ECC Burn Electrocution

sihirlifil's version from 2018-05-02 00:45

TBSA = Total Body Surface Area. SBI = Severe Burn Injury

Question Answer
3 major & severe derangements of systems czd by burns that were concerned about?(1) Metabolic
(2) Cardiovascular
(3) Pulmonary
What are the 2 ways to classify burns?(1) Burn depth (how to Tx pt an manage wounds based off this)
(2) Total body surface area affected
What should you know about the 1°, 2° 3° burn classification system?NOT USED ANYMORE. (dont reflect depth)
4 classifications of a burn based on depth?(1) Superficial
(2) Superficial partial thickness
(3) Deep partial thickness
(4) Full thickness
What are the 3 zones of a burn wound, starting from middle going out? How are they characterized?(1) Zone of coagulation: center, initial area of injury. Coagulative necrosis here
(2) Zone of stasis: zone surrounding the center, there is capillary constriction here w/ ischemia, & viable & non-viable cells. (potentially rescuable here)
(3) Zone of hyperemia: viable cells, local inflammation.
Which burn zone cane we save viable cells?Zone of stasis (zone 2)
Which zone is treatment targeted?Zone of hyperemia (zone 3) initially to make sure zone doesn’t spread to hyperemia
Depth classification: Superficial: Dermal layers involved****? Wound characteristics? Healing? (Focus on layers involved)LAYERS: Epidermis only
Characteristics: Erythematous, desquamation, dry & flakey
Heal: 3-5d via re-epithelization, minimal scar
Depth classification: Superficial partial thickness: Dermal layers involved****? Wound characteristics? Healing? (Focus on layers involved)Epidermis + upper 1/3dermis
Characteristics: Erythematous, moist, painful blisters
Heal: 1-2wk, minimal scar
Depth classification: deep partial thickness: Dermal layers involved****? Wound characteristics? Healing? (Focus on layers involved)Epidermis+ all of dermis. Character: red waxy white, reduced pain, reduced pain sensation. Heal: 2-3wk, sx intervention recc to prevent scar.
Depth classification: full thickness: Dermal layers involved****? Wound characteristics? healing? (focus on layers involved)Epidermis + dermis + SQ tissue
Character: Eschar formatin, bloodless white eschar. Hair easily plucked
Heal: requires Sx for healing.
Most important factor of tx choiceDepth
Based on % total body surface area...what is considered a local burn? Versus a severe burn injury?<20% of total body surface area is a local burn. A Severe burn injury is >20-30% of TBSA, & you will see systemic derangements, & will require intensive management
Rough estimate of how much total body surface area is affected by a burn is determined by...1 of these charts. Extrapolated from ppl so not super accurate.
Trunk is how much of TBSA?About 18%.
Head is how much of TBSA?About 9%
1 arm is about how much of TBSA?9%
Pelvis/genitals is about how much of TBSA?1%
1 leg is about how much of TBSA?18%
What is the "rule of nines"?How to classify TBSA of a burn - all percents are 9 or 18 (except genitals/pelvis is one)
What is a local burn injury again?<20-30% TBSA
What should you not use to heat PTx?Dont use heating pads- if you do, have something to separate btwn the PTx & the pad
Is there metabolic derangements w/ a local burn?No (Aggressive systemic Tx typically not required)
How long before a local burn might become evident?24-48hrs (area may be painful)
How do you Tx local burn?Tx topically, dressings, +/- debridement (can be surgically, wet to dry bandages (mechanical), chemical debridement, maggots/leeches (brings blood to area etc bc local anticoag & prevent thrombosis & ischemic necrosis) )
Clinical appearance of superficial burn?May not show up at all, might just be hypersensitive.
Clinical appearance of partial & full thickness burns?Readily apparent after injury, Thick leathery surface of dead tissue=eschar.
Why do we dislike eschars?Promotes bacterial growth (can be abscess under there), makes classification of depth difficult (cant see under it- can form w/ partial or full thickness, might not know classification till you remove it)
A severe burn injury results in...SYSTEMIC DERANGEMENTS!! Results in burn shock (poor pulses, tachycardia, pale mm)
What are the 2 distinct phases of burn shock, & what problems characterize it?PHASES:
(1) Hypodynamic or resuscitation phase
(2) Hyperdynamic hypermetabolic phase. In burn shock you will see: Intravascular volume depletion, Reduced cardiac output, Increased systemic vascular resistance, Reduced peripheral blood flow
Which phase of burn shock happens immediately following severe burn injury?The hypodynamic/resuscitation phase
When does the hypodynamic/resuscitation phase start in relation to a severe burn injury, how long does it last? How would you describe this? What is your 1* goal of this phase?Starts IMMEDIATELY following SBI & lasts 24-72 hrs (1-3d). You see INC VASCULAR PERMEABILITY (so if you try to bolus it can just leak into interstitial/3r space), the fluid shift → HYPOVOLEMIA + EDEMA in tissues. You will also see ******REDUCED CARDIAC OUTPUT (poorly responsive to therapy). So, your 1* goal for this phase is to restore & preserve tissue perfusion
When eval PTx, what should you be looking for/concerned about in terms of the resp system?Facial & nasal passage burns
Concomitant smoke inhalation
Airway obstruction (severe inflammation to lower resp system → edema)
Hypoventilation (from pain, hyperviscosity in brain)
When eval PTx, what should you be looking for/concerned about in terms of the cardio system?Hypotension
Arrhythmias (Inflammatory mediators & myocardial depression (direct damage or hypoxemia) )
When eval PTx, what should you be looking for/concerned about in terms of the neuro system?Assess for trauma
Complete neuro exam
Look for Change in mentation or seizures (Concern for CO & cyanide toxicity)
What neuro toxes are you worried about w/ burns?CO & cyanide
What should you do w/ paw pad burns?Daily debridement, topical ab’s, bandaging (can be only site of burn injury!)
When eval PTx, what should you be looking for/concerned about in terms of the ocular system?Immediate & subsequent swelling may prohibit ocular exam (periorbital tissues). Look out for exposure keratopathy, Corneal ulceration, RARELY corneal burns - IRRIGATE EYES LIBERALLY regardless of visible dmg
MOST IMPORTANT TX FOR SBI? Why?FLUIDS!!! Helps maintain perfusion & avoid ischemia (hypovol, increased vascular permeability, decreased oncotic pressure --> decreased CO) restore tissue & organ perfusion
Cooling #2 priority
What kinda fluids do you wanna use to Tx SBI? How much?CRYSTALLOIDS! 4-6ml/kg per %TBSA in 1st 24hrs (Half of this amt administered in 1st 8 hours)
Titrate your fluid therapy to maintain...Urine output, perfusion parameters, & MAP
How can cooling be helpful as burn Tx? How do you do cooling?RAPID cooling beneficial, can reduce depth of burn injury, & if w/in 30min of injury can prevent ongoing damage/prevents necrosis (eschar formation) (of zone of coag & stasis). Do COLD tap water (59*F) for 20 min
When does the hyperdynamic/hypermetabolic phase start in relation to a severe burn injury, how long does it last? How would you describe it?See 3-5d after a SBI, & you can see the associated increased metabolic rate for up to 24 MOS after the injury. The hypermetabolic phase is characterized by protein catabolism, gluconeogenesis, glycogenolysis, lipolysis (think hormones like glucagon & HSL). There is also REDUCED vascular permeability, inc HR, dec vascular resistance, & inc CO.
Wound care: SUPERFICIALKeep moist & clean
Heal in ~1w
Wound care: PARTIAL THICKNESSClean & debride
Heal in 1-2w
Wound care: DEEP PARTIAL to FULL-THICKNESSEschar removal
Topical agents
+/- sx excision/graft
How often do you need to manage SBI wounds? What solution do you use in the first 1-2 days? What do you do in general? What are other important things you MUST do?**WEAR GLOVES**Need DAILY wound management, w/ decontamination, debridement, & dressing (wet-to-dry) as well as daily hydrotherapy. FOR THE FIRST 1-2 DAYS, use a 1:40 dilute chlorhex or a 1:9 povidone iodine solution. WE ONLY DO THIS FIRST DAY OR 2 BC THESE SOLUTIONS ARE CYTOTOXIC TO THE GRANULATION TISSUE WE WANT TO FORM. so after first 1-2 days just hydrotherapy w/ water. Also, ANALGESIA is INCREDIBLY important
(1) Superficial?
(2) superficial partial thickness?
(3) Deep partial thickness+full thickness?
(1) Superficial: keep moist & clean, will heal in a week
(2) Clean & debride, heal 1-2 wk
(3) Eschar removal, topical agents, +/- sx excision/graft
2 topical therapies you can use for your deep partial thickness to full thickness burns?Silver sulfadiazine, honey
Topical Tx: Silver sulfadiazine: spectrum? Pros? Cons?Spectrum: broad spectrum: G+, G-, MRSA, yeast, mold
Pro: Painless, soothing, Penetrates eschar, Few side effects, Sustained release products available
Cons: Delayed wound healing, delays eschar separation, hypersensitivity Rxn
Topical Tx: Honey: Spectrum? Pros? Cons?Spectrum: broad, G+, G-, MRSA (silver sulfadiazine also does yeast & mold tho)
PRO: improved healing rate, less wound contracture, dec excessive granulation
CONS: tissue dehydration (if use too much can dehydrate) local hypersensitivity Rxn
Burn pts at high risk for what kinda Infxns?Pneumonia, Sepsis 2’ to loss of skin barrier, necrosis
Why are ABx not prophylactically prescribed in burn pts when there is high risk for infxn? If there IS a systemic Infxn, what do you do?Risk of resistant Infxns
Topicals typically suffice
If there IS a systemic Infxn, administer systemic ab’s x 1 week. Repeat culture
Electrical current does what, & leads to what problems?Disrupts electrophysiological activity, leading to: Muscle spasms, Cardiac arrhythmias, Loss of consciousness, resp arrest. ALSO, cellular fluids become heated (so see burns too) → Coagulation of tissue proteins, Thrombosis of vessels, Necrosis of tissues, Ischemic injury
What w/ electricity will cz more damage?Higher voltage = more damage.
Common signalment of elec. injury?Young dogs & cats (bc stupid) → Chew electrical cords. Average age= 3.5 mos. 2-12 mos most common
What/where will you commonly see w/ electrical cord burns?Mucus membranes, tongue, lips, palate, dental fractures, Fistulas (can present w/ foul smelling mouth)
Which cardio probs are common w/ electrical injury?****Arrhythmias (ESP VENTRICULAR ARRHYTHMIAS), Vfib (common cz of sudden death), v-tach, sinus tach.
When do you use a defibrillator?Only D-fib for V-fib.
If there is V-tach, how treat?LIDOCAINE!!
Resp system probs you can see w/ electrical injury?Respiratory distress
Neurogenic (non-cardiogenic) pulmonary edema
Explain neurogenic (non-cardiogenic) pulmonary edema & its relation to electrical injuryHappens bc elec can cz MASSIVE sympathetic outflow → vasoconstriction → hypertension → vessels leak & burst.
Tx for elec injury?SUPPORT!! O2, Tx arrhythmias, bronchodilators, diuretics (DONT CZ HYPOVOLEMIA THO) GI support, nutrition, Burn wound management, PAIN MANAGEMENT
Warn owners pts can take a long time to recover (weeks to months!)

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