CC final: Forensics, Burns, Organ Transplant, Acute Renal Failure Flashcards
What type of bag should you put forensic evidence in?
Paper bag. Plastic ones will produce mold because of a lack of proper drying if the evidence is wet. If wet, allow to dry before sealing the paper bag. If unable to dry, seal in paper bag, place in plastic (bio-hazard bag), and do not seal the plastic bag. Put each item in separate bags. Trace evidence can be removed with transparent tape which can be placed onto paper evidence bag (hair fibers, etc)
What is the number one priority for the medical team with forensics?
To medically stabilize the patient. All attempts should be made to preserve/collect evidence unless the patient is in imminent danger of death.
When should you describe and document wounds during forensics?
definitely prior to any medical treatment (unless life-saving measures are required); and after treatment, if possible.
What do you do with evidence photographs (in relation to the police)?
They are a physical part of the medical chart and should NOT go with the police; they stay with the chart. Police have to have a subpoena to get them.
When photographing evidence, what is the best angle to take?
90 degree.
If you are unable to get paper bags to put evidence in, what is a good way to store the evidence at the time of removal (ie of clothes)?
Place 2 sheets (one on top of other) on the ground to place evidence on. Top sheet will go into paper evidence bag once all other evidence is collected and bagged and can be used to collect trace evidence. Bottom sheet sent to laundry. If space is limited, a sheet-lined cardboard box can be used for evidence to be placed in and the sheet can be sealed upon completion to be used for trace evidence.
What is the most important organ for evidence procurement?
skin
What do you do with dried secretions?
Moisten swab with NS or Sterile water, collect specimen, and place into plastic specimen container. Allow swabs to dry before sealing, if possible. Swab any area of the patient’s body that is not obviously explained by the injuries.
Can you cut clothing off the patient when getting forensic evidence?
If it has to be, cut away from obvious evidence (ie gunshot area).
How should you remove shrapnel (ie gun fragments, explosive fragments, etc)?
Should be removed only with rubber-tipped forceps (to avoid scratching) and place in plastic cup (not metal) (to avoid scratching)
What should you do if a weapon is found?
Handle carefully (with gloves); Give to police, if present, or to the security personnel. If they are legally registered (have a concealed carry license), they are allowed to have it legally but you will still give it to security until the patient is discharged.
What info should bags/specimen containers have?
ID information
Date
Time
Where obtained (location of body)
Are direct statements of patients in documentation admissible in court?
Yes.
What are some things you should document upon arrival ?
- State of emotions
- All noted wounds (before and after treatments)
- if gunshots, note suspected entrance and exit wound locations and conditions
- any residue, powder, soot, particles, etc
- Unusual odors (ie Ammonia (meth explosions))
- Behavior, attitude, preoccupation with items or persons
When is the RN exempt from HIPAA Violations during a forensic case?
If the people have a court order or subpoena
Signs of child abuse:
- Bruises on Posterior side of body, unusual patterns/stages of healing
- Burns (especially scalding)
- Missing/loosened teeth
- Skeletal injury (look at healing patterns)
S/s of Domestic Violence:
- Partner unwilling to leave patient alone during assessment
- Delay between injury and presentation
- Bilateral, multiple or patterned injuries
- Physical findings inconsistent with medical history
- Partner controlling
What abuse is mandatory to report in KY?
Adult: Any person over age 18 who is mentally or physically dysfunctional and unable to manage resources; Any person (regardless of age) who is a victim of abuse by spouse
Child: Any person under age of 18
What are some examples of Coroner’s Cases? What do you do with the body?
- Death by homicide/violence
- Result of Suicide
- Result of presence of drugs/poisons
- Unexplained death occurs while in a state mental institution or hospital
- Death sudden & unexplained
Don’t remove any lines/tubes/airways
Clothing/belongings go with body usually
Don’t clean body
If gun-shot residue is suspected on hands, place hands in paper bags & seal with tape
The most common intrarenal condition that may occur after prolonged ischemia (prerenal), exposure to nephrotoxic substances (ie some meds), or a combination of these =
Acute Tubular Necrosis (ATN)
The absence or suppression of urine =
Anuria
Increases in BUN and serum creatinine =
Azotemia
What is Oliguria?
Urine output less than 0.5 mL/kg/hr
What’s a normal BUN level?
7-20
Normal Creatinine level?
0.7-1.4
Retention of nitrogenous substances (ie urea) normally excreted by the kidneys =
Uremia
Occurs as a result of a pressure gradient; Blood flows through each glomerulus and water, electrolytes, and waste products are filtered out of the blood across a membrane and into Bowman’s capsule; should basically be protein free and contains electrolytes (Na, Cl, Phosphate), and nitrogenous waste products (creatinine, urea, uric acid); RBC’s, albumin, and globulin are too large to pass through it in a healthy kidney
Glomerular filtration
What is a normal GFR?
80-125
With a MAP of <___ or >____, the kidneys will have a hard time adjusting to fluctuations in arterial BP. The GFR will ____ drastically with an extreme MAP.
60; 250; fall
Describe the RAAS (Renin-Angiotensin-Aldosterone System) Cascade:
Hypovolemia/Low BP/Renal Ischemia or Decreased Sodium Ion concentration of blood causes Renin production by cells in the Juxtaglomerular apparatus of the kidney; Renin plus Angiotensin (produced by the liver); Release of Angiotensin 1 from the liver (a weak vasoconstrictor); tells lungs to produce & secrete ACE which converts Angiotensin 1 to Angiotensin 2 (a major vasoconstrictor); this stimulates release of Aldosterone (causes retention/reabsorption of Na & H2O/potassium excretion)=more fluid in BV’s= Increased BP
Prerenal causes of ARF/AFI:
(60-70% of kidney probs); Interfere with renal perfusion
Volume depletion
Vasodilation/hypoperfusion
Decreased performance/Cardiac failure
Misc (meds (ie ACEI,NSAIDS–block Cox 1, the good Cox), sepsis, neurogenic shock)
What are the most common causes of ARF/AKI?
Prerenal Etiologies
How do ACE Inhibitors work?
Block Angiotensin 1 from converting to Angiotensin 2
What is often a 1st clue of stressed kidneys?
Decreased UO (because GFR decreases, solutes move more slowly=dec UO)
What is the most effective method of treatment for Prerenal ARF?
Increase fluid intake
Treatments for Pre-renal ARF:
With hypovolemia, give fluid volume challenge (type of fluid varies); UO should Increase within 10-20 mins, and if not seen within 30-45, then fluid challenge failed and may be repeated.
Meds to restore CO via increasing HR or BP as needed.
Restore defense mech’s (RAAS) by d/c-ing ACE/ARB’s
How do ARB’s work?
stop Angiotensin 2 from binding to its receptor sites.
Hypovolemia S/s?
Low CVP or PAWP Flat jugular veins Tachycardia Hypotension Poor Skin turgor Weight loss
Hypervolemia S/s?
Increased CVP or PAWP Distended jugular veins Rapid Heart Rate S3 Elevated BP Dyspnea Crackles Shallow, rapid respiration
When do you draw the peak and trough of meds?
Peak: When metabolites are at their highest (a/b 30-60 mins after latest dosage)
Trough: When at lowest: drawn right before next dose
What are some things you need to have caution with for Pre-renal ARF?
Diagnostic dyes and test that require extra filtering of substances, meds, etc.
If possible, avoid nephrotoxic substances
Peak and trough of known nephrotoxic meds to avoid toxicity (ie Antibiotics like Vancomycin, Gentamicin, etc)
Aseptic technique to avoid infections
Causes of Intrinsic/Intra-renal Failure:
Acute Glomerulonephritis Vascular Disease (malignant HTN, Hemolytic Uremic Syndrome--from E.coli exposure often) Tubular Obstruction (Rhabdomyolysis--huge release of myoglobin clogs kidneys) Acute Tubular Necrosis (the most common form of intra-renal failure)** Pre-renal failure is the most common cause of intra-renal failure**
Conditions or situations that are high risk for Intra-renal failure:
- Meds (NSAIDS, antibiotics, ACEi's) - Contrast media (dye) - Overdoses - Hemodialysis (especially on an otherwise healthy kidney, ie OD)
What is a first s/s of antibiotic toxicity?
Tinnitus
What are the two main types of ATN (Acute tubular necrosis)?
Ischemic & Toxic
What is Ichemic ATN due to?
Due to Prolonged Hypoxia
Causes the tubular cells to swell, slough off and then occlude the tubular lumen
Also permits profound renal vasoconstriction (can also be caused by pharm agents (neo, norep, ARB’s, etc)
What causes Toxic ATN?
Concentration of nephrotoxins in tubular system
Meds (aminoglycosides antibiotics–neomycin, tobramycin, gentamicin,etc)
Occurs 7-10 days after insult
Diagnostic dyes–usually within 48 hours
Aggressive hydration is main way to prevent this problem (assuming heart/lungs can handle it)
Stages of ATN (now usually only called Intra-renal Failure):
1) Onset
- begins with insult & until cell injury occurs–lasts 2-4 days
- Goal: determine cause & prevent progression of RF
- s/s: dec. UO, Inc. BUN/Cr slightly
2) Oliguric/Anuric
- main goal: support renal function & keep patient alive (inc. K+ is problematic)
* * <400 mL/day
- 10-14 days
3) Diuretic
- degree depends upon hydration state at time of onset, BUN/Cr slowly recover, lasts about 10 days
4) Convalescent
- Most fully recover
- Can last up to 1 year
What is the most sensitive indicator of kidney function?
Creatinine
What is Post-renal failure generally caused by? What occurs?
Generally deals with obstruction
Lowers GFR & Tubular fluid flow
Increased Na, water, & urea reabsorption lowering Na urine concentration & Increasing Urine Osmolality, BUN, & Cr.
Requires blockage of both kidneys (or unilateral if only one kidney present)
After obstruction is cleared, profuse urination may present (1 L/h at times); watch electrolytes closely. Don’t let all the fluids come out at once (will cause bladder spasms); clamp f/c, wait 20 mins, & restart
What will the BUN and Creatinine be like with ARF?
BUN INCREASED due to dec urine flow rate (increased urea absorption); Creatinine INCREASED due to GFR decrease
How do you do a 24-hour urine?
1) patient empties bladder, exact time is recorded, and specimen is discarded.
2) All urine for the next 24 hours is saved in container & stored in refrigerator.
3) Exactly 24 hours after the start, the patient voids again, and the specimen is saved.
4) The serum creatinine level is assessed at the end of 24 hours.
5) The urine is sent to the lab for testing. (urine can also be saved from an indwelling catheter.
The test is valid only if the collection includes all the urine you pass in a 24-hour period. The test will be inaccurate and may have to be repeated if, for any reason, some of the urine you pass during the 24-hour period is not put into the collection container.
Urine kept on ice. If they accidentally go in the toilet, you’ll have to restart.
What does a 24-hour urine check specifically?
Creatinine Clearance. The most accurate reflection of reduction in nephron functioning.
Name 3 nursing diagnoses for the patient with Acute Kidney Injury:
- Excess fluid volume r/t Na/H2O retention & excess intake
- Risk for Infection r/t depressed immune response secondary to uremia & impaired skin integrity
- Imbalanced nutrition: less than body requirements related to uremia, altered mucous membranes, & dietary restrictions.
What’s the least common type of ARF?
Post-renal ARF
Type of Dialysis that’s intermittent, can be temporary or permanent, usually in adjunct to kidney transplant; if long-term, shunt is placed.
Intermittent Hemodialysis
Type of Dialysis utilized only in the ICU, is very intense & continuous, usually utilized to rest heart/vital organs =
CRRT (continuous renal reperfusion/replacement Therapy)
Least invasive type of Dialysis that does not require a shunt; instill osmotic solution into abdominal cavity =
Peritoneal Dialysis
What is the most common type of Dialysis?
Intermittent Hemodialysis
What is CRRT often used for ?
People with HF
Indications for Dialysis: (7):
ARF CRF Fluid Overload PE HF Electrolyte Imbalances Overdoses
What do you do if a patient is on Intermittent Hemodialysis and they are also on meds?
Make sure you give meds 2 hours prior (or if you can wait, give after). If on continuous IV’s, you can just let run. Piggybacks instilled 2 hours prior (or stopped).
What med is often given with Dialysis?
Heparin. So check PTT
What is the most common complication from Peritoneal Dialysis?
Peritonitis.
What organization do you contact to talk/deal with patients getting Organ Transplantation?
KODA (Kentucky Organ Donor Affiliates).
Who started the online database used for the collection, storage, analysis, and publication of all data dealing with the patient organ donor waiting list, organ matching, and transplants? What’s it called? Why’s it important?
UNOS went online with their database in 99’; it’s called UNet; You have to be in this system to get transplant
When an organ becomes available, a list of potential recipients is generated according to the ranking of what? (6) What happens after that?
1) Blood type
2) Tissue type (Antigen/Antibody)
3) Size of the organ
4) Medical urgency of the recipient
5) Time on waiting list
6) Distance between the donor & recipient
All of first 4 things being equal, longest on list gets it.
BTSUTD “Billy took Susie up to Denver”
The procurement coordinator (usually an RN) contacts transplant physician of top candidate to offer the organ. If surgeon decides it’s not suitable, the same process happens with the next ranked candidate. Physician has last say in whether they are good to get it.
Surgical teams notified.
Kidney & pancreas are required to have additional lab tests to test immune system compatibility.
For an organ transplant, a heart or lung are best within ____ hours; Liver can be stored up to _____
6; 24 hours
What are Organ procurement organizations (OPO’s)?
They handle all organization of the transplant.
From the time of consent they assume all costs of the organ procurement (donor), except for funeral costs.
What law gives people 18 and over the right to donate organs/tissues? What starts this process?
Uniform Anatomical Gift Act; Signing back of driver’s license and/or signing a donor card starts this process.
What was passed in 1984 to address organ shortage? What did it establish?
National Organ Transplant Act; Established the OPTN
Does insurance cover costs related to living donation of organs?
Usually covers 100%, but this may vary
Medicare Part A: pays all donor’s expenses from preliminary testing to recovery
Medicare Part B: pays for physician services during the hospital stay.
They also cover follow-up care if complications arise.
What is the most common type of organ donation from?
Brain death
Which organs can be a “living donation”?
Kidney (most common)
Liver (can regenerate); rarely done any longer
Lung: (cannot regenerate); can donate lobe
Pancreas (cannot regenerate); rarely done
Intestine: very rare
Heart (when they receive a heart/lung, they can then donate their healthy heart)
What are the qualifications for a living donor?
Physically fit, between ages 18-60 Generally good health Free from: HTN DM CA Kidney Dz CAD HIV TB
Eligible Dead or Dying Donor qualifications?
< or equal to 70 years old; this doesn't apply to some tissue (eye, skin, bone, cartilage, etc) Meets criteria for brain death None of the following: TB/HIV/AIDS Creutzfeldt-Jacob Dz Herpetic Septicemia Rabies Hep B with reactive Surface Antigen Any retrovirus infection Active CA Hodgkin's Aplastic Anemia Agranuloycytosis Fungal/viral meningitis Viral Encephalitis Gangrene of bowel Uncontrolled sepsis
Eligible organ Recipient qualifications:
<70
No sign and/or hx of the following:
Untreated malignancies within last 5 years
active infections not responding to therapy
HIV
Active Hepatitis
Active substance abuse
Severe COPD
ASHD/CAD (EF <20) unless receiving a heart transplant
Psychosocial/behavior difficulties
Morbid obesity (BMI >35)
Donation requirements to be “brain dead”:
Ventilator dependent (NO spontaneous breaths at all) AND Clinically explained GCS < or equal to 5 OR Absence of 2 or more brain stem reflexes -No pupillary response -No corneal response* -No ice water lavage response* -No Doll's eyes -No gag/cough reflex -Not triggering the ventilator -No motor response OR -current plans to d/c vent or life-sustaining therapies -DNR obtained -Family asks/mentions organ donation wishes
Conditions that may mimic brain death (clinically UN-explained GCS of less than 5)(not eligible for brain death donation):
Drug OD
Severe Hypothermia
Severe Shock
Common causes of brain death: (5)
TBI (most common) Bleeding in brain Anoxia CNS Brain tumor Meningitis/encephalitis
What blood is the Universal Donor?
O neg
What blood is the Universal Recipient?
AB pos
Rh+ blood can take ____; Rh- blood can take ______
Rh +/- ; Rh-
What blood can an AB+ person receive?
All types (O-, O+, B-, B+, A-, A+, AB-, AB+)
What blood can an AB- person receive?
O-, B-, A-, AB-
What blood can an A+ person receive?
O-, O+, A-, A+
What blood can an A- person receive?
O-, A-
What blood can a B+ person receive?
O-, O+, B-, B+
What blood can a B- person receive?
O-, B-
What blood can an O+ person receive?
O-, O+
What blood can an O- person receive?
O-
Once the blood types of the organ donor/recipient are matched, the following takes place:
- Tissue-typing–typing of WBC’s
- Cross-matching: test for reaction to the organ
- Antigen/Antibody screen: Looking for PRA (Panel Reactive Antibody); WBC’s of donor and the serum of recipient are mixed to check reaction
- Urine tests: for donation, 24 hour urine is performed to determine adequate function
- X-rays: screen heart/lung for disease
- Arteriogram: view organ
- Psych eval: of living donor & recipient
Reasons for Kidney Transplant: (9)
Glomerular Dz Diabetes Polycystic kidneys HTN nephrosclerosis Renovascular & other vascular dz Congenital d/o's Tubular & Interstitial dzs Neoplasms Transplant/graft failures
Reasons for Pancreas transplant: (4)
Transplant/graft failure
DM 1&2
Pancreatic CA
Bile duct CA
Reasons for Liver transplant:
Cirrhosis Biliary dz Hepatic necrosis Metabolic Dz Malignant neoplasms
Reasons for Heart Transplant:
Cardiomyopathy CAD Congenital Heart dz Valvular Heart dz HF Transplant/graft failure
Reasons for lung transplant?
Congenital dz CF Emphysema/COPD PPH Transplant/graft failure
Reasons for Intestine transplant:
Short gut syndrome
Functional bowel problems
What are some types of tissue donation?
Cornea Skin Bone Saphenous Vein Middle Ear bones Heart Valves
*age of donor doesn’t matter with these
An organ or tissue transplant from one individual to another of the SAME species =
Allograft
A graft of skin or other tissue taken from the body of the person to be grafted rather than from another person =
Autograft
A graft from one species to another different species =
Heterograft (ie pig or cow heart valves)
Which type of graft has the lowest chance of rejection?
Autograft
Which type of graft always has a possibility of rejection?
Allograft
When caring for the organ donor who is about to donate, what is important? What are some potential complications?
- Have to keep relatively stable until time to donate
- Manage Hemo. Instability:
- Hypotension possible
- Vasoactive meds almost always required (ie Mid-Level Dopamine)
- MAP above 60
- UO greater than 1 mL/kg/hr
- EF greater than 45
- CVP of 6-8 or PAWP of 8-12 (usually use fluid bolus)
- Manage DI (occurs often (40-70%) due to insufficient ADH b/c they’re brain dead)
- UO greater than or equal to 300 mL/hr
- Urine Spec. Grav less than 1.010
- Serum Na greater than 150
- Absent urine glucose
- DDAVP can be used (mimics release of ADH)
- Vent Management
- PaO2 >70
- O2 98%+
- TV 8-12
- FiO2 <60
- PEEP <or equal to 5
- Manage Electrolytes:
- Na <150
- K+ >4
- Correct acidosis by mild hyperventilation for PCO2 30-35
- Hypothermia
- from dysfunction of hypothalamus after brain death
- Poikilothermia occurs (body takes on temp of room)=turn up room temp to 90+ and/or give warm IV fluid, warming blanket, to maintain temp about 98 degrees
- PA catheter helps with core body temp as well
What causes a Hyperacute Rejection of an organ?
Occurs if antigens are completely unmatched; ie blood types don’t match
*not as common due to antibody/antigen testing
Almost immediately takes place
What causes an Accelerated Rejection of an organ? When does it occur? What is it treated with?
- Recipient has been sensitized to some of the donor antigens; rare now due to testing
- Occurs within 1st week
- Treated with Steroids, immunosuppressants, but usually results in failure of graft
What causes an Acute rejection of an organ? When does it occur? What is it treated with?
Most common (15-60%); during the 1st year post-transplant Cell-mediated response that results in T-lymphocytes infiltrating the donated organ & damaging it by secreting lysosomal enzymes and lymphokines which severely damage the organ. Anti-rejection immunosuppressant meds are used and can result with good survival. On meds rest of life.
What is Chronic Rejection of an organ? When does it occur?
- Occurs months to years after transplant
- Not totally understood
- Combo of humoral & cell-mediated immune responses
- usually progressive failure of organ
- usually doesn’t respond well to immunosuppressive therapy.
- Prevention & early detection of stressed implanted organ is key (ie consistent blood tests, s/s monitoring, etc).
Types 1 & 2 of immunosuppression therapy :
Induction & maintenance are used to prevent rejection of the transplanted organ
*Induction: Temporary use of meds in the peri-operative period where likelihood of rejection is highest (ie Rabbit ATG & Zenapax)
Name 2 meds used for Induction Therapy (an Immunosuppressant Therapy):
Rabbit ATG (Antithymocyte globulin)
-mechanism of action unknown
-thought to reduce # and alter function of T-lymphocytes (which start antigen-antibody response)
Zenapax (daclizumab)
-binds to surface of activated T-lymphocytes
Type 3 immunosuppressant therapy is what?
To treat an acute rejection episode
- usually accomplished by high dose corticosteroid and higher doses of immunosuppressant meds (ie Rabbit ATG, Zenapax) - Corticosteroid therapy (methylprednisolone, prednisone) interferes with T-cell & macrophage functions
What are the potential SE’s of high-dose steroids? (Cushing’s)
severe fatigue weak muscles high blood pressure high blood glucose increased thirst and urination irritability, anxiety, or depression a fatty hump between the shoulders Excess hair
The role of the critical care nurse in relation to organ donation: Under federal law, the only thing the RN on the floor can do is _____
contact KODA
Most common type of burn is ______
Thermal= 90% (fire/flame-40%, scalding-30%, contact with hot object-8%)
____ burns often involved in child abuse. S/s?
Scalding. Burns on bottom of feet and hands (to stop themselves from being dipped in the hot water).
Type of burn when skin comes into contact with a temp source sufficient to cause damage (usually 140 degrees); severity r/t amount of heat, exposure time, and BSA involved; children/elderly at greater risk (decreased reaction time, thinner skin, decision making =
Thermal injury
How do you treat Thermal Burns?
1) Remove source
2) ABC’s asap: leave burn treatment until after airway established.
3) Cool Skin: with bottled water or sterile water; Don’t use pond/stream/etc (bacteria); cools surface, stops burning interiorly, dec. pain (full-thickness burns will not be initially painful)
4) Cover with dry, sterile covering (don’t use fibrous blanket & don’t remove clothes–surgically removed)
5) Transport to ER STAT
Type of burn with contact, inhalation of fumes, ingestion, or injection of alkalies, acids, or organic chemicals; occurs until chemical is completely removed or neutralized =
Chemical Burns
What is the most dangerous type of chemical burn?
Alkalies
- cleaning products (oven cleaners, wet cement, fertilizers) - loosens tissue by protein denaturation & liquefaction necrosis - binds to tissue protein=difficult to stop
Most common type of chemical burn =
Acids
- found in cleaners (bathroom, pool, rust removers); bleaches - Hurt most at 1st but are more superficial - depth is mostly limited to area involved due to their ability to cause coagulation necrosis of tissue & precipitation of protein - However, hydrofluoric acid (a weak acid) causes HYPOCALCEMIA (thus dysrhythmias) due to rapid binding to free-calcium in the blood
What do you do if you get wet cement on skin?
Wash off immediately with soap & water; if dries, can liquify skin underneath
Chemical burns caused by Phenols & Petroleum products (ie gasoline, chemical disinfectants, etc =
Organic compound chemical burns.
Phenols cause severe coagulation necrosis of dermal proteins and can produce “Eschar”
Petroleums: promote cell membrane injury and dissolution of lipids resulting in skin necrosis
-if systemic exposure occurs, CNS depression, hypothermia, hypotension, pulm. edema and intravascular hemolysis (RBC’s lysed=hypoxia) (can be severe or fatal)
Treatment for Chemical Burns:
At scene: aggressively irrigate with cool water; best defense
Use removal agent if known & available
If lime-based burn, lime must be brushed away (usually forms a powder type substance on skin)
Cement is an alkali and should be washed with soap and water (surgical excision if dried).
Electrical burns:
High voltage= >____
Low = ____
What is a household current usually?
1000; less than 1000; 100-250
Electrical Burns Duration of Injury dependent upon:
Amount of Voltage (source)**
Amps passing through tissue: liquify tissue with BV’s = risk of Compartment Syndrome
Duration of contact
Pathway of current **
**=most common deaths
Common complications of electrical burns:
**V-fib most common/other dysrhythmias--Asystole Reps. Arrest Seizures/coma Mental changes HTN Retinal detachment Cataract (delayed) Muscle necrosis Fractures Hemolysis Renal Failure Hemorrhage Limb loss Anemia **Paresis/paralysis
What do the entrance and exit wounds often look like with electrical burns?
Entrance wound may be small, but exit can be explosive; electricity follows path of least resistance; increased voltage will cause increased/multiple exit wounds
Sequence of damage for an Electrical Burn:
- Immediate damage caused by heat destruction of cells (usually patchy distribution along the path of the current)
- Devascularization follows=injury to BV’s= 3rd spacing=Compartment Syndrome possibly
- Renal Failure: damage to tissue=myoglobin released = clogs kidneys
Burn zone that’s the greatest area of tissue necrosis at the core of the wound; deepest part of burn; irreversible skin death; inside of “bullseye”; usually dark color & leathery
Zone of Coagulation
Zone of injury of burn that is the middle part of the “bullseye”; viable & non-viable cells; vascular damage & ischemia; Moist, blistered, red in color; cap refill less than 3
Zone of Stasis
Burn zone of injury with intact microcirculation which can heal spontaneously within few days; initially pink in color; Outer ring of “bullseye”; can convert to other zones if not cooled
Zone of Hyperemia
Causes of Superficial Thickness (1st Degree) Burns: (3)
Scalding, Severe Sunburn, Steam Burns, etc.
What layer(s) of the skin do Superficial Thickness (1st Degree) burns affect? How long for full healing?
Epidermis Only; 3-5 days
Treatment for Superficial Thickness (1st degree) Burns?
Treat with cool water to stop burning process.
Apply protective lotion/salve
Area will be pink/red, painful with blisters rarely forming (want to leave blisters intact; if accidentally bust them, can apply anti-microbial)
5 Different Levels of Superficial/Partial-deep Thickness burns:
Superficial 2nd degree: slightly deeper than Superficial Thickness (1st)
Mid-Dermal (mid-2nd degree): epidermis to the basement membrane; can easily convert to deep partial thickness burn
Indeterminate (mid-2nd degree to deep 2nd degree)
Deep Dermal (Deep 2nd degree): entire epidermis and at least 2/3 of dermis
Indeterminate (deep 2nd degree-3rd degree): usually initially diagnosed at Full-thickness burn
*Gets worse as you go down this list; start wet/shiny/pink….red….to white…to rough/dry
Treatment for Superficial/Partial-deep Thickness Burns:
Cool skin as needed to stop burn process
Usually involves gently removing blisters (under aseptic conditions only)
Apply grease gauze and soft gauze dressing
If face or perineum involved, apply Bacitracin or Neomycin Ointment
If ped or geriatric involved, Silver Sulfadiazine (Silvadene) is recommended
Use water-soluble Antibiotic ointment if gross contamination noted
Skin covering with cadaver or bioengineered skin may be necessary
Partial-thickness burns involve what layer of skin? What are they subdivided into?
Dermal layer (hence 2nd layer=2nd degree); further subdivided into superficial and deep classifications.
- Superficial partial-thickness=epidermis and limited portion of dermis; heal 7-10 days - Deep partial-thickness=destruction of epi and most of dermis; 2-4 weeks; may need graft
Burn with destruction of all layers of skin down to or past the subcutaneous fat, fascia, muscles, or bone is defined as ____
3rd Degree (Full thickness)
Treatment of Full-thickness (3rd degree) burn:
Remove source (initially are painless–unless if other areas of differing degrees are present)
ABC’s are first: be prepared for surgical airway as edema develops quickly
Establish IV access ASAP (fluid resuscitation is vital next to ABC’s)
Stop burning process
Continuously assess pressure in and around burned skin
Prepare for Escharotomy (especially if circumferential burn is present–completely surrounding a body part): cutting the burned skin (NOT a Fasciotomy); start exterior then go interiorly; chest area common; relieves initial pressure
____ burns are NOT included in the “Rule of Nines” when calculating Total body surface area that’s burned.
Superficial
Classification of extent of burn (in BSA-Body surface area):
MAJOR:
___% BSA burned in adults <40 years old
___% in adults >40
___% BSA in Children <10
MODERATE:
__% in adults <40
__% in adults >40
__% burned in children <10
25; 20; 20; 15-25; 10-20; 10-20
What problems can we often expect first in a burn patient?
Kidney; caused because of release of myoglobin (clogs kidneys) & because of hypovolemic shock
What is a leading cause of death in house fires?
Cyanide poisoning (causes asphyxiation)
A Supraglottic injury is usually ____ related; S/s?
Thermal related; Edema & Airway obstruction; Stridor, labored/rapid RR, difficulty swallowing, intubation considered
A Subglottic injury is usually _____ related. S/s?
Chemical; ulcerations, hypersecretions, etc; Carbonaceous sputum (soot or carbon particles in sputum)=thicker; aggressive pulm hygeine/intubation; potential for ARD’s
What is often a common early s/s of hypoxia?
Restlessness
What is a classic s/s of Carbon monoxide poisoning?
Cherry red/cyanotic lips/skin
Carboxyhemoglobin level (COHgb) is what? What are the s/s of each level?
Essential to measure this because carbon monoxide poisoning is difficult to detect because it may not have clinical findings. PaO2 and SaO2 are normal because the amount of circulating O2 is not affected by Carbon monoxide. COHgb is reported as a percentage of hemoglobin molecules bound with carbon monoxide.
<10-15%: usually asymptomatic; can be in heavy smokers and from traffic pollution
15-40%: CNS dysfunction, restlessness, Change in LOC, Impaired dexterity, etc.
40-60%: LOC, Inc. HR, Inc. RR, Seizures, Cherry red/cyanotic lips/skin
>60%: Coma, death imminent
Edema forms with burns because of what? When does this 3rd spacing peak?
leakage of protein rich fluid occurs; Resorption takes place over 5-7 days if stabilization occurs
___ injury with burns is associated with increased morbidity & mortality.
Lung injury
Large, yellow blisters that occur usually on NON-affected areas of skin from huge shifts of fluid after a burn =
Protein rich plasma blisters. Don’t evacuate these unless they occur on a joint that limits mobility
IVF Replacement Formula for burn patients: **
1) Start 2 large bore IV’s: Lactated Ringers
2) Adult/child >20 kg:
- 4 mL/kg/% burn
- Give 1/2 of fluid over first 8 hours, give other 1/2 over next 16 hours
- ie: Weight 100 kg, 55% burn area (total mL= 4 x 100 x 55 =22,000; 11,000 given first 8 hours at 1,375 ml/hr; 11,000 given next 16 hours at 688 ml/hr)
3) Child <20 kg
- 3 ml/kg/% burn
- time same as above
Doesn’t matter what they got in the field, recalculate at hospital.
Fluid resuscitation (LR) used in field:
15-25% TBS (total body surface): 500 ml/hr
25-50% TBS: 750 ml/hr
>50% TBS: 1L/hr
GI response to burn:
Revolves around ulcer formation control (inflamm response and hypovolemia=compensatory vasoconstriction & redistribution/shunting of blood flow; ischemia of stomach/duodenal mucosa); Need to prevent ulcers because will alter much needed nutrition
Metabolic response to burn?
Initial decrease due to multiple organ involvement; then return to hypermetabolic state
Enormous caloric needs (100-200% above normal BMR)–potentially for months/years post-burn
What will the SVO2 look like in a burn patient?
Should be very low (normal is 70-75, so way below that); if it’s not low, then body is not trying to heal itself which is a bad sign.
What type of pain meds are given to burn patients?
Morphine is DOC; oxycodone; acetaminophen; DONT use ASA products–coag problems.
____ is the best determination of adequate fluid resuscitation. Fluids should be given to maintain minimum of __mL/hr in adults or ___mL/kg/hr in kids (<30 kg). Constant monitoring of __&___ is essential in the burn patient–how is this assessed? What if it develops?
Adequate UO; 30-50 mL/hr; 1mL/kg/hr; hemoglobinuria & myoglobinuria; “Red-pigmented urine”; need aggressive fluid resuscitation (at least 1-1.5 mL/kg/hr in adults)
Burn Unit Referral Criteria (11):
Partial Thickness Burns >10% TBSA
Burns involving: face, hands, feet, genitalia, perineum, or major joints
Circumferential burns of extremity or chest
full-thickness (3rd) in any age group
Electrical Burns: including lightning
Chemical burns
Inhalation burns
Burns in pt’s with pre-existing probs
Burns in pt’s with concurrent trauma, where the burns pose the greatest affect on mortality
Burned kids
Burns in special needs patients
How long do skin grafts take?
several weeks to month, depending upon extent
When are grafts considered successful? Unsuccessful?
Success: New blood supply is developed; New tissue formed around the graft
Unsuccessful: Infection begins, Shearing occurs; if happens, will have to rip off graft & start over
All grafts leave scarring at donor & recipient sites (donor site usually hurts more)
Graft that include the epidermis & part of dermis layers; up to 4 inches wide/10-12 long; removed from flat surfaces (abdomen, thigh, or back); usually not grafted upon weight bearing areas of body; Covered with pressure dressing
Split-thickness Skin Graft (STSG)
Graft consists of epidermal and Full dermal layer (sheet of skin harvested down to sub-q tissue); used when cosmetic concerns are paramount (face/eyelids, hands, feet)
Full-thickness skin grafts (FTSG)
____ is removal of dead skin and blisters to expose the true depth/severity of a wound; ____ is SURGICAL removal of dead skin/blisters.
Debridement; Excision
What does Pressure Therapy for burns minimize?
The scar tissue that can develop because the normal pressure of the epidermis exerted upon the dermal layer is lost with Partial or Full Thickness burns; scarring can last for months after; Pressure therapy minimizes this effect.
Type of scar that’s thick, puckered, itchy cluster type; sometimes nodular; usually darker in color than surrounding skin; Occurs due to body continuing to produce tough, fibrous protein (collagen) after wound has healed; anywhere on body (mostly breastbone, earlobes, shoulders); Common in Asian or Middle-Eastern people……… What’s the treatment?
Keloid; Injecting steroids directly into scar, can be removed/skin grafts utilized, most people just leave alone
Scar that’s thick & raised & often darker than surrounding skin; usually confined to original damaged area (unlike Keloid scar); Not a part of normal wound healing; More in lighter skinned patients; Common areas: chest, back, shoulders, earlobes, lower face, and any movement part of body; Usually from healing of deep second degree Burns; Pressure therapy utilized with this type of scar
Hypertrophic scar
Type of scar with permanent shortening of muscle, tendon, or scar tissue producing a deformity or distortion; usually from injury resulting in loss of large area of skin & scarring that pull the edges of remaining skin together; Can and usually does restrict normal body movement; usually from poor treatment; not as common in US……..What’s the treatment?
Contracture; Surgical removal of scar; application of skin graft; Z-plasty can be utilized (wound closure method); Often intense Physical therapy needed
Burn Trauma Needs:
Cardiac Monitors (minimum of EKG, CVP, ABP) Continuous CO monitoring Ventilator management End-tidal carbon dioxide monitors ICP monitoring CRRT monitoring Rotating specialty bed usage Multiple large-bore IV usage working with computer assisting monitoring of at least: -glucose control -Insulin drip rates -Burn-fluid resuscitation EMR's Urimeter to measure hourly urine output Core body temp Chest tubes All while working in room kept between 90-100 degrees and wearing full PPE (gown, mask,gloves) at all times!!!
