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MedSurgII - Thermal Injury Tables

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cdunbar4's version from 2017-03-23 21:52

Manis of lung injury associated with burns

Question Answer
Upper airway membrane characteristicsblisters, edema
upper airway burn throat/voice characteristicshoarseness in voice; difficulty swallowing
upper airway secretionscopious
upper airway breathing characteristicsstridor; substernal & intercostal retractions
What is the major concern with lung injury associated with burns of the upper airway?total airway obstruction
What makes a high degree of suspicion of a lung injury being of lower airway origin?if patient was trapped in a fire in an enclosed space or if their clothing caught fire
Clinical findings of face & nasal passage with lower airway injury?facial burns or singed nasal or facial hair
Breathing & LOC characteristics of lower airway injury?dyspnea; wheezing; hoarseness; altered mental status
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ER mgmt. Thermal Burns

Question Answer
Etiologies • Hot liquids or solids • Flash flame • Open flame • Steam • Hot surface • Ultraviolet rays
Partial-Thickness (superficial; first-degree) Burn: assessment findings• Redness • Pain • Moderate to severe tenderness • Minimal edema • Blanching with pressure
Partial-Thickness (deep; second-degree) Burn: assessment findings• Moist blebs, blisters • Mottled white, pink to cherry-red • Hypersensitive to touch or air • Moderate to severe pain • Blanching with pressure
Full-Thickness (third- and fourth-degree) Burns: assessment findings• Dry, leathery eschar • Waxy white, dark brown, or charred appearance • Strong burn odor • Impaired sensation when touched • Absence of pain with severe pain in surrounding tissues • Lack of blanching with pressure
Initial interventions: what are the first few things you would do/assess for if someone came in with a burn?ABCs; Stabilize c-spine; assess for inhalation injury; Give supplemental O2 PRN
What type of collaborative intervention could you expect if someone came in with circumferential full-thickness burn to the chest & neck or a large TBSA (total body surface area) burn?endotracheal intubation & mechanical ventilation
MonitorVS, LOC, respiratory status, O2 sat & heart rhythm- ongoing monitoring
If patient has articles of clothing on or other accessories, what should you do with those?Remove nonadherent clothing, shoes, watches, jewelry, glasses or contact lenses (if face was exposed).
Cover burned areas with: dry dressings or clean sheet
If burn is >15% TBSA what other interventions would you complete?2 large bore IV needles; begin fluid replacement; indwelling catheter; analgesia (assess frequently)
interventions to help decrease edemaElevate burned limbs above heart
After initial ER interventions....don't forget to ID and treat other associated injuries (fractures, head injury, etc.)
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ER mgmt. Inhalation Injuries

Question Answer
Etiology• Exposure of respiratory tract to intense heat or flames • Inhalation of noxious chemicals, smoke, or CO
Assessment findings historytrapped in an enclosed space, being in an explosion, or having clothing catch fire
Respiratory assessment findingsrapid, shallow respirations; increasing hoarseness; coughing; singed nasal or facial hair
Mucous membranes characteristicsdarkened oral or nasal
Sputum & breathcarbonaceous sputum, productive cough that produces black, gray or bloody sputum; smoky breath
Upper airway findingsirritated, burning pain in throat or chest
If CO levels >20%, what does the skin color look like?cherry-red
Mental Statusaltered, confusion, coma
Other findingsdecreased O2 sat, dysrhythmias
ER assessment & interventions are same as thermal burns, plus...get ABGs, carboxyhemoglobin levels & chest xray; O2 supplementation is at 100%; anticipate need for firberoptic bronchoscopy or intubation
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ER mgmt. Electrical Burns

Question Answer
Alternating current etiologieselectric wires & utility wires
Direct current etiologieslightning or defibrillator
Skin assessment findingsleathery, white or charred skin; location of contact points; thermal burns if clothing ignited; burn odor; impaired touch sensation (minimal or absent pain)
Cardiac & mental status findingsdysrhythmias, cardiac arrest, loss of consciousness
How can fractures occur?from the force of the current itself; head or neck injury if a fall occurred
Assume injury is greater than what you can seedepth & extent is difficult to visualize
Initial interventions same as thermal & electrical, plus...remove patient from electrical source (while protecting rescuer); check pulses distal to burns
Ongoing monitoring• Monitor urine for development of myoglobinuria secondary to muscle breakdown and hemoglobinuria secondary to RBC breakdown.
Anticipate possible administration of ____________ to alkalinize the urine and maintain serum pH >6.0NaHCO3
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Fluid Resuscitation

Question Answer
Parkland (Baxter) Formula4 mL lactated Ringer’s solution per kilogram (kg) of body weight per percent of total body surface area (% TBSA) burned = Total fluid requirements for first 24 hr after burn
Application1⁄2 of total in first 8 hr.; 1⁄4 of total in second 8 hr; 1⁄4 of total in third 8 hr
Example for a 70 kg patient with a 50% TBSA burn (Parkland formula)4 mL × 70 kg × 50 TBSA burned = 14,000 mL in 24 hr
Example application of 14,000 mL in 24 hr1⁄2 of total in first 8 hr = 7000 mL (875 mL/hr); 1⁄4 of total in second 8 hr = 3500 mL (437 mL/hr); 1⁄4 of total in third 8 hr = 3500 mL (437 mL/hr)
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Wound Care

Question Answer
Main Goals of wound care (2)prevent infection by cleansing and debriding the area of necrotic tissue that would promote bacterial growth and promote wound re-epithelialization and/or successful skin grafting.
Enzymatic debridementmade up of natural ingredients (such as collagen) and used to speed up the removal of dead tissue from the healthy wound bed
Cleansing woundsuse soap & water or NS-moistened gauze to gently remove the old antimicrobial agent & any other loose necrotic tissue, scabs or dried blood.
During the debridement phase, what should you cover the wound with?topical antimicrobial creams (like silver sulfadiazine) or silver-impregnated dressings.
When partial-thickness burns have been fully debrided, what is applied to the wound bed?a protective, coarse or fine-meshed, greasy-based (paraffin or petroleum) gauze dressing is applied to protect the re-epithelializing keratinocytes as they resurface and close the open wound bed.
Skin graftingprotect skin graft with same gauze dressings next to the grafts; with facial grafts the unmeshed sheet graft is left open so small blebs of serosanguineous exudate forms b/t graft & recipient bed.
What do these blebs do?prevents graft from permanently attaching to the wound bed
Excision & grafting proceduredevitalized tissue (eschar) is excised down to the subcutaneous tissue or fascia, depending on the degree of injury. Surgical excision can result in massive blood loss.
Collaborative care to minimize blood loss of surgical excisiontopical application of epinephrine or thrombin, injection of saline and epinephrine, application of extremity tourniquets, or application of a new fibrin sealant (Artiss) is used
Donor site goalspromote rapid, moist wound healing; decrease pain; prevent infection (average healing time is 10-14 days)
Cultured epithelial autograftsgetting permanent skin from someone with only a limited amount of skin by growing it asap (takes about 18-25 days); indicated for large body burns
Artificial skin requirementsmust replace all functions of skin & have both dermal & epidermal elements. Indicated for tx of life-threatening burns. Examples: Integra or AlloDerm
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Gerontologic Considerations

Question Answer
Skindecreased elasticity and longer healing times
Co-morbiditiesother disorders such as COPD, increase rates of morbidity as chance of acquiring pneumonia is greater
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