
= 0.6-1.2 mg/kg. TTP: 60-90 secs. DOP: 45-120 mins
Sodium Bicarbonate 8.4%) Dynamics:
Indications:
Contra:
Suspected acidosis Dose:
Hyperkalemia Dose:
= Alkalinizing Agent. Increases plasma bicarbonate, buffers excess hydrogen ion concertration, raises blood pH & reverses clinical manifestations of acidosis.
= Suspected hyperkalemia, suspected bicarbonateresponsive acidosis (DKA, OD on TCA’s, Aspirin or Cocaine)
= Patients in cardiac arrest
= 1 mEq/kg, Hyperkalemia:
= 50 mEq IV bolus.
Fentanyl) Dynamics:
Indications:
Contra:
Dose:
=Synthetic Narcotic (Schedule II Opioid)
= Analgesia & sedation via binding to opiate receptor, sig/ more potent than morphine (100 mcg = 10 mg of Morphine)
= Moderate-Severe pain
= Hypersensitivity, SBP<90
=1mcg/kg to a max dose 100 mcg (IV/IO/IM/) may repeat PRN in 5-10
= 1mcg/kg IN may repeat PRN 5-10mins (Max 1mL PRN if admin/ed IN)
Methylene Blue) Dynamics:
Indications:
Contra:
Dose:
= H20 soluable thiazine dye promotes converting metHb>hemoglobin
= Methemoglobinemia (metHb), Nitrate overdose/poisoning = Hypersensitivity
= 1 mg/kg IV/IO over 5-30 mins
Morphine) Dynamics:
Indications:
Contra:
Dose:
Narcotic (Schedule II Opioid). Analgesia & sedation w/ binding to opiate receptor
= Ischemic chest pain not relieved by Nitro
= Hypersensitivity. Uncorrected SBP<90
= Analgesia: 2-10 mg up to max 20 mg
STEMI: 2-4 mg slow IV/IO, may admin 2nd dose of 2-8 mg IV/IO q5-15 mins intervals
NSTEMI-ACS: 0.1mg/kg slow IV/IO or IM up to 10 mg.
Rocuronium) Dynamics:
Indications:
Contra:
Dose:
= Nondepolarizing neuromuscular blocker Binds to ACh receptors
= DSI/RSI
= Hypersensitivity
= 0.6-1.2 mg/kg. TTP: 60-90 seconds. DOP: 45-120 minutes
Sodium Bicarbonate 8.4%) Dynamics:
Indications:
Contra:
Dose:
= Alkalinizing Agent +plasma bicarbonate, buffers excess H+ conc/, raises blood pH & reverses manifestations of acidosis.
= Suspected hyperK or acidosis (DKA, OD on TCA’s, Aspirin or Cocaine)
= PTs in cardiac arrest
= Suspected acidosis:1 mEq/kg
=Hyperkalemia: 50 mEq IV bolus.
(Propofol/ Diprivan) Class:
Dose:
= Sedative
= 1-2 mg//kg IV/IO Onset: <1min, Lasts: 5-10mins
1 Alkalis are commonly used as:
2 Acids burns:
3 Alkalis burns:
1= oven and drain cleaners, agricultural fertilizers, and in industry
2= form thick, insoluble mass where they contact T. via coagulation necrosis, limiting burn damage
3= continue destroy cell membranes via liquefaction necrosis, allowing them to penetrate underlying tissue & causing deeper burns
Beta radiation can travel and can penetrate
6 to 10 feet through air & a few layers of clothing.
Alpha rad/ strength, traveling distance, & penetration:
very weak energy source & travels only INs in air, cannot penetrate the epidermis & stopped by paper & clothing
Factors Affecting Exposure to Radiation:
Duration of exposure, Distance from source, Shielding from source
1 Minor burn criteria:
2 3 Critical burn criteria:
3 Moderate burn criteria:
1= Partial thickness: BSA <10%, Superficial: BSA <50% (sunburns, etc)
3= Inhale injury, Full thickness: BSA >10%, Partial thickness: BSA >30%
2= Superficial: BSA >50%, Partial thickness: BSA <30%, Full thickness: BSA <10%, partial or full thickness burns involving hands, feet, joints, face, or genitalia
1 (PTs in severe pain w/ narcotic analgesia) morphine:
2 Fentanyl
3 Ketamine use:
1 = 2-5 mg IV increments every 5mins til’ pain is relieved. Use w/ caution b/c it can depress resp/ drive & increase any existing hypovol/
2= start w/ loading dose 25-50mcg IV & repeat doses as needed
3= may be an alternative to fentanyl in selected patients.
Remember w/ IVs on burn PTs:
Adhesive tape doesn’t stick to burn tissue & can injure the skin when it is removed. Try to secure the IVs by alternative means (w/ gentle circumferential bandaging) when possibly
Avoid prophylactic antibiotics because
early use has been shown to actually worsen outcomes for burn PT
2 cyanide antidote regimens are available:
Sodium nitrite dose :
Sodium thiosulfate dose:
= Pasadena cyanide kit (amyl nitrite, Na nitrite, & Na thiosulfate) & newer antidote Cyanokit (hydroxocobalamin)
= 300 mg sodium nitrite over 2 to 4 minutes for adults.
= administer 12.5 g of for the adult.
blepharospasm
Examine the eyes for eyelid spasm
