Test #2 Flashcards
what ribs are floating?
11 and 12
what do we want to keep the GCS above? SpO2 above? MAP above?
GCS- 9
SpO2- 95%
MAP- 60
for a sucking chest wound hole must be greater than what of the trachea for it to effect the air going into the chest?
1/3 the size of the trachea.
what is a big function of skin?
regulates body temp.
What are the layers of skin?
Epidermis-mostly dead skin, external layer, cells created in the germinativum
Dermis-important stuff, wound healing (nerves, capillary vessels, hair, sweat glands, mast cells, macrophages, neutrophils, etc.)
Subcutaneous layer-where the fat is
what is the big function of the Dermis?
to help with wound healing.
what do the fascia do?
Superficial: connective tissue surrounds subcutaneous fat
Deep fascia: final layer of defense against infection and internal structures; supports underlying anatomy
where does compartment syndrome and crush injuries effect?
Deep Fascia
what are tendons?
connect muscle to muscle and muscle to bone
what allows the muscle to move the bone
what are some health issues that will effect coagulation?
- Hepatitis (liver helps make clotting factors)
- ETOH
- Diabetes
- Age and Anemia
what are high risk wounds?
Bites
- dogs (bad), humans (worse for infection), cat (the worst)
- Foreign bodies (teeth)
- Farm equipment
- Drag and Crush injuries
- Immunocompromised (cancer, HIV, Diabetics, transplants, autoimmune disorders)
Areas of the body that are high risk of infection from a wound?
Areas that have poor circulation.
Biggest one is your feet.
what are the 4 process (4 phases) to wound healing?
- Bleeding (helps bring clotting factors to site and force out bacteria)
- Inflammatory (macrophages and fibroblast go to work)
- proliferative (fibroblast pull wound together)
- Remodeling (formation of scar tissue (80%) as strong as original tissue, or new skin cells)
what is a Keloid Scar?
Excessive accumulation of scar tissue that extends beyond the original wound borders
More common in- darkly pigmented patients, those who have injuries to the ears, upper extremities, lower abdomen, or sternum
Hypertrophic scar-
excess accumulation of scar tissue confined within original wound borders. Raised appearance.
More common in areas of high tissue stress, suck as the flexion creases across joints.
what is a hematoma?
Bruise
- collection of blood under the skin
- can get very big, and can hold almost a L of blood under the skin (they can cut off blood supply and can cause a pt to be in shock)
What is an Abrasion?
outer skin layer damage Little to no bleeding, capillary oozing Painful often contaminated Can be treated like a burn.
what are Lacerations
superficial or deep
linear (straight line) or stellate (jagged)
avulsion
Fascia stays intact, a full thickness skin loss in which the wound edges cannot be approximated . Frequently involves the ear lobes, nose tip, and fingertips. Distal and proximal avulsions. Bleed profusely. Pull as much debris out that you can, then lay it flat.
injection injury
a type of puncture wound that may result in the injection of a gas, liquid, or solid into the body under pressure- Often have life or limb- threatening potential. Usually associated with minimal bleeding. Maintain a high index of suspicion. Consider the composition of the injected substance.
Amputation
Complete or partial loss of a limb secondary to mechanical force. Bleeding is potentially fatal. Care of patient and parts. Select appropriate hospital. Use tourniquets
what do we do with an amputated limb?
Transport limb, but do not delay transport if you cannot find. Dress and bandage, use moist dressing for stump. Wrap amputated limb in moist sterile dressing and seal in plastic bag, kept cool Not Frozen
when a artery is severed what is something you have to keep in mind?
They will retract.
Also they can suck in air.
Crush injuries, what are they?
occur when tissue is compressed by force that damages structural and metabolic function of underlying vasculature, muscle, and cellular structures. Becomes an ischemic injury to the tissue that was effected.
what are some major concerns with crush injuries metabolically?
They become acidic (we are not refusing that tissue)
Rhabdomyolysis usually results in these injuries. – need lots of fluid!
Releases proteins and the kidneys clog up.
release a lot of electrolytes. Can cause major spirally problems.
What is the reperfusion issues with crush injuries?
injury will cause O2 superoxide, which causes more damage to the tissue with the influx of Ca+ into the Mitochondria. H2O, Na+, Ca+ influx into the cells causing swelling and cellular death. – huge wash of acidosis upon relief creating dysrhythmias, metabolic acidosis, etc..
what is the treatment for a crush injury?
Bicarb, IV bolus 1- 1.5L
LOTS of fluids (to dilute the blood and help the kidneys)
Bicarb is to help make blood alkolitic (reduce the acid build up)
how do we fight or treat rhabdo?
Fluids
Compartment Syndrome
Happens within the fascia, and when that is higher than it can contain, it has no where to go, and builds up pressure.
A continuation in the disease spectrum of crush injury. Usually results from compressive forces or blunt trauma to muscle groups confined in tight fibrous sheaths with minimal ability to stretch.
What can cause compartment syndrome?
Elderly falls, cast swelling, burns, electrical injuries, injections, tissue edema, sprains, snake bites, sepsis, and fractures. Muscle fascia will not stretch, resulting in increased pressure.
what are the 6Ps of compartment syndrome?
- Pain that is out of proportion to the injury
- Paresthesia- burning/ prickling sensation
- Paralysis
- Puffiness
- Pallor
- Pulselessness (late or nonexistent sign)
what is Cellulitis?
local infection common in DM or immunosuppressed
Necrotizing faciitis-
typically polymicrobial, will spread
Necrotizing cellulitis-
skin and SQ tissue after recent trauma or surgery
Gangrene-
Life threatening condition, chlostridium infection
Initial presentation of heaviness of effected limb, brawny edema, extreme pain
Herpes (what two types?)
HSV1- mouth
HSV2- genitals
Varicella
viral infection of dermatomes
Hand infections
commonly caused by Staphylococcus, splint in position found
where do you place a tourniquet?
At least 1.5” wide, reduces trauma to vasculature.
Can be challenging to cut flow completely when there are two long bones involved (tib/fib or rad/ulna) vs. one (humerus, femur).
who is more likely to be effected by burns (men or female)
female (less surface area)
what is the frequency in order of burns and most commonly seen.
Scald/ flame
Contact
Chemical
Electrical – High voltage > 1000 volts, significant cutaneous injuries and internal injuries. Low voltage < 1000 volts
High Risk – Infant and elderly
what is considered high voltage?
> 1000 volts
<1000 volts (low voltage)
what are the zones for burns?
- Zone of coagulation
- zone of stasis (ischemia)
- zone of hyperemia
Zone of Coagulation
Skin is dead, necrosis in days
Area of direct contact with source
Devoid of blood flow
If tissue is not removed, leads to sepsis
Zone of Stasis (ischemia)
Weak blood supply
Greatest risk for necrosis if perfusion is untimely
>2hrs, full thickness injury
Goal of fluid resuscitation preserving zone of stasis
Zone of hyperemia
Salvageable
Hyperemia (excess blood)
Blanches when touched, redness, swelling
how many degrees of burns are there?
4
1st degree-superficial
Sunburn like
Very painful
Dehydrated
Epidermis damage
2nd degree-partial thickness
Most painful
Will form blisters
Down to dermis-hair follicles, sweat glands, nerves
3rd degree-full thickness
Burned to the subcutaneous tissue and possibly muscle
Skin is falling off
Open capillary bleeding
Nerve endings have been burned off
Little pain…. area around burned area is painful (lower degree)
Seen in structure fires
(painless, no nerve endings, around the burn is painful)
4th degree
You be dead homie
Burned down to the bone
Partial Thickness in Minor Burn %
<15% of total body surface area in adults
<10% in children and elderly
Full thickness burn for minor burns
<2%
-think ember fall on skin, more then 2% is major burn
Moderate Burn %’s
Partial- 15%-25% adults
Partial 10-20% in children over 10yrs
Full 2%-10% not involving area of function (eyes, hands, feet, or perineum)
Does not include high voltage (>1000 volts)
No inhalation injury trauma,
Not in high risk individuals (infants and elderly (over 60))
For treatment, best to round up, hard to categorize a moderate burn.
Severe Burn %
Partial > 25% in adults
>10% TBSA in children < 10 y/o and elderly > 50 y/o
Full >10%
Involves area of function
Caustic chemicals
High voltage electrical injury
Complicated by inhalation injury
Complicated by trauma
If a pt automatically have an inhalation burn what severity will they have?
Severe!!
what is the most common death in burns?
Organ failure
what are other causes of death with burns?
- pneumonia
- burn shock
- pulmonary failure
- sepsis
- cardiovascular failure
what is our #1 goal with inhalation burn?
Airway
If you can’t intubate yet with an inhalation burn, what can we give them?
O2 with neb saline
When do we give a cyanokit?
- when in an enclosed space structure fire
- low BP
With burn treatment what do we want to consider?
- hypothermia
- Coagulopathy
- acidosis
Keep them warm and keep them from burning
use sterile dressing
what is the patients palm in % of total burn?
1%
what can giving too much fluid to a burn pt do?
it can create compartment syndrome. (abdominal)
what is burn shock?
Its distributive shock
Its comparable to septic shock, difference is that there is a lot of leaking.
we want to give fluid, but be very careful with how much to not create edema.
what types of fluids are better?
colloids (larger solute) to pull fluid back into the vascular system.
What is myocardial depressant factor?
an enzyme that says the heart can slow down.
The release of Cytokines also have an effect on the heart. A cytokine called Myocardial Depressant Factor, causes the heart to lose its contractility.
what is Parkland Formula
4ml x kg x BSA (body surface area)
it is given over the next 24 hrs
1/2 over 1st 8 hrs
1/2 over last 16 hrs
what is the mortality rate of a burn inhalation pt?
30%
what makes up the burn center criteria:
- > 10% TBSA
- face, hands, feet, genitalia, perineum , major joints
- 3rd degree
- electrical burns
- chemical burns
- inhalation injury
what do ligaments do?
connect bone to bone
don’t have good blood supple.
what do tendons do?
they connect muscle to muscle or bone to muscle.
They have better blood supply
what is osteoporosis?
porous bone
what is an indirect injury (skeletal)?
occurs away from the point of impact
impact sends wave of energy though the body
what is the definition of a fx?
breaks in the cortex of the bone
what type of fx can you have?
open
closed (bleeding control included)
what is a sprains?
ligaments
- stretched beyond normal range of motion
- tearing
what are strains?
Tendons
- damage to muscles
what is one assessment to do with every orthopedic injury?
check for distal pulses and blood supply
what does RICE stand for in muscle skeletal injuries?
Rest
Ice
Compress
Elevate
What is traumatic asphyxia?
crush injury to the upper torso or epigastrium.
deep purple color of the head and neck. v
puts pressure on the heart and superior vena cava, causing an increase of pressure to head.
What is subcutaneous Emphysema?
presence of air in the soft tissue space.
what is pulmonary contusion?
bruise on the lungs
can cause resp distress and dec. oxygenation due to build up of blood on the lung tissue destroys the capillary bed and blood will go into the alveoli.
major S/S: hemoptysis, dec in pulse ox, capno will most likely go down (shallow and fast breathing), crackles in area of injury
who should you not do a needle decompression on?
someone that is NOT hypotensive.
where do you needle decompress? (what are the land marks)
mid clavicular (between the 2nd and 3rd rib)
mid axillary between 4th and 5th rib.
what is tracheobronchial injury?
when there is blunt or penetrating injuries to the respiratory tree.
SS: could have subq air in the neck.
what will have JVD? Tension Pneumothorax or hemothorax?
Tension pneumothorax (there is pressure on the major vessels as well as the heart, causing back up of blood)
what is pericardial tamponade.
fluid that is built up around the heart.
impedes the cardiac filling and CO, dropping the systolic (less force)
what is pulses paradoxus?
a drop in systolic BP of more than 10 mmHg during inspiration. (good indication of cardiac tamponade)
becks triad?
hypotension (usually tachycardia), JVD, muffled heart tones
indicative of pericardial tamponade
what can happen with a diaphragm rupture?
Stomach and intestines can enter the thoracic cavity.
Best to get an advance airway to eliminate air going into the stomach.
what are eviscerated organs?
when the organ is on the outside of the abdominal cavity.
Pt can become hypothermic
cover in a wet sterol dressing then a dry sterol dressing
Exsanguinate
To bleed out
Vesicants
chemicals that destroy tissue through BLISTERING
ex: mustard gas
Organic chemical burns
primarily carbon atoms
ex: paint strippers, paints, wax
when will chemical burn stop?
they will continue to burn until they are neutralized.
Alkolotic burns can be some of the worse burns. (need an acid to neutralize them)
what is considered low voltage?
1000 V or less.
word for nerve pain?
neuralgia
what are the 4 criteria to go to a burn center?
1) partial thickness burn >10%
2) Burns to face, hands, feet, genitalia, perineum or major joints
3) Third degree burns
4) Chemical, electrical, or inhalation injuries
what is bioburden?
If not going to surgery right away need to cover wound w/ antimicrobial agent b/c wound accumulates bacteria
epiphyseal plate ?
(growth plates)
Grade 1 sprain?
least serious (most common)
Grade 2 sprain?
ligament partially torn
Grade 3 sprain?
complete tear of ligament.
Volkmann Contracture
permanent shortening of the forearm muscle resulting in deformity of hand, fingers, and wrist
what does wound healing require to have proper healing?
good blood flow and ability to have proper dilation to allow the immune cells into the cell to heal.
health causes that may limit wound healing?-
- diabetes
- atherosclerosis
- prolonged compression (cast)
- infections (other pathogens are competing for O2)
- swelling
folliculitis
infection of the hair follicle
furuncles
boils (zit looking)
carbuncles
several furuncles
burn zone of coagulation?
full thickness burn (central area) void of blood flow (not salvageable)
burn zone of stasis (ischemia)
outside zone of the zone of coagulation. blood supply is weak, greatest risk of necrosis if perfusion not restored.
burn zone of hyperemia?
outermost layer that will likely remain well perfused.
according to the parkland formula, how many mL of fluid should be administered in a burn pt?
4ml/kg
what % of fluid is administered with in the first 8 hours in the parkland formula?
50%
What % of fluid is administered in the last 16 hours of the parkland formula?
50%
