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SURFACE TRAUMA

SURFACE TRAUMA. Luis Enriquez, RN, BS Trauma Nurse, Nursing Educator Los Angeles County USC Medical Center Level I Trauma Center . STUDENT LEARNING OBJECTIVES. At the end of this session the learner will be able to: Describe the different types of surface trauma.

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SURFACE TRAUMA

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  1. SURFACE TRAUMA Luis Enriquez, RN, BS Trauma Nurse, Nursing Educator Los Angeles County USC Medical Center Level I Trauma Center

  2. STUDENT LEARNING OBJECTIVES At the end of this session the learner will be able to: • Describe the different types of surface trauma. • Perform and document a complete neurovascular assessment on an injured extremity. • Calculate total body surface area using the rule of 9s. • Calculate the amount of IV fluid to be administered to a patient using the Parkland equation. • Identify the risk factors and explain the systemic complications associated with extensive burn injuries. • Explain how to assess for smoke inhalation injury. • Describe and explain the complications of electrical burns. • Compare/contrast mechanism of injury caused by acids and alkali. • List and explain the reasoning behind burn transfer criteria.

  3. ANATOMY AND PHYSIOLOGY MAJOR SKIN FUNCTIONS • Protection • Damage from: heat/cold, pathogens, chemicals • Loss of fluids and electrolytes • Thermoregulation • Sensory reception • Pain • Touch • Temperature • Pressure Epidermis Dermis

  4. SURFACE TRAUMA Disruption of integumentary system • Variety of causes, and forces involved • Compression/Tensile • Shearing • Thermal injury • Primary vs. concurrent injury • Limited to skin and soft tissues • Indication of injury to underlying structures or systems • Localized or systemic effect

  5. SURFACE TRAUMA TYPES • Abrasions: Mechanical scraping of skin • Avulsions: Tearing or ripping of the skin • Contusions/Hematomas: closed wound resulting from rupture of small vessels • Lacerations: open slash-like wound • Punctures: wound made by pointed object • Burns: Exposure to excessive thermal, chemical or electrical energy

  6. PHYSICAL ASSESSMENT History • Mechanism of injury • Associated Symptoms • Time • Comorbidities • Diabetes • Hemophilia • Atrial fibrillation: warfarin • Tetanus Immunization

  7. PHYSICAL ASSESSMENT • Describe the wound • Location • Length, depth, shape • Swelling, exudate • Wound contamination • Foreign bodies • Vascular integrity • Pulses • Capillary refill • Skin color and temp

  8. NEUROVASCULAR ASSESSMENT • Circulation • Pulse • Capillary refill • Temperature • Color • Swelling • Motor function • Loss of movement • Sensation • Pain • Paresthesia • Pressure

  9. TYPES OF BURNS • Thermal: flames, scalds, contact • Chemical • Acid • alkali • Electrical • Electricity • Lightning • Radiation • Ultraviolet/ionizing radiation

  10. PATHOPHYSIOLOGYOF BURNS Body’s response to burns varies with • Degree of tissue damage • Cellular impairment • Fluid shifts Burn injuries result in • Vasodilation • Increased capillary permeability • Intravascular fluid loss • Tissue edema • Hypovolemic shock

  11. CLASSIFICATION • Depth • 1st Degree: limited to epidermis • 2ndDegree: Involve dermis • 3rd Degree: Full thickness • 4th Degree: muscle and bone • % Total Body Surface Area • Rule of Nines • Lund-Browder diagram

  12. EXTENT OF INJURY • Rule of Nines • Rule of Palms • Lund and Browder chart Total Body Surface Area

  13. SYSTEMICCOMPLICATIONS The larger the area involved, the greater the risk of systemic complications • Hypovolemia (Shock) • Hypothermia • Metabolic abnormalities • Infection • Ileus

  14. SYSTEMIC COMPLICATIONS Risk Factors for severe complications and death • > 40% total Body Surface Area • Age > 60 years or < 2 years • Additional Injuries (fractures) • Smoke inhalation • Circumferential Burns

  15. SMOKE INHALATION • Inhale smoke, hot gases and particles enter the lungs and cause injury • Accumulation of debris and secretions • Inflammatory cascade: • Vasodilation • Capillary leak • Pulmonary edema and pneumonia • Impaired ciliary clearance • Atelectasis • Airway obstruction

  16. SMOKE INHALATION Signs and Symptoms • Shortness of breath • Horse voice, cough • Stridor, wheezing • Facial burns • Singed facial/nasal hair • Presence of carbonaceous sputum

  17. EMERGENT MANAGEMENTSMOKE INHALATION • High-flow humidified oxygen by mask • Primary medication used • Relive hypoxia • Assist in removal of carbon oxide from Hemoglobin • Secure a patent airway: Most urgent concern • Endotracheal intubation • 50% of patients require intubation • Monitor CO level • Arterial blood gas will be normal • Pulse oximetry will be normal • Measure serum carboxyhemoglobin

  18. ELECTRICAL BURNS Sources Direct Current • Batteries (Car battery 12V) • Lightning • High voltage: Electrical power lines (1million V) Alternating Current • Household source (120V/240V) • Cause tetany (6-16 ma) • Causes death (100ma or more)

  19. ELECTRICAL BURNS • Produce heat injuries by passing through tissue • Difficult to assess extent of injury • Most of the injury is deep under the skin • Two wounds: entrance and exit • Travels path of lease resistance • Nerves • Vessels • Causing damage to internal tissues

  20. ELECTRICAL BURNS Complications • Cardiac Injuries • Direct myocardial injury • Dysrhythmias • Visceral injuries • Long bone and spinal fractures • Myoglobinuria: muscle breakdown • Hemoglobinuria: Red blood cell breakdown • Compartment syndrome

  21. ELECTRICAL BURNS Emergent Management • Monitor cardiac rate and rhythm (4-72 hrs.) • Monitor Arterial Blood Gases • Maintain urinary output at 75 to 100 ml/h • Observe color of urine • Monitor for compartment syndrome

  22. CHEMICAL BURNS Direct Contact with caustic chemicals • Acids: Coagulation necrosis • Denaturing of proteins • Eschar limits the penetration • Bases: Liquefaction necrosis • Denaturing of Proteins • Saponification of fats • Tissue penetration not limited • Deeper burn

  23. CHEMICAL BURNS History should include • Chemical involved • Concentration, pH • Physical form: liquid, solid • Route of exposure • Time of exposure • Volume of exposure • Possibility of coexisting injury • The timing and extent of irrigation

  24. EMERGENT MANAGEMENT Chemical Burns • Prompt thorough wound irrigation • Prevent contaminated irrigation solution from running onto unaffected skin. • Remove contaminated clothes • Do not waste time identifying neutralizing agent: flush it out • Cool tar/asphalt burns

  25. EMERGENT MANAGEMENT • Stop the burning process: flush with water • Ensure patent airway, assist ventilation, give oxygen • Determine depth and extent of burn • Remove rings or other jewelry • Elevate burned extremities • Diagnostic procedures • Fluid resuscitation • Pain management • Insert urinary catheter • Keep patient warm • Wound care • Determine need for transfer to burn center or admission

  26. PAIN MANAGEMENT • Burns are intensely painful injuries • Every burn patient will experience pain regardless of size, depth, mechanism of injury • Provide effective pain control once primary and secondary assessment is complete • Burn injuries require high doses of opiates • Morphine • Hydromorphone • Fentanyl • Give Intra venous route, avoid oral/intramuscular

  27. EMERGENT MANAGEMENT Diagnostic procedures • Arterial Blood Gases • Carboxyhemoglobin level • Hemoglobin and Hematocrit • Complete Blood Count • Basic Metabolic Panel • 12-lead Electrocardiogram • Chest radiograph

  28. FLUID RESUSCITATION • The goal of fluid resuscitation is • Maintain Tissue perfusion • Maintain organ function • Over-resuscitation can lead to • Excessive edema • Compromise blood flow to burned tissue • Under-resuscitation can result in • Shock • Organ damage • Use warm Lactated Ringers

  29. FLUID RESUSCITATION PARKLAND FORMULA • Used to calculate amount of fluid to be given in first 24 hours after injury (from time of actual injury • Adults 2-4 ml X weight (kg) X %Total Body Surface Area • Children 3-4 ml X weight (Kg) X %Total body Surface Area Application of formula • Give ½ of total amount in first 8 hours • Give second ½ half over remaining 16 hours • Fluid Resuscitation should be loosely guided by formulas • Continually re-evaluate & adjust fluid infusion rates • Urine output best indicator of adequate fluid resuscitation Adult: 0.5-1 ml/hour Children 1-1.5 ml/hour

  30. AMERICAN BURN ASSOCIATION TRANSFER CRITERIA • Partial Thickness (2nd degree) burns greater than 10% Total Body Surface Area • Full Thickness (3rd degree) burns • Electrical, chemical burns • Inhalation Injury • Patients with other trauma injuries • Existing medical complications (diabetes) • Circumferential burns • Burns to face, hands, feet, major joints, perineum

  31. COMPLICATIONS AND LOCATION OF INJURY • Circumferential Burns: • Neck or chest: respiratory compromise • Extremities: neurovascular compromise • Face and Neck: respiratory compromise • Hands: self care • Feet: ambulation • Major joints: function • Perineum: risk of infection

  32. INFECTION CONTROL Burn patients are uniquely susceptible to infection and pose a risk to other patients • Infection- leading cause of morbidity and mortality in the burn patient • Particularly susceptible to infection due to the nature of the injury • Loss of protective skin cover • Airway and lung damage due to inhalation injury • Susceptible to colonization, become a source infectious organisms • The larger the size of the burn the greater the risk for infection • Incidence of infection dramatically higher if > 30% total body surface area • Increase use invasive devices that bypass the bodies defense mechanisms (endotracheal tubes, intravascular catheters, urinary catheters • Infection control in the burn patient is dependent in • Strict barriers to transmission of infection: standard precautions, isolation • Appropriate decontamination of equipment and environment

  33. SITES OF INFECTION • Sites of infection particularly important for burn patients • Bloodstream infection • Pneumonia • Urinary tract infection • Burn wound infection • Bloodstream infections occur more often in burn patients than in any other patient population • Associated with Intravascular catheter use • When possible intravascular catheter should be placed in unburned skin away from the wound

  34. DRESSING CHANGES • Burn wound assessment should be done with every dressing change. • Look for changes in character, odor, amount of drainage • Note presence of necrotic material • Use strict aseptic technique when handling the open wound and dressing materials • Wear sterile gloves, mask and disposable gown • If necrotic material is present a debriding dressing should be chosen while a protective dressing is best for healing wounds

  35. PRINCIPAL MODES OF TRANSMISSION • Hospital personnel can transfer infectious organism from one patient to another • Hands: gloves and hand washing • Clothing: use gowns • Contact with inadequately decontaminated equipment can spread infectious organisms • Organism from the patient heavily contaminate beds, side rails, tables equipment • Equipment used on the patient: blood pressure cuffs, thermometers, wheel chairs, IV pumps

  36. STANDARD PRECAUTIONS Assume the blood and body substances from all patients are potential sources of infection

  37. HAND WASHING Washing hands between contact with each patient is the single most significant factor in preventing the spread of disease

  38. REFERENCES: • ATLS, advanced trauma life support for doctors (8th ed.). (2008). Chicago, IL: American College of Surgeons. • Beers, M. H. (2006). The Merck manual of diagnosis and therapy (18th ed.). Whitehouse Station, N.J.: Merck Research Laboratories. • Coven, D. L., & Yang, E. H. (n.d.). Medscape.com. Retrieved September 1, 2010, from emedicine.medscape.com/article/1910735-overview • Howard, P. K., Steinmann, R. A., & Sheehy, S. B. (2010). Sheehy's emergency nursing: principles and practice. (6th ed.). St. Louis, Mo.: Mosby Elsevier. • Tintinalli, J. E., & Stapczynski, J. S. (2011). Tintinalli's emergency medicine: a comprehensive study guide (7th ed.). New York: McGraw-Hill. • TNCC: trauma nursing core course (5th ed.). (2000). Park Ridge, Ill.: Emergency Nurses Association. • Harkins HN: The Status of the Problem of Thermal Injuries. Physiol Rev 1945, 25:531-572 • Webber, J. Infection Control in Burn Patients, Retrieved January 22, 2013, from woldburn.org/documents/infection/pdf

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