Trauma

Defined as “injury to human tissues and organs resulting from the transfer of energy from the environment” (Emergency Nurses Association, 2004)

lack of oxidation- being emerged in water

combustion- smoke inhalation

electricity- lightening

chemical- drugs, insect bites

poison- solid liquids or gases

Mechanism of Injury with Trauma

       “Mechanisms of injury refers to the mechanisms whereby the energy is transferred from the environment to the person”

       a. Mechanical        e. Radiant-steam

       b. Thermal-fire               f. Oxygen Deprivation

       c. Chemical-drugs, insects, snakes

       d. Electrical-wires and lightening

Incidence of Trauma

       Third leading cause of death for all ages in U.S.*****TEST

       First leading cause of death for persons between ages of one and 44.

               Motor vehicle crashes 28%-32%

               Suicide 21%

               Homicide 17.5%

               Other 33.5%

-most at risk for suicide= older white male (retired)****

-men that have been in long term marriages, wife dies, friends all around them die, social world diminishes

Trimodal Pattern of Fatalities

What are the three phases of trauma care?

What does each phase entail?

       First phase (50% of deaths)

               Occur immediately at the scene

-many of these people die at the scene

       Second phase (30% of deaths)

               Early deaths within two hours of injury

               This is the golden hour- from time of injury to 2 hours out

-have a serious complications and can die r/t blood and fluid loss

       Third phase (20% of deaths)

-pretty late

-able to stabilize them after golden hour then late situations occur

-could be days or week after initial injury.

-M.O.D.- multiple organ failure- resp. failure, cardiac arrests, ARDS

               Late deaths occur from days to weeks of injury

               Sepsis, ARDS, multiple organ failure

Trauma Care

What is Primary Assessment?

What is Secondary Assessment?

What phases should/should NOT occur simultaneously?

       Four phases

               Primary assessment - Life-threatening injuries are treated.

-life threatening injuries taken care of at the scene of the accident

              -Resuscitation - ACLS

-provided by EMS and nurses

               Secondary assessment - Identify all injuries

               Definitive care - surgery, ICU

-try to stabilize patient enough to get them to ICU

-look things other than ABC's, then they move patient to see if there are any posterior injuries

In trauma centers the first three phases

should occur simultaneously

-head to toe cannot occur simultaneously

Primary  and Secondary Assessments in Trauma

(A through I)

What do A-I stand for?  

...Mainly A-D.

A - Airway with cervical spine immobilized

B - Breathing (determine if it's effective or ineffective)

C - Circulation (skin temp, cold, clammy)

D - Disability (neurologic assessment-determine if there is brain function)

E - Expose (remove clothing)

F - Fahrenheit (keep patient warm)

G - Get complete set of vital signs- determines which way things are going.

H - History and head-to-toe assessment (ask patient questions, if you can get information)

I -  Inspect posterior surfaces

Airway Assessment

What are the things we look for when assessing the airway?

       Inspect airway

               -Vocalization*** can they speak to you?

               -Tongue obstruction- can obstruct airway, open airway and make sure tongue isn't blocking

               -Loose teeth, foreign objects- they can aspirate down to the bronchus

               -Bleeding- hemorrhaging vs. bleeding slowly

               -Vomitus

               -Edema- how much swelling?

-swelling over a boney area means that they probably have a fracture****TEST

               -Injury to face or neck- lacerations.  Anything around lower portion of face can cause swelling and obstruction of airway.

Airway Management

What types of airways do we use for patient's who are either unconscious or conscious?

       Maintain cervical spine stabilization-major factor, yet DOES NOT rate higher than airway!

       Clear airway*** most important intervention!

               -Modified jaw thrust

               -Chin lift

               -Removal of debris

               -Suctioning

       Maintain airway

               Oropharyngeal airway for unconscious****

               Nasopharyngeal airway for semi-conscious****

Airway Management (cont'd)

What type of intubation is full intubation?

What type do we use on patients that have respirations?

What type do we use on a patient that had apnea?

What is the name of the procedure that is done when the airway is completely swollen?

       Endotracheal intubation- FULL intubation

-if you wait too long and swelling progresses too far, intubation may not be possible.

               -Nasotracheal if patient has respirations

               -Orotracheal if patient is apneic- will probably go ahead and intubate them before they crash.

       Needle cricothyroidotomy

-done when all the swelling has occured, you can't get ET tube in through any route, may be having stridor.

-tissue is cut, large bore needle inserted so that patient can get air into lungs

       Surgical airway

               Surgical cricothyroidotomy

               Tracheostomy

Breathing Assessment

       Spontaneous breathing- does chest rise and fall? 

       Chest rise and fall (depth and symmetry)

       Skin color, Respiratory rate and depth

       Integrity of soft tissue and bony structures of chest wall

       Use of accessory muscles- can see sternocleidomastoid

       Breath sounds (2ndICS, MCL/5th ICS, Anterior Axillary Line)

Breathing Interventions

       Breathing present: EFFECTIVE

               Administer oxygen via a nonrebreather mask @ 12 to 15 L/minute

       Breathing present: INEFFECTIVE

               Assess for life-threatening lung injuries

                       Tension pneumothorax

                       Open pneumothorax

                       Massive hemothorax

                       Flail chest

       Breathing ABSENT - Intubate, ventilate

Circulation Assessment

       Palpate a Central pulse-carotid, femoral

-will tell us what patient is like with circulation

-bounding pulses are not good

       Inspect and palpate skin for color, temperature, and degree of diaphoresis

       Inspect for external bleeding

       Auscultate blood pressure

-if patient has lost a lot of volume, you may not be able to hear it, so you can palpate or use a dinamap

Circulation Interventions

What do you do if there isn't a pulse present?

What do you do is the pulse is present, yet ineffective?

What are the potential causes of an ineffective pulse?

No pulse

  -Initiate CPR****

  -Initiate ACLS protocols

   -Prepare for open thoracotomy if blunt trauma to the chest occurs

      -will drain blood out of chest cavity

Pulse present, ineffective (weak, thready)

   Uncontrolled external bleeding

   Shock, Cardiac Tamponade (RAPID accumulation of blood around the patients heart)

-should be no more than 50 cc of fluid in pericardial sac

-Tx: MD does needle aspiration removing fluid from pericardial sac (pericardial synthesis***

-shock range BP: 90 or less is a shock range BP

-assess for alert, oriented, skin is warm and dry, BP may not be too low for that patient.*****

-patients who are severely dehydrated and confused may have low BP

   Interventions: Control bleeding, 2 large IV’s, warm solutions, prepare for central IV.

Disability Assessment

When assessing a disability what does this mean?

A

V

P

U

THIS WILL BE ON THE TEST.  SHE SAID TO MEMORIZE IT.

A - Alert, awake, responsive to voice, and oriented

V - Responds to voice, but NOT fully oriented

P - Responds to painful stimuli, but NOT voice

U - Unresponsive to painful stimuli

*Trauma patient can go from A to U.  It can be caused by hemorrhage, maybe a blood clot, etc.

Disability Interventions

       Narcan for potential drug overdose****

-drug of choice

       Thiamine for alcoholics

-once you discover that they are an alcohol, you give them Ativan, Thiamine, and give fluids that have vitamins in them.

       -50% Dextrose/water if hypoglycemic

Investigate any secondary assessment in a decreased level of consciousness.

Secondary Assessment in Trauma Patients

-Cut away clothing and inspect for injuries (expose - E)

-Use overhead warmers, light blankets (you want them to be warm), and warmed IV fluids to maintain body temperature

-Get B/P**, pulse, resp. rate, and temperature (vitals)

-trending of vital signs in VERY important.

Additional Assessments and Interventions prior to history

-Cardiac monitor, ECG, Pulse oximeter

-X-rays of cervical, chest, and pelvic areas 

-Indwelling urinary catheter and NG tube

-Diagnostic peritoneal lavage (you want to know if blood is sitting in peritoneal area)

-Blood to lab

               blood type, H&H, BUN, creatinine, blood alcohol, toxicology, ABGs, electrolytes, glucose, PT, PTT, and platelets

-PT, PTT, Platelets- you want to know if they have a poor clotting history.

-Platelet count- low can cause bleeding

-20,000 or less- patient can hemorrhage***TEST

-too high? risk for clotting.

History and head to toe assessment in trauma

What information do you need to obtain?

Think:

M

I

V

T

What time of blood do you give if you don't know patient's blood type?

-Will not be done simutaneuosly with the Primary and Secondary Assessment

-Prehospital Information- you get this info from E.M.S.

M - Mechanism of injury (what caused it)

I - Injuries sustained (what have they assessed)

V - Vital signs (pay attention trends)

T - Treatment

-If they don't know blood type, you give O blood because it can be given to any patient.

Mechanism of Injury

-Type of impact

-Location of patient upon arrival of EMT

-Length of time since injury

-Reason for extended on-scene time (document and report why they were on the scene for so long)

 Frontal Impact, Unrestrained Driver- no seat belt

-causes massive trauma to chest

-will cause cardiac contusion, if they were on blood thinner, it could cause hemorrhage.

-can cause cardiac rupture as well.

Possible injuries:

-head

-chest

-ankle

-knee

-hip

Cardiac Contusion

-Rear Impact with Improper Headrest- whip lash

-can cause injury to cervical spine

-Assess vitals signs very carefully***

-Proper versus Improper Seatbelt

-improper application above the iliac spine may cause injury to abdominal organs:         pancreas, liver, spleen, duodenum

-Pedestrian Triad of Injuries

-front vehicular bumper impact

-vehicular hood and windscreen impact

-ground impact

-Adult struck by vehicle

-When Thrown on Top of Vehicle

-When Sliding from Vehicle to Ground

-When Dragged under the Vehicle.

Injuries

Ask EMTs to describe scene of injury

               Patient’s general condition

               Level of consciousness

               Apparent injuries

-are they on vasopressors?-Monitor I and O's.

Vital signs

Treatment initiated and patient responses

Patient generated information

Ask questions and talk to the patient to evaluate LOC, gather data, and provide reassurance.

-If patient isn't alert enough, ask family.  You want it to be as accurate as possible.

               Patient’s description of pain, numbness, tingling, and ability to move extremities.

-numbness and tingling- could be a nerve problem

               Allergies, medications, chronic illnesses, previous surgery, age.

               Last tetanus immunization

-you want to know about meds they're taking- anti hypertensives, etc.

-you want an accurate age and weight.

-meds can be give based on weight

-when patient got their last tetanus, must get it every 10 years********* TEST

               Recent use of alcohol or drugs- need truth because of meds, anesthesia, withdrawl*****

-Alcohol withdrawl  Protocol- Ativan--> Thiamine --> or multi vitamins and IV fluids

-Librium can be given instead of Ativan

General Appearance

       Body position, posture, guarding or self-protection movements

       Stiffness, rigidity, flaccidity

       Characteristic position of limbs, trunk, head for flexion or extension

       Unusual odors such as alcohol, gasoline, chemicals, vomitus, urine, or feces

Head to toe assessment

Make sure ABC's are stable then you can do a focused assessment.       

Head and face- swelling can develop that may cut off airway

       Neck- any injury from waistline up can cause difficult breathing because of swelling

       Chest- rise and fall equally, breathing on one side? BAD***

       Abdomen-check for distention, are they guarding*** holding one side of stomach

       Pelvis and genitalia- pelvis- iliac crest can go unnoticed

       Extremities- is one extremity longer than the other

       Posterior Assessments- LOG ROLL****** to the side and get some help and inspect the posterior surface of the body!

Specific Injuries

       Thoracic- front impact injuries can be very critical

       Abdominal- can take a little while for doctor to figure out what's going on

       Extremities- cervical spine***, lumbar fractures of the femur can cause major problems of the tibia and fibia and can lead to fat entering the circulation and this can cause patient to have a fatty emboli---long bone fractures can lead to a fatty emboli

***fatty emboli-give a 10% alcohol drip***

Thoracic Injuries

       Life-threatening chest injuries identified in the primary survey

               Airway obstruction

               Tension pneumothorax

               Open pneumothorax (sucking chest wound)

               Massive pneumo/hemothorax- massive bleed out*******TEST

               Flail chest-chest actually goes in, ribs detach from sternum

               Cardiac tamponade- rapid accumulation of fluid around the heart

Tension Pneumothorax

**air has escaped inside and can't get outsides so it causes tracheal deviation**       

Respiratory distress

       Tachycardia

       HYPOtension

       Tracheal deviation******* CLASSIC ON TEST, if they don't have tracheal deviation, then they don't have tension pneumothorax

       Unilateral absence of breath sounds

       Neck vein distension

**Tension pneumothorax should be picked up on assessment rather than CXR**

**Treatment is immediate decompression by inserting a needles into the 2nd intercostal space, MCL followed by chest tube placement**

Open Pneumothorax

       Similar signs and symptoms as tension pneumothorax plus hypoxia*

       Treatment:

               Close promptly with a sterile occlusive dressing (plastic wrap or petroleum gauze)

-if you tape gauze too tightly, you can cause tension pneumothorax

-only tape down three sides.

-doctor will put in chest tube, wrap it with vaseline gauze***, three pieces of tape does not apply once chest tube is in place!

               Tape only on three sides to provide a flutter-like valve effect until surgical closure

               Chest tube placement

Massive Pneumo-Hemothorax

       Rapid accumulation of more than 1500 ml of blood in chest cavity

-1 unit of whole blood is 500 ml****

-3 units of whole blood lost into chest cavity

               Pt will go into Shock

               Hypoxia

               Flattened neck veins because of loss of blood.  NO distention of veins at this point.

               Absence of breath sounds

               Dullness on percussion to chest*** because chest is filled with blood.  

       Treat by restoration of blood volume and placement of chest tube****

OLDER patients often get packed cells instead of whole blood, but in an emergency setting they might get packed cells.  IDK why but thats just what Milner said.

Flail Chest

       A segment of the chest wall does not have bony continuity with the rest of the thoracic cage

               Disrupts normal chest wall movement

               Paradoxical motion of the chest wall- the chest goes in when you breathe instead of normally goes out***

       Treatment

               Ventilation- the younger they're the better they will do with the fractured ribs.

               Administration of humidified oxygen- through the circuit on the ventilator tubing

               Judicious fluid resuscitation

Cardiac (Pericardial) Tamponade

       Pericardium filled with blood

       Beck’s Triad- the patient has an elevated CVP which reflects RIGHT ATRIAL PRESSURE***** TEST and patient had distended neck veins as a result of right atrial pressure.

               Elevated CVP (Distended neck veins)

               Decline in arterial pressure (Hypotension)

               Muffled heart tones- bc of blood that is building up around of heart

-large amount of blood around heart, heart cannot pump properly and can go into cardiac arrest

       Treatment

               Pericardiocentesis to aspirate blood- long needle, inserted into pericardial sac, aspirate

-followed up with chest tubes

               Thoracotomy to inspect the heart- makes sure blood isn't leaking into the abdominal cavity and could potentially save a life

-happens a lot in people with breast cancer

Abdominal Trauma

       Abdominal injuries may be unrecognized during the first examination

               Any patient sustaining a significant deceleration injury or penetrating torso wound must be assumed to have an abdominal visceral injury

-these patients can die very quickly on you

-injury isn't apparent at first--so you need to do CT and some other diagnostic tests

-doctor will do a exploratory laparotomy

Assessment of Abdominal Injuries

       Physical exam

               Inspection- do it fast but efficiently.

                       Contour of abdomen- round, lop sided, more swollen on one side, echhymosis?

                       Seat belt abrasions or soft tissue injury

                                Ecchymosis @ LUQ = splenic injury*

                                Ecchymosis @ umbilicus = intraperitoneal bleeding*- could be a ruptured stomach

                                Ecchymosis @ flank = retroperitoneal bleeding*- could be a ruptured kidney and there will be blood in urine*** bright frank bleeding***

               Auscultation

               Percussion & Palpation

-patient with an acute abdomen (guarding stomach) you want to be sensitive when palpating the abdomen.  DO NOT DO deep palpation on patient with an acute abdomen injury**********

                       Guarding, rigidity, pain, or spasm- helps to make the diagnoses

Diagnostic Procedures for Abdominal Trauma

       NG intubation-decompress the stomach (secretions that can be aspirated)

-patient can become nausea

-can get secretions to do toxicology

       Bladder catheter-indwelling catheter (FOLEY)

-Good urine output means that you are getting good cardiac output***********

-if BP is less than 90, not much urine outside because of decreased cardiac output

       X-rays

       Diagnostic peritoneal lavage- to see if they can get some blood

-if they get blood, they know they have to go in

       CT scans- to see where blood is coming from

-only done if they have time to do it

Most Common Sites of Blunt Abdominal Trauma**

       Liver- blunt trauma to the RIGHT side

       Spleen- blunt trauma to LEFT side

       Kidneys- blunt trauma from the SIDE

       Pancreas- blunt trauma from the BACK

Penetrating Abdominal Trauma

       Gunshot wounds

               High-velocity bullets cause damage to internal organs such as bowel and liver

               Require surgical repair most often

       Stab wounds

               Can sometimes be stabilized without surgery

-NEVER remove an impaled object!!!!!!!!!!!!!!!!!!!!!!!

       Impaled Objects: Do not remove

Pelvic Fractures

       Mortality from pelvic fractures exceeds 50%*****( she said it'd be on the test) due to hemorrhage

       Signs & Symptoms

               Pain

               Hypovolemic Shock where they're actually bleeding out

               Shortening or rotation of leg.

               Genitourinary/intra-abdominal injury.

       Treatment: 

Stabilize fracture- only way to safely do this is to put patient in traction*

treat shock,

diagnostic peritoneal lavage,- will clue u in to massive bleeding in area

arteriogram- will tell you if artery is lacerated

Nursing Diagnoses for Clients with Trauma AND burns

       Airway ineffective- ABG's

       Aspiration, risk

       Breathing pattern ineffective

       Gas exchange impaired

       Cardiac output altered

       Fluid volume deficit- b/c they're bleeding out

       Tissue perfusion altered- because kidneys perfusion

       Pain, acute

Thermal Injuries

       4th leading cause of death due to unintentional injury

-BURNS FROM HEAT

-if its greater than 10%, 2nd and 3rd degree, face, head, or neck, they WILL go to the burn center****

       Approximately 6,000 persons die from burns annually.

       Most deaths (73%) are the result of house fires.

       Of the deaths from house fires, 76% die from inhalation of toxic substances.

Classification of burns

       Depth

       Degree

       Characteristics

Superficial Partial Thickness

FIRST DEGREE

       Superficial depth involving the epidermis and superficial dermis

       Commonly referred to as first degree burn

-FIRST thing you do is cool the burn down.  Cool it by putting it under cold water********

       Characteristics

               Dry**

               Red (no blisters)**

               Blanches

               Tender

-can get it from sunburn, tanning beds, etc.

**Charring of the bone--consider it 3rd degree for standardized tests***

**When you see blisters, it becomes a second degree burn*****

Deep Partial Thickness

SECOND DEGREE

       Involves destruction of the epidermis and deeper dermis

       Commonly known as second degree burn

       Characteristics

               Hyperemic (increased blood flow to area) then it goes to the stasis phases

               Moist**

               Bullae (blisters)**

               Painful

**Once blisters appear, it becomes a 2nd degree burn!

**SECOND DEGREE BURNS ARE THE MOST PAINFUL BURNS. NERVES ENDINGS ARE DAMAGED.**

**Leave the damn blister alone!  The blister has serious fluid and protein and keeps bacteria out!  LEAVE. IT. ALONE.**

**Dressing on for 48 hours then take it off so it can start to heal**

Full Thickness

3rd DEGREE BURN

       Involves destruction of the epidermis, superficial & deep dermis, the subcutaneous layer, and possibly muscle and bone

       Commonly known as third degree burn

-charring of the bone is sometimes called a fourth degree burn

       Characteristics

               Dry, leathery* looking or translucent or shiny*

               Color varies from yellow to red (in bone)  to brown or black (in muscle)

               Sweat glands and hair follicles are destroyed

               NOT PAINFUL********

-You can have 1st, 2nd, or 3rd degree burn all in one limb.

Zones of burn injury

       Zone of hyperemia

-gets very red

       Zone of stasis

 -Gets a little deeper

-blood stasis

       Zone of coagulation

-blood is thicker

-worse and deepest area of tissue destruction

-can be irreversible

Rule of Nines

Pathophysiology

  Loss of protective barriers against infection

-Skin is the largest organ we have.

       Escape of body fluids from burn injury

       Lack of temperature control

       Destroyed sweat and sebaceous glands

       Diminished number of sensory receptors**** one reason why 3rd degree burns are painless

      Vascular Changes

RULE OF 9 PERCENTAGES WILL BE ON THE EXAM*******

ESTIMATES BURN INJURY

Face- 9% All around

Chest all the way down- Front 18% (Total 36%)

                                       Back 18%

Arms and hand EACH-WHOLE ARM is  9% 

-One side of arm 4.5%

Crotch- 1%

Each leg is 18%

-front- 9%

-back 9%

Phases of Brain Injury

SHE SPECIFICALLY SAID WE NEED TO KNOW THIS!!!!!!******      

1.) Hypovolemic phase (burn shock)

-low volume

-rapid shift of fluid from intravascular space to interstitial spaces

2.)Diuretic phase

3.) Rehabilitation 

Hypovolemic Phase

       Rapid shift of fluid from the intravascular space to the interstitial space**

WILL NOT SEE INFECTION

       Body compensates during the first 1-2 hours

               BP normal or slightly elevated

               Pulse rapid- goes along with low BP

               Oliguria- scanty urine

               Vasoconstriction

Imbalances in Burn Shock

       Hemoconcentration - hematocrit rises

       Hematuria and oliguria - fluid loss, hemolysis of  RBC’s, decreased renal blood flow. DECREASED URINE

       Hyperkalemia - K+ leaks out of cells- you want to get Potassium back IN cell and sodium OUT of the cell.

       Hyponatremia - Na+ lost in trapped edema

       Metabolic acidosis - HCO3+ accompanies Na+

**where sodium is, bicarb is as well.

Movement of Fluid and Electrolytes
     

Shock & Diuretic Phases

Diuretic Stage

       Occurs 48-72 hours after injury****

       Edema and fluid shifts back to intravascular space

       Diuresis from increased renal blood flow

       Hemodilution

               decreased Na⁺ & K⁺ and HCT

       Anemia and malnutrition

       Weight loss- occurs in diuretic r/t to losing large volume of fluid

Emergent Care of the Patient with Burns (Injury to 72 hours)

Time of injury to 72 hours is Diuretic Phase.

A - Airway with cervical spine immobilized

B - Breathing - use humidified oxygen

C - Circulation

D - Disability (neurologic status)

***ACLS Protocol

E - Expose (remove clothing) only as much as you need.

F - Fahrenheit (keep patient warm)

G - Get complete set of vital signs

**It will be 3 days out before you see an elevation in temperature, indication infection*** TEST TEST TEST If she gives you a question saying its between 72 hours, answer is wrong.

**Do not put patients on ototoxic and nephrotoxic drugs.

H - History and head-to-toe assessment

I -  Inspect posterior surfaces

**LOG ROLL

Emergent Care 
(Hypovolemic Stage)

       Begin two IVs- you need to replace fluids! LARGE SITES.

-needs to be an 18 or a 20 gauge

-either AC or jugular.*****

-look for area that isn't burned.

-PICC lines can be put in the upper extermities.

               -RINGERS LACTATE at 1000cc/hr. Keep UOP @ 30-50cc/hr

-ringers lactate has electrolytes

       Vital signs and breath sounds

-if patients lungs tell you they have too much volume, back off.

-how to determine if they can handle volume?  LISTEN TO LUNG SOUNDS FREQUENTLY.******* 

-you will hear crackles. "wet lungs"

       Estimate depth of burn and amount of body surface area involved

               Rule of nines

       Treat any other injuries

               Wound care is not essential, no ointments- not necessary at this point in time.

Emergent Care 
(Hypovolemic Stage)

CONTINUED

THIS IS GONNA BE ON THE TEST.  SHE SAID SO.

       Foley- give fluid fast enough so you can get 30-50 cc per hour.

               Measure UOP hourly

       Maintain IVFs, vital signs

-First thing they're going to do is to see if they have adequate volume.  See if volume will increase BP.  If not, they will give vasoconstrictors (dopamine) after.

BAGSTER FORMULA:

               4cc RL x Kg x % BSA burned = cc needed for first 24 hours

-FOR AN ELDERLY PERSON you start out with 2cc of LR times KG times % of burn.

-BSA burned= rule of nine

                       Give 1/2 first 8hours (3000 cc's in 8 hours**), then give other 1/2 over the next 16 hours

-if they develop crackles, panicy, distress, you're giving fluids too fast.

               Plasma to replace albumin losses and intravascular deficit after 24 hours

Emergent Care History

       How, when, & where burn occurred. What type of burn: thermal, electrical, or chemical

       Past medical history

       Usual body weight- compare that to what they currently weight.

       Current medications- if a patient becomes unstable, and they took a shit ton of meds before the fire, you may have a patient that could bottom out because of the meds.

       Drug and alcohol use

Emergent Care (Collaborative)

**Always play well with other.

       Administer medications

               Narcotics (morphine or Demerol) given IV

-Pain med of choice: MORPHINE*

               Tetanus toxoid booster or  Tetanus antitoxin

               Antibiotics (IV)- that may or may not be done depending on patient's response

       Laboratory:  ABGs, H&H, electrolytes

       CXR- monitor how lungs are doing

       Gastric Tube (decompression)- NG tube.  If they can't get NG tube down, then they will do a G tube*** Pt needs to start on GI feeding ASAP

       Cover small burns with sterile saline gauze- use wet and dry dressings

       Assist with escharotomy

Emergent Care (diuretic stage)

       Replace fluids based on breath sounds, BP, pulse, and UOP to avoid fluid overload

       Monitor electrolytes and H&H

       Monitor ABGs for metabolic acidosis

       Treatment for anemia- may need blood replacement at some point

-fluid is more important than blood at this point!

       Nutritional support

Nsg Diagnoses:Emergent Phase

       Airway clearance ineffective- burn across chest, monitor ABG's, suction

-teaching burn victim to cough and deep breathe:

-use balloon with water in it.

       Gas exchange impaired

       Breathing pattern ineffective- go from effective to ineffective

       Fluid volume deficit / overload- PRIMARY CONCERN, then blood replacement.

       Hypothermia

       Infection- usually comes a bit later.

Acute Period of Burns

       Begins at the end of emergent period and lasts until wounds heal

       Goals are

               Treatment of wounds based on what doctor orders.

               Avoidance , detection, and treatment of complications (infection, renal disease, & heart failure)

Care of partial thickness

       Partial thickness

               Minimize infection to prevent conversion to a full thickness wound.  Daily wound cleaning until eschar forms

               Topical antimicrobials- all have sulfar in them.

                       Sulfamylon

                       Silver sulfadiazine

                       Remove old medication before applying new 1/8 inch film.****

-use sterile blade, cant use gloves.***

-Steven Johnson's- giving antibiotic for a long period of time then they become allergic to it.

Care of full thickness wounds

Full thickness wounds

               Keep free of dead tissue, eschar, & infection

               Escharotomy- compartment syndrome- cut area and leave open

               Debridement- take off dead tissue to evaluate old tissue

-if tissue is grey and dark, it isn't health.

-viable tissue is pink and red.

               Prevention of infection

                       Reverse isolation

                       Clean technique for general care

                       Sterile technique for burn wounds

               Cleansing hydrotherapy-use water for agitation  (20-30 minutes in NS or other prescribed solution) 

Grafting

       Preparation for grafting

once grafting moves off, it can't go back on.

               Burn wounds must have a good blood supply

               Heterograft- used as biologic dressing

               Homograft-used as biologic dressing

               Autograft: solid or mesh- use as biologic dressing

       Grafting - protect from trauma, slippage, infection and blisters

       Immobilize joint above and below graft until first dressing change

**Nurse does first dressing change

Nutrition Needs for Burn Victims

       Increased protein

               Need 1.5 to 3.2 gm/kg weight

       Increased calories

               Need 3500 to 5000 calories per day

       Vitamins and minerals

               Give 2 to 3 times the RDA

       Hyperalimentation

Given through peripheral IV or central line

TPN- total parenteral nutrition*** has vitamins, electrolytes, sugar, insulin

-TPN/hyperalimentation is given to patients who can't eat and is given before G tube

-TPN goes 83 cc/ hour and you can IVPB the 500 cc of lipids

-give insulin and sugar as a balance!

-Do BS checks frequently.  DO not totally cut TPN off because it can send patient into hypoglycemia.******

Major Complications of BURNS

       Sepsis

       ARDS

       CHF

       Acute tubular necrosis

       Renal failure

       Compartment syndrome

       Paralytic ileus

       Curling’s ulcer

       Disfigurement

       Emotional responses to losses

Pain control in thermal injuries

       Pain is severe and difficult to control.

**PAIN CONTROL FROM 2ND DEGREE BURNS IS SUPER IMPORTANT

       Pain  medication is delivered I.V.

               Demerol or Morphine

-Morphine before Demerol

               PCA Pumps, IV Push

               Conscious Sedation for Debridement

               General Anesthesia

Rehab: anti deformity positioning

       Head and neck

               No pillow under head.** Use donut or roll behind the neck to maintain neutral position***

       Shoulders

               Place arms in 90 degrees abduction at the shoulders (prevents axillary banding)

-banding- tissues grows together.

Elbows

               Fully extend to prevent immobile flexed position

 Ankles

               Neutral dorsiflexion/plantarflexion

               Neutral inversion/eversion

               Keep heals free from pressure

Rehab continued

       Maintenance of musculoskeletal, and cardiopulmonary function

               Passive to active ROM bid

               Progressive activity bedrest to ambulation

       Scar management

               Compression garments, non sticky wraps, silicone gel

       Return to independence in self-care and pre-burn lifestyle

**you know they're well when they can talk about their feelings

TEST REVIEW

-look at the things she told you to pay special attention to.

BURN

Vascular permeability

Intravascular volume

Increased hematocrit

Increase Viscosity

EDEMA

Decrease in blood volume

Increased peripheral resistance- increase in BP***