Week 12 Flashcards
Burn patients are trauma patients
Major burns affect all body systems – burn patients are trauma patients
•Burn survivability increased as a result of
- Burn survivability increased as a result of
- Broad spectrum antibiotics, burn centers, aggressive nutrition and excision and improved wound care treatment
- The very young & the very old are less able to respond to therapy and have higher incidence of mortality
- 3rd leading cause of death in children ages 1 – 9 years
- 6th leading cause in the rest of the population
- Management of a seriously burned patient in first few hours can significantly affect long-term outcome
Function of skin
X
Primary survey
X
A B C D E F
X
- Major burns affect all body systems – burn patients are trauma patients
- Burn survivability increased as a result of
- Broad spectrum antibiotics, burn centers, aggressive nutrition and excision and improved wound care treatment
- The very young & the very old are less able to respond to therapy and have higher incidence of mortality
- 3rd leading cause of death in children ages 1 – 9 years
- 6th leading cause in the rest of the population
- Management of a seriously burned patient in first few hours can significantly affect long-term outcome
X
- Burns have a devastating effect on people in terms of human life, suffering, disability and financial loss
- Most burns are preventable accidents, thermal burns being most common, from:
- Fires from motor vehicle accidents, in-home accidents, arson or electrical malfunctions
- > 50% decline in burns over past 20 years
- 2.5 million → 1 million
- 500,000 ED visits / year
- 40,000 hospitalizations
- ~ 20,000 burn treatment centers
- Average burn is 10% of total body surface area (TBSA)
X
TBSA
Secondary survey Circumstances Estimating Total Body Surface Area (TBSA) •Lund Browder Scale •Rule of Nines •Rule of Palm
Function of Normal Skin •Protects from assault •Including chemical, mechanical injury •Bacterial & viral pathogens •Ultraviolet radiation •Prevents excessive loss of fluid & electrolytes to maintain homeostasis •Regulation of body temperature •Sensory contact with environment
X
Case study
X
Rule of Nines
Rule of Nines
Front half
Bilah ant arms
Lund-Browder Scale
Lund-Browder Scale
First 24 hours
Rule of Palm
Rule of Palm
Used on smaller burns
PT hand=1% TBSA
Burn depth classification
Temp
Time
Exposed
Depth of injury
1
2
3rd
Thickness
Superficial 1rst degree
Sunburn
2nd degree
Partial thickness
Painful
Nerve endings exposed
Deep partial thickness
Decreased sensation
Diff
Partial and full
Deep
Not blanch able
Full thickness
No blood flow
Fourth degree
Muscle and bone
Case study
Blotchy
Chest less severe
2nd & 3rd
Carbon Monoxide Poisoning
Change in mental status =red flag
Cyanide Poisoning
Change in RR
HA
Tx
Cyonide kit
Urine cranberry color
Burns referral criteria
- Partial thickness burns greater than 10% total body surface area (TBSA).
- Burns that involve the face, hands, feet, genitalia, perineum, or major joints.
- Third degree burns in any age group.
- Electrical burns, including lightning injury.
- Chemical burns.
- Inhalation injury.
- Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality.
- Any patient with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality.
Zone of Injury
Zone of Injury
•Zone of Coagulation
•irreversible damage
- Zone of Stasis
- Impaired blood flow
- Zone of Hyperemia
- Vasodilation
- Usually recovers
Fluid Resuscitation
•Goals:
Fluid Resuscitation
•Goals:
•Maintain tissue perfusion and organ function
•Avoid complications of over/under-resuscitation
•Prevent vs treat hypovolemia
Pathophysiology
•Burns >20% TBSA increased capillary permeability, most severe in the first 24hrs post injury
- ↑PVR with ↓CO
- r/t neurogenic and humoral effects, compensatory vascular response
- Magnitude of response directly proportional to the extent and depth of TBSA
- Fluid loss slow, progressive
Systemic Response cont…
•Major changes @ cellular level triggers systemic response:
•Coagulation of cellular proteins → irreversible cell injury
•Complement activation, histamine release, O2 free radicals altered cell membrane
•Problematic in endothelium of the microvascular circulation, cell membrane disruption increases vascular permeability
Loss of plasma proteins into interstitium
Interstitial edema – peaks @ 24-48 hours
•Large fluid loss due to fluid shifts & losses from exposed burns
•Pulmonary interstitial edema with intraalveolar hemorrhages thought to be precursor to acute respiratory distress syndrome (ARDS)
•Marked decrease in circulating volume
Systemic Response cont….
•Release of vasoactive substances:
•Histamine, prostaglandins, interleukins, arachidonic acid metabolites → initiate the Systemic Inflammatory Response Syndrome (SIRS)
- Mediators & cytokines (nitric acid, platelet activating factor - PAF), serotonin, tumor necrosis factor (TNF) → ↓ intravascular volume→ decreasing flow kidneys & GI tract
- ↑ intestinal mucosal permeability → translocation of bacteria → systemic infection
- ↓ blood flow to intestines → paralytic ileus
Systemic Response cont….
•If not corrected, can → hypovolemic shock, metabolic acidosis, and hyperkalemia
- Nitric acid relaxes smooth muscle → vasodilation and hypotension → myocardial depression and blocks platelet aggregation
- PAF activates neutrophil and WBCs → tissue inflammation
- TNF responsible for increased free radicals → injury to lungs, GI tract, kidneys
- hyperglycemia followed by hypoglycemia, ↓ BP, metabolic acidosis, coagulopathy -may lead to thrombi, ischemia, and necrosis
ABLS Fluid Resuscitation Formula •1st 24hrs post burn •1st half infused in 1st 8 hrs post burn •2nd half infused over next 16hrs 2 mL LR x weight in kg x %TBSA
•Electrical Injury- “The Great Masquerader”
4 mL LR x weight in kg x %TBSA
ABLS Fluid Resuscitation Formula •1st 24hrs post burn •1st half infused in 1st 8 hrs post burn •2nd half infused over next 16hrs 2 mL LR x weight in kg x %TBSA
Urine Output *Gold Standard
•Hourly output goal (obtained by indwelling cath)
0.5mL/kg/hr (30-50mL/hr)
•Resuscitation fluid should be
increased or decreased by 1/3 to maintain goal
Resuscitation
•BP – not always indicative of fluid status r/t edema, peripheral vasoconstriction
•HR – tachycardia (100-120s) common
•H:H – unreliable resuscitation guide, blood should not be administered for resuscitation unless pt anemic from associated trauma
•Chemistry – obtain baseline; treat accordingly
Resuscitation
•BP – not always indicative of fluid status r/t edema, peripheral vasoconstriction
•HR – tachycardia (100-120s) common
•H:H – unreliable resuscitation guide, blood should not be administered for resuscitation unless pt anemic from associated trauma
•Chemistry – obtain baseline; treat accordingly
•Electrical Injury- “The Great Masquerader”
4 mL LR x weight in kg x %TBSA
Can’t see damage
Assume greater TBSA
Case study
Tobias
Start time at burn
Lost 2 hrs
Higher rate initially
Resuscitation •BP – not always indicative of fluid status r/t edema, peripheral vasoconstriction Do not start meds right away
- HR – tachycardia (100-120s) common
- H:H – unreliable resuscitation guide, blood should not be administered for resuscitation unless pt anemic from associated trauma
- Chemistry – obtain baseline; treat accordingly
Patients with Increased Fluid Needs •Associated injuries/trauma •Electrical injury •Inhalation injury •Delayed resuscitation •Prior dehydration •ETOH/Substance abuse •Methamphetamine explosion
Patients with Increased Fluid Needs •Associated injuries/trauma •Electrical injury •Inhalation injury •Delayed resuscitation •Prior dehydration •ETOH/Substance abuse •Methamphetamine explosion
Under-resuscitation
Damage is done
•End organ failure
•MODS
•Wound progression
Over-resuscitation
Over-resuscitation
•Severe edema
•Pulmonary edema, ARDS
•Compartment syndrome
Compartment Syndrome
Xx
Fasciotomy
- Utilized in situations with rising compartment pressures (>25mmHg)
- Should be performed in operating room
Fasciotomy
- Utilized in situations with rising compartment pressures (>25mmHg)
- Should be performed in operating room
- Oliguria – inadequate fluid intake, do not admin diuretic
- Hemochromogenuria – u/o goal 1-1.5mL/kg/hr (75-100mL) until clear
- *persistent red may indicate compartment syndrome
- Oliguria – inadequate fluid intake, do not admin diuretic
- Hemochromogenuria – u/o goal 1-1.5mL/kg/hr (75-100mL) until clear
- *persistent red may indicate compartment syndrome
Case study
***Output
Up by 1/3
•Increased capillary leak → fluid to interstitial space, fascia → increased edema → circulatory compromise
•Excessive fluid resuscitation, high voltage electrical injury, ischemia-reperfusion injury, crush injuries
Escharotomy
Chest wall to ventilate
Progress to faciotomy
5 Ps
Monitor
Nurse driven fluid
X
Burns in older adults
2nd leading cause of death
100% mortality
Death from shock
Saddle
