Class 12: Fractures, inflammation/immunity & burns Flashcards
1
Q
In infants, fractures are…
A
Rare
2
Q
The highest incidence of fractures is in blanks and blank
A
Young males (15-24) and old people (>65)
3
Q
Etiology of fractures
A
-Direct blow, crushing force & torsion
-Cancer, osteoporosis & Cushing’s syndrome
4
Q
Classification of fractures
A
-Name of the bone, location of injury, orientation of the fracture & condition of the overlying tissues
5
Q
Location of injury in fractures includes
A
Metaphysial, diaphysial and epiphyseal
6
Q
Orientation of fracture includes the…
A
Type
7
Q
Condition of the overlying tissues in a fracture includes..
A
Open or closed
8
Q
Fracture identification sentence
A
A (orientation) (fragmentation) fracture of the (side) (location) of the (bone)
9
Q
Example of a fracture identification sentence
A
A (transvere) (segmental) fracture of the (medial) (diaphysis) of the (tibia)
10
Q
Closed fracture
A
Skin is intact
11
Q
Complete fracture
A
The bone is separated in 2 pieces
12
Q
Depressed fracture
A
Bone fragments are driven inward
13
Q
Impacted fracture
A
A part of the fractured bone is driven into another bone
14
Q
Oblique fracture
A
The fracture line runs at an angle across the axis of the bone
15
Q
Pathological fracture
A
The fracture results from weakening of the bone structure by pathological processes such as neoplasia
16
Q
Transverse fracture
A
The bone is fractured straight across
17
Q
Comminuted fracture
A
The bone is splinted or crushed, creating numerous fragments
18
Q
Compression fracture
A
A fractured bone is compressed by another bone
19
Q
Greenstick fracture
A
One side of the bone is broken and the other is bent; common in children
20
Q
Incomplete fracture
A
The fracture line does not extend through the full transverse width of the bone
21
Q
Open fracture
A
The skin is not intact, bone is exposed and infection/soft tissue injury are common
22
Q
Spiral fracture
A
The break partially encircles the bone
23
Q
A broken bone can…
A
Cause damage to the surrounding tissue, periosteum and blood vessels in the cortex and marrow
24
Q
Bone tissue destruction…
A
Triggers an inflammatory response
25
Procallus formation
A bony callus formation that is part of bone remodeling
26
Fracture healing time (neonates to later childhood)
-Neonatal period; 2-3 weeks
-Early childhood; 4 weeks
-Later childhood; 6-8 weeks
27
Fracture healing time (adolescence to adults)
-Adolescence; 8-12 weeks
-Adults vary depending on risk factors
28
Clinical manifestations of fractures
-Often numbness up to 20 minutes following injury
-Unnatural alignment, swelling, muscle spasms, tenderness, pain, impaired sensation, loss of function, discolouration, bleeding and crepitus
29
5 P's to assess in fractures
-Pain & point of tenderness
-Pulse distal to the fracture site
-Pallor
-Paresthesia: Sensation distal to the fracture site
-Paralysis: Movement distal to the fracture site
30
Assessing injured limb: CSM
-C: Circulation
-S: Sensation
-M: Motion
31
Positive local factors influencing bone healing
Immobilization, timely reduction, application of ice and electrical stimulation
32
Positive systemic factors influencing bone healing
-Adequate amounts of growth hormone, vitamin D and Ca+
-Adequate blood supply, younger age and moderate activity level prior to injury
33
Negative local factors influencing bone healing
Delayed reduction, open fracture (increased risk for infection) and presence of foreign body at the fracture site
34
Negative systemic factors influencing systemic factors
Immunocompromised, decreased circulation (DM & PVD), malnutrition, osteoporosis and advanced age
35
Complications of fracture
Avascular necrosis, compartment syndrome, fat embolism, infection and osteomyelitis, PE, nerve compression, delay union/nonunion and skin breakdown
36
Fat emboli subjective data
-Dyspnea & chest pain
-Confusion, aLOC, numbness, feeling faint, DM & obesity
37
Fat emboli objective data
-Cyanosis, chest petechiae, pallor & cold extremeties
-Pupillary changes, buccal cavity, conjunctiva and soft palate
-Muscle twitching, shock & vomiting
38
Nerve compression subjective data
Discomfort, pain, referred pain, burning, tingling, "stinging sensation", numbness, aSensation & inability to distinguish touch
39
Nerve compression objective data
Diminished movement & reflexes, weakness, paralysis, irritability, colour changes r/t impaired circulation
40
Avascular necrosis subjective data
Tenderness & pain, especially on passive motion
41
Avascular necrosis objective data
Edema, swelling, bleeding from wound, decreased colour, temperature & mobility
42
Delayedunion/nonunion subjective data
Pain
43
Delayed union/nonunion objective data
Lack of callus formation on x-ray & poor alignment
44
Skin breakdown subjective data
Pain
45
Skin breakdown objective data
-Elevated temp & HR, erythema, edema-cast edges, exposed distal portion of limb within cast and hyperactive reflexes
-Draining and foul odour from break in skin; crepitus
46
Compartment syndrome subjective data
Severe, unrelenting pain, unrelieved by narcotics and associated with passive stretching of muscle and paresthesias
47
Compartment syndrome objective data
Edema, paralysis, decreased/absent peripheral pulses, poor cap refill, and limb temp change
48
Innate & adaptive immunity are..
The 2 main defence systems
49
Innate immunity
-1st line of defence
-Natural or native immunity
-Inflammation (2nd Line of Defense); biochemical and cellular mechanisms
50
Adaptive immunity
-3rd line of defence
-Slower but more specific process
51
Innate & adaptive immunity are blank
Separate but also interdependent
52
Innate immunity is..
Non specific & always prepared to act quick
53
First line of defence
Physical (ie. skin)
54
Common bacteria we encounter
-Staph. aureus
-MRSA, streptococci, VRE & STI
55
Second line of defense
-Inflammation: First response to injury, quick & non specific
56
Inflammation vascular response
Vasodilation, increased permeability, and WBC adhere to vessel walls
57
Inflammation plasma protein systems
Complement system, clotting system & kinin system
58
Second line of defence: Cell components + leukocytes (1)
-Granulocytes (neutrophils): Band cells/immature neutrophils, eosinophil, basophil (histamine), and mast cells (released during inflammation & healing)
59
Second line of defence: Cell components + leukocytes (2)
Agranulocytes (monocytes & macrophages): Precursors of macrophages, slower than neutrophils, and better suited for long term defence
60
Second line of defence: Cell components + leukocytes (3)
B&T cells
61
Acute inflammation symptoms + local
Swelling, pain, heat & redness
62
Early/mild inflammation + local
Serous exudate
63
Severe inflammation + local
Fibrinous & purulent exudate
64
Fever + systemic signs
-Normal temperature 36-37
-Leukocytes and macrophage; pyrogen
-Pyrogen "fire"
-Mild-moderate vs high fever (39.4-41.1)
65
Leukocytosis + systemic signs
-Increase in circulating WBC
66
Inflammation with wounds
-Normal response of living tissue to injury
-Starts- Tissue damage (but NOT destroyed)
-Until healing starts
67
Infection & wounds
Maggots, cleaning MRSA infection and group A streptococcus
68
Burns
A traumatic injury to the skin or other organic tissue primarily caused by thermal or other acute exposures
69
Types of burns
Thermal, cold, electrical, radiation (sunburn), chemical and inhalation (flash burns from fire & steam, hot smoke & CO)
70
Most common type of burn in children is...
From a scald injury (thermal)
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The most common type of burn in adults is...
From a flame
72
Males are blank..
Twice as likely to be burn victims than females
73
Childrens skin is...
Thinner & burns 4x more quickly & deeply than adult skin
74
Children's rapid physical growth means ..
They also scar more easily
75
Superficial burn
-1st degree, involing only the epidermis, no blisters
-Painful, dry, red, and blanch with pressure
-Commonly seen with sunburns
76
Partial thickness burns
-2nd degree involving the epidermis & dermis
-Superficial or deep, caused by prolonged exposure (>10 seconds) to intense heat
77
Characteristics of partial thickness burns
Blister, moist, serous, edema, pink or red mottling, blanching and very painful
78
Full thickness burns
-3rd degree extending through all layers of dermis & SC tissue
79
Characteristics of full thickness burns
Waxy white to leathery gray to charred & black, dry, inelastic, does not blanch, no vesicles or blister formation
80
Fourth degree burns
Potentially life threatening burns extending through the skin into underlying tissues & fascia, muscle and/or bone
81
Severity of the burn is determined by...
-Location, pt age, causative agent, contact duration, presence of respiratory involvement and pt general health
82
Minor burn
3rd degree appear on <2% of the TBSA, 2nd degree burns appear on <10% of a child's TBSA
83
Moderate burn
3rd degree burns appear on 2-10% of TBSA regardless of the body size, 2nd degree burns appear on 10-20% of a child's TBSA
84
Major burn
20% of TBSA in most adults are major burns, 2nd degree burns covering >20% of a child's TBSA
85
Burn assessment tools
-Pt palmer surface, lund-browder chart and rule of nines
-These assessments are used to estimate the % of TBSA involved in a burn injury
86
Pt palmer surface (hand chart)
-The hand chart is a practical method to determine the extent of a burn, since the palm of the human hand comprises 1% of BSA. Use the patients own hand when using this assessment tool. It can be used to accurately measure the extent of burns that have occurred over many different areas of the body.
-From finger tips to wrist
87
Rule of nines, look at picture online
Divides the body surface into areas of equal 9% or multiples of 9% of TBSA. This chart is used for adult patients only as BSA proportions do not follow this 9% configuration for children less than 14 years of age
88
Factors influencing a positive outcome in burns
Multidisciplinary team involved, airway, rehydration, depth and extent of burns, nutrition, pain control, activity, psychological impact on patient and family
89
Airway + burns
-The first priority of burn care is airway maintenance
-If there is evidence of respiratory involvement, 100% oxygen is administered and blood gas values are drawn including carbon monoxide levels
-If the child is displaying signs of respiratory distress, intubation is performed
90
The following suggest inhalation of noxious agents or respiratory burns
-Thermal injuries to the face, nares, and upper torso
-A hx of injury in an enclosed space
-An examination of the oral and nasal membranes that reveals edema or blisters
-Evidence of trauma to the upper respiratory passage
91
CO poisoning
-Colorless, odorless and tasteless gas that has an affinity for hemoglobin 200 x greater than that of oxygen
-Oxygen molecules are displaced and carbon monoxide reversibly binds to hemoglobin to form carboxyhemoglobin (tissue hypoxia)
92
Mild CO poisoning
-1-10 is normal and 11-20% is mild
-Headache, flushing, aVisual acuity, aCerebral functioning and slight breathlessness
93
Moderate CO poisoning
-21-40%
-Headache, N/V, drowsiness, tinnitus, vertigo, confusion & stupor, pale to reddish-purple skin, decreased BP, increased & irregular HR
94
Severe CO poisoning
-41-60%
-Coma & seizures
95
Fatal CO poisoning (61-80)
Death
96
Infection control + burns
-Hand & forearm washing is the best
-Large burns may require iso
97
Infection control + burns cont'd
-Chief danger is wound infection, generalized sepsis and bacterial pneumonia
-Ongoing assessment is crucial
98
Assessments in burn pts
-ABC
-Signs of shock (hypovolemic and septic), increased temperature
-Intake (both IV and PO), U/O (minimum 1-2 cc/kg/hr), pain control, wound & dressing assessments and psychosocial support
99
Burn size is...
Essential to guide therapy
100
The most accurate assessment of TBSA burn in children & adults is the...
Lund-Browder chart
101
3rd line of defence
-Adaptive immunity
-Slower than innate
-Antigen: Substance capable of stimulating antibodies
102
3 benefits of adaptive immunity
-Specific: Engages a particular target
-Systemic: Not restricted to a local site
-Memory: It remembers
103
Adaptive defence system
-Humoral: B lymphocytes
-Cell mediated: T lymphocytes
104
Lymph nodes
B & T lymphocytes act as surveillance, lymph nodes are widespread
105
Adaptive immunity: Humoral immunity
-Humoral: Virus free in the fluids of our bodies
-Plasma cells secrete antibodies (immunoglobulin) that binds to antigens
-Memory cell that prevents future re-exposures
106
Adaptive immunity: Humoral immunity steps
-Bone marrow; B lymphocytes; memory cells & plasma cells
-Plasma cells; antibodies
107
Humoral immunity
-Antibody circulates in the blood and binds to antigens on infectious agents
-Either directly inactivates the microorganism or activates the inflammatory mediators
-Antibodies are primarily responsible for protection
108
Adaptive immunity: Cell-mediated immunity T lymphocytes
-Helper: Activates B cells, cytotoxic T cells, NK cells & macrophages
-Cytotoxic (killer): Cell lysis
-Suppressors Th: Expressed as CD4 & T regulatory cells
109
Adaptive immunity: Cell-mediated immunity
-Cellular: Virus infected cells
-T cells activate lymphocytes & macrophages
-Memory produced
110
Adaptive immunity: Cell-mediated immunity steps
Bone marrow; T lymphocyte; helper T cell, suppressor T cell, cytotoxic T cell and memory cells
111
Active & passive immunity
-Adaptive immunity can be either
-Active (active acquired) immunity is produced after either natural exposure to an antigen or after immunization
-Passive (acquired) immunity occurs when preformed antibodies or T lymphocytes are transferred from donor to recipient
112
To recognize & respond
-Antigen is a molecule that reacts with antibodies or antigen receptors on B and T cells
-Most antigens are immunogenic
-Must be recognized by and bound to an antibody
113
To recognize & respond cont'd
-Antibodies are aka immunoglobulins
-There are 5 molecular classes of immunoglobulins
114
5 molecular classes of immunoglobulins
-GAMED
-IgG, IgA, IgM, IgE & IgD
115
IgG
Most abundant & crosses the placenta
116
IgA
Found in the blood & body secretions
117
IgM
Biggest size & first to respond in a primary response
118
IgE
Least concentrated but specific to allergic responses & in the defense against parasitic infections
119
IgD
Found in low concentrations with limited knowledge of function
120
Live/attenuated
Measles, mumps, rubella (MMR), varicella (chicken pox), zosters (shingles), influenza (nasal spray), rotavirus and yellow fever
121
Inactivated/killed
Polio (IPV), hepatitis A and rabies
122
Toxoid (inactivated toxin)
Diphtheria, tetanus (DTaP)
123
Subunit/conjugate
Hepatitis B, influenza (injection), haemophilus influenza type B (Hib), pertussis (DTaP), pneumococcal & meningococcal & HPV
124
Early & late signs in fractures
-Early: Numbness & tingling
-Late: Cyanosis
125
Pain is not always....
Congruent with the injury
126
Avascular necrosis
Fracture interrupts blood supplu to the bone leading to bone death
127
Fat embolism
Only occurs in larger limbs (ie. Femur) and will develop 48-72hr after the injury
128
PE in fractures occurs as a result of...
Fat emboli
129
Compartment syndrome timeline
-Early symptom is numbness & tingling
-4-6 hours after compartment syndrome develops, it is irreversible
130
The kinin system..
Responds to pain
131
Inflammation steps
-1. Protect tissue
-2. Limits inflammatory response to a specific area
-3. Interacts with adaptive immune response
-4. Starts the healing process
132
Agranulocytes live...
Longer than granulocytes in acidic environments
133
Pt palmer surface burn assessment tool pros & cons
It is the most innacurate but easiest way to measure burns in children
134
Hourly U/O is used to determine...
Fluid resuscitation in burn pts
135
IgM & IgG are...
Most common
136
IgM is the first to...
respond when getting a vaccine and turns into IgG antibodies
137
Immunocompromised people cannot get...
Live vaccines
