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NUR 335 - Exam 4 > Burn Emergencies > Flashcards

Burn Emergencies Flashcards

1
Q

Burn definition

A

A burn is an injury to tissue resulting from direct thermal injury, exposure to caustic chemicals or radiation, or contact with an electric current.

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2
Q

Burn injury - Severity

A
  • Depth
  • Extent (%)
  • Location
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3
Q

Burn classification

A
  • Superficial (1st degree)
  • Partial thickness (2nd degree)
    • Superficial
    • Deep
  • Full thickness (3rd degree)
  • Muscle, bone involved (4th degree)
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4
Q

Superficial burn

A

First degree.
Destruction of epidermis only
Classically sunburn, scald injury
Healing time: 3 - 5 days

  • Red or pink
  • Dry
  • Uncomfortable
  • Intact skin

Tx: Cooling agents, aloe

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5
Q

Partial thickness - Superficial

A

Second degree.
Destruction of the epidermis and some dermis
Healing time: 7 - 10 days

  • Moist
  • Pink or mottled red
  • Painful
  • Blister (common)
  • Blanching
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6
Q

Full thickness

A

Third degree
Destruction of epidermis, dermis and underlying subcutaneous tissue.
Does not heal; requires skin grafting.
RISK FOR INFECTION

  • Thick
  • Dry
  • White, brown, yellow or black
  • Non-pliable
  • No pain
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7
Q

TBSA % calculation

A
  • Rule of 9s
  • Lund Browder Chart
  • Rule of Palms
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8
Q

To cool or not to cool?

A
  • Initial cooling of a burn injury for 3 - 5 minutes with cool water is acceptable
  • Never use ice or apply ointments
  • After cooling, all wet clothing, sheets, etc must be removed and the patient is to be covered with clean sheets and blankets and kept warm to prevent hypothermia.
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9
Q

Inhalation Injuries

A
  • Facial involvement
  • Large fire, explosion
  • Carbon monoxide poisoning
    • Higher affinity for hemoglobin than O2
    • Rx with 100% oxygen
    • Protect airway before edema occurs
  • Confusion, hoarse voice, stridor
  • Surfactant: inactivated
    • Deficiency lead to ateletasis
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10
Q

Toxic components of smoke

A
  • Carbon monoxide
    • all organic matters
  • Hydrogen Cyanide
    • polyurethane, wool, silk, paper
  • Ammonia
    • Nylon, wool, silk, polyurethane
  • Hydrogen Chloride
    • Polyvinyl, upholstery
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11
Q

Burn emergency - History

A
  • Explosion
  • Occurrence in a closed space environment
  • LOC of patient at scene
  • Heavy smoke
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12
Q

Upper airway injury

A
  • Secondary to thermal damage or chemical irritation
  • 150 C: Instant damage to mucosa
  • Glottic swelling
  • Irritants: bronchorrhea/bronchospasm
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13
Q

Upper airway injury

Assessment findings

A
  • Confusion or restlessness
  • Hoarseness of voice
  • Burns to face
  • Singed facial hair
  • Carbonaceous sputum
  • Swelling/blistering to mouth
  • Wheezing, coughing, nasal flaring
  • Noisy breath sounds
  • Rapid, labored breathing
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14
Q

Upper airway injury

Inactivation of surfactant

A
  • A direct effect of smoke
  • Alveolar collapse
  • Atelectasis
  • Pneumonia
  • Pulmonary edema
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15
Q

Carbon monoxide poisoning

A
  • Greater affinity for hemoglobin
  • Decreased HGB’s O2 carrying capacity
  • Half life of CO HGB in room air is 3 - 5 hrs
  • Half life in 100% O2 is 30 - 80 mins
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16
Q

CO HGB levels (%) - Symptoms

A
  • 0-5 Normal value
  • 15-20 Headache, confusion
  • 20-40 Disorientation, fatigue, nausea, visual changes
  • 40-60 Hallucinations, coma, shock, combativeness, cherry red coloring
  • > 60 Mortality > 50%
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17
Q

CO intoxication

A

A pulse oximeter cannot differentiate between oxyhemoglobin and carboxyhemoglobin

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18
Q

Circumferential chest burn

A
  • Pressure is created by the loss of fluid from the capillaries and the rigid eschar
  • Sit patient upright
  • 100% O2
  • Intubation
  • Escarotomy
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19
Q

Burn shock

Capillary Permeability Increases

A
  • Burns < 30% (Burn area)

- Burns > 30% (Generalized)

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20
Q

Indications for resuscitation

A
  • Adults 20% TBSA
  • Children 10% TBSA
  • Electrical injury: any pt with hemochromogens in the urine
  • The extremes of age of pre-existing disease that would likely reduce normal compensatory responses to even mild hypovolemia
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21
Q

IVF Resuscitation

A
  • Administer LR as per protocol

- Pain medication by IV route only

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22
Q

Burn/Trauma - Shock

A

If the pt is showing signs of shock (increase HR, decreased BP) within the first hour of the injury… they are probably losing blood as well.

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23
Q

Fluid estimation first 24 hours (since initial burn)

Parkland Formula - Adult

A
  • Adult with burns > 20%
  • 4 ml x % burn x weight (kg)
  • Fluid of choice is LR
  • Give first half over 8 hours
  • Give second half over 16 hours
  • Titrate to urine output
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24
Q

Maintenance calculation

A
  • 0 - 10 kg 100 ml per kg
  • 11-20 kg 50 ml per kg (+1000)
  • 21 kg and up 20 ml per kg (+1500)

Divide total by 24 for hourly maintenance rate

  • A table of maintenance calculation needs 5-35 kgs is attached to the Pediatric Burn Shock Fluid Resuscitation Protocol
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25
Q

How do you monitor resuscitation?

A
  • UO
    • 0.5 - 1ml/kg/hr
    • Burn patient: expect higher, 30 - 50/hr min
  • HR < 120 bpm
  • BP
  • HCT
  • Na, K, Cl
  • Serum lactate / serum pH
  • Sensorium
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26
Q

Consequences of Inadequate Fluid Resuscitation

A
  • Delayed or underresuscitation
    • Inadequate organ perfusion
    • ATN –> Renal Failure
    • PT&raquo_space; FT wound conversion
    • GI stress ulcer formation (Curling’s)
  • Overresuscitation
    • Pulmonary Edema
    • Burn wound edema - decreased perfusion
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27
Q

25 - 48 Hours Post Burn

A
  • Change IVF to D51/2 NS (Adult) *Na
  • Change IVF to D5.2 NS (Pediatric) *Na
  • Maintain UO as on Day #1
  • Colloid may be given
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28
Q

49 - 72 Hours Post Burn

A
  • Change IVF to D5W
  • Maintain Na of at least 130
  • Adult maintenance 35 - 40 ml per kg
  • Evaporative H2O loss = 1 ml x kg x %burn
  • Infuse Blood to maintain HCT 40-45%
  • Start enteral feedings (TPN as last resort)
  • Urine Na is now indicator of volume status, not output
  • Pt should lose approximately .5 kg of third spaced fluid daily
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29
Q

Plasmapheresis

A
  • Alternative for when fluid resuscitation fails (1.5 - 2 times the calculated fluid was required to maintain urine output)
  • Reduce inflammatory response factors
  • Restoration of capillary integrity
  • Hematology consult
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30
Q

Circumferential Extremity Burn

A
  • Pain numbness and tingling
  • Rigid
  • Non-functional
  • Decreased capillary refill
  • Cool to touch
  • Elevate extremity
  • Escharotomy
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31
Q

Electrical burns

Lightning injuries

A
  • Direct current
  • High voltage
  • Exposure is instantaneous
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32
Q

Electrical burns

A
  • AC or DC
  • Voltage
  • Amperage
  • Length of exposure
  • Pathway of current
  • Tissue resistance
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33
Q

Compartment syndrome

A

Heat generated by the electrical current causes the muscle to swell within the fascial lining.

  • Signs of vascular compromise
  • Pain
  • Fasciotomy
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34
Q

Chemical burns

A
  • IRRIGATE, IRRIGATE, IRRIGATE
  • Apply the basic ABCs of trauma care
  • Remove clothing
  • Lavage, lavage, lavage.
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35
Q

Radiation tissue injury

A
  • When tissue is radiated in the treatment of a malignancy, some normal tissue cells are also damaged.
  • A near linear and progressive radiation fibrosis and destruction of capillary microcirculation may occur.
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36
Q

Triple H

A
  • Tissue damaged by radiation (progressive radiation fibrosis and destruction of capillary microcirculation)
  • Hypovascular, Hypo-cellular and Hypoxic
  • Often remain viable for years and then may breakdown spontaneously or as a complication of surgical wounding or trauma when these tissues are required to meet the increased demands of healing.
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37
Q

Hyperbaric oxygen therapy (HBO2)

A

RARELY USED NOW. USED FOR CARBON MONOXIDE POISONING.

[Induces significant capillary angiogenesis and fibroplasia in compromised tissue (Triple H)]

38
Q

Rule of 9s

A

Estimate extent of burns
Measure 2nd and 3rd degree burns

Head = 9% total (front = 4.5%, back = 4.5%)
Chest (front) = 9%
Abdomen (front) = 9%
Upper and mid back = 9%
Low back and buttocks = 9%
Each arm = 9% total (front = 4.5%, back = 4.5%)
Each leg = 18% total (front = 9%, back = 9%)
Groin = 1%
Hand = 1% (PT’S HAND NOT YOUR HAND)

39
Q

Types of grafts for burn treatment

A
  • Autograft
  • Cadaver skin
  • Synthetics (Op-site)
  • Semisynthetics (Biobrane, artificial skin)
  • Biological dressing (Pigskin)
40
Q

Autograft

A

Skin graft from an unburned area of the burn victim.

  • Split-thickness skin graft (STSG): Partial thickness of epidermis and dermis. Can be applied as a meshed graft or a sheet graft.
    • Meshed graft: A sheet of skin that is expanded 1.5 to 9 times its original size. Used to cover a large wound.
    • Sheet graft: A sheet of skin that is placed over a small wound. Often used for cosmetic effects.
  • Full-thickness skin grafts (FTSG): Entire thickness of the dermal layer as a pedicle or flap. This type includes skin and subcutaneous tissue as well as an artery and vein.
41
Q

Epicel

A
  • Cultured epidermal autografts
  • Humanitarian device: Authorized for use in pts who have deep dermal or full thickness burns comprising a total body surface area of greater than or equal to 30% and in congenital nevus pts.
  • Autologous keratinocytes
42
Q

Radiation

A
  • Energy. Waves or particles trying to become stable.
  • Radioactive materials contained energized atoms that are unstable and release energy.
  • This energy may damage certain critical cellular structures and cause a cell to malfunction or die; it may also interact with water molecules in the body to create unstable, hyperoxide molecules that cause further damage.
  • Harmful health consequences may not be seen for many years.
43
Q

The gray (Gy)

A
  • Unit of measure for absorbed dose and reflects the amount of energy deposited into a mass of tissue (1 Gy = 100 rads)
  • The annual occupational exposure allowed by the Department of Energy is 0.05 Gy.
44
Q

Contamination

A

Radioactive material where it does not belong. It can be solid, liquid, gas or even dust particles.

  • External contamination:
    • Radioactive material on the outside of the body, usually on the skin or on clothing
    • Easily removed by removing clothing and washing the skin with soap and water.
  • Internal contamination: Involves the deposition of radioactive material inside the body through inhalation, ingestion or penetrating wounds.
45
Q

Incorporation

A
  • Uptake of radioactive materials by body cells, tissues and organs, such as in the bone, liver, thyroid or kidney, which causes chemical changes at the cellular level.
  • It cannot take place unless contamination occurs.
46
Q

Most radiation-sensitive tissue

A
  • Lymph tissue

- Bone marrow

47
Q

Most radiation-sensitive organs

A
  • Skin
  • Intestines
  • Kidneys
  • Gonads
48
Q

Factors that affect radiation effects

A
  • Amount of radiation absorbed by body (dose)
  • Type of radiation
  • Route of exposures
  • Length of time a person is exposed
49
Q

Special populations that are more radiation-sensitive

A
  • Under age 12
  • Pregnant women (rapidly growing tissues)
  • Peple over 60 (immune system and commorbidities)
  • People with preexisting conditions that may result in immunosuppression, blood loss, or infectious complications.
50
Q

Nursing considerations: radiation

A
  • The Joint Commission requires facilities to exercise emergency plans for radiologic incidents that use the Incident Command System.
  • Document the presence of radioactive materials, activity levels and accident details; collect samples that document contamination; assist in decontamination procedures, conduct and document dose calculations, and dispose of radioactive wastes.
  • Other federal guidelines: OSHA
51
Q

How to protect yourself from radiation

A
  • Limit radiation exposure
  • Use personal protective clothing and controlling contamination
  • Reduce your exposure through time, distance and shielding. Limit time near a radiation source, increase distance from the source, and use shielding between yourself and the radiation source.
52
Q

Protective clothing in a radiation emergency

A
  • Gowns
  • Caps
  • Masks
  • Splash shield
  • Waterproof boots
    • Tape all open seams and cuffs with masking or adhesive tape
    • Wear two pairs of gloves: One pair, preferably colored, should be worn under the arm cuff of the outer gown and secured by tape. One pair should be easily removable and replaced if the gloves become contaminated. The outer gloves should be white to show clearly if they have been removed and not replaced.
    • Assign a radiation dosimeter to each team member and attach it to the outside of the surgical gown at the neck, where it can be easily removed and monitored by a radiation safety officer. (Geiger counter)
    • Waterproof aprons can be worn when using liquids for decontamination.
    • The Nuclear Regulatory Commission limits the exposure of pregnant workers to a maximum of 5 mGy. Pregnant hosptial workers should be reassigned to areas where exposure is unlikely.
53
Q

Acute Radiation Syndrome

A

Characterized by a large radiation dose (greater than 0.7 Gy), a dose that is usually external, penetrating radiation, a significant portion of the body having received the dose, and the dose being delivered in a short time.

54
Q

Four stages of ARS

A
  • Prodromal stage
  • Latent stage
  • Manifest illness stage
  • Recovery or death stage
55
Q

ARS: Prodomal stage

A

Classic symptoms are nausea, vomiting, and possibly diarrhea beginning minutes up to days after the exposure.

56
Q

ARS: Latent stage

A

In this stage, the patient generally looks and feels better. This stage can last for a few hours or a few weeks

57
Q

ARS: Manifest illness stage

A

Symptoms are dose dependent and determined by the type of specific syndrome the patient exhibits. This stage may last from hours up to several months

58
Q

ARS: Recovery or death stage

A

For those who recover, the process may last from several weeks up to two years. Those who do not recover will die within several months of exposure.

59
Q

Burn pain

A

IV MEDS PREFERRED DURING THE ACUTE PHASE
PRE-MEDICATE 20-30 MINS BEFORE PROCEDURES

  • Procedural: Caused by wound care procedures. Excrutiating without adequate analgesia.
  • Background: Experienced between wound care procedures. Often described as mild to moderate in intensity. It usually responds to typical doses of opioids or PCA

Procedural pain is more severe than background pain

60
Q

Deep partial-thickness

A

Destruction of epidermis and most of dermis; some skin appendages remain
Healing time: 2 - 4 weeks

  • Pale
  • Mottled
  • Pearly red/white
  • Moist or somewhat dry
  • Tipically less painful
61
Q

Somke inhalation

Supraglottic

A
  • Inhalation inury above the glottis
  • Most often a thermal injury
  • Damage occur mostly in the pharynx and larynx
62
Q

Smoke inhalation

Subglottic

A
  • Inhalation injury below the glottis
  • Usually a chemical injury
  • Hallmark sign: carbonaceous sputum
63
Q

Functions of the skin

A 
Protection
Heat regulation
Sensory perception
Excretory
Vitamin D production
Cosmesis
64
Q

Types of burns

A 
Heat (most common)
Electrical
Cold
Chemical
Radiation
(Medications)
65
Q

Partial thickness - Deep

A

Second degree
Deeper
Nerves and blood vessels damaged

Less painful than partial thickness -superficial
NO blanching, more of a pale color
some moisture

Tx: admission to a burn center
surgical intervention needed to prevent necrosis and infection

66
Q

Zones to injuries

A
  • Zone of coagulation necrosis (center of burn)
  • Zone of stasis
  • Zone of hyperemia (edges)
67
Q

Physiologic changes

A
  • Capillaries leak: third spacing
  • Imbalance of fluids
    • Electrolytes: Na, K, Ca, Lactate
    • pH
    • Hypovolemic
    • Hyperkalemic
    • Hyponatremia (affects brain, swelling)
  • Hemoconcentration
    • Increased viscosity
    • Decreased perfusion (shock)
    • Tissue hypoxia
68
Q 
Electrolyte disturbances
Initial Resuscitation (0 - 36 hrs)
A

Hyponatremia - leakage, edema
Hyperkalemia - cell damage, release of K
Depends on severity of burn

69
Q

Electrolyte disturbances

Post resuscitation

A 
Hypernatremia
Hypokalemia
Hypocalcemia
Hypomagnesemia
Hypophosphatemia
70
Q

Physiological responses to burn injury

Integumentary

A

Skin loss –> sensory loss –> decrease temp

71
Q

Physiological responses to burn injury

Cardiovascular

A

Third spacing –> decrease BP –> increase pulse –> decrease RBC –> decrease CO –> decrease tissue perfussion

72
Q

Physiological responses to burn injury

Respiratory

A

Hypoxia –> increase respiration –> rhonchi –> decrease ciliary movement –> airway obstruction

73
Q

Physiological responses to burn injury

GI

A

Hyperacidity –> Ileus –> Melena –> Hematemesis –> increase abd girth

Curling’s stress induced ulcer. Always in stomach. The edges of ulcer are curled over.

74
Q

Physiological responses to burn injury

Urinary

A

Decrease GFR –> increase creatinine –> increase BUN –> increase spec gravity –> increase uric acid –> myoglobinuria

IV wide open to flush kidneys

75
Q

Physiological responses to burn injury

Immune

A

Decrease T-cell –> decrease B-cell –> increased WBCs –> decrease proteins –> phagocytosis

76
Q

Physiological responses to burn injury

Metabolism

A

Increase catabolism –> decrease anabolism –> weight loss –> acidosis –> hyperglycemia

77
Q

Electrolyte disturbances with post resuscitation

A
  • Hypernatremia: fluid shifts back to vascular system
    • Change to isotonic or hypotonic solutions
    • MAY NEED TO CHANGE TO NS or even 1/2NS
  • Hypokalemia: secondary to shift of K back into cells
    • Due to urinary loss
    • Monitor EKG
  • Hypocalcemia: Shift of Ca back into cells and urinary loss
    • Urinary losses
    • WATCH OUT FOR MUSCLE SPASMS
  • Hypomagnesemia: Coexistent with hypokalemia & hypocalcemia
    • MAY NEED TO BE CORRECTED FOR HYPOKALEMIA AND HYPOCALCEMIA TO RESOLVE
  • Hypophosphatemia: mobilization of fluids
78
Q

Initial burn evaluation - Trauma basics

A 
Airway
- Inhalation? Intubation?
  * Singed nose hairs, soot in oral cavity
  * Stridor indication they may loose airway.
Breathing
- Intubation
Circulation
- IV access for resuscitation
Deficits
- Motor? Neuro?
Exposure
- Must remove all clothing
- EVERYTHING COMES OFF, INCLUDING JEWERLY.  METAL HOLDS HEAT AND CONTINUES TO BURN
79
Q

Wound Care

A
  • Topical agents
    • Silvadene
    • Silver nitrate
    • Sulfamylon
  • Surgical intervention
80
Q

Goals of wound care

A

Close would quickly
Prevent infection
Reduce scarring and contractures
Provide comfort

81
Q

Topical wound care

Antimicrobial agents

A
  • Silvadene (sulfadianine) cream
    • Side effect: Leukopenia
    • Cooling effect
  • Silver nitrate team
    • Blackens skin
    • Side effect: Electrolyte abnormalities (Na and K)
  • Sulfamylon cream/solution
    • Side effect: Metabolic acidosis –> face & neck edema
    • Great penetration into burn wounds
82
Q

Surgical intervention

A
  • Escharotomy - prevent circumferential constriction, removal of eschar facilitates healing
  • Surgical debridement - remove burn wound to level of viable tissue, should bleed briskly before coagulation
  • Autografting - permanent skin coverage
    • Homograft/allograft - human skin
    • Heterograft/xenograft - animal usually pig
    • Biologic dressings - Biobrane, Integra
83
Q

Watson

A

Blade use for debridement

84
Q

Dematome

A

Used to harvest skin.

Harvest skin from upper thigh

85
Q

Management of burn patient

A 
Wound care
Nutritional optimization (higher calorie)
Pain control
Psychosocial
Prevent sepsis
86
Q

Child abuse

A

Donut pattern in buttocks
Sparing of soles of feet
Stocking or glove pattern burns
Waterlines

87
Q

Stevens Johnson Syndrome or TENS

A

Stevens Johnson Syndrome ( 20% body: TENS

88
Q

Guidelines for burn center referral

A
  • Partial-thickness burns > 10% total body surface area
  • Full-thickness burns
  • Burns involving the face, hands, feet, genitalia, perineum, or major joints.
  • Chemical and electrical burns
  • Inhalation injury
  • Preexisting medical disorders
  • Associated trauma
  • Hospitals without qualified personnel or equipment to care for burn-injured children
  • Patients requiring special social, emotional, or rehabilitative intervention
89
Q

Escharotomy

A

Lineal incision. Cut through eschar and to the superficial fat, NOT THROUGH SUPERFICIAL FAT

90
Q

Diet

A

HIGH PROTEIN AND CALORIES IN DIET

NUR 335 - Exam 4 (3 decks)

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