Exam 4 Flashcards
what is an open fracture?
occurs when the skull is punctured causing the dura to be punctured exposing the brain
what is a primary TBI?
damage that occurs at the time of injury due to stress on the brain
is a open fracture primary or secondary?
primary
what is a linear fracture?
a crack to the skull that does not move bone
is a linear fracture primary or secondary?
primary
what is a depressed fracture?
a portion of the skull is caved inward towards the brain
what is a comminuted fracture?
fractured in one spot with many pieces
what is a basilar fracture?
fracture at the floor of the skull
what causes basilar fracture?
MVA, assault,
what will a basilar fracture patient present like?
Bleeding from ears/nose, CSF from nose, Racoon eyes, mastoid bruising
what is battles sign?
bruising at the mastoid
what type of fracture will have a positive battles sign?
basilar fracture
what is the halo test?
a test that looks for csf being present in blood from some ones nose
what fracture do you do the halo test on?
basilar
how can you test if what is coming from someones nose is CSF?
do a blood sugar the fluid if it has a glucose content its csf and the halo test
what is a closed brain injury?
occurs when skull integrity is good but damage has occurred to the brain
what is a concussion?
a closed brain injury that causes tissue to be stunned
what is a contusion?
a closed brain injury that causes damage to the brain
does a concussion or contusion cause brain damage?
contusion
what does the contusion do to the brain?
causes bruising in a area
what is a diffused axonal injury?
damage to the axons in the white matter
and tearing of vessels
what is the severity of a diffused axonal injury?
extreme deficits
what is a secondary brain injury?
something that occurs after a injury
what are examples of secondary brain injury?
hemorrhage, epidural, subdural, intracerebral, brain herniation
what is a epidural hemorrhage?
ARTERIAL bleeding between the inner skull and the dural space
is an epidural bleed slow or fast?
fast bleed
what can trick you about an epidural bleed?
they will brief loss of LOC, get better, and then rapidly deteriorate
what is a subdural bleed?
Venous bleed beneath the dura and above the arachnoid…..blood touching the brain
is a subdural bleed slow or fast?
slow
what is a intracerebral bleed?
arterial and venous bleeding into the subcortical white matter inside the brain
what is brain herniation?
continued edema in the brain causes the brain tissue to be squeezed into structres
what type of bleed is usually not caught right away?
subdural because it is a slower bleed
what are symptoms of brain herniation?
rapid decrease in neuro status, rapid decline in LOC, pupils will change into many different things
how is a brain herniation fixed?
****cranioplasty to remove part of the skull
what should be done with the patient prior to surgery?
CT scan
what is done in the OR to help with increased ICP?
drains
how do you treat tbi patients?
like SCI
what precautions are TBI patients on?
spinal precautions and seizure precautions
whats included in spinal precautions?
lay flat, spinal board, log roll, c collar
what acronym should you keep in mind with TBI?
ABC
what questions should you ask yourself when thinking airway on TBI?
can they breath on their own, clear secretions, maintain spo2, is their pattern normal
what may be done prophylactically to TBI patietns?
intubation
what are the early neuro changes for TBI?
change in LOC, restless, irritable, coordination changes, different strength in extremities
what might a TBI patient be doing with their hands?
posturing
what are the two kinds of posturing?
Decorticate and decerebrate
what does decerebrate posturing look like?
arms at side and wrists extension
what does Decorticate posturing look like?
arms on chest and wrist in flexiom
what is glasgow scale?
Extent of neuro activity
what are the diagnostics for TBI?
full rainbow and CT/MRI
what are the interventions for TBI?
could be trached, could be intubated, seizure precautions, neuro checks q 2, reorient, restraints, repeat ct/mri
what should be used sparingly with TBI?
sedation
why is sedation used cautiously in TBI patients?
it can mask neuro changes
what meds are TBI patients on?
Dexamethasone, Fentanyl, and pheytoin
what does dexamethasone do for TBI?
alleviates edema and decreases ICP
what should you watch for when giving dexamethasone?
hypoglycemia, hyperglycemia,
why is fentanyl given to TBI?
pain
is fent iv push or continous?
both
why is phenytoin given to TBI?
anticonvulsant to prevent seizures
is phenytoin iv push or continous?
both
what should you always do when giving phenytoin?
run the drug through a filter, check ALT/AST, and check serum levels in blood
why should phenytoin be run through a filter?
it crystalizes
what is a good phenytoin serum level?
10-20
what is the monroe kellie hypothesis?
brain, blood, and CSF are in a constant equilibrium where if one increases the others decrease
what are early signs of increased ICP?
decline in LOC, restless, irritable, confusion, headache, unilateral weakness, pupil changes
what are late signs of increased ICP?
severe headache, LOC change, coma, erratic resp rate/cheyenne stokes, irregular pulse, hyperthermia, projectile vomitting, loss of corneal reflex, loss of gag reflex, posturing, seiaures, flaccidity, unreactive pupils, cushings triad
what reflex changes can increase ICP lead to?
loss of corneal, cough, and gag
what is the corneal reflex?
when you touch their eye they move their head
what are signs of cushings triad?
hypertension with a widened pulse pressure, bradycardia, bradypnea
what is a widened pule pressure?
a pulse pressure greater than 40
how is pulse pressure calculated?
SBP - DBP
in someone with increased ICP what are you monitoring?
5 lead, pulse ox, ICP, CO2
what is used to monitor ICP?
bolt or EVD
what type of ICP device is a surgical procedure?
EVD
why is edema in the skull bad?
leads to ischemia of the brain
why is CO2 monitored in increased ICP?
because CO2 has a direct effect on pressure in the skull
what does high CO2 do to the brain?
increases pressure
what does low CO2 do to the brain?
decreases venous outlfow increasing the pressure
what are the diagnostics done for increased ICP?
CT and MRI
what are the procedures done for increased ICP?
Craniotomy, burr holes, cranioplasty, and drains
what is a craniotomy?
cut into skull suck out blood and put the flap back
what are burr holes?
hole is made for needle to suck out contents
what is a cranioplasty?
cut into the skull and remove a portion
what are the interventions for increased ICP?
keep CPP greater than 70, HOB at 30 degrees or more, keep head midline, help with temp control, low stim enviroment, paralyzing to lower ICP
what should be avoided in increased ICP patients?
low HOB, dont cluster care, avoid hip flexion, suctioning for more than 10 seconds
why should you avoid hip flexion in increased ICP?
it reduce venous outflow
how is CPP calculated?
MAP-ICP
what does CPP tell us?
cerebral perfusion pressure tells you xxx
what meds are given for increased ICP?
mannitol, succinylcholine, and vecuronium
why is mannitol given for increased ICP?
reduces icp by directly targeting the brain
is mannitol k sparring or wasting?
wasting
what other med maybe given with mannitol?
furosemide
is mannitol continuous or bolused?
bolused
what should always be done when giving mannitol?
filter on IV line
what should be hooked up before giving mannitol?
ICP monitoring and filter
what happens to mannitol if it sits too long at room temp?
crystalize
what paralytics are given to reduce ICP?
succinylcholine and vecuronium
what are side effects of paralytics?
apnea
what paralytic is IV push only?
suc
what paralytic is IV drip?
vec
what paralytic can raise K level?
succinylcholine
what is a complete SCI?
spinal cord damage enough to eliminate function below injury
what is incomplete SCI?
injury allowing some function below injury
what is a hyperflexion SCI?
sudden forward acceleration
what is hyperextension SCI?
sudden acceleration and deccelerationw
what is an example of hyperflexion sci?
head on collision or diving
what is an example of hyperextension SCI?
rear ended
what is axial loading sci?
vertical compression of vertebae
what are some examples of axial loading SCI?
diving, falling on butt, landing on feet
what is a rotational SCI?
turning head beyond ROM
what is penetrating sci?
damage to spine due to knife, gun shot etc
what are secondary sci?
hemorrhage, ischemia, shock, edema
why are you worried about ABC with SCI?
high risk of resp complications in cervical sci because of damage to the phrenic nerve
what does the phrenic nerve control?
diaphragm and accessory muscles
how often do you assess resp function in sci?
q2
what might be done to SCI injury to help with oxygenation?
intubated/trach
what is also calculated on SCI?
glasgow scale
how can you assess hemodynamics in SCI?
art line
what is common in sci in relation to waste?
illeus and neurogenic bladder
what is neurogenic bladder?
they dont empty all of the way
what are diagnostics for sci?
ct, mri, x ray
what do you want MAP to be in SCI patient?
90 or more
what prophylaxis are SCI patietns on?
DVT/ clot
what are the intervention for DVT porphylaxis?
TED, SCD, ROM, heparin,warfarin, enoxaparin, IVC
what patients cant get blood thinning medications?
hemmorhage
what is an IVC
filter that goes into inferior vena cava that catches clots
what are sci patients at risk for resp wise?
mucus plugs, pneumonia, atelactasis
what can be done to help sci patients with resp comp?
incentive spirometry, suction, quad cough
what kind of rolling for sci patients?
log
what devices help keep spine neutral?
c collar, halo, and tlso
whats better c collar or halo?
halo
is a halo removable?
no
why cant the halo be removed?
its screwed into the skull
what if halo comes undone?
hold head in neutral, yell for help, keep them still
what meds do sci patients take?
methlyprednisone and baclofen
what should be avoided if taking methylprednisone?
grapfruit
what should be checked in patients taking methyl prednisone
hypo/hyperglycemia
what are then complications of sci?
spinal shock, neurogenic shock, autonomic dyseflexia
what does the sympathetic control?
fight or flith
what does parasympathetic do?
calm down
what happens during spinal shock?
temporary complete loss of function below the injury
symptoms of spinal shock?
hypotension, bradycardia, flaccid,
what are the interventions for spinal shock?
maintain airway, mobilize spine, fluids, control body temp
how long does it take to recover from spinal shock?
48 hours
what is neurogenic shock?
imbalance of sympathetic and parasympathetic
what is too high in neurogenic shock?
parasympathetic
what can cause neurogenic shock?
issue below the injury like urinary retention or constipation
what are symptoms of neurogenic shock?
hypotension, bradycardia, periphreal vasodilation, decreased LOC, and decreased UOP
what might neurogenic shock patients need?
pressors
what can neurogenic shock lead to?
organ failure
how can you tell the difference between spinal shock and neurogenic shock?
spinal shock has flaccidity is that it?????
what type of injury increases your risk of neurogenic shock?
injury above t6
what is anutonimc dyseflexia?
sympathetic is too high
symptoms of autonomic dyseflexia?
headache, hypertension, bradycardia, N/v, stuffy, flushing/sweating above injury, pale/goosbumps below the injury
what non med interventions for autonomic dyserflexia?
sit up, loose clothing, check catheter for obstruction, check for retention, check for impactment, adjust temp
what meds are given to autonomic dyserflexia patiens?
nifedipine
what are the types of burns?
dry heat, moist heat, contact, electrical, and chemical
what is dry heat?
open flame
what are open flame burns at risk for ?
inhalation injury
what is a moist hear burn?
steam or hot water
what is contact burn?
hot metal, grease, tar
what is also know as a grand masquerader ?
electrical burn
why are elctrical burns so bad?
it burns outside and inside the body
what is considered a superficial burn?
first degree
what causes first degree burns?
sunburn, flame, scald
what layers are involved in first degree?
epidermis
symptoms of first degree burn?
tingling, pink, red, hyperthesia, itching, peeling/desquamation, possible blisters
what happens if you rub first degree burns?
the epidermis wont rub off
what meds might help first degree burns?
Ibuprofen and cooling lotions
what is the other term for second degree burns?
partial thickness
what are some causes of second degree burns?
scalds, flames, contact
what layers are burned in second degree?
epidermis and part of the dermis
what are the symptoms of second degree burn?
pain, hyperthesia, sensitive to air
what does the burn look like in second degree burns?
blistered, red, weeping, edema, mottled
how long do second degree burns take to heal?
10-21 days
is there scarring in first degree burns?
no
what does the wound look like after its healed in a second degree burn?
scarring and pigment change
what is another name for a third degree burn?
full thickness burn
what are causes of a third degree burn
flame, prolonged hot lot liquids, eletrical burn, chemical
what skin layers are involved in a third degree burn?
epidermis, dermins, and some sub cu tissue….no muscle and bone?????
what are symptoms of third degree burn?
insensate, shock, myoglobinuria, contact points
what is insensate?
occurs when nerves are burned so there is no pain
what is myoglobin uria?
red urine due to break down of myoglobin from muscle damage
what are contact points?
entrance and exit wound from electrical burns
what does the wound look like in third degree burns?
pale, white, red, brown, black/charred, leathery, dry, edema
what is another term for black/charred skin?
eschar
what is another name for fourth degree burns?
full thickness
what tissue involment in fourth degree burns?
all skin layers, tissue , muscle, bone
what causes fourth degree burns?
prolonged exposure to hot surfaces, high voltages, chemicals
when do burns cause coagulated vessels?
third degree onward
what are symptoms of fourth degree burns?
shock, myoglobinuria, no edema, no pain,
what does the wound look like in fourth degree?
charred
what is the only treatment option for fourth degree?
amputation
does second degree burn require graft?
it could
does third degree require graft?
yes
what is a circumferential burn?
a burn that goes around an entire area
what are cirucmferential burns of the abdomen and chest at risk for?
resp issues due to the chest not being able to fully expand
what is an escharotomy?
a cut to the skin to allow for expansion
what is a fasciotomy?
a cut that is deeper than a escharotomy to allow for even more expansion
what should be kept in mind with electrical burns?
there is an entrance and exit but tissue internal can still be destroyed
what is considered a major burn?
more than 20% of the body or burn to the eyes, ears, face, hands, feet, genitals, or perenium
at what point do you go to burn center?
if you have more than 20% burn, third degree, electrical or inhalation
what systemic changes are there for major burns?
vascular changes, fluid and electrolytes shift, cv changes, pulmonary changes, renal, Gi,
what vascular changes occur during major burn?
clots, necrosis, and bad perfusion
what fluid/electrolyte changes occur from major burn?
Fluid shifts causing hypovolemia, hyperkalemia, hyponatremia, metabolic acidosis??
what cv changes occur during major burn?
hyperkalemia, tachycardia, decreased cardiac output low bP???
what pulmonary changes occur during a major burn?
pulmonary edema, swelling of airway, carbon monoxide poising, inability to breath deeply if circumfrential burn
what renal changes occurs during a major burn?
the kidneys dont have good blood flow due to hypovolemia/low cardiac output, pre renal failure due to the excessive amount of cellular debris
what gi changes occur during major burns?
ulcers, impaired motility, and bowel obstruction
what immunoloical changes occur during major burns?
infection/sepsis risk
what thermoregulation problems occur with burns?
hypothermia or hyperthermia without infection
what kind of shock do burn patients go in?
hypovolemic or septic
whats the range for ICP?
10-15
what are priorites during a emergent/resuscitative burn?
secure airway, support perfusion, stop burning, remove clothes/jewlery, prevent infection, maintain body temp, fluid resuscitation, and pain management
when will patient be intubated for burns?
if they are having trouble breathing, airway burns, cant keep spo2 high
if airway burn is not present what will they do for oxygenation?
100% oxygen on a non rebreather
what are signs of airway burns?
burnt facia/eyebrow hair, sut in mouth, cough, dry nagging cough, drooling
what should be inserted into burn patients?
NG, foley, and possible ET for intubation
what kind of IVs should you have for fluid resuscitation?
2 or more 16-18 gauge
besides IV what other line may burn patients have?
central line
how often should you check output?
hourly
what characteristics do you look for in urine output?
color, volume, odor
what are signs of fluid overload?
JVD, crackles, weight gain, SOB, High blood pressure ??????
what else besides urine would increase output in burn patients?
chest tube, blood, vomit, diarrhea
what is parklands formula?
kg x 4ml x % of body burned = fluid for 24 hours
what fluid is used during fluid resuscitatiuon?
lactated ringers
what is an expected weight gain in the first 72 hours?
15-20 %
how much fluid is given in the first 8 hours?
50%
how much fluid is given over the next 16 hours?
50%
what urine output indicates adequate fluid replacement in electrical burns?
electrical burns 75-100ml per hour
what urine output indicates adequate fluid replacemnt in burns?
0.5 -1 ml per kg/hour
what HR indicates adequate fluid replacement in burns?
less than 120
what BP indicates adequate fluid replacement?
greater than 100 systolic
what cvp indicates adequate fluid replacement?
2-6
what is used to measure cvp?
swan or equation
where does cvp get measured?
in the pulmonary artery
what is typically given for pain in burns?
morphine
what does morphine due to bodily function?
reduces resp functino and decreases motility
what non pharm interventions for burn patients in emergent phase?
relaxing, breathing, guided imagery
what should be avoided in emergent burn phase?
ointments
what shot should burn patients get?
tetanus
what are signs that someone is coping with burns?
dressing changes and looks at themselves
what are the percentages for the rule of 9s
head is 9%, arms are 9%, abdomen is 18%, back is 18%, legs are 18%, privates 1%
when does the acute/intermediate phase start?
after 24 hours
when does the diuretic phase start?
after 36-48 hours
what are lab values in the first phase of a burn?
hyponatremia and hyperkalemia ????
what are the lab values before the diuretic phase?
hyponatremia and hypokalemia???
what are the lab values after the diuretic phase?
xx
what should be assessed in relation to CV in the intermediate phase?
???
what should be assessed in relation to resp in the intermediate phase?
watch for pneumonia and infection
what should be assessed in relation to immune in the intermediate phase?
infection this is the most common time to get a infectino
what should be assessed in relation to muscle in the intermediate phase?
rom
what should be assessed in relation to neuro endocrine in the intermediate phase?
daily weights, caloric intake, loosing weight
when will feedings be considered in burn patients in the intermediate/acute phase?
if they lost more than 10% of initial body weight
when does fluid shift back into the normal spaces?
after 36-48 hours
what should be assessed during burn wound care?
color, drainage, odor, sloughing,
what should be given before wound care?
morphine and hydromorphone??
how to prevent infection during wound change?
aseptic technique, silver nitrate for regular burn, and mefnide acetate, monitor for s/s of infection
what do you need to know for mefnide acetate
only for electrical burns, penetrates eschar, painful, give pain meds
what does silver nitrate do to K and Na
> >
what do you need to know silver nitrate?
monitor wbc, k, na???????
what burns require silver nitrate?
xxx
what burns need telemetry?
electricity
what is the equation for ICP
Map - ICP
how many cal do burn patients need ?
5k or more
what nutrient needs to be high in burns?
high protein
what happens if burn patient doesnt eat?
tpn or tube feedings
what factors affect severity of burn?
skin, patient, agent, depth, diabetes, HF
what does a low cvp indicate?
dehydration
what does a high cvp indicated?
fluid overload
why would emergent burns patients need pantoprazole?
risk of stress ulcers
can burn patients eat during emergent phase?
no
what happens if brain herniation goes untreated?
resp arrest or cardiac arrest
what is eye opening response rate ?
1-4
what is a 1 eye response?
never open eyes
what is a 2 eye response
only open to pain
what is a 3 eye response?
open to voice
what is a 4 eye response?
spontaneous…keeps eyes open
what is verbal response rate by?
1-5
what is a 1 verbal response?
never say anything
what is a 2 verbal response?
only sounds no words
what is a 3 verbal response?
inappropriate wordswha
what is a 4 verbal response?
confused
what is a 5 verbal response?
oriented
what is best motor response rated?
1-6
what do you do when testing motor response?
pressure or pain
what does a 1 motor response mean?
no reaction
what does a 2 motor response mean?
extension or decerebrate
what does a 3 motor response mean?
flexion or decorabate
what does a 4 motor response mean?
withdraw hand from stimuli
what does 5 motor response mean?
localizes pain…..opposite hand to move the painful side away
what does 6 on motor response mean?
obeys command
what is the lowest glasgow scale mean?
coma
what is the lower glasgow scale score?
3
what is the highest glasgows scale?
15
