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66 Cards in this Set

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How do percentage of burns relate to length of hospital stay?

approximately one day in the hospital per 1% burn




20% burn ≈ 20 days in the hospital

What are some common ways we might see someone in middle TN getting thermal, electrical, and chemical burns?

thermal: trash burning in areas w/o trash pickup




electrical: stealing copper from wires




chemical: meth explosions

What pediatric age range is going to see higher burn incidence, which gender is more likely to be burned, and what are the anatomical areas where the burns are likely to be seen?

age range: 1-5 yo




gender: boys > girls




where: upper extremities, head, & neck

what are the most common types of child abuse burns?

thermal = contact or scald

What percentage of burns are going to be life threatening in peds, and which sorts of burns -- scalds, thermal, or chemical/electrical -- are going to have a higher BSA involvement and risk of inhalation injury?

% of peds life threatening: 3-5%




BSA/inhalation involvment: thermal

what admission requirements must be met regarding percentage of partial thickness burns, burn location, & degree of burns per the American Burn Association?

partial thickness burns: must involve > 10% TBSA




burn location: any involving face, hands, feet, genitalia, perineum, or major joints




degree of burns: 3rd degree in any age group are admitted

Do electrical burns, chemical burns, and inhalation injuries qualify for admission?

Yes, all three require admission

What are other contributing factors with burns that require admission?

burns + trauma = admission




burns + kids in non-qualified hospitals = admission




burns + pre-existing condition = admission




burns + pt with social/emotional/long-term rehab = admission

what does "mechanism" refer to with burns?

how they were burned




i.e. bonfire w/gas on it, car fire, etc

what do primary and secondary survey refer to?

primary: life-threatening stuff = ABC; will dictate if we need to intubate before moving to other interventions




secondary: non life-threatening stuff

what would primary survey assessment findings of deep facial burns, carbonaceous sputum, agitation/hypoxia, hoarseness/stridor, & respiratory distress be indicative of?

inhalation injury

what is carbonaceous sputum?

what it is: carbon in sputum

What might be another cause of hoarseness or stridor in a burn pt?

smoking

what is a supraglottic inhalation injury, what burn is it caused by, what sort of edema would be seen in it, and what is the major risk for the ABC of this pt?

what it is: above vocal cord burn




type of burn: direct heat or chemical




edema: upper airway edema




ABC: edema causes loss of airway

what is a subglottic inhalation injury, what burns is it caused by, what sort of edema is it caused by, what sort of ABC issue would it cause, and what blood lab levels would we need to evaluate?

what it is: below vocal cord burn




type: chemical = CO or byproducts of combustion




type of edema: pulmonary




ABC: respiratory epithelial sloughing = mucous plug




Lab: carboxyhemoglobin = CO levels

what is the fluid of choice for initial management of burns, and what are the rates for less than or equal to 5 yo, 6-13 yo, and greater than or equal to 14 yo, per the consensus formula?

fluid choice: lactated ringers




rates:




less than or equal to 5 yo = 125 mL LR/hr




6-13 yo = 250 mL LR/hr




greater than or equal to 14 = 500 mL LR/hr

when should we bolus fluids in burns?

ONLY in hypotensive situations




even if UOP drops we will only increase fluids, not bolus

do fluids begin in primary or secondary survey?

primary

what are the areas we need to assess during the secondary survey and why is 2ndary so important?

assessment: burn/trauma hx, PMH, allergies, medications, complete physical exam, calculate consensus formula = for fluids




why important: bc burns can sometimes distract us from other serious trauma

what degrees of burns count toward calculation of TBSA?

2nd = partial thickness




3rd & 4th = full thickness

what is the rule of nines, what age group is it used for, and what percentage TBSA calls for fluid replacement in adults & peds?

what it is: percentage of BSA allocated to certain body parts




head = 9%


each arm = 9%


each leg = 18%


anterior torso = 18%


posterior torso = 18%


perineum = 1%




age group: >15 yo




fluid replacement: > 20% adults; > 10% peds

how is BSA allocated for < 15 yo?

head = 18%


each arm = 9%


anterior torso = 18%


posterior torso = 18%


each leg = 14%

what is the formula for fluid resuscitation for adult burns?

(kg x TBSA % x 2mL LR)/16 = mL/hr

what is the formula for fluid resuscitation for peds burns?

(kg x TBSA % x 3 mL LR)/16 = mL/hr

what specific fluid do infants & young kids need for maintenance and why?

fluid: 5% dextrose




why: bc they have minimal glycogen stores

what is the palmar method of TBSA calculation and why must TBSA be reassessed after 24 hr?

palmar method: one of their hands = 1%




reassessment: bc it can can 24 hrs for burns to develop

what is the UOP goal of adult fluid resuscitation, why is UOP so important, and how will we adjust fluids to meet goal?

goal: 30 mL/hr




why: UOP is #1 indicator of fluid tx success




adjust: up rate by 20% each hour until UOP is met i.e. rate is 100 mL/hr then up to 120 mL/hr




*** no bolus except in hypotension ***

what are the peds UOP goals for 0-1, 2-8, & 9-14 yo?

0-1 yo = 2 mL/kg/hr




2-8 yo = 1 mL/kg/hr




9-14 yo = same as adults

why do we start fluid resuscitation at 10% for peds versus 20%, and what are the fluids we'll give to 0-1 yo and 2-14 yo?

why: greater BSA:body mass & glycogen stores are small (monitor BG!)




fluids:




0-1 yo = D5LR + D5 1/2 NS for maintenance




2-14 yo = LR + D5 1/2 NS for maintenance

what is a major safety concerns for staff and pt with chemical burns, when will we stop irrigation of a pt, and what might we need to do to tx chemicals in the eyes?

concern: decontamination




stopping irrigation: when pH of runoff h2o is low enough




chemicals in eyes: morgan lens = emergency irrigation; ophthalmology referral

what is the range of pH paper we'll need to have on hand to test during chemical burns?

1-14

what is a normal carboxyhemoglobin level, what happens at 20% and 50-60%, how are too high CO levels tx, and what is the half-life of CO cut to by O2 tx??

normal: 3%, but up to 15% in smokers




20%; 50-60%: HA/dizziness; comatose/no recovery




tx: 100% O2 non-rebreather, cyanide kits, aggressive ventilator therapy




O2 tx: half-life of CO cut to 30 min

how is a cyanokit reconstituted, what is it administered with, what is the dose, what is the length of time for infusion, and what are SE?

reconstituted: 200 mL NS




administered with: nothing




dose: 5 g




time: 15 min




SE: pink excretions

what is the benefit of early intubation for a inhalation injury and what procedure might be done to promote thoracic expansion in pt w/thoracic burns?

benefit: sometimes airway compromise r/t inhalation injury is delayed so we won't see effects until later on




promote thoracic expansion: escharotomy

which cause more death, high or low voltage electrical injuries, why, and what is the difference between electrocution and electrical injury?

more death: low voltage




why: cause cardiac arrhythmias i.e. v fib




electrical injury v. electrocution: electrocution = death; electrical injury ≠ death

what are the indicative marks of a lightning strike and what other issues come from a lightning strike besides burns?

pattern: fern patterned burns




other injuries: blood in urine, muscle damage

what is the difference between a high tension injury and a flash injury?

high tension injury: current passes through the pt




flash: current arcs causing a flash but the current does not pass through the pt

what is the fluid resuscitation formula for high voltage injury and what are the UOP goals for adults and peds?

formula: (kg x TBSA% x 4 mL LR)/16 = mL/hr




UOP: adults = 75-100 mL/hr; peds = 1 mL/kg/hr

what are complications of the airway, cardiac issues, and spine r/t high voltage injury?

airway: edema




cardiac: VT, VF




spinal: lightning strike can fracture vertebrae and impact injury from being thrown across the room

what are the zones of coagulation, stasis, and hyperemia?

zone of coagulation: innermost point; where the burn occurred; NOT SALVAGEABLE




zone of stasis: second most inner point; capillary occlusion and decreased perfusion; MIGHT BE SALVAGEABLE




zone of hyperemia: redness and blood flow to this area; SHOULD BE SALVAGEABLE

which part of the skin is involved in a superficial/1st degree burn, is there pain/redness, how long to heal, and should it be used when calculating TBSA %?

skin: epidermis only




pain/redness: yes/yes, localized




healing: 2-5 days




TBSA %: not considered

which part of the skin is involved in partial thickness/2nd degree burns, is there pain/redness, and how long will it take to know if it is developing into 3rd degree?

skin: epidermis and dermis




pain/redness: extremely painful; partial thickness = pink, beefy red, blistered, deep partial thickness = pale & mottled




*will blanch*




3rd degree development: 24 hrs

which part of the skin is involved in 3rd degree/full thickness burns, is there pain/redness, and how long will they take to heal?

skin: epidermis, dermis, subcutaneous tissue




pain/redness: little to no pain but may have neuropathic pain -- white/waxy,red/brown/leathery appearance that will not blanch




healing: will not heal; tissue must be excised or it will become necrotic

what causes 4th degree burns, which part of the skin is involved in 4th degree burns, is it painful, what is the appearance, and what procedures may be indicated?

cause: prolonged exposure to flame, chemicals, & high voltage




skin: all parts + muscle/bone




pain: none




appearance: black or charred




procedures: amputation, fasciotomy, escharotomy

why do hypermetabolism and hypercatabolism occur in burns?

hypermetabolism = body unable to regulate temperature




hypercatabolism: body is unable to get enough energy so it begins to break down muscle

why might peripheral neuropathy, delirium, and PTSD occur in burn PTs?

neuropathy: bc of nerve death




delirium: due to long ICU stay; countered by regulating light cycles w/ lights on @ 0700 & lights off @ 1900




PTSD: trauma r/t intense pain; Pt may have trouble getting back to activity that led to the burn

what effect will fluid loss have on the blood, the heart, and the periphery?

fluid loss = increased hemoconcentration = increased blood viscosity




increased viscosity = increased cardiac workload




increase viscosity = decreased peripheral pulse strength





what method of IV tx might we need to consider if the pt has lost significant fluid?

central line

why might someone with smoke inhalation be at risk for decreased gas exchange and pneumonia, and why is the rotoprone bed going to be used during aggressive pulmonary tx??

pneumonia: sloughing lung tissue might not get cleared and increased chances of pneumonia




decreased gas exchange: buildup of soot in the lungs r/t poor filtration (i.e. singed nose hairs etc)




rotoprone: increases the lung surface area

what GI risks are there in a burn pt and what interventions will be taken to mitigate the risks?

risks: ileus, malabsorption, ischemia, supplemental nutrition, constipation




interventions: ice cream for extra calories, > 400 mL residual will result in 50% cut in feed volume, nocturnal tube feeds to maintain nutritional status

why might acute & late renal failure occur in these PTs, what is myoglobinuria, what is abdominal compartment syndrome, and what is normal abdominal pressure?

acute renal failure: poor perfusion r/t decreased CO r/t fluid loss




late renal failure: coincides with sepsis & MODS




myoglobinuria: myoglobin in urine r/t insufficient fluid = ARF risk




abdominal compartment syndrome: burns put pressure on visceral organ s& bladder so UOP drops = visceral ischemia and bowel necrosis




normal abdominal pressure: < 15 mmHg





for pre-hospital wound care, what should be given IV, how should the wounds be covered, should we be giving antibiotics, and what shot should we give?

IV: pain meds = morphine & fentanyl




cover wounds: clean, dry sheet & prevent hypothermia




Antibiotics: no, wounds have been sterilized by the burn




shot: tetanus



what should be done with initial wound care with respect to blisters, hair, and method of wound cleaning?

blisters: open them




hair: shave them




cleaning: wash them with antibacterial soap

how should pain meds be dosed for daily wound care, how should the wound be tx with the dressings, and what should be done with loose tissue?

pain meds: PRN




dressing: soak off/remove topical ointment, wash wound




tissue: debride loose tissue

what is the difference between sheet grafts and split thickness sheet grafts with respect to care and placement on the body?

sheet graft: skin laid whole and intact on wound; used in cosmetic areas of the body; requires meticulous care to prevent fluid accumulation




split thickness sheet graft: skin passed through a machine to create mesh slits to it can be expanded to cover a larger wound; often wrapped & protected for 3-5 days while graft adheres to wound bed

what is a xenograft and what is the purpose of it?

what it is: pig skin graft




purpose: lets the body think there is a scab over the wound to speed the healing process; might sometimes be used before grafting their own skin on

what are the SE at the harvest site of harvesting skin for a graft?

infection




may become full-thickness wound

when is an escharotomy going to be done and what aspects is it going to be performed on?

full thickness circumferential burns




loss of circulation




loss of movement




performed medial & lateral

what is integra and where does it sit on a burn dressing?

what it is: collagen-like substance, looks like saran wrap




where: goes on wound bed & sits between wound and negative pressure dressing

what is a cultured epithelial autograft and when is it used?

what it is: PT's own skin grown in lab; skin can grow up to one inch around itself




when used: with pt who has significant damage and grafts not possible

when is bacitracin used and what is the main SE or prolonged use?

when used: almost all the time




prolonged use: contact dermatitis





what is silvadene-silver used for, what is the risk, and what is the benefit with respect to antibiotic properties?

used for: penetrating deep eschar wounds




risk/downside: sulfa drug = allergy risk; have to scrub it from the wound bed to get it off




benefits: Gram neg & gram positive coverage

how is sulfamylon reconstituted & used, and what is the downside?

reconstituted: NS




used: wet to dry




downside: high price

what is collagenase used for and what is the downside?

used for: debriding; good for small 3rd degree burns




downside: Pt may say it hurts

what is Acticoat, what is the benefit, what is the downside, and when will a pt most likely have this?

what it is: antimicrobial dressing




benefit: can stay up to 7 days so daily wound care not needed




downside: high cost




seen: when leaving OR

when should splints be used for rehab?

in joint burns to prevent contractures




pt may sleep in a splint




seen frequently in axillary burns