burns and blood cancers

thermal burns

exposure to external heat sources (hot or cold)

ex. frost bite, hot metal, scalding liquid, steam, flames

chemical burns

from contact with acids, alkaline, or organic compounds that can be absorbed through inhalation, ingestion, or topical

do not dust it off, person needs to be decontaminated first

electric burns

due to intense heat generated from an electrical current

ex. powerlines

can cause TBI, rhabdo, AKI, death of muscle

1st degree (aka superficial* burn)

involves the epidermis

skin is red in color, blanches when touched

blisters are NOT present

ex. sunburn

2nd degree (superficial partial thickness*)

involves epidermis and underlying layer of dermis

skin is red, blistered and wet

may have swelling and pain

hair follicles remain intact

heals spontaneously

minimal scaring if properly treated

2nd degree (deep partial thickness*)

involves the dermis

skin may appear white, or yellowish, can be wet or dry

blisters may not be prominent, area may look waxy

damaged hair follicles, sweat and sebaceous glands

pain is less than superficial partial as nerve endings start to become damaged

may leave scar or skin color change

3rd degree (aka full thickness*)

involves the destruction of both layers of the skin (epidermis and dermis) including the base layer of the dermis

skin is white and pale, brown and leathery or charred

no capillary refill as capillaries are destroyed

no sensation of pain as the sensory nerves are destroyed

usually varying degrees of burns around this burn, therefore may still have pain

skin graft is required as the dermis is completely destroyed

pre-hospital care DOs for burns

• scene is safe

• cool off burn if thermal

• cover with lukewarm wet dressing

• call for help

• anticipate a professional to:

  • remove particles and clothes if chemical

  • remove the electrical source if electrical

pre-hospital care DONTs for burns

• use butter or oil based products

  • it’ll need to be scrubbed off

• douse in water

• administer ice to the area

  • causes cellular damage and more pain

• add ointments

• spray with antiseptic, or pain reliver

• apply first aid cream

what is classified as a major burn

20% or more

emergent phase of burn management (1st phase)

capillary permeability causes massive shift of fluid from the intravascular to interstitial space

VS change as there is a shift in water, sodium, and plasma protein → can lead to hypovolemic shock

needs fluid resuscitation

monitor for hypotension, tachycardia, tachypnea, and elevated Hct

can develop AKI

emergent phase interventions

• ABCs

• assess burn (degree and area)

• provide 100% oxygen (inhalation burns need this for a long time)

• possible intubation

• obtain ABGs and carboxyhemoglobin levels

  • detects levels of carbon monoxide

• obtain chest x-ray

• remove non-adhered clothing (what it not melted onto the skin)

• establish 2 large bore IVs

• fluid replacement

• insert catheter

  • for strict I&Os and monitor fluid shift

• elevate burned limbs above the heart to decrease edema

• give analgesics

• cover concurrent burned areas with dry dressing or clean sheets

• monitor heart rhythm if they had an electrical burn

Parkland formula

used to calculate amount of fluid resuscitation needed in the first 24 hours

4mL x kg x total body surface area (TBSA)

give ½ of total in first 8 hours

give ¼ of total in the second 8 hours

give the last ¼ of total in the third 8 hours

acute phase of burn management (2nd phase)

begins with the mobilization of interstitial fluid and subsequent diuresis and continues until wound is almost healed

their oxygenation improves, except for inhalation burns

VS are more stable

can have complications like infection, dehydration, compartment syndrome

monitor for:

• hyponatremia

  • due to excess GI suction, water intake, or diarrhea

• hyperkalemia

  • due to AKI, mass deep muscle injury, or adrenocortical insufficiency

• hypokalemia

  • due to vomiting, diarrhea, excessive GI suction

rehab phase of burn management (3rd phase)

begins with patient’s wounds nearly healed

can engage in some self care

can happen between 2 weeks to 8 months of injury

goal is to work toward resuming functional role in society

rule of nines: head and neck

9% (all of it)

4.5% for the front and 4.5% for the back

rule of nines: trunk

anterior: 18%

• ex. diaphragm and up = 9%

posterior: 18%

rule of nines: arm

each is 9% and includes hand

rule of nines: legs

each is 18% and includes sole of feet

leukemia

(know differences between the 4 classifications)**

cancer of the blood affecting blood, bone marrow, lymph system, and spleen

is progressive and fatal if untreated

no single cause; increased risk factors include chemicals, chemo, viruses, radiation, and immunologic deficiencies 

4 classifications: acute myeloid, acute lymphocytic, chronic myelogenous, chronic lymphatic

general manifestations of all leukemias

• anemia

• thrombocytopenia

• increased number and decreased function of WBCs

• as it progresses

  • splenomegaly

  • hepatomegaly

  • lymphadenopathy

  • bone pain

  • meningeal irritation

    • HA, photophobia, neck stiffness, seizures

  • oral lesions

  • solid masses

• systemic presentations that bring people in

  • weight loss

  • fever

  • frequent infections

  • bone and joint pain / tenderness

  • easy bleeding and bruising

diagnostic studies for leukemia

• H&P

• CBC - WBCs and neutrophils

• peripheral blood smear

• bone marrow aspiration / biopsy 

  • gold standard

• cytochemistry

• lumbar puncture - CNS cells

• genetic / chromosome testing

• PET/CT scan

  • all cancers get this

  • shows metastasis

  • show enlarged liver and spleen

acute myeloid leukemia (AML)

uncontrolled, rapid increase in numbers of myeloblasts and hyperplasia of bone marrow

there is replacement of hemopoietic cells in bone marrow by leukemic myeloblasts

onset is abrupt and dramatic

there are serious infections and abnormal bleeding

acute lymphocytic leukemia (ALL)

(ALL the _____)

most common type of leukemia in children*

there is an increase of immature small lymphocytes in the bone marrow, most of B-cell origin

most have fever by time of diagnosis; symptoms are abrupt

manifestations:

• fever

• bleeding

• progressive weakness, fatigue, bone and/or joint pain

  • not commonly seen in healthy children, they are usually energetic

• petechiae

chronic myelogenous leukemia (CML)

caused by excessive development of neoplastic granulocytes in the bone marrow

the granulocytes move into the blood in massive numbers and infiltrate the spleen and liver

has a chronic stable phase followed by a more acute, aggressive phase (blastic phase - swollen lymph nodes, infections, lack of appetite)

no symptoms in early disease; manifestations:

• fatigue

• weakness

• fever

• night sewats

• sternal tenderness

• weight loss

• bone and joint pain

• splenomegaly

  • Kehr’s sign - pain referred to  left shoulder

philadelphia chromosome **

chromosome very prevalent in chronic myelogenous leukemia (CML)

originates from the translocation between BCR gene on chromosome 22 and ABL gene on chromosome 9 - the protein encoded interferes with normal cell cycle events

people with ALL or AML can also have it

chronic lymphatic leukemia (CLL)

there is production and accumulation of long lived, mature appearing lymphocytes

they infiltrate the liver, spleen, and bone marrow

most common leukemia in adults

incidence increased after 72 years of age and in males

manifestations (frequently none):

• chronic fatigue

• anorexia

• splenomegaly

• lymphadenopathy

• hepatomegaly

• progressive

  • fever

  • night sweats

  • weight loss

  • frequent infections

induction therapy (1st stage of chemo)

aggressive treatment to destroy leukemic cells in the tissues, blood, and bone marrow

bone marrow is severely depressed, so many become critically ill (very neutropenic)

after 1 course of this therapy, many achieve complete remission

postinduction / postremission therapy (2nd stage of chemo)

for the people who did not achieve remission the first time

an intensification therapy - a high dose therapy that may start immediately after induction therapy and last for several months

could also be consolidation therapy - started after remission is achieved

consists of 1 or 2 more courses of the same drug as induction therapy

the purpose is to eliminate the remaining leukemic cells that may not be clinically evident

maintenance therapy (3rd stage of chemo)

for chronic leukemias

the goal is to keep the body free of leukocytic cells

treatment therapies for leukemias

combination drug therapy is the standard

purposes:

• decrease drug resistance of chemo

• minimize drug toxicity (to use less doses of chemo)

• interrupt cell growth at multiple points in the cycle

other therapies

• steroids

• radiation

• immunotherapy

• hematopoietic stem cell transplant

  • body can reject it

  • can relapse

  • high risk of infection and sepsis due to eliminating all WBC

neutropenic precautions for patients with leukemia*

• Hand hygiene before every patient contact

  • Ensure anyone entering the room performs proper hand hygiene

• Private room required

  • positive-pressure or HEPA-filtered room

• No fresh flowers, plants, or standing water

• No fresh fruits or raw vegetables

  • Only fully cooked foods; avoid unpasteurized products.

• No sick visitors or staff

  • Patient should wear a mask when leaving the room

  • Some units require visitors to wear masks too.

• Avoid invasive procedures whenever possible

  • Limit rectal temps, enemas, suppositories

  • Avoid unnecessary catheterizations and blood draws

• Soft toothbrush only; no flossing (prevents mucosal injury)

• Check IV sites, wounds, and skin folds frequently for signs of infection

• Immediate reporting of fever of 100.4°F (38°C) or higher

• Avoid crowded public places

hodgkin lymphoma

cause is unknown

starts in a single location and then spreads

originates either above or below diaphragm

• above - stays confined to lymph nodes for a period of time

• below - spreads to extralyphoid sites like liver

has a rapid increase of reed-sternberg cells (abnormal, giant, multinucleated cells) and hodgkin cells (mononucleated cells that increase in the lymph nodes)

caused by epstein-barr virus (EBV), genetics, exposure to toxins, and HIV

males are affected twice as much

can be cured

manifestations of hodgkin lymphoma

• enlargement of cervical, axillary, and inguinal lymph nodes

  • nodes movable and nontender

• fatigue

• chills

• tachycardia

• B symptoms

  • weight loss

  • fever

  • night sweats

• advanced

  • hepatomegaly and splenomegaly

    • pain with alcohol intake

    • jaundice

  • anemia

diagnostics for hodgkin lymphoma and non-hodgkin lymphoma

• peripheral blood analysis

• lymph node and bone marrow biopsy

• PET/CT scan

standard therapy for hodgkin lymphoma

ABVD

• Adriamycin 

• Bleomycin

• Vinblas Dacarbazine

number of cycles / rounds depends if cancer is in early, intermediate, or advanced stage

can be used alongside with chemo and radiation 

consequences: can later develop secondary cancers like acute myeloid leukemia

non-hodgkin lymphoma

a broad group of cancers containing primarily B, T, and natural killer cells

most common hematological cancer

several types; most common is large B cell lymphoma (found in neck and abd) and follicular lymphoma

can affect all ages

most common in people with immunodeficiency, use immunosuppressives, or received chemo/radiation

can be classified by differentiation, cell of origin, phenotype, genetics, and clinical features

manifestations of non-hodgkin lymphoma

• spread is unpredictable

• painless lymph node enlargement

• hepatomegaly

• neurologic symptoms

• lymphadenopathy

• B symptoms

  • fever

  • weight loss

  • night sweats

difference between non-hodgkin lymphoma and hodgkin lymphoma

non-hodgkin lymphoma only originates ABOVE the diaphragm and treatment is more aggressive and easier to treat

it also spreads all over so additional diagnostic tests include:

• MRI for liver

• lumbar puncture for CNS

• bone marrow biopsy

• colonoscopy for GI

treatment options and interventions for non-hodgkin lymphoma

chemo, radiation, immunotherapy

educate on:

• treatment

• activity intolerance

• infection precautions

multiple myeloma

cancerous plasma cells that increase in number in the one marrow and destroy the bone

over proliferation of plasma cells and over production of immunoglobulin and proteins cause end organ effects (liver, marrow, kidney)

most common in males and african americans 

manifestations of multiple myeloma

develops slowly

• skeletal pain - pelvis, spine, ribs

• fractures

• osteoporosis

  • causes vertebral collapse = back pain

  • hypercalcemia due to bone destruction

  • high protein levels can cause renal failure

• anemia

• excessive bleeding due to low platelets

• numbness - from affects on spinal cord

diagnostic testing for multiple myeloma **

• H&P

  • decrease in height?

  • is this back pain new?

• CBC

• CMP - calcium

• urinalysis - M protein

• skeletal survey - osteoporosis

• MRI / PET

treatment options for multiple myeloma

• steroids

• chemo; dont usually do radiation

• immunotherapy

• stem cell transplant

• Zoledronic acid and denosumab

  • inhibit bone breakdown

goals are to relieve symptoms, produce remission (not common due to age), and prolong life