CBRN Review 2

A 7 year old, weighing 25 kg, presents with a scald burn. The nurse estimates the TBSA is greater than 20%, obtains IV access and begins infusing lactated Ringers solution at: 

• 63 mL/hr 

• 250 mL/hr 

• 94 mL/hr 

• 325 mL/hr 

• 250 mL/hr 

Comments: During the primary survey, after assessing airway and breathing, intravenous access should be placed and intravenous fluids should be started at a set rate of 250 mL/hr for children 6-13 years old that present with burns greater than 20% TBSA. Lactated Ringers at 500 mL/hr is appropriate for 14 years and older. Lactated Ringers at 94 mL/hr would be appropriate during the secondary survey, after % TBSA has been determined, using the adjusted fluid resuscitation rate of 3mL/kg/tbsa for 24 hr post burn. Lactated Ringers at 63 mL/hr would be appropriate for a patient 14 years and older during the secondary survey, after TBSA has been determined, using the adjusted fluid resuscitation rate of 2mL/kg/tbsa for 24 hr post burn. 

A patient presents with burns from a phenol-based cleaner. The burn nurse knows the wounds must be irrigated and decontaminated with: 

• Buffered phosphate 

• Calcium gluconate 

• 50% polyethylene glycol 

• 0.5% copper sulfate 

• 50% polyethylene glycol 

Comments: 50% PEG increases the solubility of phenol in water thereby allowing rapid removal of the compound from the skin. A 0.5% copper sulfate solution is used to oxidize phosphoric acid particles so they can be identified and removed. Calcium gluconate gel is used to treat hydrofluoric acid burns. Buffered phosphate solution is to treat chromic acid burns. 

A patient, who was extricated from a house fire two hours ago, presents to the burn center with full-thickness burns to the entire head and face, anterior and posterior torso, and circumferential burns to bilateral upper extremities. Family reports that the patient weighs 75kg and fluid resuscitation efforts were delayed due to the inability to obtain IV access. During the secondary survey, the nurse recognizes the fluid rate should be set at: 

• 788 ml/hour 

Comments: The secondary survey indicates the use of 2ml LR x 75 kg x 63% TBSA = 9,450/2 = 4,725 / over initial 6 remaining hours = 788 (787.5 rounded up) ml/hour (since two hours have elapsed since time of burn injury). 500 ml/hour is the initial rate that the LR is to be infused during the primary survey. Once the TBSA is accurately calculated and an accurate weight is obtained during the secondary survey, the adjusted fluid rate should be calculated and initiated. 

• 675 ml/hour 

• 500 ml/hour 

• 591 ml/hour 

• 788 ml/hour 

Comments: The secondary survey indicates the use of 2ml LR x 75 kg x 63% TBSA = 9,450/2 = 4,725 / over initial 6 remaining hours = 788 (787.5 rounded up) ml/hour (since two hours have elapsed since time of burn injury). 500 ml/hour is the initial rate that the LR is to be infused during the primary survey. Once the TBSA is accurately calculated and an accurate weight is obtained during the secondary survey, the adjusted fluid rate should be calculated and initiated. 

An 80kg adult was involved in a motor vehicle collision and sustained 40% TBSA burns after the car caught fire. They appeared to have hit their head on the steering wheel. Initial vital signs: 

HR 140 beats/min 
BP 70/40 mmHg 
SpO2 91% (room air) 
Temp 36.5 degrees C (temporal) 

While the team works through the primary and secondary assessments, the burn nurse gives IV fluid resuscitation. What is the BEST indicator of a successful resuscitation in this patient? 

• Heart rate less than 110 beats/min 

• Urine output at least 40mL/hr 

• Systolic pressure above 90mmHg 

• MAP greater than 60 mmHg 

• Systolic pressure above 90mmHg 

Comments: Life threatening injuries always take priority over burn injuries. Tachycardia outside of the expected burn "normal" ranges of tachycardia (100-120bpm in adults) is often due to acute hypovolemia, hypoxemia or pain. Per trauma guidelines initial resuscitation should target SBP>80mmHg if no concern for head trauma and SBP>90mmHg with known head trauma. Urine output is the most commonly used resuscitation endpoint for burns, but in this case the trauma concerns supersede the burns. MAP is not used as the primary metric to measure resuscitation success in either trauma or burns. 

A patient was admitted 10 days ago with a 35% TBSA burn. The patient has had a decreased appetite and is meeting less than 25% of protein needs. Enteral feeds are started, and the patient complains of weakness, nausea, and numbness in the face and fingers. Electrolyte levels are low despite serial replacement. In addition to continuing electrolyte replacement, what action should the nurse anticipate? 

• Increasing rate of enteral feeds 

• Changing enteral feed formula 

• Initiating parenteral feeds 

• Decreasing rate of enteral feeds 

• Decreasing rate of enteral feeds 

Comments: The patient has clinical features of refeeding syndrome so enteral feeds should be decreased until the electrolyte imbalance is corrected. Initiating parental feeds is contraindicated in patients with extreme electrolyte imbalance. Increasing the rate of enteral feeds will further worsen the refeeding syndrome. Changing enteral feeds is indicated if the patient shows symptoms of intolerance.

A 65kg patient is admitted with an 85% TBSA burn over bilateral upper and lower extremities and full torso. At 18 hours post injury, the patient is ventilated with ongoing fluid resuscitation of lactated Ringers solution at 1125ml/hour. 
 
Trending output and pressure: 

Time	1300	1400	1500
Urine Output	35 mL	22 mL	5 mL
Bladder Pressure	15 mmHg	22 mmHg	27 mmHg

 

Current vital signs: 

BP: 143/87 mm Hg 
HR: 138 beats/min 
SpO2: 89% on 90% FiO2 
Temp: 37.1 (core) 

  

The nurse should anticipate which intervention? 

• Performing a bladder scan 

• Preparing for a decompressive laparotomy 

• Increasing resuscitation fluids 

• Administering a diuretic 

• Preparing for a decompressive laparotomy 

Comments: Large volume fluid resuscitation has contributed to a potential abdominal compartment syndrome assessed by an increasing bladder pressure, decreased urine output and increased ventilatory demands. A decompressive laparotomy may be required to correct the compartment syndrome. Increasing fluids may add further complications as their hourly fluid rate is over 6mL/kg. In abdominal compartment syndrome, urine output decreases due to decreased renal perfusion. In this instance, urine would not be left within the bladder and the nurse should be anticipating a decompressive laparotomy. Diuretics are not indicated in this situation because they may cause hemodynamic instability in the midst of the patient's abdominal compartment syndrome. 

A patient arrives in the burn unit following a house fire. EMS estimates a 35% TBSA burn and states they were unable to establish IV access. The patient is awake and alert but is complaining of a headache, dizziness, and a rapid heartbeat. What is the PRIORITY intervention for this patient? 

• Administer 100% humidified oxygen 

• Initiate fluid resuscitation 

• Determine extent of wounds 

• Establish intravenous access

• Administer 100% humidified oxygen 

Comments: The patient is displaying signs of carbon monoxide poisoning and should immediately receive 100% oxygen through a non-rebreather. Airway interventions should take priority and all other interventions can be performed following oxygen administration. 

What is the hourly maintenance rate for a 25kg pediatric patient with a 30% TBSA burn injury? 

• 25ml/hr 

• 65ml/hr  

• 140ml/hr 

• 90ml/hr 

• 65ml/hr 

Comments: D5LR maintenance fluids are required for pediatric patients less than 14 years of age. It is calculated utilizing the 4-2-1 formula. 4 ml/kg/hr for the 1st 10 kg 2 ml/kg/hr for the 2nd 10 kg 1 ml/kg/hr for each additional kg over 20 For a 25 kg child, maintenance fluid rate would be: 40ml/hr + 20ml/hr + 5ml/hr = 65ml/hr of D5LR  

When caring for a patient with a large burn, the nurse understands the MOST effective infection prevention through the alimentary tract is achieved by administering: 

• enteral feedings 

• an antacid 

• a steroid 

• intravenous antibiotics

• enteral feedings 

Comments: The intestinal tract contains various species of bacteria and fungi. The gastric tract provides an ideal environment for microbial proliferation. The alimentary tract has protective barriers in place in healthy individuals. Still, when there is a disruption, such as decreased blood flow to the gastric tract, the protective barriers no longer offer the infection control protective mechanisms. Failure of these mechanisms can lead to the systemic spread of enteric pathogens. Enteral tube feedings produce a trophic effect on the GI tract to help maintain the pH and structural integrity. Studies have demonstrated patients who receive enteral feedings do not require any further prophylactic measures for stress ulcer prevention. 

Children less than six months of age are inherently challenged to maintain core body temperature because they: 

• lack sufficient subcutaneous fat. 

• have a smaller TBSA to body weight ratio. 

• lack the ability to shiver. 

• have thicker skin compared to adults. 

• lack the ability to shiver. 

Comments: Children less than six months of age do not have the muscle mass to shiver and depend on metabolic means and environmental measures to gain temperature. Children have a greater body surface area ratio to unit body mass compared to adults. Children have thinner dermal layers than adults.

An elderly diabetic patient sustained a foot burn from a space heater 5 days ago. On arrival, the caregiver reports the patient is "not acting himself." The patient's vital signs are: 

BP 109/78 mm Hg 
HR 126 beats/min 
RR 30 breaths/min 
Temp 35.5 C (95.9 F) 

The wound is black and hard with swelling and redness to the surrounding foot. The nurse should anticipate performing which action FIRST? 

• Applying antimicrobial dressing 

• Initiating active rewarming 

• Obtaining wound cultures  

• Applying negative pressure wound therapy at -125mmHg 

• Obtaining wound cultures 

Comments: Sepsis is a change in the burn patient that triggers the concern for infection. The trigger includes: Temperature >39 C <36.5 C, Progressive tachycardia for adults >110 bpm, Progressive tachypnea for adults >25 bpm not ventilated. 

Which patient meets referral criteria to a verified burn center? 

• 25% TBSA superficial burn to back and chest 

• 5% TBSA partial thickness burn to the stomach 

• 3% TBSA full-thickness burns to bilateral hands  

• 8% TBSA burn that is pink, moist and painful to the back 

• 3% TBSA full-thickness burns to bilateral hands 

Comments: Partial or full thickness burns that involve the hands and face with a possible inhalation injury as evidenced by the singed nose hairs meets ABA requirements to transfer to a verified burn center. Less than 10% 2nd or 3rd degree burn over a non-joint area, a person with stable comorbidities and a 5% burn and large superficial burns do not meet transfer criteria.

While documenting a partial thickness burn wound, the nurse describes that it is: 

• white and dry 

• revealing exposed tendon 

• red and blistered with serous drainage 

• pink without blisters 

• red and blistered with serous drainage 

Comments: Partial thickness wounds involve the epidermis and dermis leading to blisters and serous drainage. Superficial burns involve the epidermis only, are red and have no blisters. Full thickness burns involve further structure beyond the epidermis and dermis and lead to the white, dry wounds and possibly with tendons exposed. 

The patient asks the nurse why so many vitamins and minerals are prescribed. The burn nurse explains to the patient that vitamins and minerals promote: 

• growth of muscle tissue. 

• wound healing. 

• hair and nail growth. 

• immune function.

• wound healing. 

Comments: Micronutrients are utilized by the burn patient as antioxidants, as components of wound healing and to support the immune system. Oxandrolone promotes growth of muscle tissues and improves lean body mass. Vitamins and minerals may help promote hair and nail growth, but that is not the main reason they are given to burn patients. 

A 75 kg adult sustained a 30% TBSA burn from a high voltage electrical injury. Fluid resuscitation at 4 mL/kg/tbsa is initiated. The patient produces 50 mL/hr of clear yellow urine over the next two hours. During the third hour, the burn nurse observes 30 ml of dark, red-tinged urine. The burn nurse notifies the physician, anticipating the following action: 

• Bolus 1 liter of Sodium Bicarbonate 

• Administer hydroxocobalamin 

• Increase of intravenous fluids 

• Bolus 1 liter of normal saline 

• Increase of intravenous fluids 

Comments: The treatment for patients with a high-voltage electrical injury that have red-pigmented urine is to increase fluid resuscitation to maintain UOP of 1-1.5 mL/kg/hr in an adult until the red pigment clears. Normal saline should not be utilized, unless there is a mass casualty situation and LR is unavailable. Hydroxocobalamin would not be indicated for an electrical injury. The first line intervention is increasing lactated ringers to maintain urine output of 1-1.5 mL/kg/hr. Infusing sodium bicarbonate will alkalinize the urine and make myoglobin more soluble. There is limited data to support sodium bicarbonate, LR should be increased as first line. 

When performing the secondary assessment on a newly burned patient, what vaccination is important to verify? 

• COVID-19 

• Shingles 

• Tetanus  

• Influenza 

• Tetanus 

Comments: Although all vaccines are important, verifying that a burn patient has had their tetanus vaccination within five years reduces the risk of developing a tetanus infection. The risk of developing tetanus increases as the burn creates an easy entry point to become infected. 

A child arrives to the burn unit accompanied by both parents. The hospital social worker informs the nurse that a formal consult to Child Protective Services will be placed. The burn nurse knows the social worker suspects non-accidental trauma because: 

• the father became angry when the child cried. 

• the mother admitted to a history of depression. 

• the mother told two versions of how the child was burned. 

• the father stated he was not home when the injury occurred. 

• the mother told two versions of how the child was burned. 

Comments: Child abuse or neglect should be suspected when the history changes between individuals or over time.  

A patient presents with a blistered, weeping burn on their upper arm. The patient is complaining of pain at the site when touched. When the nurse presses the wound, it turns white and, when released, it turns pink again. The nurse understands this burn is: 

• superficial. 

• full thickness. 

• partial thickness.  

• subdermal. 

• partial thickness. 

Comments: The patient has a break in the skin with sensation in the wound, describing a partial thickness burn. 

A burn nurse receives a 55kg 11-year-old patient with a 25% TBSA burn that occurred 6 hours ago. Advanced Burn Life Support (ABLS) fluid guidelines are being used and fluids are infusing at 345mL/hr. The nurse understands the patient has experienced which mechanism of burn injury? 

• Inhalation 

• Electrical 

• Chemical 

• Scald 

• Electrical 

Comments: Per the ABLS Fluid Guidelines, adult electrical burns are resuscitated at 4 mL x kg x %TBSA burned. This is due to the internal cell death that occurs when electrical current passes through the patient's body. Flame, scald, and chemical burns are resuscitated at half this rate as this internal damage is not present. Inhalation burns are known to potentially increase fluid requirements and this is controlled through altering fluid rate according to patient response. There is no alteration in the calculation for inhalation injury. 

The burn nurse understands that burn wound depth is determined by: 

• ethnicity, type of heat source, and temperature. 

• burn size, time of injury, and type of heat source. 

• temperature, duration of contact, and thickness of the skin. 

• gender, age, and location of wound. 

• temperature, duration of contact, and thickness of the skin. 

Comments: Burn depth is determined by the length of exposure(time), the temperature of the offending agent and the physical location of the injury due to thickness of skin. Burn size, ethnicity, and gender are independent of burn depth. 

An intubated adult patient has multiple rib fractures and a 30% TBSA burn involving the torso, bilateral upper extremities and face following a motor vehicle collision. On arrival to the burn unit, the nurse notes the patient is difficult to ventilate. 

Vitals signs: 
HR 140 beats/min 
BP 90/70 mmHg 
RR 38 breaths/min 
SpO2 82% on FiO2 100% 

The burn nurse observes unequal chest rise and fall, auscultates unequal breath sounds and notes jugular venous distention. What procedure should the nurse prepare for? 

• Bronchoscopy 

• Needle decompression 

• Chest tube thoracostomy 

• Chest escharotomy 

• Needle decompression 

Comments: The patient demonstrates signs of a tension pneumothorax. The treatment by the burn nurse would be needle decompression. Insertion of chest tube thoracostomy may be warranted but not before immediate stabilizing treatment. A burn patient with extensive torso burns would have equal diminished breath sounds and rise and fall of chest, and with other diagnostic indicators be considered for chest escharotomy. Bronchoscopy is not indicated because this patient is in shock and respiratory failure and rapidly decompensating. 

A patient presents to the burn unit with a burn to the foot that occurred three days ago. Upon assessment the nurse notes the wound has a erythema, edema, induration, and increased pain. These symptoms MOST likely suggest: 

• fungal infection. 

• folliculitis. 

• metatarsal fracture. 

• cellulitis. 

• cellulitis. 

Comments: Cellulitis is a wound infection characterized by erythema, edema, induration, and increased pain. Folliculitis is infection of hair follicles usually presenting on donor sites, face and scalp, creating pustules and slough. Fungal infections are characterized by rapid dark growth within the wound, usually not occurring within days of injury

A patient arrives after attempting to unclog a toilet with multiple household chemicals, the last being concentrated sulfuric acid. The chemical reaction caused an explosion directly into the patient’s face and eyes. After removing the contacts, and irrigating with copious amounts of water, what is the NEXT step? 

• Administer steroid ophthalmic solution 

• Administer prostaglandin ophthalmic solution 

• Prepare for tarsorrhaphy 

• Prepare for fluorescein exam 

• Prepare for fluorescein exam 

Comments: Fluorescein dye in combination with a Wood’s lamp is used to assess the corneal surface for abrasions. If corneal abrasions are present, ophthalmology should be consulted for ongoing treatment. Steroid drops are contraindicated. A tarsorrhaphy is a procedure to sew the scarred eyelids shut in the case of ectropion. There is no indication from the scenario of elevated ocular pressures requiring treatment with prostaglandin ophthalmic drops 

A patient has full thickness burns to the ears and nose. Which topical antimicrobial is the MOST appropriate? 

• Mupirocin (Bactroban) ointment 

• Bacitracin (Baciguent) ointment 

• Silver sulfadiazene (Silvadene) cream 

• Mafenide acetate (Sulfamylon) cream 

103

• Mafenide acetate (Sulfamylon) cream 

Comments: Mafenide acetate (Sulfamylon) penetrates into eschar and cartilaginous areas of the body and thus has a superior antimicrobial effect for the nose and ears compared to the other topical applications listed. The other three options are effective for partial thickness burns.