Vol.4-Ch.5 "Burns"

Question 1

How does a thermal burn occur?

What 3 major factors determine the damaging effect of a hot substance? (thermal burn)

Answer 1

As a substance gets hotter its molecules move faster and collide faster, this creates heat and energy. When this head and energy gets close to skin it transfers that energy to the skin, denaturing proteins and cell membranes.

1) its temperature
2) concentration of heat it has (depends on density)
3) length of time in contact

(for #2 imagine steam at a certain temp hitting you VS grease hitting you at same temp)

Question 2

What are the 3 zones of Jackson’s Theory of Thermal Wounds? Describe what is happening in each zone.

Answer 2

1) Zone of Coagulation - the closest to the heat source; cells membranes are rupturing, protein are denaturing, and blood is coagulating
2) Zone of Stasis - just outside zone of coagulation; is a less damaged area that is still inflamed and has decreased blood flow
3) Zone of Hyperemia - outside zone of stasis; this has limited inflammation and blood flow restriction, it mostly just accounts for erythema

Question 3

If the zone of coagulation penetrates the _____ the burn is considered to be full thickness or 3rd degree

Answer 3

Dermis

Question 4

At what % of the body being burned can you get large scale pathological effects on the body as a whole?

Answer 4

15-20%

Question 5

What are the 4 phases of the bodies response to burns?

Answer 5

• Emergent Phase
• Fluid Shift Phase
• Hypermetabolic Phase
• Resolution Phase

Question 6

What happens in the Emergent Phase of the bodies response to a burn?

Answer 6

First phase ; includes a pain response and the dumping of catecholamines in response to pain. The Pt will experience:

• tachycardia
• tachypnea
• mild hypertension
• mild anxiety

Question 7

What happens in the Fluid Shift Phase of the bodies response to a burn?

Answer 7

Second phase ; this occurs in patients with burns 15-20% of the bodies surface and happens over up to 24 hours, but peaking at 6-8 hours. It is when the body begins releasing agents to initiate the inflammatory response which increases blood flow to capillaries near the burn and capillary permeability. This causes a large shift of fluids from the intravascular space to the extravascular space.

Question 8

What occurs in the Hypermetabolic Phase and Resolution Phase of the bodies response to a burn?

Answer 8

Hypermetabolic Phase:
-third phase; can last days or week and is the bodies increase of demands for nutrients as the body begins to heal

Resolution Phase:
- fourth and last phase; scar tissue is formed and the Pt is rehabilitated and back to normal function

Question 9

What is:

• voltage
• current (measured in?)
• resistance (measured in?)

Answer 9

Voltage - is the difference between two concentration of electricity (like difference in pressures)

Current - is the rate/amount of flow of electricity and is measured in AMPERES.

Resistance - is how resistance electricity is faces as it travels through a material and is measured in OHMS

Question 10

What is Ohm’s Law?

Answer 10

V = IR

V = voltage
I  = current
R = resistance

Question 11

What is Joule’s Law? What does it calculate?

Answer 11

It calculates the heat produces by electrical current (power)

P = I^2 x R x t

P = power
I = current
R = resistance
t = time during which it flows

Question 12

How does skin and nervous tissue resistance electrical current?

Answer 12

Skin is highly resistant but the nervous system is not resistant as it is the bodies electrical impulse system

Question 13

Where does the highest heat occur at in an electrical burn?

Answer 13

At the point of greatest resistance; i.e the skin with dry skin being more resistant than wet and thin skin

Question 14

Are blood vessels and nerves more likely to be damaged in an electrical burn or bone and muscle?

Answer 14

Blood vessels and nerves because they offer less resistance

Question 15

The _____ the area of contact the _____ the concentration of energy and therefore the _____ the injury.

Answer 15

The smaller the area of contact the greater the concentration of energy and therefore the greater the injury.

Question 16

How do chemical burns do damage? What are the 2 most common causes?

Answer 16

They denature the biochemical make up of cell membranes (mostly proteins) and destroy the cells.

Acids and Alkalis are the most common causes.

(damage is usually LIMITED except with the most caustic substances b/c the injuries are not transmitted through the body, it must destroy what it is currently in contact with first before it can go deeper)

Question 17

What is coagulation necrosis and what causes it?

Answer 17

Acid burns cause this and it is the formation of a thick, insoluble mass called a COAGULUM, and it helps to limit the depth of the acid burn but causes immediate pain.

Question 18

What is liquefaction necrosis and what causes it?

Answer 18

Alkali burns cause this, it is the destruction of cell membranes and the release of intercellular and interstitial fluid, destroying tissue. It causes limited pain but does NOT form a coagulum, making these burns go much DEEPER THAN ACID burns.

It also progressively denatures proteins and collagen, dissolves fats, dehydrates tissues, and damages blood vessels.

Alkalis are commonly used in oven and drain cleaners, agricultural fertilizers and in industry.

Question 19

How does radiation damage occur?

Answer 19

It does damage through IONIZATION, in which radioactive energy particles travel into a substance and change an internal atom

Question 20

What 3 things happen to cells that are effected by ionization?

What human cells are most sensitive to radiation injury?

Answer 20

1) cell repairs damage
2) cell dies
3) cell produces more damaged cells (cancer)

Cells that reproduce quickly are most sensitive:
erythrocytes, leukocytes, platelets, cells in intestinal tract, and reproductive cells

Question 21

What are the 4 types of ionizing radiation? Describe them.

Answer 21

1) Alpha Radiation : very weak; stopped by paper, clothing, or the epidermis; can only travel a few inches, though very large atomically (only dangerous if inhaled)
2) Beta Radiation : although smaller than alpha it can travel up to 6-10ft and penetrate clothing and first few millimeters of skin. It has potential for external/internal injury
3) Gamma Radiation : (x-rays) most powerful ionizing radiation, has no mass (is pure electromagnetic energy, or protons), has great penetrating power, requires thick concrete or lead protection
4) Neutron Radiation : great penetrating power b/c of small size and no charge, not found outside of nuclear reactors or bombs

Question 22

What are the 2 mechanisms people get exposed to ionization through?

Answer 22

1) unshielded person in direct exposure to source

2) exposure through dust, debris, or fluids that contain small particles of radioactive material

Question 23

What are the 3 main factors that may affect the damage done by radiation exposure?

Answer 23

1) Duration of exposure
2) Distance from the source
3) Shielding from the source

Question 24

What tools are used to detect radiation and in what units do they measure?

Answer 24

A Geiger Counter or Dosimeter (for prolonged exposure) measuring in a rad or Gray (1 Gray = 100 rads)

Question 25

What is carbon monoxide? How many more times does hemoglobin have an affinity for CO2 than O2?

Answer 25

CO is a product of incomplete hydrocarbon combustion, it is tasteless, odorless, and hemoglobin has an affinity for it 200x more than oxygen.

Question 26

What are the 3 different burn depths?

Answer 26

1) Superficial or 1st degree:
- red skin, pain at site

2) Partial Thickness or 2nd degree:
- Blisters, intense pain, white to red skin, moist and mottled skin

3) Full Thickness or 3rd degree:
- penetrates dermis and reaches subcutaneous, no pain b/c nerves are damaged, charring or white/dark brown skin, skin feels hard

Question 27

The rule of 9s for an adult are?

Answer 27

1) head and neck = 9%
2) upper back = 9%
3) anterior chest = 9%
4) each upper extremity = 9% (both = 18%)
5) anterior abdomen = 9%
6) lower back = 9%
7) each Pos. lower extremity = 9% (front and back of
8) each Ant. lower extremity both legs = 36% total)
9) external genetalia = 1%

only difference for babies is the legs = 13.5% each

Question 28

Rule of 9s are better for large scale burns but what is used for smaller scale burns (less than 10% of body)?

Answer 28

Rule of Palms :

- the pts palm is = to about 1% total BSA

Question 29

What are the 4 common systemic problems associated with burns?

Answer 29

• Hypothermia
• Hypovolemia (also electrolyte imbalance and possible
  hyperkalemia from release of break
  down products like potassium causing
  heart issues)
• Eschar (this is caused by the constriction of skin,
  specifically the dermis, after it is burned which
  can cut off blood flow entirely or reduce chest
  movement for breathing if on the torso)
• Infection

Question 30

Consider carbon monoxide poisoning to be present if reading of CO levels exceed _____%?

How do you treat this?

Answer 30

10-12%

Treat with O2, Positive pressure ventilation, and rapid transport

Question 31

What is often found in combination with CO poisoning?

Answer 31

Cyanide poisoning

Question 32

What drug can be given when CO poisoning is suspected (and sub sequentially cyanide poisoning)?
What does it do?

Answer 32

Hydroxocobalamin (marketed as a cyanide antidote - Cyanokit)

Hydroxocobalamin is a precursor to vitamin B12, it binds to cyanide by freezing it from the cytochrome enzyme needed by cells for O2 processing, and becomes cyanocobalamin (vitamin B12) and is nontoxic now and excreted in urine.

Question 33

Why would it be important to start an ET tube early on a burn patient?

What drug should be avoided or used with extreme caution for RSI and why?

Answer 33

An ET tube placement should be done quickly because of the edema associated with inhilation injuries to the airway that may make it very hard or impossible to do one later.

Succinylcholine should be used sparingly if at all because of its ability to worsen hyperkalemia which is already a risk for severe burn patients

Question 34

What two broad categories can burns be places into when it comes to treatment?

What are the 3 main goals of burn treatment?

Answer 34

Local and minor burns OR Moderate to severe burns

1) prevent shock
2) prevent hypothermia
3) prevent further wound contamination

Question 35

For partial thickness burns or very small full thickness burns you should? (4)

Answer 35

• Remove any clothing or jewelry that could become a restriction when swelling occurs
• you can apply local cooling or cold water ONLY for partial thickness burns 15% or less or for very small full thickness burns (any large scale cooling will increase hypothermia)
• Provide comfort and support and in severe cases consider fentanyl or morphine
• Cover with non adhesive bandage to prevent contamination (not wet for large scale b/c it could increase hypothermia)

Question 36

For moderate to severe burns what should you do?

Answer 36

• Use dry, clean (not necessarily sterile), nonadherent dressings or a sheet to cover partial thickness burns OVER 15% or full thickness OVER 5%.
  (reduces pain from limited air flow over wounds and helps keep contamination from worsening)
• Keep pt warm
• Early, aggressive fluid therapy helps to reduce the later impact of the severe fluid loss once fluids shift
  (2 large bore, 1000ml bags normal saline or Lactate Ringer’s, parkland formula or modified pre hospital formula EX. 4ml or .25ml)

Question 37

Describe the process of starting an IV and deciding how much fluids to give for a severe burn patient? (Parkland flormula)

Answer 37

• 2 large bore catheter
• 1000ml bags of normal saline or lactate ringers
• long term care (over an hour) uses Parkland formula for deciding how much to give over a 24 hour period
  4ml x Pts Wt in Kg x %BSA of 3rd degree burn
  (the pt will recieve the first half of the amount in the first 8 hours)
• for prehospital care (less than 1 hour of treating) a modified version is used
  .25ml x Pts Wt in Kg x BSA of 3rd degree burn
  (the Pt can receive this amount 1-2 times within first hour)

Question 38

What 2 drugs can be given for severe pain with burns?

Answer 38

• Morphine : 2-5mg via IV every 5 minutes till suffering is eased
  (this should be used with caution as it can depress
  the respiratory drive and increase any hypovolemia)
• Fentanyl : loading dose to start with of 25-50mcg via IV and repeat doses of 25mcg as needed

Question 39

What do you do for electrical burns?

Answer 39

Treat them similar to thermal burns

however,

since this can have great impact on the bodies electrical system you should suspect circulatory and respiratory arrest. Fight these with aggressive circulatory, ventilatory, and airway management

Check immediately for heart arrhythmias

Start 2 large IVs, 1000ml bag of fluid per hour in 20mL/kg boluses

Question 40

What 2 meds can be used for severe electrical injuries?

Answer 40

Sodium Bicarbonate and Mannitol (usually at descretion of online med control) to prevent rhabdomyolysis and hyperkalemia

Sodium Bicoarbonate : 1 mEq / kg
Mannitol : 10g

Question 41

What 4 things should you record when dealing with a chemical burn? (if info is attainable)

Answer 41

• Type of chemical agent
• Exact name of chemical agent
• Length of time exposed
• Precise body parts exposed

Question 42

What are 4 common chemical burn culprits and how do you treat them?

Answer 42

1) Phenol - gelatinous and caustic, is used in powerful industrial cleaner. You must use alcohol to dissolve and remove it. (if no alcohol is present use copious amounts of cool water to remove)
2) Dry Lime - (calcium oxide) is a strong corrosive powder that reacts with water to produce heat. Brush as much off Pt as you can and rinse the rest off with cool water. This cool water will reduce the heat made by reacting with the water and get rid of any left so it does not react with Pts sweat.
3) Sodium - unstable metal that reacts violently with many substances including human tissue and especially water (even water in the air). It is typically stored in oil and if present on Pt, brush as much off as you can and then coat the wound in oil
4) Riot Control Agents - CS (tear gas), CN (mace), and oleoresin capsicum (OC, pepper spray) are used in riot situation and typically irritate the eyes, mucous membrane, and respiratory tract. Typically symptoms dissipate in 10-20 minutes but irrigate eyes as necessary

Question 43

What organ is of special concern with chemical burns?

Answer 43

the eye, as they are extremely sensitive to chemical