Exam 2 Flashcards
What is the criteria for SIRS
two or more of the following: temp greater than 38 or less than 36 HR greater than 90bpm RR greater than 20 or PaCO2 less than 32torr WBC >12k or < 4k More than 10% immature (band) forms
What puts a pt at high risk for SIRS
ANY injury that causes hypoperfusion. Not just infection
What are the 4 reasons for shock
alteration in blood volume
decrease in contractility of the heart
any alteration in blood flow
any alteration in vascular resistence
What is shock
decreased tissue perfusion with impaired cellular metabolism. Causes an increase in metabolic needs and O2 demands
Describe the initiation stage of shock
hypoperfusion inadequate O2 delivery Decreased CO Increased sympathetic NS activity difficult to determine, not incredibly pronounced
What are the stages of shock?
initiation
compensatory
progressive
refractory
Describe the compensatory stage of shock
reversible neural, endocrine, and chemical compensation. blood is shunted toward vital organs initially bounding pulses then weaker Increase HR decrease Urine output
Describe the progressive stage of shock
hypoperfusion
decreased cap blood flow
aerobic to anaerobic metabolism!! - hypermet state
lactic acid production - aggressive FR above 4.0
Low BP, decreased CO, decrease contractility
Intravascular to interstitial fluid shift
What is the definitive lab test for shock and what are the values?
Lactic acid testing - shows us overall picture of imp tissue perfusion
aggressive fluid resuscitation above 4.0
Refractory stage
IRREVERSIBLE dysrythmias endothelial damage cerebral ischemia AKI thrombis formation
What is the Parkland burn shock formula for the FIRST 24hrs
4mL x kg x TBSA
Give first half over 8 hours, then second half over next 16hrs
A pt is admitted to the ED with severe burn injuries. No fluids were started pre hospital. What solution would you hang first
Lactate Ringers - isotonic crystalloid
For BURN shock
A client is just reaching 24hrs post admit for severe burn injury. The bag of lactate ringer’s is finished infusing. What do you do?
Obtain colloid containing fluid such as dextrose in water + potassium as per the second 24hr parkland formula
What is the urine output goal for a pt in shock?
- 5-1.0mL/kg/hr for adults
1. 0mL/kg/hr for children
A pt presents w a burn injury that appears wet and weeping and blanches briskly. The pt is in terrible pain. What would you consider this burn and how long would you tell the pt before it heals
A partial thickness burn - 2nd degree
it will heal in 7-10days can be up to 21
A pt presents with a burn injury that is red with patchy white areas that blanch when you apply pressure. There is only a scant amount of plasma leakage. What would you consider this burn and how long would you tell the pt it will be before it heals
a Deep partial thickness burn (2nd degree, deep)
it will heal in 2-4weeks and is usually excised and grafted.
Could heal w contractures if not treated
A pt presents with a burn injury that doesn’t blanch. What would you consider this burn and what would you tell the pt of its tx?
A full thickness or 3rd degree burn
eschar created from destruction of epithelial elements
skin grafting is required
What is important to note about superficial burns?
They are not counted in the formula for fluid resuscitation
A pt presents to the ED with LOC and cherry red skin. Their HR is 160 & RR 26. What would be your assumption and what would you do?
The pt is experiencing Carboxyhgb levels of 40-60% and I would treat w 100% O2 IMMEDIATELY.
A pt is experiencing burn shock. You are most concerned about fluid imbalance at what point?
within the first 8hrs, during the greatest shift in fluid!
The nutritionist is coming to talk to your pt that has severe burn injuries about her needs. What do you expect the RD to discuss with the pt
The need for INCREASED caloric intake d/t hypermetabolic state
35-50cal/kg
High calorie, high protein, high carb!
you’re reviewing orders for a pt with severe burn injuries. The orders are as follows: LR @ 600mL/hr. TPN via PEG at 50mL/hr and Morphine 10mg q4hr SQ. Which order would you question
morphine. No IM or SQ injections w burn victims bc ou don’t know about absorption.
IV opiates are indicated
Describe wound care for a burn victim
Tetanus is there is any chance they haven’t had booster in last 5yrs
topical antimicrobial NOT indicated for ER care - only once they’re in the hospital
Cover with clean DRY dressing or sheets
hydrotherapy to slough off dead tissue
keep wound moist AFTER 24hrs to promote new tissue growth
keep pt warm
You get report on one of your pts for the day: HR 120 WBC 20k \+ Blood culture Lactic acid level of 4.6 What do you expect the current dx to be?
severe sepsis
criteria for SIRS + KNOWN infection + organ dysfunction e/b increased lactic acid levels
You go in to a pt room and find them to be extremely tachycardic and have a temp of 38.6c. You know the pt has not tested positive for any infection. What do you do
Call the physician with a recommendation that the pt is experiencing SIRS
