Exam 3

Question 1

What systematic assessment approach is used for all trauma patients?

What does A,B,C… G mean?

Answer 1

Primary and Secondary survey.

Primary, followed by focused.

A,B,C,D,E,F,G...
Airway/Alertness
Breathing
Circulation
Disability/Deformity
Exposure/Environmental
Facilitate adjuncts/Family
Get resuscitation adjuncts

Question 2

What does LMNOP stand for in primary survey?

Answer 2

L - Lab tests
M - Monitor ECG
N - Nasogastric tube
O - Oxygenation and Vent assessment 
P - Pain assessment and management

Question 3

What ESI level would the following example fall under?

• Chest pain probably resulting in ischemia,
• Multiple trauma, unless responsive

Answer 3

ESI - Emergency Severity Index

ESI level 2

Question 4

What does AVPU (part of Disability) stand for?

What does the Glasgow Coma Score consist of?

Answer 4

Alert
Verbal
Pain
Unresonsive

GCS:
-Eye Opening: 4-spontaneous, 3-to voice, 2-to pain, 1-none

• Verbal Response: 5-Normal, 4-Disoriented, 3-Incoherent words, 2-Incomprehensible, 1-none
• Motor Response: 6-Normal, 5-Localizes pain, 4-Withdraws from pain, 3-Decortiate, 2-Decerebrate, 1-None

“Even a tree can get a 3”

Question 5

What is the pathophysiology of burns?

Answer 5

Massive fluid shifts are occurring. The fluid is moving out of the blood vessels d/t increased capillary permeability.

This leaking causes protein and sodium to move into the interstitial spaces. D/T the loss of protein, the osmotic pressure decreases, causing further fluid loss to the interstitial spaces.

The patient will start to go into hypovolemic shock from this significant loss of fluid.

Question 6

Which degree of burn is classified as full thickness?

Which degree of burn is described as red, some pain/tenderness, mild swelling, blanchable?

Which degree burn is deep partial thickness?

Answer 6

Third (&4th): Dry, eschar present, waxy, white or brown charred look, burn odor, impaired sensation, no blanching.

First degree burn.

Second degree: blisters, mottled white, moderate to severe pain, blanchable, moderate edema.

Question 7

What is the depth of 1st, 2nd and 3rd degree burns?

Answer 7

First: Epidermis
Second: Dermis
Third: Fat, muscle, bone

Question 8

What are the %’s of TBSA of each portion of the adult body, ex: head, torso, etc. using the Rule of Nines?

Answer 8

Head is 9%: 4.5% anterior + posterior
Upper arms are 9%: 4.5% anterior + posterior
Hand is 1%
Torso is 36%: 18% anterior + posterior (buttocks included)
Legs are 18%: 9% anterior + posterior
Genitalia is 1%

Question 9

What are the three chronological phases of burn management?

Answer 9

1. Emergent phase: Resuscitative: the time required to resolve the immediate, life-threatening problems resulting form the burn injury. *Usu. lasts up to 72 hours post injury.
2. Acute phase: Wound Healing:
3. Rehabilitative phase: Restorative:

Question 10

What are the major concerns in the emergent phase of burn management?

When does this phase end?

Answer 10

1. Hypovolemic shock. Caused by a massive shift of fluids out of the blood vessels as a result of increased capillary permeability and can begin as early as 20 minutes postburn.
2. Edema. R/T the capillary permeability, leading to water, Na, and plasma proteins (esp albumin) leaking out into the interstitial spaces. This results in more fluid shifting d/t the colloidal osmotic pressure changing d/t Na and albumin.

This phase ends when fluid mobilization and diuresis begin.

Question 11

How is circulation affected by burn injuries?

Answer 11

• Fluid shift = intravascular volume depletion. S/S: low BP and high HR. If not corrected leads to refractory shock and possible death.
• Hemolysis of RBCs from the burn leading to oxygen free radicals released into the circulation
• Thrombois in the capillaries of burned tissue causes an additional loss of circulating RBCs. An elevated Hct is commonly caused by hemoconcentration d/t fluid loss.
• Potassium shift. This occures first bc injured cells and hemolyzed RBCs release K into the circulation. Na rapidly moves into interstitial spaces and remaines there until edema formation ends.

Question 12

What is refractory shock?

Answer 12

Continuing to progress despite tx… maybe irreversible.

Question 13

Normal lab value for:

Hct
Hgb
K
Na

Answer 13

Hct: men = 40-50%, women = 36-48%

K: 3.5 - 5

Hgb: men = 13.8 - 17.2 g/dL, women = 12.1 - 15.1 g/dL

Na: 135 - 145

Question 14

During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion?

Answer 14

Urine output; measured hourly.

If adequate, should have UO of at lease 0.5 - 1 mL/kg/hr

Question 15

When does the acute phase of burn management begin and when does it end?

What are the common complications of this phase?

Answer 15

Begins with the mobilization of extracellular fluid and subsequent diuresis.

It concludes when partial-thickness wounds are healed or full-thickness burns are covered by skin grafts.

This may take weeks or months.

Question 16

When does the rehabilitation burn management phase begin and what are the goals for the patient at this time?

Answer 16

It begins when the patient’s wounds have healed and he/she is engaging in some level of self-care.

This happens as early as 2 weeks but could also be 7-8 months after the injury.

Goals:
1. Work toward resuming a functional role in society

2. Rehabilitate from any functional and cosmetic postburn reconstructive surgery that may be necessary.

Complications:

• Skin and joint contractures
• hypertrophic scarring

Question 17

S/S of hypokalemia:

Answer 17

Hypokalemia alters the resting membrane potential, resulting in hyperpolarization and impaired muscle contraction… cardiac changes (flattened T wave, depressed ST segment, and the presence of a U wave. The P waves peak and the QRS complex is prolonged.)

There is in increased risk of heart block and potentially lethal ventricular dysrhythmias.

Skeletal. muscle weakness and paresthesias may occur.

May decrease GI motility.

Impairs insulin secretion, leading to glucose intolerance and hyperglycemia.

Severe hypokalemia may result in paralysis. Usu the extremities but can involve the respiratory muscles.

The most common cause is abnormal loss from either the kidneys or GI tract.
Kidneys = diuresing or has a low magnesium level - low plasma mag stimulate renin and aldosterone release, resulting in potassium excretion
GI tract = Diarrhea, laxative misuse, vomiting, ileostomy drainage.

Question 18

What are the most common complications during the acute phase of burn management (first 3 out of the 6)?

Answer 18

• Infection: s/s: hypo/hyperthermia, increased HR and RR, decreased BP, decreased UO. May have mild confusion, chills, malaise, and anorexia. WBCs are usu between 10,000 and 20,000 microliters. The WBCs have functional defects and the pt is immunosuppressed for many months after the burn injury.
• Cardiovascular and Respiratory Systems: those that present in the emergent phase may continue into the acute phase of care. Additionally new ones may arise, requiring timely intervention.
• Neurologic System: none unless severe hypoxia from respiratory injuries or complications from electrical injuries occur. Other potential causes = electrolyte imbalance, stress, cerebral edema, sepsis, sleep disturbances, and the use of analgesics and anti-anxiety drugs.

Question 19

What is a Curling’s Ulcer and how do you prevent it?

Answer 19

Curling’s Ulcer is a type of gastroduodenal ulcer characterized by diffuse superficial lesions (including mucosal erosion). It’s caused by a general stress response to decreased blood flow to the GI tract.

Prevention: feeding the patient ASAP after the burn injury.
Antacids, H2-histamine blockers (ranitidine [Zantac]), and proton pump inhibitors (esomeprazole [Nexium]) are used prophylactically.

Question 20

What are the most common complications during the acute phase of burn management (second 3 out of the 6)?

Answer 20

• Musculoskeletal: This is particularly prone to complications during the acute phase and the involvement of both the PT and OT is vitally important. Skin and joint contractures will occur. Painful stretching, ROM, and proper splinting are needed.
• GI: Paralytic ileus can be caused by sepsis. Diarrhea may result from the use of enteral feedings and/or abx. Constipation from opioids, decreased mobility, and low fiber diet. Curling’s ulcer from generalized stress response to decreased blood flow to the GI tract… pt has increased gastric acid secretion. Burn patients may also have occult blood in their stool and need to be closely monitored for bleeding.
• Endocrine System: Watch for transient increases in the patient’s BG levels as a result of stress-mediated cortisol and catecholamine release. There is an increased mobilization of glycogen stores and gluconeogenesis. Subsequently, glucose is produced, along with an increase in insulin. Insulin’s effectiveness is decreased because of relative insulin insensitivity. Resulting in an elevated BG level. Hyperglycemia may also be caused by the increased caloric intake necessary to meet some patients’ metabolic requirements. When this occurs, tx with IV or SQ insulin, not decreased feeding. Serum BG testing is more accurate than point-of-care testing. Once the metabolic demands are met and less stress on the entire system, this condition is reversed.

Question 21

Why is it super important to acquire sulfa allergy information from burn patients?

Answer 21

Many burn antimicrobial creams contain sulfa!

Question 22

What is metabolic asphyxiation?

Answer 22

The majority of deaths at a fire scene are the result of inhaling certain smoke elements, primarily carbon monoxide (CO) or hydrogen cyanide.

Oxygen delivery to or consumption by tissues is impaired. The result is hypoxia and death when carboxyhemoglobin (hemoglobin combined with CO) blood levels are greater than 20%.

Question 23

What is lactated ringers solution?

Answer 23

Is a sterile, nonpyrogenic solution for fluid and electrolyte replenishment in single dose containers for intravenous administration. It contains no antimicrobial agents.

It contains sodium chloride (NaCl), sodium lactate (C3H5NaO3), Potassium Chloride (KCl), Calcium Chloride (CaCl2·2H2O), and a pH of 6.5.

Question 24

What doe we call a stable complex of carbon monoxide and hemoglobin that forms in red blood cells upon contact with carbon monoxide?

What is a catecholamine?

Answer 24

Carboxyhemoglobin.

A catecholamine is a monoamine, an organic compound that has a catechol and a side-chain amine. Catechol can be either a free molecule or a substituent of a larger molecule… any of a class of aromatic amines that includes a number of neurotransmitters such as epinephrine and dopamine.

Question 25

What does DMAT stand for?

Answer 25

Disaster Medical Assistant Teams

Dr’s, RN’s, communication… they are able to load equip and travel to disaster for about 2 wks. Can independently help during interim, provide triage and care

Question 26

What are organophosphates?

What are two poison version used by terrorists?

What are S/S? (SLUDGE, DUMBELS)

What is the treatment?

Answer 26

An organophosphate or phosphate ester is the general name for esters of phosphoric acid. Organophosphates are the basis of many insecticides, herbicides, and nerve agents.

2 poisons: Sarin and VX

SLUDGE: S-Salivation, L-Lacrimation (tears), U-Urination, D-Defication, G- GI, E-Emesis

DUMBELS: D-Diaphoresis, U-Urinary incontinence, M-Myosis, B-Bradycardia/Bradypnea/Broncho Spasms, E-Emesis, L-Lacrimation, S-Salivation/Secretion

Severe = respiratory paralysis (from the muscarinic affect of ACH)

Treatment: Atropine A LOT of it!!!!

Question 27

Myosis:

Answer 27

Excessive constriction of the pupil of the eye.

Question 28

Treatment for cyanide poisoning (chemical):

Answer 28

Antidote, Decon, Airway support

s/s SOB, dyspnea = interferes with cellular oxygenation

Question 29

Treatment for pulmonary agents (chemicals: phosgene, chlorine):

Answer 29

Decon, Airway support

s/s airway irritation, pulmonary edema

Question 30

What biologic agent is bacillus anthracis?

What’s the worst version?

s/s?

Tx?

Answer 30

Anthrax.

Inhalation is the worst. Cutaneous and gastrointestinal are the other two kinds.

s/s: fever, cough after inhalation

Tx: quinolone, doxy, penicilin, antitoxin - needs to be started right away. Can also be used prophylactically… The quinolone kills off the bacillus, the antitoxin takes out the toxin.

Question 31

What is the incubation period for the biologic agent variola?

s/s?

tx?

Answer 31

Incubation period for smallpox is 7-17 days

s/s: fever, HA, myalgia, lesions

No cure - vaccine. Symptomatic treatment. There is improvement if given the vaccine within 4 days of exposure.

Question 32

What biologic agent is Yersinia pestis?

What are the three types?

What is the incubation period?

s/s and tx?

Answer 32

Plague: Bubonic, Pneumonic, Septicemic

Incubation is 2-4 days

s/s of pneumo: hemoptysis, cough, fever, myalgia, respiratory failure - Droplet precautions, more serious, isolation.

Bubonic: HA, fever, swollen lymph nodes (buboes)

Septicemic: most serious

tx: Antibiotics. Quinolones. Gentamycin. Early tx.

Question 33

What is a clinical manifestation of the biologic agent botulism?

Tx?

Answer 33

Descending paralysis, beginning in the head.

Tx: ventilatory support, antitoxin - prevents progression but doesn’t cure.

Have to regrow nerves, if respiratory may need ventilation for weeks to months.