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Complex care final > Burns- part 2 > Flashcards

Burns- part 2 Flashcards

1
Q

burns less than 20% TBSA

A
  • produce localized tissue response
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2
Q

burns greater than 20% TBSA

A
  • considered major injuries and we are worried about all body systems because they are all affected by the release of cytokines
  • admitted to burn unit
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3
Q

how to evaluate burn size “TBSA”

A
  • rule of nines
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4
Q

rule of nines

A
  • hand: 1%
  • head: 9%
  • one arm: 9%
  • one side of arm: 4.5%
  • chest front: 18% (each half- top and bottom is 9%)
  • chest back: 18%
  • peri area: 1%
  • whole leg: 18%
  • whole one side of leg: 9%
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5
Q

Primary survey assessment involves

A
  • ABCDE
  • A: airway and c spine
  • B: breathing
  • C: circulation
  • D: disability
  • Ex: exposure and examine
  • F: fluid resuscitation
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6
Q

primary survey- airway and c spine

A
  • maintain patent airway (may need intubation- assess for inhalation injury since 50% of burn patients will have it)
  • check if possible for advanced directive/ code status prior to ETT
  • cervical spine immobilization if warranted
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7
Q

Primary survey- Breathing

A
  • high flow 100% oxygen mask

- assess burns and the impact they have on work of breathing

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8
Q

primary assessment- circulation

A
  • elevate extremities
  • no pillow under the head
  • remove tight jewelry or clothing
  • pulse checks with circumferential burns or electrical burns
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9
Q

primary assessment- disability

A
  • neuro exam
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10
Q

primary assessment- exposure and examine

A
  • extent and depth of burn wounds and possible associated trauma
  • trauma care tumps burn care
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11
Q

primary assessment- fluid resuscitation

A
  • insert at least 2 large bore (> 18 G) IV and start LR

- 18 or lower number

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12
Q

secondary assessment includes

A
  • circumstances
  • medical history
  • head to toe
  • extent of burn
  • covering wounds
  • maintain core body temp, pain meds, iv narcotic preferred
  • tetanus statues and lab tests
  • ABG
  • 12 lead EKG and CK-MB/ troponin levels
  • Fluid resuscitation
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13
Q

secondary assessment- circumstances

A
  • cause?
  • time of injury
  • enclosed space?
  • associated trauma (electrical)
  • length of time before rescue
  • chemicals involved
  • use of accelerant
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14
Q

secondary assessment- medical history

A
  • current meds
  • allergies
  • vaccinations
  • last flood and fluid intake
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15
Q

secondary assessment- what do you cover the wounds with

A
  • clean dry sheet
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16
Q

secondary assessment- lab tests

A
  • CBC
  • CMP
  • PT/aPTT
  • urinalysis
  • surveillance cultures
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17
Q

secondary assessment- what do you do an ABG and carboxyhemoglobin for

A
  • suspected inhalation injury
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18
Q

secondary assessment- what do you do 12 lead EKG and CK-MB/ troponin levels for

A
  • suspected electrical injury
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19
Q

Phase of interventions

A
  • Emergent: first 48 hours
  • Acute: weeks to months (day to day care)
  • Rehab: > 2 years: once the wound is closed- pt skin is fragile and may get scraps and cuts
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20
Q

Burn Shock

A
  • right after the burn
  • hypovolemic and distributive shock: your not bleeding and you only have edema but the fluid is in the wrong place
  • Massive fluid loss externally: heavy protein loss
  • significant interstitial fluids: wound edema, thrid spaci
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21
Q

inside cell

A
  • normally: k+

- with burns: K+ leaves the cell

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22
Q

outside the cell

A
  • normally: Na+

- with burns: Na+ moves into the cell

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23
Q

with burns what moves outside of capillary

A
  • H20
  • Na
  • Albumin (more edema)
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24
Q

first 48 hours after a burn

A

add stuff

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25
Q

longer than 48 hours after a burn

A

add stuff

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26
Q

circulation

A
  • need large fluid amounts to maintain tissue perfusion
  • want early and adequate resuscitation
  • begins with the parkland formula and the rule of nines
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27
Q

under resuscitation

A
  • leads to overwhelming acidosis (lactic acidosis)
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28
Q

over resuscitation

A
  • leads to increased complications
  • lung injury
  • ARDS
  • Compartment syndrome
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29
Q

ABLS recommendation for fluids for EMS when > 30% TBSA

A
  • determined by age
  • <5: 125 ml/hr
  • 6-13: 250 ml/hr
  • > 14: 500 ml/hr

*once in ED: fluids calculated via formula, foley catheter inserted, temperature control

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30
Q

parkland fluid formula

A
  • 4 ml LR x TBSA x kg
  • give 1/2 of volume within first 8 hours then the rest over the next 16 hours
  • adjust fluid rate to maintain UO of 30-50 ml/hr
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31
Q

Fluids when UO is 75 cc for 2 consecutive hours

A

-decrease

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32
Q

Fluids when UO is 20 or 15 cc for 2 consecutive hours

A

-increase

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33
Q

electrical injury fluid resuscitation

A
  • 4 ml LR x kg x TBSA
  • maintain UO of 75-150 ml/hr or whatever is deemed necessary to clear the urine and protect the kidneys (dont want red bloody urine)
  • may need to increase UO 10 1-1.5 per kg/hr to clear urine
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34
Q

goals of burn care

A
  • prevent secondary injury by performing adequate resuscitation
  • extent of burn cant be calculated until 24 hours after and poor tissue perfusion in these first 24 hours = extend the depth of the burn
35
Q

Airway- breathing- assess

A
  • facial burns, inhalation injury or burn (>25% TBSA)= inhalation injury and early intubation is important
36
Q

airway-breathing- bronchoscopy

A
  • into the airway to see
37
Q

airway- breathing

A
  • humidified o2 to keep airway clear
  • 100% o2 to help remove CO and monitor carboxyhemoglobin
  • Assess sputum: thick? dry? soot?- may need aggressive pulmonary interventions to prevent mucous plug (keep moist)
  • monitor: pulmonary edema, atelectasis, PNA, ARDS
  • elevate HOB
38
Q

circulation

A
  • want adequate tissue perfusion

- assess for compartment syndrome and check pulses

39
Q

circulation: cardiac concerns- hypovolemic shock

A
  • massive metabolic acidosis (tissue lactate)
40
Q

circulation: cardiac concerns- k+

A
  • released in massive amounts
  • monitor K+
  • treat dysrhythmias
41
Q

circulation: CARDIAC concerns

A
  • hypovolemic shock
  • K+ released in massive amounts
  • decreased CO which increases complications
42
Q

circulation: hemodynamic markers

A
  • CVP: > 10 (not really used too much)
  • SV 70% or SVV < 13-15
  • UO: >30-50 ML/HR
  • ABG: acidosis- want lactate < 2
43
Q

emergent phase

A
  • pain management (small frequent doses or infusion)
  • sedation-anxiolytic
  • gi symptom management
44
Q

emergent phase: gi symptom management

A
  • NG to prevent and manage ileus
  • small bore feeding tube- placed early: feed within 24 hours; hypermetabolic injury
  • curlings ulcer: stress ulcer- H2 blocker, cytoprotective, PPI
45
Q

why does ileus form in burn

A
  • blood is sent to vital organs since in truama state

- which means GI tract is not getting blood = frozen and not working = ileus

46
Q

emergent phase- thermal control

A
  • they cant maintain temp so we need to
  • warming blankets
  • high room temp (84-86)
  • warming lamps
47
Q

emergent phase- infection control

A
  • gown and gloves for contact when > 20%
  • topicals
  • high risk for sepsis
48
Q

compartment syndrome is usually found in…

A
  • full thickness circumferential burns or electrical burns

- pt. with large resuscitation

49
Q

compartment syndrome assessments

A
  • constant neuro
  • sensation/paresthesias
  • pupils checks= Q 15 - 60 min
  • cap refill
  • general feeling of the limb
50
Q

treatment for compartment syndrome

A
  • escharotomy or fasciotomy
51
Q

when do escharotomy or fasciotomy

A
  • compartment pressures of greater than 30 (we want them less than 25)
  • loss/decrease of sensation in extremity
  • loss of dopplerable pulse
52
Q

escharotomy or fasciotomy

A
  • cuts through the inelastic eschar or into the fascia
  • non compliant and doesn’t stretch or expand so can affect breathing and even cause ARDS
  • End result of tx: return of blood flow through/to the body part (return of pulses, perfusion, and sensation)
53
Q

when to get fasciotomy instead of escharotomy

A
  • when its deeper
  • electrical or thermal burns
  • deep burns
54
Q

emergent phase summary

A
  • first 48 hours
  • up to 72 hours of resuscitation- could last longer
  • pt and family is emotional and have information overload
55
Q

acute phase

A
  • 72 hours to closure
  • fluid balance
  • edema management
  • promote wound closure with wound care
56
Q

acute phase goals

A
  • infection prevention
  • pain control
  • nutrition
  • prevent complications
57
Q

when does wound care happen

A

once pt is stable

58
Q

wound care

A
  • topicals
  • antimicrobials
  • enzymatic collagenase
  • medical grade honey
  • anti-fungal
  • NON STICK DRESSINGS ALWASY
59
Q

antimicrobials used for wound care

A
  • bacitracin
  • silver sulfadiazine
  • sulfamylon: cream/soaks
60
Q

enzymatic collagenase for wound care

A
  • chemical debridement

- places (like cheeks) that you wouldn’t want to scrub but you want to break down the dead skin to get it off

61
Q

anti-fungal used for wound care

A

nystatin

62
Q

hydrotherapy

A
  • every day
  • uses water to loosen dead tissue and assist with removal of tissue and agents
  • prevent hypothermia
  • give: high does medications for pain and anxiety (fentanyl, Ativan, ketamine, presedex)
63
Q

debridement

A
  • chemical
  • mechanical
  • surgical
  • this is where you wash off the topicals and bandages and then take off any dead skin that can fall off
64
Q

types of grafts

A
  • autograft
  • allograft- temporary
  • xenograft: pig - temporary
  • CEA
65
Q

CEA

A 
-Cultured epithelial
cells “grown” from
small portion of skin (skin grown from pt own skin)
• Expensive
• Used when tissue
can’t be taken from
patient (if already took skin from somewhere and cant take more because hasn't grown back yet) 
• TBSA > 85%
66
Q

autograft types

A
  • sheet or mesh
67
Q

mesh graft

A 
-Holes or “interstices” are
placed in harvested skin to
increase the surface
coverage area (stretch it out) 
-Covers larger areas of the
body
68
Q

sheet graft

A 
•One continuous piece
of skin
•better cosmetic
outcome
•Used for faces, hands,
feet, and joints (highly exposed areas)
69
Q

downside to autograft

A
  • now have two sites to take care of (graft and donor)
70
Q

care for graft site

A
  • No pressure on site
  • Roll out bubbles of air and fluid
  • Keep edges moist
  • Observe for “take”…usually 5-6 days
71
Q

care for donor site

A 
• Pain Management
New increased pain area because now have another wound site so the total wound area is bigger 
• Moist to dry wound healing
(think of a scab)
• Thin dressing
• Heals 7-14 days
72
Q

pain management

A 
•Hypermetabolism= Patient: rapid metabolizing
meds.
•Higher dosing
•more frequent dosing
needed
•Not addiction…
73
Q

other meds for burn pt

A
  1. anxiety: benzo and antidepressants
  2. B blockers to reduce heart rate: propranolol of metoprolol if have breathing issues
  3. anabolic steroid to increase muscle protein metabolism: oxandrolone
  4. growth hormone
74
Q

nutritional concerns with burns

A

-Hypermetabolic state
- TBSA > 40%= 2X resting
metabolic rate
• Consumes nutrients
• Metabolizes drugs more quickly
• >20% need additional kcal
-Malnutrition primary concern
-High dose Vitamin C
• Decrease fluid needs and increase
healing
-Protein & calorie rich diet
• 2-3g/per kg q 24 hr
-Enteral nutrition preferred
Versus TPN
• Low fat High Carb
• Post pyloric
• Tube feeds: 24 hour goal
and hourly goals used

75
Q

burn wound infection

A
  • don’t do prohylaxtic abx just give if s/s of infection
    -Cellulitis
    • Assess for erythema,
    edema, increased pain
    • Will need debridement
    and possible IV
    antibiotics
    • Will prevent the wound
    from healing
76
Q

rehabilitation phase

A 
•Wound closed
•80% tissue
strength
•Itching
•Temperature
regulation
• Longest stage--years
77
Q

mobility

A
  • IMPORTANT
  • Starts with first day in hospital
    •ROM (open and close hans)
    •Positioning: splinting position of greatest
    function
    •Prevent contractures by keeping area under the joints stretched out
    Scars constrict & decrease mobility
    •concern over joint spaces= contractures
    form
  • no pillow with neck burns
78
Q

skin care later on for years

A 
-Scar compression
– Elastic wraps
– Pressure garments
– Tight fitting
– Skin stretch
• Cosmetic
concerns for
patients
• Compliance
concerns
79
Q

laser therapy

A

Transformation of light
into heat - Vaporizing old scar
creating new wound with new
healing

80
Q

ablation therapy

A
  • removal of target tissue
81
Q

downsides of laser therapy and ablation

A
  • Dry, peeling, itching ,delayed
    hypopigmentation, infection
    •Cost
    •Covered by insurance
82
Q

psychosocial

A 
- Body Image Distress/disorder
• Visible cosmetic alteration
• Scars/melanin does not come back
• Grafting leaves marks
• Pressure garments in public
• Make-up products
-Depression
-Shame
83
Q

new therapies

A
  • Spray on skin
    • clinical studies in progress in USA and Europe
    Fish skin graft
    • used in areas where access to Allograft and
    Xeonograft is limited
    • not likely to be used in US on People at this time
    • We have enough access to allograft
    • See next slides how it is used in animals

Complex care final (8 decks)

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