[20] ERDN - Part 2

What is the contraindicated route for pain management in burn patients?

IM due to damage to muscles 

True or false? Codeine is considered a strong opioid and is the drug of choice for burn pain

False; codeine is just a weak opioid. Morphine is the DOC.

Morphine:

• Route

• WOF

• Antidote 

• IV 

• Respiratory depression 

• Naloxone 

Naloxone can be administered via ________ route in emergencies

Intranasal

The diet of choice for burn patients in the first 48 hours

TPN

• The patient should be on NPO because burn patients due to the decreased flow to the GIT, which can lead to paralytic ileus

Nutrition for burn patients: increased or decreased?

• Calories

• Carbohydrates 

• Protein 

• Increased calories and carbohydrates due to hypermetabolism 

• Increased protein for tissue repair 

Vitamins given for:

• Skin integrity 

• Metabolism

• Infection prevention 

• Vitamin A

• Vitamin B

• Vitamin C 

The stress ulcer common in burn patients

Curling’s ulcer due to thinner GI lining

Why are PPIs and H2 blockers given to burn patients?

To prevent Curling’s ulcer

Thermoregulation problem during:

• Emergent phase

• Acute and recovery phase

• Hypothermia due to skin loss

• Low grade fever due to inflammation 

Hypothermia prevention:

• Remove ____ clothing

• Cover with ____ blanket

• ____ room temperature 

• ____ ____ at bedside

• ____ fluids 

• Wet

• Warm

• Increased

• Heat lamp 

• Warmed 

What is the 1st line of defense of the body?

Skin

Isolation precautions for burn patients?

Reverse isolation

Most effective way to prevent infections?

Handwashing

Vaccine given to burn patients

Tetanus vaccine

Solution used for wound irrigation in burn patients

NSS because it’s isotonic and sterile

The most common gram-positive bacteria causing burn wound infections

Staphylococcus aureus

The most common gram-negative bacteria causing burn wound infections

Pseudomonas aeruginosa

Debridement of burn wounds is done using a ________ dressing technique, and the first action before performing it is administering ________

Wet-to-dry; analgesics

Surgical intervention for full thickness burns

Skin grafting

What are the 4 types of skin grafting?

• Isograft

• Allograft 

• Xenograft 

• Autograft 

Identify the type of skin grafting being described:

1. From identical twins 

2. From other humans

3. From animals 

4. From self 

1. Isograft

2. Allograft

3. Xenograft

4. Autograft

Common donor site for autografts?

Anterolateral thigh 

Most common type of shock

Hypovolemic shock

Most fatal type of shock

Septic

• Deds ka na within 24 hours

Involved: blood

A. Hypovolemic shock

B. Cardiogenic shock

C. Distributive shock

D. Neurogenic shock 

A. Hypovolemic shock

Involved: heart

A. Hypovolemic shock

B. Cardiogenic shock

C. Distributive shock

D. Neurogenic shock 

B. Cardiogenic shock

Involved: blood vessels 

A. Hypovolemic shock

B. Cardiogenic shock

C. Distributive shock

D. Neurogenic shock 

C. Distributive shock

D. Neurogenic shock 

What are the 2 types of distributive shock?

• Septic shock

• Anaphylactic shock 

Provide the cause of the following:

• Hypovolemic shock

• Cardiogenic shock

• Distributive shock

• Neurogenic shock

• Decreased blood volume

• Decreased cardiac output 

• Massive vasodilation

• SCI

What causes massive vasodilation in:

• Septic shock

• Anaphylactic shock 

• Cytokine release

• Histamine release 

Vital signs: ↓ BP, ↑ HR, ↑ RR

A. Hypovolemic shock

B. Cardiogenic shock

C. Distributive shock

D. Neurogenic shock

A. Hypovolemic shock

B. Cardiogenic shock

C. Distributive shock

What type of shock causes bradycardia due to loss of SNS response?

Neurogenic shock 

What are the 3 stages of shock?

1. Compensatory 

2. Progressive 

3. Irreversible 

Which of the following best describes the compensatory stage of shock?

A. Severe hypotension, MODS, lactic acidosis

B. SNS activation, vasoconstriction, normal BP

C. Anuria, metabolic acidosis, irreversible damage

B. SNS activation, vasoconstriction, normal BP

Which of the following best describes the progressive stage of shock?

A. Severe hypotension, MODS, lactic acidosis

B. SNS activation, vasoconstriction, normal BP

C. Anuria, metabolic acidosis, irreversible damage

A. Severe hypotension, MODS, lactic acidosis

Which of the following best describes the irreversible stage of shock?

A. Severe hypotension, MODS, lactic acidosis

B. SNS activation, vasoconstriction, normal BP

C. Anuria, metabolic acidosis, irreversible damage

C. Anuria, metabolic acidosis, irreversible damage

What is the first sign of shock?

Restlessness

Which physiologic responses occur during the compensatory stage? SATA

A. Activation of SNS

B. Release of aldosterone & ADH

C. Vasoconstriction → cool skin

D. Blood flow shunted to heart & brain

E. Severe hypotension

A. Activation of SNS

B. Release of aldosterone & ADH

C. Vasoconstriction → cool skin

D. Blood flow shunted to heart & brain

Which physiologic responses occur during the irreversible stage? SATA

A. Asystole

B. Comatose state

C. Apnea

D. Oliguria

E. Anuria

A. Asystole

B. Comatose state

C. Apnea

E. Anuria

BP starts to drop 

A. Compensatory 

B. Progressive 

C. Irreversible 

B. Progressive 

Characterized by decompensation and severe hypoperfusion

A. Compensatory 

B. Progressive 

C. Irreversible 

B. Progressive 

Respiratory alkalosis

A. Compensatory 

B. Progressive 

C. Irreversible 

A. Compensatory 

Metabolic acidosis

A. Compensatory 

B. Progressive 

C. Irreversible 

B. Progressive 

C. Irreversible 

Oliguria

A. Compensatory 

B. Progressive 

C. Irreversible 

A. Compensatory 

B. Progressive 

Which interventions provide respiratory support in shock? SATA

A. Intubation

B. 100% oxygen via NRB mask

C. Incentive spirometry

D. Mechanical ventilation

A. Intubation

B. 100% oxygen via NRB mask

D. Mechanical ventilation

IV access for shock should be established with ________ large-bore catheters, ideally ≤ ______ gauge

2; 18 

Type of fluid used for fluid replacement in shock

Crystalloids

The first-choice crystalloid for fluid replacement in shock

PLR

The second-choice crystalloid for fluid replacement in shock

PNSS

The position used in shock management to improve venous return

Modified Trendelenburg

The drug given to correct severe metabolic acidosis in shock

Sodium bicarbonate (NaHCO₃)

How to treat underlying cause of hypovolemic shock?

Control bleeding → PIE (pressure, ice, elevate)

How to treat underlying cause of cardiogenic shock?

Give inotropes → dobutamine and dopamine

How to treat underlying cause of anaphylactic shock?

IM epinephrine 

How to treat underlying cause of septic shock?

Antibiotics

How to treat underlying cause of neurogenic shock?

Immobilize

First-line vasopressor for shock

Norepinephrine

The target MAP in shock management using vasopressors is > ___ mmHg

65

What are the common causes of airway obstruction? (Hint: AIA)

AIA

• Allergic reaction

• Infection

• Angioedema 

What type of medications cause angioedema leading to airway obstruction?

ACE inhibitors

• REMEMBER: ACE stands for angioedema, cough, elevated potassium 

Disease process of airway obstruction: 

• Obstruction → absent ventilation → ____ & ____

Hypoxemia; hypercapnia

Disease process of airway obstruction: 

• Hypoxemia → ____

• Hypercapnia → ____

• Hypoxia

• Acidosis 

Disease process of airway obstruction: 

• Hypoxia and acidosis → ____ arrest → death

Cardiopulmonary

BONUS: disease process of airway obstruction

Obstruction → absent ventilation → impaired gas exchange → hypoxemia and hypercapnia → hypoxia + acidosis → cardiopulmonary arrest → death

Able to cough 

A. Partial airway obstruction

B. Complete airway obstruction 

A. Partial airway obstruction

Unable to cough, breathe, or speak

A. Partial airway obstruction

B. Complete airway obstruction 

B. Complete airway obstruction 

Wheezing

A. Partial airway obstruction

B. Complete airway obstruction 

A. Partial airway obstruction

Universal sign: clutching of neck

A. Partial airway obstruction

B. Complete airway obstruction 

B. Complete airway obstruction

Cyanosis

A. Partial airway obstruction

B. Complete airway obstruction 

B. Complete airway obstruction 

Stridor 
A. Partial airway obstruction

B. Complete airway obstruction 

B. Complete airway obstruction 

Intervention: encourage to cough forcefully

A. Partial airway obstruction

B. Complete airway obstruction 

A. Partial airway obstruction

Intervention: Heimlich maneuver

A. Partial airway obstruction

B. Complete airway obstruction 

B. Complete airway obstruction

Airway obstruction interventions for conscious:

• Adults/children

• Infant (<1 yo):

  • ____

  • ____

• Pregnant/obese

• Heimlich 

• Back blows

• Chest thrust 

• Chest thrust 

Airway obstruction: The correct management for an unconscious choking victim

Continue CPR

Airway obstruction: The method used to remove a visible foreign object from the mouth

Finger sweep method

Airway obstruction: The finger sweep method is contraindicated if the object is ___

Invisible 

Airway obstruction: The Heimlich maneuver involves a quick ____ thrust performed above the ____ and below the ____ ____

Abdominal; umbilicus; xiphoid process

BONUS: Heimlich maneuver

Heat-induced illness: What age group is the most at risk? Why? 

Older adults d/t decreased sweating mechanism → decreased heat loss

Heat-induced illness: What are the causes of heat exhaustion/stroke? (Hint: HIP)

HIP

• Hot environment

• Inadequate fluid intake

• Physical activity

Early effects of heat exposure causing fluid & electrolyte imbalance

A. Heat illness

B. Heat exhaustion

C. Heat stroke 

A. Heat illness

Result of prolonged heat exposure (hours–days) → dehydration and ↓ perfusion

A. Heat illness

B. Heat exhaustion

C. Heat stroke

B. Heat exhaustion

Untreated heat exhaustion

A. Heat illness

B. Heat exhaustion

C. Heat stroke

C. Heat stroke

Failure of thermoregulation due to hypothalamic dysfunction

A. Heat illness

B. Heat exhaustion

C. Heat stroke

C. Heat stroke

Core temp > 40°C → protein denaturation, cytokine release, multiorgan failure

A. Heat illness

B. Heat exhaustion

C. Heat stroke

C. Heat stroke

Heat-induced illness: The structure in the brain responsible for temperature regulation that fails in heat stroke

Hypothalamus

Heat-induced illness: The absence of sweating due to hypothalamic failure

Anhidrosis 

Heat-induced illness: The process in which high temperature damages proteins within cells

Protein denaturation

Heat-induced illness: Hyperthermia leads to protein denaturation, resulting in ________ and systemic inflammation

Encephalopathy

Heat-induced illness: The life-threatening end result of shock and systemic inflammation in heat stroke

Multiorgan failure 

Heat-induced illness: A 25-year-old athlete collapses during a marathon. His core temp is 41.5°C, and he has hot, dry skin and confusion. Which event most likely triggered his neurologic symptoms?

A. Vasoconstriction from dehydration

B. Metabolic alkalosis

C. Excessive sweating

D. Protein denaturation and cerebral inflammation

D. Protein denaturation and cerebral inflammation

• REMEMBER: Heat stroke causes protein denaturation → encephalopathy → CNS s/sx 

Heat-induced illness: A patient with heat stroke is found hypotensive, with poor urine output and metabolic acidosis. What physiologic process led to this condition?

A. Cytokine-mediated vasodilation and tissue hypoperfusion

B. Vasoconstriction and decreased cardiac output

C. Hypothermia-induced shivering

D. Hypoglycemia

A. Cytokine-mediated vasodilation and tissue hypoperfusion 

≥ 40°C

A. Heat stroke

B. Heat exhaustion

A. Heat stroke

< 40°C

A. Heat stroke

B. Heat exhaustion

B. Heat exhaustion

Anhidrosis → dry, hot 

A. Heat stroke

B. Heat exhaustion

A. Heat stroke

Diaphoresis → moist; F&E loss

A. Heat stroke

B. Heat exhaustion

B. Heat exhaustion

Severe CNS s/sx: confusion, severe, coma 

A. Heat stroke

B. Heat exhaustion

A. Heat stroke

Mild CNS s/sx: restlessness. anxiety, headache 

A. Heat stroke

B. Heat exhaustion

B. Heat exhaustion

HypoTachyTachy

A. Heat stroke

B. Heat exhaustion

A. Heat stroke