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Flashcards in Week 12 Deck (49):
1

Burn patients are trauma patients

Major burns affect all body systems – burn patients are trauma patients

2

•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

3

Function of skin

X

4

Primary survey

X

5

A
B
C
D
E
F

X

6

•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

7

•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

8

TBSA

Secondary survey
Circumstances
Estimating Total Body Surface Area (TBSA)
•Lund Browder Scale
•Rule of Nines
•Rule of Palm

9

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

10

Case study

X

11


Rule of Nines


Rule of Nines
Front half
Bilah ant arms

12

Lund-Browder Scale

Lund-Browder Scale
First 24 hours

13

Rule of Palm

Rule of Palm
Used on smaller burns
PT hand=1% TBSA

14

Burn depth classification

Temp
Time
Exposed

15

Depth of injury

1
2
3rd
Thickness

16

Superficial 1rst degree

Sunburn

17

2nd degree

Partial thickness
Painful
Nerve endings exposed

18

Deep partial thickness

Decreased sensation

19

Diff
Partial and full

Deep
Not blanch able

20

Full thickness

No blood flow

21

Fourth degree

Muscle and bone

22

Case study

Blotchy


Chest less severe
2nd & 3rd

23

Carbon Monoxide Poisoning

Change in mental status =red flag

24

Cyanide Poisoning

Change in RR
HA

Tx
Cyonide kit
Urine cranberry color

25

Burns referral criteria

1. Partial thickness burns greater than 10% total body surface area (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. Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality.
8. Any patient with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality.

26

Zone of Injury

Zone of Injury
•Zone of Coagulation
•irreversible damage

•Zone of Stasis
•Impaired blood flow

•Zone of Hyperemia
•Vasodilation
•Usually recovers

27

Fluid Resuscitation
•Goals:

Fluid Resuscitation
•Goals:
•Maintain tissue perfusion and organ function
•Avoid complications of over/under-resuscitation
•Prevent vs treat hypovolemia

28

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

29

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

30

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

31

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

32

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

33

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

34

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

35

•Electrical Injury- “The Great Masquerader”
4 mL LR x weight in kg x %TBSA

Can’t see damage
Assume greater TBSA

36

Case study

Tobias
Start time at burn

Lost 2 hrs
Higher rate initially

37

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

38

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

39

Under-resuscitation

Damage is done
•End organ failure
•MODS
•Wound progression

40

Over-resuscitation




Over-resuscitation
•Severe edema
•Pulmonary edema, ARDS
•Compartment syndrome

41

Compartment Syndrome

Xx

42

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

43

•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

44

Case study

***Output
Up by 1/3

45


•Increased capillary leak → fluid to interstitial space, fascia → increased edema → circulatory compromise


•Excessive fluid resuscitation, high voltage electrical injury, ischemia-reperfusion injury, crush injuries

46

Escharotomy
Chest wall to ventilate

Progress to faciotomy

47

5 Ps

Monitor

48

Nurse driven fluid

X

49

Burns in older adults

2nd leading cause of death
100% mortality
Death from shock
Saddle