Exam 1, Deck 2 Flashcards
What burn zone?
cells in this area receive maximum contact with heat source, necrosis occurs
zone of coagulation (site of injury)
what burn zone?
decreased blood supply, high risk of burn wound progression without adequate fluid resus
Zone of stasis (area extending peripherally from site of injury):
what burn zone?
cells sustain minimal injury, mild inflammation, spontaneous heals in 7-10 day
Zone of hyperemia (located furthest away from injury):
Burns > __% TBSA have a larger systemic response
15%
what happens in large TBSA burns that places the pt at risk for compartment syndrome
Fluid shifts
Complications in Burns
Infection
Fluid shifts -risk for compartment syndrome
Rhabdomyolysis
Hypermetabolic response - 24-72 hours ->Gluconeogenesis, weight loss, negative nitrogen balance, decr in E stores, incr risk of infection
Body temp -> risk for heat loss (increased cortisol, glucagon and catecholamine secretion)
most common cause burns in pediatric
Scalds
child maltreatment
What degree burn
restricted to the epidermal layer
Sunburn
Erythematous, painful, absent of bullae
Heals 2-5 days without scarring
Superficial 1st degree
what degree burn
extends into dermal layer – have bullae (fluid containing blisters) and very painful due to nerve ending exposure, assess cap refill
Partial Thickness (2nd degree)
most frequent burn for which treatment is sought out
Partial Thickness (2nd degree)
what degree burn
Entire epidermis and deeper dermis
Blistering
Dermal base is less
blanching, mottled pink or white, less painful than superficial partial thickness
Require excision and grafting
Deep partial-thickness (2nd degree):
what degree burn
all layers of the skin — epidermis and dermis — are destroyed, and the damage may even penetrate the layer of fat beneath the skin.
full thickness
3rd degree
what type of burn
Involved underlying fascia, muscle, or bone
May need reconstruction and grafting
4th degree burn
Non-blanching wound is a ________ _____ wound
full thickness
when should you suspect inhalation injury
facial burn
singed nose hairs
Carbonaceous sputum
Hoarseness
Labs and imaging in burn
CBC, type/screen, coags, chem10, ABG, chest xray
Carboxyhemoglobin if inhalation exposure
Cyanide level: smoke inhalation with AMS
Burn >15% TBSA: BMP, BUN, Cr, prealbumin
Electrical: get UA (goal urine pH >6), myoglobin, ECG to eval for ST changes
Care of wound pt
Nutrition must be assessed within first 24hr – needed to manage the hypermetabolic state
-High protein, high calorie
- Steroid-Oxandrolone (incr protein synthesis),
–propranolol (helps blunt hypermetabolic state), growth hormones (aid in wound healing)
Pain control, blood glucose control
Wound care
Topical antimicrobials: silver sulfadiazine (can cause kernicterus in peds, pancytopenia), bacitracin, mafenide cream (metabolic acidosis)
100% humidified O2 if hypoxia or inhalation suspected
Silver sulfadiazine used as topical antimicrobial in burns can cause
Kernicterus in peds
Pancytopenia
Mafenide cream used in burns can cause
metabolic acidosis
Urine output goal in burn
<30kg: 0.5-1ml/kg/hr
>30kg: 1-2 ml/kg/hr
If UO too high, titrate LR infusion down by ⅓
If UO too low, titrate LR infusion up by ⅓
Reassess UO in 2hr and adjust as needed
Parkland formula for TBSA >
15%
Parkland formula
4ml x weight in kg x %TBSA burned = volume of LR to deliver in 24 hrs.
deliver first half of fluid in 1st 8 hrs
second half over the next 16 hrs
For pt <30kg: deliver MIVF (4-2-1 rule) with dextrose in addition to parkland fluid
special considerations
chemical burns
cleanse immediately, do not alkalize, call poison control
special considerations
eye burns
ophtho consult, erythromycin ointment
special considerations
Perineum burns
urinary drainage catheter, bacitracin
Bleed
injury to the middle meningeal artery or vein
Epidural
Bleed?
Bridging vein rupture
Subdural
Bleed?
Tearing of small vessels in the pia matter
Subarachnoid
Which bleed has a lucid interval
Epidural
which bleed is from shaken baby
Subdural
Bleed?
result from direct trauma or rotational forces from vigorous shaking
Subdural
Bleed?
Sudden, severe HA due to rupture of intracranial aneurysm
Subarachnoid
acceleration/deceleration forces that result in shear trauma at the interface of grey and white matter
diffuse axonal injury
Secondary Brain injury is
local and systemic events triggered by primary injury
-Posttraumatic energy failure and excitotoxicity
-Axonal injury
-Cerebral edema with increased ICP
Mild TBI has GCS of
13-15
Moderate TBI has GCS of
9-12
Severe TBI has GCS of
<8
Cushing Triad
Bradycardia
Hypertension
Irregular resp
Secondary impact syndromes
repeated concussions carry r/o permanent brain injury
ICP > ____= poor outcome
> 20
CPP =
MAP-ICP
CPP Infant
children
adolescent
Infant >40-50
Children >50-60
Adolescent >60
Physical abuse fractures
-Long bone fracture in non-ambulatory child
-Rib fracture (needs a lot of force to fracture)
-Grabbing baby and squeezing chest
-Fractures of sternum, scapula or spinous process (needs a lot of force to fracture)
-Multiple fractures in various stages of healing
-Digital fracture in child < 3 years old
-Complex skull fracture
-Metaphyseal corner and bucket fractures
- Bone shaved off
Baby GCS
Eye opening
spontaneous - 4
speech - 3
pain- 2
none - 1
Verbal
coos, babbles - 5
irritable cries - 4
Cries to pain - 3
moans to pain-2
none- 1
Motor
Normal - 6
withdraw touch-5
withdraws pain 4
abnormal flexion -3
abnormal extension 2
none 1
GCS
eyes
spontaneous 4
to command 3
to pain 2
none 1
verbal
oriented -5
confused-4
inappropriate words-3
incomprehensible sounds - 2
None-1
Motor response
obeys commands -6
localizes pain-5
withdraws-4
abnormal flexion-3
abnormal extension-2
none-1
maintenance fluid for SJS
2ml/kg x TBSA
for 24 hours
maintenance rhabdo
2xs maintenance
Hypotension formula
70 + 2(age)
systolic
if systolic is this number. Lower limit for hypotension
for children 1-4 yrs old what is the leading cause of death?
drowning
for children less than 1 yr what is the leading cause of death
suffocation
Highest death rate across all age groups cause of death is
MVC
leading cause of nonfatal injuries
falls
pediatric anatomy differences
Larger head with shorter neck
Occiput causes neck to flex while laying flat
Posterior pharynx can buckle anteriorly without proper shoulder support
Large floppy tongue and tonsils can obscure view
Funnel shaped larynx allows secretions to accumulate
Gather medical history, allergies, medications, last food/fluids and events surrounding incident
Primary or secondary survey?
secondary
Trauma
hemoptysis
subcutaneous emphysema
Tension pneumothorax with mediastinal shift
What type of injury should you be thinking about
Tracheobronchial tree injury
Trauma with the following symptoms
> 2 ribs fractured in 2 or more places
Abnormal chest wall movement
Crepitus of ribs
Pulmonary contusion.
Ventilation/Oxygenation
what are you thinking?
Flail chest
what type of pneumothorax has neck vein distention and tracheal deviation
Tension pneumothorax
What type of pneumothorax requires needle decompression and chest tube
Tension pneumothorax
Symptoms of cardiac tamponade
Becks Triad:
1)Hypotension is the first sign, but it is not related to hypovolemia
2)Jugular venous distention is often noted as the veins begin to back up
3) Lastly muffled heart sounds are heard
Other signs include Pulsus Paradoxus:
A decrease of at least 10 mm Hg in arterial blood pressure when the patient inhales
Electrical Alternans
signs of Tension pneumo
Hypotension
JVD
Absent breath sounds
what type of bleed?
Caused by tears in bridging veins that rupture across the subdural space
Blood gathers between the dura mater and the brain
Subdural bleed
When does a subdural bleed need surgical decompression
if 5mm midline shift or greater
What type of bleed?
Often located in temporal or parietal region
Results from tear in Middle Meningeal Artery
Usually causes midline shift of brain matter
Common for patient to have “lucid event” from time of injury to deterioration
Epidural bleed
(requires immediate surgical decompression)
leading cause of TBI and mortality in children
Skull fractures
what skull bone is most frequently involved in skull fx
Parietal bone
Type of skull fracture most common
Linear fx
skull fx signs
Bogginess to palpation of scalp
Skull bone depression or “Step-Off”
Periorbital bruising (raccoon eyes)
Bruising behind ears (battle’s sign)
CSF leakage from the nose or ears
Paralysis of the face
Hearing loss
symptoms of TBI with Herniation
Altered MS
Hypotension with tachycardia
Retinal hemorrhage
Unequal pupils
Seizures
Altered respiratory rate