Unit 3: Burns: Emergent Phase Flashcards
Starting Emergent Phase of Burns
although the emergent phase does not officially begin until the patient reaches the hospital, it is vital that basic burn care is initiated at the scene
Initial priorities for the emergency personnel on the scene
- stopping the burn process
- airway management
- fluid resuscitation
- prevention of hypothermia
What are the 2 key pieces of information that are essential in the handoff report?
- the circumstances surrounding the injury
- the total amount of fluid the patient received during transport
What is the primary goal during the emergent phase?
- resolve immediate life-threatening issues resulting from the burn injury
- priorities: baseline diagnostic evaluation, airway management, fluid resuscitation, pain management, prevention of hypothermia, and initiation of wound care
Priorities for the Emergent Phase Care
- baseline diagnostic evaluation
- airway management
- fluid resuscitation
- pain management
- prevention of hypothermia
- initiation of wound care
Diagnostic Studies
- Complete blood count (CBC)
- Serum glucose
- Creatinine
- Blood Urea Nitrogen (BUN)
- Prothrombin time/activated partial thromboplastin time (PT/aPTT)
- International normalized ratio (INR)
- Complete metabolic panel (CMP)
- Arterial Blood Gases (ABGs)
- ECG
- Chest x-ray
- Toxicology screen
- Serum carboxyhemoglobin level on inhalation injuries; Bronchoscopy indicated for definitive diagnosis
- ECG for electrical injuries
- Baseline ECK, Troponin, and Creatine-kinase (CK-MB)
Fluid and Electrolyte Changes in the Emergent Phase
> Generalized dehydration
-plasma leaks through damaged capillaries (third spacing) and into interstitial spaces
> Reduction in blood volume
-secondary to third spacing, blood pressure falls, and CO diminished
> Decreased urinary output
-secondary to fluid loss and decreased renal blood flow
> Hyperkalemia
-massive cellular trauma causes the release of potassium into extracellular fluid
> Hyponatremia
-large amounts of sodium are lost to third spacing, wound drainage, and shifting into cells as potassium is released
> Metabolic Acidosis
-loss of bicarbonate ions accompanies loss of sodium
> Elevated hematocrit
-plasma is lost to extravascular spaces, leaving the remaining blood very viscous
Airway Maintenance
- assessment of airway takes top priority
- 100% oxygen w/ non-rebreather mask w/ all burn injuries
- patients at risk for intubation: facial burns, changes in voice (hoarseness), carbon noted in sputum, and injury associated with a fire in an enclosed space
- essential to secure the endotracheal tube with umbilical twill or commercially prepared endotracheal tube holders and not adhesive tape because tape does not stick to the burned face and does not allow for swelling
Fluid Resuscitation
- crucial to the survival of the patient who has suffered a burn of 20% TBSA or greater
- objective: maintain tissue perfusion and organ function; avoiding potential complications of inadequate or excessive fluid resuscitation
- inadequate leads to organ failure and death
- IV resuscitation is initiated in adults at 20% TBSA
- if possible, consult burn center prior to resuscitation
- fluid of choice: Lactated Ringers (LR)
- IV access should be obtained ASAP
Fluid of choice for resuscitation
-Lactated Ringers (LR)
Intravenous Access
- essential and be obtained ASAP
- two large-bore (No. 20 gauge or larger) peripheral IV catheters are placed through unburned skin
- if no such area exists, the IV lines can be inserted through burned tissue but must be well secured
- if obtaining a peripheral IV catheter is extremely difficult, an intraosseous line is acceptable
- major burns often require a central venous catheter b/c of the large volumes of fluid that need to be administered
Fluid Resuscitation Calculation
- 2 to 4 mL of lactate ringers x kg x %TBSA
- Half of the total volume is given in the first 8 hours post burn and the remaining half is given over the next 16 hours
- resuscitation begins from the time the burn injury occurred; Ex: if EMS were unable to obtain an IV line on the scene and the patient arrives at the ED 2 hours post injury, fluid volume should be adjusted, and the initial 8 hour volume must now be infused over 6 hours
Examples of Fluid Resuscitation
Patient weight: 70 kg
TBSA burned: 50%
> 2 mL x 70kg x 50 = 7000 mL of LR in the first 24 hours
- First 8 hours: 7000 divided by 2(half is given first 8 Hours) = 3500
- rate: 3500/8 = 438 mL/hr
- Next 16 hours = 3500
- rate: 3500/16 = 218 mL/hr
During Fluid Resuscitation
- indwelling urinary catheter is placed to monitor urine output; reliable indicator of adequate fluid resuscitation
- urine output maintained at 0.5 mL/kg/hr
- if myoglobin present in urine, output should be maintained at 1 mL/kg/hr until clearing of the urine occurs to prevent the development of acute renal failure
- diuretics not indicated during emergent phase
- if urine output drops, rate of fluid administration is increased
- monitor HR, BP, central venous pressure, serum chemistries, hemoglobin, and hematocrit
Connection Check: Using the resuscitation guidelines, the nurse determines that a patient requires a total of 12 L of fluid in the first 24 hours post-injury. How much of the total volume needs to be given within the first 8 hours? A. 4,000 mL Lactated Ringers B. 6000 mL Lactated Ringers C. 8000 mL Lactated Ringers D. 10000 mL lactated Ringers
B. 6000 mL lactated ringers
>half of the fluid is given within the first 8 hours