Burn, Shock, Sepsis Flashcards
Burn Pathophysiology:
-describe the cellular changes seen
Cellular Changes:
- intracellular influx of Na/H2O (edema)
- extracellular migration of K
- Disruption of cell membrane function
- failure of Na pump
Burn shock with depression of myocardium and metabolic acidosis
Burn Pathophysiology:
- hematologic changes
- cell damage occurs at what temperatures?
Heme:
- increase in HCT
- increase blood viscosity
- anemia d/t RBC destruction
Cell damage at temperatures greater than 113F
Burn Size:
-how is this quantified? also, describe two methods.
Quantified as a % of body surface area (BSA) burned.
Rapid method: based on the area of the back of the pts hand is approximately 1% of BSA
Rule of 9’s breaks portion of body into multiples of 9 with the perineum being 1% (Lund and Browder burn diagram)
First degree burn:
- signs/sx
- ex
2nd degree burn:
- sx/signs
- ex
3rd degree:
- signs/sx
- ex
Signs/Sx:
- erythema
- possibly edema
- minimal pain
(e. g. sunburn)
2nd degree:
Signs/sx:
- partial thickness
- much more painful than 3rd degree burn
- skin appears:
- -red/mottled
- -blisters with broken epidermis
- -considerable swelling
- wet/weeping surfaces
- -sensitive to air
e.g. deep sunburn, contact with hot liquids, flash burns from gasoline flames
3rd degree:
Signs/sx:
- damage to all skin layers, subQ tissues, and nerve damage
- pale white or charred
- leathery
- broken skin with fat exposed
- dry surface
- painless to pin prick
- edema
Inhalation Burns:
- signs
- causes
- management
signs:
- carbon around nose
- burns involving the mouth
- peri oral edema
- talking in raspy voice
- significant resp problems
Cause:
- fire in enclosed area
- remember CO exposure
- Toxic gases from combustion*
Management: intubate early
Chemical Burns:
- types
- -which type is worse?
- tx
Types:
- alkali
- acids
Alkali burns are more serious than acid burns b/c the alkalis penetrate deeper
Tx:
-the solution to pollution is dilution (IRRIGATE!!!)
Electrical Burns:
-more damage is done to the skin or deeper structures such as bone, muscle, blood vessels, and nerves?
- what are the consequences of muscle destruction?
- How would we tell muscle destruction has occurred and how do we manage that?
- how do we control metabolic acidosis?
More damage is done to the deeper structures.
Consequences:
-occult destruction of muscle can cause rhabdomyolysis which causes the release of myoglobin and can lead to acute renal failure
Rhabdo
- if urine is dark, assume myoglobin and increase fluids to achieve a urine output of 100 ml/hr
- if urine doesn’t clear, use mannitol to ensure continued diuresis
Metabolic acidosis controlled by perfusion and sodium bicarbonate to alkalinize urine to soluble myoglobin.
Burn Management
- check for evidence of airway involvement and if present consider endotracheal intubation early!
- start 2 large bore IVs ASAP
- inspect for corneal burns
- estimate depth and extent of burn and record.
- greater than 20% BSA partial thickness burn needs NG tube placed as ileus is likely
- CBC, CMP
- ABGs, carboxyhemaglobin level
- CXR and EKG
Urine for myoglobin and CPK
Tetanus Status
Foley catheter placement (every pt with significant burns gets one)**
Pain control
Burn Management:
-adult/child fluid resuscitation, what type of fluids are used?
Adult fluid resuscitation: NS or RL
Minimal burns/outpatient burns Tx
Which burns require admission to burn center?
Minimal:
- sulfadiazine/silvadene
- re-evaluate every 24hrs
- change dressings BID until burn stops weeping
Admission to burn center:
- partial thickness burns of greater than 10% BSA
- burns involving face, hands, feet, genitalia, perineum, or major joints
- 3rd degree burns in any age group
- electrical burns
- burns with preexisting complications (medical disorders)
- children with significant burns taht are not in a childrens hospital
Shock:
- definition
- cardiac response
- renal response
- neuroendocrine response
Definition:
- inadequate tissue/organ perfusion
- -pump failure, decreased peripheral resistance, hemorrhage
Cardiac response:
- tachycardia
- increased myocardial contractility/oxygen demand
- constriction of peripheral blood vessels.
Renal Response:
- stimulating an increase in renin secretion
- vasoconstriction of arteriolar smooth muscle
- stimulation of aldosterone secretion by the adrenal cortex
Neuroendocrine Response:
-increase in circulating ADH
What are the types of shock?
Types:
- hypovolemic:
- -decreased vascular volume
- -hemorrhagic
-Septic: systemic infections leads to hypotension, decreased vascular volume
- Cardiogenic:
- -shock resulting from some abnormal cardiac function (pump failure)
- Neurogenic:
- -failure of vasomotor regulation and pooling of blood in dilated capacitance vessels
Signs of shock
Tachycardia
Hypotension
Decreased urine output
Altered Mental Status
What clinical signs can be relied on to guide fluid resuscitation?
Which fluids do we use for resuscitation in shock?
Clinical signs:
- BP
- Urine output
- Mentals Status
- Peripheral perfusion (warm, cold)
Fluids used in resuscitation:
- **Isotonic saline
- colloids
What are the physiological responses to blood loss?
Heart Rate Increases
Cardiac contractility increases
Blood shunted to vital organs (pale extremities)
Conservation of water and sodium (decreased urine output)
Hemorrhagic Shock:
-physiologic effects @ site of loss
Local activation of coagulation system
affected blood vessels contract
activated platelets adhere to damaged vessels
Activated platelets release thromboxane A2 causing platelet aggregation and increased vessel contraction.
Hemorrhagic Shock clinical presentation
tachycardia
tachypnea
narrow pulse pressure
decreased output
cool clammy skin
poor capillary refill
Decreased CVP (flat neck veins)
hypotension (late)
AMS
Hemorrhagic Shock:
- Tx
- -how many IV lines?
- -what size needle/catheter
- -administer how much fluid for initial bolus in adults/children?
- -normal urine output/hr in adults and peds
- -if VS return to normal after initial bolus then what? if they responed and then drop?
Tx:
- 2 large bore IVs
- 16 gauge
- 1-2L in adults as rapidly as possible
- 20ml/kg
Normal urine output/hr:
- adults 30-50ml/hr
- peds: 1ml/kg/hr
If VS return to normal after initial bolus then
type/cross/hold blood and monitor urine output and vs.
If vs return to normal and then drop you give them blood and plan to go back to OR.
Hemorrhagic Shock:
- Tx:
- -other than blood replacement what are some other blood products may need to be infused?
- Labs to monitor
- management of hypothermia
Other blood products:
- FFP
- Platelets
Labs:
- ABG
- Calcium
- Coagulopathy
Hypothermia:
- use warm fluids
- use warm blankets
- keep recovery rooms warm
What is the goal of therapy in hemorrhagic shock?
Restoration of organ perfusion and adequate tissue oxygenation
Signs of restoration of organ perfusion and adequate tissue oxygenation?
Appropriate urine output
central nervous system function
skin color (pink up)
return of pulse and blood pressure towards normal.
Cardiogenic Shock:
- hallmark sign
- other signs
- tx
Hallmark signs:
-hypotension with signs of increased peripheral vascular resistance (weak, thready pulse, cool, clammy skin)
- Other:
- -inadequate organ perfusion: AMS and decreased urine output
Tx:
-pressors
Septic Shock:
- define
- gram -/+ bug
- explain why there is relative hypovolemia in septic shock.
Define:
- sepsis induced with hypotension despite adequate resuscitation along with the presence of perfusion abnormalities with may include but are not limited to:
- lactic acidosis
- oliguria
- acute alteration in mental status
Gram - bacteria causing endotoxic shock, except for TSS this is usually caused by Staph
Relative Hypovolemia occurs d/t loss of fluid into the interstitial spaces d/t increased capillary permeability. (decreased volume in vessels)
Septic Shock:
- wide or narrow pulse pressure?
- what are the common bugs causing Septic shock in each of the following:
- -GU
- -Resp
- -Below diaphragm
Wide pulse pressure
GU:
-e. Coli, Klebsiella, proteus, pseudomonas
Resp: strep pneumo, staph aureus
Diaphragm:
-aerobic gram - bacilli like clostridium
