burns Flashcards
BURNS: DEFINITION
TISSURE INJURY CAUSED by THERMAL, CHEMICAL, ELECTICAL, or INHALATION BURNS
INITIAL ASSESSMENT AND TREATMENT - and what organ is important?
Assessment and initial treatment of burns is performed simultaneously with trauma resuscitation.
The initial management focuses on
Stabilizing the airway, breathing and circulation.
The primary evaluation includes:
Assessing for evidence of respiratory distress and smoke inhalation
Evaluating cardiovascular status
Determining the depth and extent of burns
INHALATION INJURY - is it a common cause of death?
Inhalation injury remains a leading cause of death in adult burn victims.
INHALATION INJURY - what type of breathing? and mental status?
COMMON SIGNS OF SIGNIFICANT SMOKE INHALATION INJURY:
Persistent cough, stridor or wheezing.
Hoarseness
Deep facial or circumferential neck burn
Nares with inflammation or singed hair
Carbonaceous (black) sputum
Depressed mental status
3 types of smoke & inhalation injuries (gloat about the types of inhalation)
Carbon Monoxide Poisoning
Inhalation injuries above the glottis
Inhalation injuries below the glottis
CARBON MONOXIDE (CO)
Colorless, tasteless, odorless, poisonous gas that is produced by incomplete combustion of burning materials.
CARBON MONOXIDE
When inhaled displaces O2 on the Hgb molecule causing hypoxia.
Has 250X’s the affinity to the Hgb molecule than O2
Accounts for the majority of deaths at the fire scene
INHALATION INJURY - what do pts usually need w/ severe inhalation burns?
CLINICAL HIGHLIGHTS:
SUPPLEMENTAL OXYGEN AND AIRWAY PROTECTION ARE THE CORNER STONES OF TREATMENT OF INHALATION INJURY. PTS WITH SEVERE BURNS OFTEN REQUIRE TRACHEAL INTUBATION.
FLUID RESUSCITATION - when does shock occur?
24-48 HRS after a MAJOR BURN, burn shock may develop
FLUID RESUSCITATION
Delay in fluid resuscitation is associated with increased mortality.
Pts. with moderate to severe burns , establish 2 large IV bore placed through unburned skin. May place through burned tissue to avoid delays
The most common formula is the Parkland formula
FLUID RESUSCITATION: THE PARKLAND FORMULA
Parkland Formula: (Commonly used)
4ml LR /Kg of body wt X Percent of TBSA burned
Give ½ of total in first 8 hours
½ in next 16 hours
Most reliable indicator of adequate fluid resuscitation in Burn patient is (how much)
urinary output. 30-50ml/hr ( 0.5 ML/KG )
RHABDOMYOSIS (Myoglobin)
Acute Renal Necrosis
Muscle damage leads to Myoglobin release from damaged muscle tissue
The Myoglobin (protein) can clog the renal tubules.
Clogged renal tubules lead to Acute Renal Necrosis.
Monitoring for Acute Renal Necrosis (necrosis is brown) AND
Myoglobinuria
Red to reddish-brown urine.
If urine dipstick is positive for blood, but neg for RBC’s on micro – consider Myoglobinuria
TREATMENT OF MYOGLOBINURIA (sodium and urine kills protein)
Increase urine output to 75 –100cc/hr
Increase urine alkalinity as this makes myoglobin more soluble.
Add NaHCO3 (sodium bicarbonate) to IV fluid.
The goal is to prevent myoglobin from clogging the renal tubules.
CONTRACTURES AND HYPERTROPHIC SCARS and KELOIDS - splinting for how long?
ROM, P.T.
Splinting and pressure garments for > 1 year
Multiple cosmetic or reconstructive surgeries
COMPLICATIONS: COMPARTMENT SYNDROME (compartmentalize the eschar)
With increased edema , there is elevation of the compartment pressure.
This may compromise distal circulation and requires escharotomy
Decompressive escharotomy of an extremity may be required for circumferential full thickness burn.
Escharotomy of the neck and chest may be required if mechanical constriction from eschar prevents respiration
GI COMPLICATIONS - SHOCK FROM THERMAL BURNS RESULTS IN (what about stomach?)
MESNTERIC VASOCONSTRCITION PREDISPOSING TO GASTRIC DISTENSION , ULCERATION AND ASPIRATION.
NUTRITION in MAJOR BURNS: - when can you start?
Hypermetabolic: 50 – 100% above normal.
Pain management - what drugs? (3 of them)
Procedures, Drsg changes, P.T. everything can hurt.
Pain management is critical, especially prior to procedures.
IV pain medication
MS, Dilaudid, Ativan
WOUND CARE - when are Allografts or homografts (cadaver grafts) used?
in emergent phase.
SKIN GRAFTING
Initially Synthetic or temporary grafts are used until permanent grafting is possible
PERMANENT GRAFTS: - when is autografting done?
AUTOGRAFTING is done when the patient can tolerate grafting/transplanting their own skin to the burn area.
PERMANENT GRAFT: - CEA (The CEA is permanent)
CEA
(CULTURED EPITHELIAL AUTOGRAFTS)
Must have auto-grafts or CEA to heal full thickness burns
REHAB PHASE (pink in rehab)
and when does the skin become raised? (raised the dead skin in 1 month)
New skin appears flat and pink.
After 4 to 6 weeks the skin will become raised and hyperemic (blood going to tissue)
PRESSURE DRSGS - how long? and bathing?
Gentle continuous pressure applied 24 hours per day for 1 – 2 years
Removed for bathing.
Less scarring and keloids
BURNS HIGHLIGHTS - how is Fluid resuscitation determined?
Pts with severe thermal burns are at significant risk of death and major morbidity.
Initial resuscitation : ABCs
Look for evidence of respiratory distress and inhalation injury.
Fluid resuscitation is determined by burn depth and size and is key to reconstitute intravascular volume
Parkland formula is the most commonly used formula.
BURNS HIGHLIGHTS (hot or cold cleanse?)
Urine out put is a key determinant in the efficacy of fluid resuscitation.
Monitor for RHABDOMYOSIS
Early initiation of feeding .
Wound care: cool and cleanse wounds
Pain control
Burn : a colossal psychological toll: coordinate care
Lastly : be safe.
new terms for 1st, 2nd, 3rd degree burns
superficial, superficial partial thickness, deep partial thickness, full thickness
study slide 6
dont need to know slide 7
need to memorize slide 8!!! Rule of 9s (for 18, you need 9)
for 18, you need 9
have an idea about slide 15
Common cause of death within 48 hrs
inhalation injury
inhalation injury - how prevalent
The risk of inhalation injury increases with the extent of the burn
It is present in 2/3 of patients with burns greater than 70% of TBSA
MAJOR BURNS CAUSE A HYPERMETABOLIC STATE THAT IS ASSOCIATED WITH:
immunosuppression
Impaired wound healing
Muscle catabolism
Hepatic dysfunction.
All full thickness burns must be
covered with autografts to heal.
TEMPORARY GRAFTS
Xenografts or heterografts
Allografts or homografts
Synthetic materials
Xenografts or heterografts
from animals (pigs)
Allografts or homografts
from humans (donor, or cadaver)
Synthetic materials - grafts (the opposite of integrity is lying)
Integra, Opsite, Lyofoam
who should get fluids? (Mr. Burns is 15)
Ant patient with greater than 15% of TBSA of nonsuperfacial burns should receive fluid resuscitation.
signs of shock
Myocardial depression
Increased capillary permeability
what happens if pt develops shock?
Large fluid shifts
Depletion of intravascular volume
shock - treatment
Rapid aggressive fluid resuscitation to expand intravascular volume is critical to maintain end-organ perfusion.
carbon monoxide - levels? (CO10)
Carboxyhemoglobin levels > 10% abnormal
Standard pulse oxymetry is not reliable with CO poisoning.
how to treat CO2
Tx with high flow O2 ( hyperbaric O2 if CO level are high)
bowels after a burn?
Bowel can become ischemic and translocation of bacteria can lead to sepsis.
when can you start eating? (starving for 2-3 days)
When bowel sounds return (2 – 3 days), start feeding (clear liq →reg diet)
IF NPO - where does the feeding tube go?
Feeding tube (BELOW the Pyloris to prevent aspiration) (Test Question) or
TPN (total parental nutrition
GI complications - same
Adynamic ileus (Paralytic ileus)
Translocation of bacteria
Sepsis
superficial
blanches, dry red
superficial partial thickness
blanches, weeping
deep partial thickness
no blanching, cheesy white and red
full thickness
no blanching, waxy gray black
