Burns And Toxicology Flashcards
What is a syndrome What are the classes of Poisons State the signs for each Drugs for each How to reverse them if they’re reversible
Syndrome is a condition with multi system presentation
Sympathomimetics:
Aggressive,agitated cognitive state
Increased bp and pulse
Decreased secretions
Dilated pupil(midriasis)
Increased body temperature due to increased metabolism
Tachyarrhythmia
Sweating which will later become dry
Examples: heroine,cocaine,adrenaline,amphetamine , ephedrine
Give fluids due to reduced secretions
Give anti hypertensives such as labetalol or nitro Prusside
Cholinergics:
Miosis or pinpoint pupils
Hypothermia
Increased salivation
Peeing,pooing,sweating too much
Examples organophosphate,acetylcholine,carbachol,muscarine,pilocarpine
Give atropine , oximes.” Examples of oximes are pralidoxime and obidoxime[ to reverse
Anticholinergic:
Acts like sympathomimetic
But in this one there’ll be miosis not midriasis
There’s more dryness here than in sympathomimetics
There’s no sweating here
Examples atropine,tricyclic antidepressants,overdose of antihistamines example cetirizine ,amphetamine,scopolamine, belladonna alkaloids.
Drug given to reverse it is physostigmine or pilocarpine
Sedatives:
Examples benzodiazepines , barbiturates, Diazepam,lorazepam,midazolam,pentobarbital
An aesthetic agents
Signs: state of coma or semi conscious state,sleeping no matter what you do to them , RR reduces cuz sedatives depress the respiratory center
Slow cognitive state and hesitate To answer simple questions like what’s their name
Drug to reverse is naloxone and Flumazenil
- Opiate:
Example petidine
Morphine
Tramadol,codeine
Petidine and morphine are given to patients who don’t respond to normal pain medications
Signs: behaving like sedatives but there’s drop in bp,pulse,they depress the respiratory center worse than sedatives. They’re usually addictive. If you take ‘em for more than five days you can get addicted to them. So make sure the patient knows not to take them for more than five days .
Drug to reverse toxic effect is naloxone - Acetaminophen which is converted to N acetyl P benzoquinoneimine (NPQI) which is a toxic metabolite. Thiol plus NPQI in small doses is harmless but a high dose of NPQI depletes Thiol causing harmful problems
Para overdose after three days without treatment causes fulminant liver damage
Antidote: N-acetylcysteine (NAC). It is most effective when given within eight hours of ingesting acetaminophen
What fluid is given to patients w hyperkalemia
What kind of fluid is 10 percent dextrose
How much para will destroy the liver
Ringers
Hypotonic
24 tablets and one tab is 500g
How is toxicity managed
When is intubation required
How will you recognize a hysteria case
Which route does activated charcoal work?
Organophosphate fall under which major toxin group
How will you manage Cholinergics
What does consciousness depend on
ABCDE
In patient w GCS less than or equal to 8
It’s not the job of the PA to intubate
Go through the usual
D- find out from relatives what to patient took
There’s no specific antidote for sympathomimetics
If pulse is heading towards ventricular fibrillation (150bpm) and flutter it’s very dangerous
The time the patient presents is important
In cases beyond 6-8 hours activated charcoal is useless
It works between 4-8 hours
Hysteria cases the vitals are normal but the patient is in coma or is very unresponsive. There’s constant blinking of eyes when closed when you gaze in their eye.
If patient took poison through the mouth,that’s when activated charcoal will work.
If taken through Iv,IM,anus,aerosol it won’t work cuz it’ll go straight into systemic circulation
Cholinergics
Pick the signs you see even when others say otherwise example if they say it’s an organophosphate poisoning use your signs to confirm if it’s truly that kind of poisoning
Cholinergics:
Airway patency is unlikely cuz if the bunch secretions even when patient respond to name. Intubate if secretions are too much to suction
B- breathing will reduce
C- bradycardia so give atropine,secure IV line,give fluids (R/L or NS never DNS)
Cuz the vessels will be dilated leading to reduced cardiac return leading to reduced CO
Depend sim the amount infested so if patient takes a lot,the patient will be unconscious,if little delirious or (sometimes conscious,sometimes unconscious)
In high poison patient can go into shock
What’s the average normal RR When is it high When is it low What is 5 percent dextrose What are you worried about in patients w anticholinergic poisoning What will you give to reverse it What ar you worried about in sedative poisoning What will you give to reverse it
18cpn
More than 20 is high
Less than 12 or 15 is low
It’s 5g of sugar in 1000 mls of water
The more the seolvent the most e diluted the solution is. Sugar goes into the cells leaving behind the water in the cells. This causes increased conc of the cell against the plasma and decreased conc of the plasma. Through the semipermeable membrane which is the membrane of the plasma and the cells membrane. This causes osmosis and water moves from the plasma into cells causing cells to burst
Anti Cholinergics: hypothermia is more there than in sympathomimetics so give warm fluids
Give an agent to destroy the substance who sing to muscarinic receptors. Give acetylcholinesterase
Sedates : depress respiratory center so management of airway is important
Antidote is naloxone
Opioid overdose too the antidote is naloxone
Anything that depresses the resp center give naloxone
Beyond 8 hours activated charcoal is useless
Justine is an an aesthetic agent that doesn’t depress the respiratory center it makes patient sleep
What are you doing for someone w para poisoning
When is the lethal effect of para overdose seen
Observe the overdosed patient since signs will be mild. Overdose is different from poisoning.
12-24 tabs body can handle it as an overdose so detain and if presentation is between 4-8 hours five activated charcoal
Give antidote N acetyl cysteine if patient takes 24 and above tabs
After the first two days on the third day
24 hours there’s LFT elevation
48 hours: liver failure signs set in(hypoglycemia so be checking RBs,mild bleeding in mouth due to reduced clotting factors
72 hours : full blown liver failure or fulminant or end stage liver failure
What causes burns Treatment and recovery depends on what? When is rule of nines you used Check slide for better understanding How do you classify burns
Fire •Hot surfaces •UV rays •Electric currents •Chemicals
Depends on the total amount of the body burned & the severity of the burn
Rule of Nines”
– used for adults to estimate the percentage of the body burned
must be adjusted slightly for children because their proportions are different from adults
Front of face or head is 4.5
Back of face or head is 4.5
Front of chest is 9 and back of chest is 9
One arm is 4.5 the other is 4.5 so upper limb is 9
Front of abdomen is 9 and back of abdomen is 9
Genitalia is 1
One leg is 9 so both is 18
Degree of burn is decided according to the number of skin layers involved
First degree: First Degree Burn – involves only the upper epidermis
•causes reddening of the skin, minor discomfort
•Ex.) mild sunburn
Second degree: •Second Degree Burn – involves deep epidermal layers and damages upper dermal layers
•damages sweat glands, hair follicles, sebaceous glands
•causes blistering, severs pain, swelling, fluid loss, scarring
Third Degree Burns – complete destruction of the epidermis and dermis, damages the subcutaneous tissue & sometimes muscle and bone
•lesions are insensitive to pain at first
•causes serious scarring, extremely susceptible to infection
What are the vascular chnages that result from burns
Circulatory disruption occurs at the burn site immediately after a burn injury
•Blood flow decreases or cease due to occluded blood vessels
•Damaged macrophages within the tissues release chemicals that cause constriction of vessel
•Blood vessel thrombosis may occur causing necrosis
•Macrophage: A type of white blood that ingests (takes in) foreign material. Macrophages are key players in the immune response to foreign invaders such as infectious microorganisms.
What is fluid shift
Occurs after initial vasoconstriction, then dilation
•Blood vessels dilate and leak fluid into the interstitial space
•Known as third spacing or capillary leak syndrome
•Causes decreased blood volume and blood pressure
•Occurs within the first 12 hours after the burn and can continue to up to 36 hours
What is fluid imbalance
Occur as a result of fluid shift and cell damage
•Hypovolemia
•Metabolic acidosis
•Hyperkalemia
•Hyponatremia
•Hemoconcentration (elevated blood osmolarity, hematocrit/hemoglobin) due to dehydration
What is fluid remobilization
Occurs after 24 hours
•Capillary leak stops
•See diuretic stage where edema fluid shifts from the interstitial spaces into the vascular space
•Blood volume increases leading to increased renal blood flow and diuresis
•Body weight returns to normal
•See Hypokalemia
What is curlings ulcer
How do patients present w it
In burns replace fluid and electrolyte due to fluid shift
Do electrolyte test to find out which are depleted
Do RFT
In chemical and exhaust fumes,gas,the burns usually cause airway obstruction
Acute ulcerative gastro duodenal disease
•Occur within 24 hours after burn
•Due to reduced GI blood flow and mucosal damage
•Treat clients with H2 blockers, mucoprotectants, and early enteral nutrition
•Watch for sudden drop in hemoglobin
Days after burns the patient complains of stomach pain or presents w signs of gastritis or ulcer
State the phases of burn injuries
What is the emergent phase and what are the goals
Emergent (24-48 hrs)
•Acute
•Rehabilitative
Immediate problem is fluid loss, edema, reduced blood flow (fluid and electrolyte shifts)
•Goals:
1. secure airway
2. support circulation by fluid replacement
3. keep the client comfortable with analgesics
4. prevent infection through wound care
5. maintain body temperature
6. provide emotional support
In the emergent phase,what do you need to know? Why are Calculations based on weight obtained after fluid replacement is started are not accurate?
What is important in determining BSA
Knowledge of circumstances surrounding the burn injury
•Obtain client’s pre-burn weight (dry weight) to calculate fluid rates
•Calculations based on weight obtained after fluid replacement is started are not accurate because of water-induced weight gain
•Height is important in determining body surface area (BSA) which is used to calculate nutritional needs
•Know client’s health history because the physiologic stress seen with a burn can make a latent disease process develop symptoms
What are the clinical manifestations of the emergent phase and what values should you measure
Clients with major burn injuries and with inhalation injury are at risk for respiratory problems
•Inhalation injuries are present in 20% to 50% of the clients admitted to burn centers
•Assess the respiratory system by inspecting the mouth, nose, and pharynx
•Burns of the lips, face, ears, neck, eyelids, eyebrows, and eyelashes are strong indicators that an inhalation injury may be present
•Change in respiratory pattern may indicate a pulmonary injury.
•The client may: become progressively hoarse, develop a brassy cough, drool or have difficulty swallowing, produce expiratory sounds that include audible wheezes, crowing, and stridor
•Upper airway edema and inhalation injury are most common in the trachea and mainstem bronchi
•Auscultate these areas for wheezes
•If wheezes disappear, this indicates impending airway obstruction and demands immediate intubation
Cardiovascular will begin immediately which can include shock (Shock is a common cause of death in the emergent phase in clients with serious injuries)
•Obtain a baseline EKG
•Monitor for edema, measure central and peripheral pulses, blood pressure, capillary refill and pulse oximetry
Changes in renal function are related to decreased renal blood flow
•Urine is usually highly concentrated and has a high specific gravity
•Urine output is decreased during the first 24 hours of the emergent phase
•Fluid resuscitation is provided at the rate needed to maintain adult urine output at 30 to 50- mL/hr.
•Measure BUN, creat and NA levels
Sympathetic stimulation during the emergent phase causes reduced GI motility and paralytic ileus
•Auscultate the abdomen to assess bowel sounds which may be reduced
•Monitor for n/v and abdominal distention
•Clients with burns of 25% TBSA or who are intubated generally require a NG tube inserted to prevent aspiration and removal of gastric secretions
How is the skin assessed in the emergent phase
What nursing diagnosis is given in this phase
Assess the skin to determine the size and depth of burn injury
•The size of the injury is first estimated in comparison to the total body surface area (TBSA). For example, a burn that involves 40% of the TBSA is a 40% burn
•Use the rule of nines for clients whose weights are in normal proportion to their heights
- Decreased CO
- Deficient fluid volume r/t active fluid volume loss
- Ineffective Tissue perfusion
- Ineffective breathing pattern
