Common problems in acute care part 2 Flashcards
First degree burn
Involves epidermis only.
Dry, red, no blisters.
Second degree, partial thickness burn
Extends beyond the epidermis.
Moist, blisters.
Third degree, full thickness burn
Extends from epidermis to dermis and underlying tissues, fat, muscles and/or bone.
Dry, leathery, black, pearly, waxy.
Not painful d/t nerves being destroyed.
Rule of 9’s
Approximately 1% of TBSA may be depicted by the size of the pts palm.
Each arm-9%
Each leg- 18%
Thorax- 18% front, 18% back
Head-9%
Perineum/genitals-1%
Fluid resuscitation in burns
- Parkland formula: 4ml/kg x TBSA % burned during the first 24 hours, crystalloids.
- Lack of fluid is grequently a major problem.
- Fluid resuscitation begins at the time of the burn injury, not when the pt reaches the hospital burn center.
- 1/2 of all fluid given in first 8 hrs, then 1/4 over next 8, then 1/4 over remaining 8 hours.
- Monitor for metabolic acidosis which is expected during early resusciation phase.
- Monitor for hyperkalemia during first 24-48hrs then hypokalemia following 3 days post burn d/t diuresis.
- UO goal 30-50ml/hr
Indications for prophylactic intubation in burns
Laryngeal edema is a common and quick complication of some burns, immediate prophylactic intubation should occur with any evidence of the following:
* Burns to the face
* Singed nares or eyebrows
* Dark soot/mucus from nares and/or mouth
Burn center referral criteria
1.) Partial thickness burns >10% TBSA
2.) Burns that involve the face, hands, feet, genitalia, perineum or major joints.
3.) Third degree burns in any age group
4.) Electrical burns, including lightning injury
5.) Chemical burns
6.) Inhalation injury
7.) Burni njury in pts with preexisting medical disorders that could complicate management, prolong recovery or affect mortality.
8.) Any pts with burns and concomitant trauma
9.) Burned children in hospitals without qualified personnel or equipment for the care of children.
10.) Burn injury in pts who will require special social, emotional, or rehab interventions.
Giant cell arteritis
Also known as temporal arteritis
An inflammatory condition primarily affecting pts over the age of 50.
Causes inflammation of certain arteries, especially those near the temples.
Can lead to permanent blindness.
Accounts for 15% of all cases of fever of unknown origin in older adults.
S/S:
* HA
* Scalp tenderness
* Visual complaints
* Jaw claudication
* Temporal artery may be nodular, enlarged or tender
* Fevers sometimes >40c
* Chills/rigors
Lab/diagnostics:
* Very high ESR
* Normal WBC (tells you it’s not bacterial in nature)
* Temporal artery biopsy is gold standard
Management:
* Prednisone and referral
Assessment of the eye
- Optic disc: doughnut like shaped with an orange/pink neuroretinal rim and a central white depression (called physiologic cup)
- Cup/disk ratio: cup should not be more than 1/2 the size of the disc diameter, if larger consider glaucoma.
- Arteries are brighter red and narrower than veins.
–A:V ration 2:3 or 4:5 - Macula: is centered temporal to the optic disk and is avascular
- Fovea centralis looks slightly darker and lies in the center of the macular region. If macula difficult to visualize, have pt look directly into the light.
Diabetic retinopathy
- Microaneurysms are the earliest detectable sign.
- Ruptured microaneurysms result in retinal hemorrhages either superficially or deeper layers of the retina.
- Cotton wool spots.
Arteriovenous (AV) nicking
When artery and vein intersect and create bridge.
Signs of chronic HTN
Arcus senilis
A cloudy appearance of cornea with grat/white circle around the limbus due to deposition of lipid material.
No affect on vision.
Conjuctivits
The most common eye disorder, also known as pink eye.
Inflammation/infection of the conjunctiva resulting from allergies, bacteria, viruses or STIs.
S/S:
* Itching/burning
* Redness
* Increased amounts of tears
* Blurred vision is possible
* Sensation of a foreign body in eye
* Swelling of eyelid
* Eyelids may show a crust of sticky, mucopurulent
* No pain in eye
**Management: **
Depends on type
* Chemical- No discharge, flush with NS. Self limiting
* Bacterial- Purulent discharge, antibiotic drops (fluoroquinolone)
* Gonococcal/chlamydial- copiouos purulent discharge, ceftriazone + azithromycin
* Allergic- Stringy, increased tearing discharge. Tx with oral antihistamines and refer to allertist/opthalmologist. Steroids should not be ordered in primary care due to possible increase IOP and activation of herpes.
* Viral- Watery discharge. If mild tx with saline drops or arterficial tears. If moderate tx with antihistamines and NSAIDs
* Herpetic- refer to opthalmologist
Corneal abrasion
Trauma to the eye resulting in interruption in the epithelial surface.
S/S:
* Intense pain in affected eye, worsens with time
* Tearing
* Redness
Lab/Diagnostics:
* Recent history of trauma to eye
* Sodium fluorescein stain detects abrasion
Management:
* Anesthetize the ye for thorough exam to ensure no foreign body
* Topical antibiotic ointmen may be prescribed, especially in pts who wear contact lenses
* Steroid drops are contraindicated
* Should heal in 24 hours, if not refer
Glaucoma
Increase IOP, can be open or closed
Open angle: chronic
Closed angle: acute (emergency)
Uknown cause
S/S:
Open angle chronic:
* Asymptomatic
* Elevated IOP (normal 10-20)
* Cupping of disk, usually 1st physical sign (icre cream scoop)
* Constriction of visual fields
Closed angle acute:
* Extreme pain
* Blurred vision
* Halos around eyes
* Pupil dilation or fixed
Lab/diagnostics:
* Tonometry, national screen >40
Management:
* Open angle chronic:
* Prostaglandin analogs (latanoprost)
