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Flashcards in BURNS Deck (28)
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1
Q

What are the three zones of injury that occur with burns?

A

Zone of coagulation – closest to the source of the burn, its called zone of coagulation because of coagulation of cellular proteins and destruction of the microcirculation which results in rapid cell death, necrosis.

Zone of stasis – around the zone of coagulation is called zone of stasis due to slow blood flow to the area and characterized by decreased tissue perfusion

Zone of hyperaemia - increased tissue perfusion, where healing takes place.

2
Q
  1. Discuss the systemic responses that occur with a major burns injury.
A

Systemic damage caused by burns exceeding 20% of the total surface body area is considered major burns and will have systemic effects. (Hypovolemic shock, electrolyte shifts)

Cardiovascular – reduced cardiac output, increased afterload, decreased contractability

Respiratory – lung inflammation, hypoxemia, pulmonary arterial and vascular hypertension

Metabolic – hyper metabolic state leads to increased oxygen consumption, the release of adrenalin and cortisol which is a stress hormone resulting in a higher body temperature

Immunological – immune function is supressed which increases susceptibility to wound infections and potential sepsis.

3
Q

Explain how burns are classified.

A

Epidermal burns – involves the epidermis, the skin is pink, red and painful, heals in 7 days

Superficial partial thickness – involves the epidermis and the superficial dermis, it blisters, is red or mottled, painful with exudate and heals in 14 days

Mid-dermal partial thickness – involves the epidermis, large zone of non-viable tissue, less painful with exudate, pale to dark pink.

Deep partial thickness – involves deep into the dermis, pink to pale ivory colour, the skin does not blanch, hair falls out, surgically removed

Full-thickness – the epidermis and dermis is destroyed, may penetrate underlying structures, dense white, waxy, charred, skin often feels leathery (eschar)

4
Q

Outline the problems that can arise as a result of the loss of skin integrity caused by a burn injury.

A

The normal protective from invasion of harmful substances, loss of fluids and electrolytes and regulation of the body temperature are altered. Following a burn the normal protective defence mechanisms including defensives derived from the kerstinocytes and acis secreations from sweat and sebaceous glands are lost, resulting in wounds becoming colonised and invaded by microorganisms.

5
Q

Identify the criteria for fluid resuscitation in a burns patient and the formula used to calculate fluid requirements.

A

Adult: >15%TBSA
Children:>10% TBS

FORMULA:

4ml x TBSA (%) x body weight (kg); CSL
50% given in first eight hours;
25% given in second eight hours.
25% given in third eight hours.

Add daily intake 83mls on top

6
Q

Which two factors determine the extent of the systemic effects of a burn?

A

The total body surface area burnt and the depth of the burn

7
Q

Describe and compare a superficial partial thickness burn to a deep partial thickness burn.

A
superficial partial thickness:
epidermis and superfcial dermis
blister, red or motted
painful, exudate
heals 14days 
deep partial thickness burn:
deep into the dermis 
pink to pale ivory colour
skin does not blanch
hair falls out
suergly excised
8
Q

Complete the following table using Wallace’s Rule of Nines – Adults TBSA%

A
Fingers and hands-1%
Head: 9%-4.1/2%)
Chest (anterior trunk): 18% -9% top and bottom half
Back (posterior trunk): 18%-9% top and bottom half
Right arm: 9%-41/2% front and back
Left arm: 9%-41/2% front and back
Genitalia-1%
Right leg: 18%-9% front and back
Left leg: 18%-9% front and back
9
Q

What is a circumferential burn?

A

When the burn is a circumferential (burned all the way around). In full-thickness burns, both the epidermis and the dermis are destroyed along with sensory nerves in the dermis. The tough leathery tissue remaining after a full-thickness burn has been termed eschar.

10
Q

An 80kg patient has suffered Thermal burns to his entire thorax and back (circumferential).:

Calculate the percentage of burns this patient has sustained using the ‘rule of nines’.

A

Thorax – 18%
Back – 18%
Total body surface area affected by burns is 36%

11
Q

An 80kg patient has suffered Thermal burns to his entire thorax and back (circumferential).:

Using the adult formula for fluid resuscitation, calculate the fluid requirements for this patient in the:

A

4mls / x 80kg x 36% (TBSA) = 11520mls
50% of 11520mls is required in the first 8 hours post burn. 5760 / 8hrs = 720mls / per hr + 83mls
25% of 5760mls is required in the second 8hrs post burn. 2880 / 8hrs = 360mls / per hr + 83mls
25% of 5760mls is required in the third 8hrs post burn. 2880 / 8hrs = 360mls / per hr + 83mls

Note: on top of this fluid quantity the patient will also require the ‘normal’ daily intake of hydration over 24 / 24. Average intake 2000mls thus 2000mls over 24/24 = 83mls / hr
In the first 8 hours 720mls + 83mls = 803mls /ph
In the second 8 hours 360mls + 83mls = 443mls / ph
In the third 8 hours 360mls + 83mls = 443mls / ph

12
Q

An 80kg patient has suffered Thermal burns to his entire thorax and back (circumferential).:

Discuss in detail why intravenous fluid resuscitation is required for this patient? Please also include an example of the type of IV fluid likely to be administered to this patient in the first 24 hours, and why this choice of fluid is appropriate?

A

Indication of TBSA is above 15% therefore this patient requires fluid resus. The patient will have sustained systemic effects causing adverse effects such as fluid loss, dehydration. The IV fluid likely to be administered in CLS / Hartman’s solution. The reason for this choice of fluid is because it is the most physiologically adaptable fluid and because its electrolyte content is most closely related to the body’s blood serum and plasma.

13
Q

You are caring for a 20 year old female patient that has partial thickness burns to the anterior aspect of her left leg and full thickness burns to her perineum. What percentage of body surface area is burned?

A

10%

14
Q

A 47 year old male has been admitted with circumferential burns of both his legs and genitals. What percentage of his body has been burned?

A

37%

15
Q

A 20-year-old male presented to ED after he tripped and fell into a small camp fire. He has burns to his hands, anterior aspect of his arms and upper chest. What percentage of his body has been burned?

A

20%???

16
Q

A 17 year old female under your care has second degree burns on her left lower leg and foot. What percentage of body surface area is burned?

A

4.5%

17
Q

A 25 year old female brought in via ambulance has sustained deep-dermal partial thickness burns to the chest, abdomen and right arm. What percentage of body surface area is burned?

A

22.5%…?

18
Q

A 60 year old gentleman has presented to the ED with full thickness burns to both legs, groin, front of his chest and abdomen. What percentage of body surface area is burned?

A

37%

19
Q

Identify five factors that need to be considered when determining the depth of a burn.

A

Classified according to the depth of injury

Epidermal, 
superficial partial thickness, 
mid dermal partial thickness, 
deep partial thickness, 
full thickness
20
Q

Discuss when an escharotomy may be required in burns management.

A

Involves full thickness incision of the circumferential burn down to the subcutaneous fat, to release constricting underlying eschar. This will allow reperfusion of the limb distally or chest or abdominal expansion. If circumferential burns happen in the neck or chest, the pressure will prevent chest expansion leading to breathing problems. This procedure allows easier movement for muscles and return of blood flow by removing the tourniquet effect.

21
Q

Discuss in detail why patients with severe full thickness burns (greater than 20% TBSA), experience reduced cardiac output and how this impacts other systems and the resulting clinical manifestations likely exhibited by the patient.

A

Burns exceeding 20% of TBSA is considered to major burns, after burn injury the systemic microcirculation loses its vessel wall integrity and plasma leaks out of the damaged capillaries into the surrounding tissues. Damage to the cells causes a shift of electrolytes with sodium moving into the injured cells and potassium moving out, leading to hyperkalemia. Reduced cardiac output results from decreased plasma volume, increased afterload and decreased contractility. This leads to decreased blood flow to the liver, gastrointestinal organs and kidneys resulting in slowed peristalsis and gastric emptying and reduced urine output. Immune function is suppressed increasing systemic wound sepsis. Clinical manifestations include heart rate increasing to maintain cardiac output. Loss of skin integrity leads to loss of body temperature which leads to increased metabolism. Irritation of nerves cause pain. Loss of the protective barrier function, together with immunosuppression, leaves the patient at risk of developing localised and systemic infection.

22
Q

Explain why burned patients have a prolonged hyper-metabolic state.

A

The hypermetabolic response may persist for 1 to 2 years after the initial burn and is characterized by hyper dynamic response with increased body temperature, oxygen and glucose consumption, CO2 production, glycogen lysis, proteolysis, lipolysis. The hypermetabolic response causes loss of lean body mass, loss of bone density, muscle weakness and poor wound healing. Z

23
Q

Explain why PCA analgesia is the preferred method of pain management for major burns patients? Please include paediatric considerations in your answer.

A

PCA is the preferred method for pain management when inadequate analgesia results from oral, intermittent IV boluses. The PCA unit may record all patient dosing attempts, therefore, the prescriber can monitor and evaluate the need for analgesia. Children must have the cognitive ability to understand the concept of PCA and be willing to self-manage. Nurse controlled analgesia set up can be used. Considerations for sensitivity to CNS, adverse reactions including respiratory depression. The child’s parents must also understand the concept of PCA, and must not press the button for the child, but they may encourage the child as required.

24
Q

Discuss the use of silver sulfadiazine and Nanocrystaline Silver (Acticoat) in the wound management of burns, including common adverse effects experienced by patients. Why is Acticoat the preferred product, in the wound management of burns?

A

Burn wounds are susceptible to infection and can result in septicaemia, evidence shows that acticoat is a silver impregnated dressing that facilitates the delivery of silver to the burn wound surface. The invitro antimicrobial action of silver has been demonstrated to destroy within 30 minutes, both GRAM POSITIVE AND NEGATIVE bacteria. It is fast in destroying pathogens, is less painful that silver sulfadiazine cream dressings, it has an anti-inflammatory effect. Acticoat compared to silversulphadiazine cream reduces burn wound cellulitis, antibiotic usage and reduction in inpatient costs. Silversulphadiazine has pro-inflammatory properties and shown to cause leucopenia (reduction in white blood cells) this places patients at increased risk of infection.

25
Q

Morphine
Opioid Analgesic:

Usual dosage and route of administration:
Adverse Effects:

A

Usual dosage and route of administration:
• Oral solution/tablet: 5-20mg
• CR (controlled release) preparations: 5-100mg
• IM/SC/IV: 0.5-10mg
• Epidural, IT (Intrathecal-administered into the spinal theca): 0.2-5mg

Adverse Effects:
•	Constipation
•	Nausea & Vomiting
•	Itch
•	Urinary retention
•	Sedation
•	Circulatory and respiratory depression
•	Miosis (pin point pupils)
26
Q

Midazolam
Benzodiazepine (short acting)
Anxiolysis:

Usual dosage and route of administration:
Adverse Effects:

A

Usual dosage and route of administration:
• IV: 0.5-10mg/h (infusion)
1-2mg (bolus)

Adverse Effects:
Hypotension
Nausea & vomiting
dizziness, or drowsiness

27
Q

Lorazepam
Benzodiazepine:

Usual dosage and route of administration:
Adverse Effects:

A

Usual dosage and route of administration:
• Oral or sublingual:
• Initial daily dose of 2mg and increased by 0.5mg depending on tolerance and response.
• Optimal daily dose of 1-4mg with max dose of 6mg

Adverse Effects:
•	Sedation
•	Hypotension
•	Confusion 
•	Ataxia
28
Q

Fentanyl
Opioid Analgesic
(very potent which is why prescribed in mcg):

Usual dosage and route of administration:
Adverse Effects:

A

Usual dosage and route of administration:
• SC/IV: 50-100mcg
• Patch: 12-100mcg/h
• Lozenge (lollipop): 200-1600mcg

Adverse Effects:
• Bradycardia
• Nausea &Vomiting
• Constipation