Burns: Injury Phases and Emergency Protocol

Burns

• Fire emergency protocol: Rescue, Alarm, Confine, Extinguish.
• To use a fire extinguisher: Pull the safety pin, aim at the base of the fire, squeeze the handle, and sweep from side to side.
• If a person is on fire: Throw a wet blanket on them, and instruct them to stop, drop, and roll.
• The most fatal burn injury is inhalation injury.
• Inhalation of carbon monoxide has a higher affinity to hemoglobin than oxygen and can lead to hypoxemia and ultimately death.

Phases of Burn Injury

• There are multiple phases of burn
• Emergent/Fluid Accumulation Phase occurs during the first 48 hours of the burn injury.
• During this phase, plasma shifts to the interstitial space.
• Plasma shift to interstitial space causes low blood volume (hypovolemia), increased hematocrit, low blood pressure (hypotension), edema, low renal perfusion (oliguria), and concentrated urine.
• Watch out for fluid emergency (hypovolemic shock); signs and symptoms include tachycardia, tachypnea, and hypotension.
• Priority during the emergent phase is airway management, looking for signs and symptoms of inhalation injury, such as burns on the face or singed nasal hair.

Fluid Resuscitation

• Use the Baxter Parkland Formula for fluid resuscitation, which calculates: 4 ml × TBSA × weight in kg.
• Administer fluids in three shifts: the first half of the total fluid over the first 8 hours, and the remaining half over the next 16 hours (1/4 each shift).
• The preferred IVF (intravenous fluid) is PLR (PlasmaLyte).
• In the first phase, cellular disruption causes potassium to shift from the cell to the blood (hyperkalemia), while sodium shifts to the interstitial space (hyponatremia).

Acute/Fluid Remobilization Phase

• This phase occurs after 48 hours of the burn injury.
• Here, fluid shifts from the interstitial space back into the intravascular space.
• Increase in blood volume (hypervolemia), increased blood pressure (hypertension), low hematocrit (hemodilution), increased renal perfusion (polyuria), and diluted urine are likely.
• Watch out for circulatory overload during this phase.
• Hemodilution leads to fluid and electrolyte imbalances, causing hypokalemia and hyponatremia.

Convalescent Phase

• The convalescent phase focuses on healing and repair of the burned tissue.

Electrolytes

• Electrolytes are charged ions classified as cations (positive charge) or anions (negative charge).
• Cations include Na+, K+, Ca2+, and Mg2+, while anions include P- and Cl-.
• Normal potassium levels are 3.5-5 mEq/L.
• Food high in potassium include: bananas, passion fruit, jackfruit, avocado, grapes, oranges, cantaloupe/watermelon/melon, and apricots.
• Apples have less potassium content.

Potassium Considerations

• Do not drink water after sweating; instead, consume fluids with electrolytes.
• Potassium is the most abundant intracellular electrolyte and maintains intracellular osmolality.
• It assist in Nerve impulses & transmission, and muscle contractility
• Low potassium in skeletal muscle causes leg weakness, while low potassium in smooth muscle causes constipation, and high potassium causes diarrhea; avoid giving laxatives to constipated patients.
• Cardiac muscle: low and high potasium can cause arrhythmias/cardiac arrest.

Potassium and Acid Base Balance

• Maintains acid-base balance through cellular ion exchange.
• Acidosis (high H+ in blood) leads to hyperkalemia, while alkalosis (low H+ in blood) leads to hypokalemia.
• Hypokalemia: low potassium (less than 3.5 mEq/L).

Hypokalemia

• Causes of hypokalemia include GI losses (diarrhea, vomiting, GI fistula/suctioning), decreased potassium intake, and potassium-wasting diuretics like furosemide (Lasix) and thiazide diuretics (hydrochlorothiazide).
• Other causes: osmotic diuretics (mannitol), carbonic anhydrase inhibitors (acetazolamide), Cushing's syndrome, burns, and alkalosis.
• Signs and symptoms include limp muscles, leg cramps, low and shallow respirations, low BP, lethargy, and low peristaltic movement.
• ECG: Prominent U wave.
• Management includes identifying and stopping ongoing K losses, treating the underlying cause, and giving K supplements, check renal function/urine output especially Creatinine:(0.7-1.20mg/dL) and BUN: (10-20mg/dL)
• Potassium supplements can be given PO (KCl tablet/ Kalium Durule), KCl solution (with juice), or KCl parenterally (incorporated in IV with infusion pump, agitate bag, no IVTT, Bolus, or direct IM).
• Increase of potassium through Potassium-sparing diuretics such as spironolactone, eplerenone, amiloride, or triamterene

Hyperkalemia

• High potassium (more than 5 mEq/L).

Hyperkalemia Causes

• Causes include medications (K-sparing diuretics, K supplements, NSAIDS, ACE inhibitors), acidosis, cellular destruction (injury, burns, hemolysis, chemotherapy), hypoaldosteronism/Addison's, increased K intake, and impaired excretion due to nephron damage (renal failure).
• Signs and symptoms include muscle weakness, urine output changes (oliguria/anuria), respiratory distress, dysrhythmia/cardiac arrest, diarrhea, early muscle twitching, and rhythm changes on ECG (tall tented/peaked T wave).
• Management involves decreasing/limiting potassium intake, treating the underlying cause, and medications.
• Medications include: calcium gluconate (antidote to prevent cardiac arrest), regular insulin (IVTT), Kayexalate/exchange resin/Na polystyrene sulfonate, and potassium-wasting diuretics.

ABG Interpretation

• ABG interpretation: pH (7.35-7.45), HCO3 (22-26 mEq/L) metabolic, PaCO2 (35-45mmHg) respiratory PaO2 (80-100mmHg), SaO2/SpO2 (95-100%)
• Uncompensated has one value as normal
• Partially compensated all values are abnormal
• fully compensated has normal pH

Defense Mechanisms

• Operate at the unconscious level and protects the ego by falsifying/distorting reality.
• Examples include Regression, Repression, Suppression, Undoing, Reaction formation, Displacement, Conversion, Splitting, Confabulation, Fantasy, Denial, Rationalization, Intellectualization, Projection, Introjection, Identification, Sublimation, Substitution, and Compensation.

Personality Disorders

• Cluster A (odd, eccentric, weird)
  • Paranoid Personality Disorder: Suspicious, mistrustful, finds meaning in all intentions.
  • Schizoid personality disorder: Loner, alone, aloof, indifferent.
  • Schizotypal Personality Disorder: Similar symptom with schizophrenia,magical thinkers.
• Cluster B (dramatic, erratic, wild)
  • Antisocial Personality Disorder: Sociopath, Law breaker, Can lead to become a criminal
  • Borderline personality disorder: Self mutilating , self destructive,Very manipulative
• Cluster C (anxious, fearful, worried)
  • Dependent personality disorder: Clingy, Indecisive
  • Avoidant personality disorder: Playing safe, Social inhibition
  • Obsessive-compulsive personality disorder: Perfectionist, High superego

Alzheimer's

• Alzheimer's is the most common irreversible dementia.
• Discovered by Alois Alzheimer and is caused by advance age, poor cardiovascular health, head injury, family history, neurofibrillary tangles in the brain, and beta-amyloid plaque formation and biological cause (low acetylcholine)
• Acetylcholine function: memory, muscel strength & contact Signs & symptoms: forgetfulness, confabulation, word finding, misidentification, sundowning=wandering
• Amnesia, Aphasia, Agnosia, Apraxia

Develpmental Disorders

• Autism Spectrum Disorder (ASD)
  • Impairment with social interaction & communication
  • abnormal & repetitive behavior, interest, and activities
• Attention Deficit Hyperactivity Disorder (ADHD) -Categories: Inattention, Hyperactivity, Impulsivity -drug of choice is stimulants (increases focus & concentration= improved academic performance)
• Intellectual Disability -Three Domains of Intellectual Disability (Conceptual, Social, Practical)
• Conduct Disorder
  • Persistent, repetitive behavior that violates basic human rights or societal norms and values
  • Aggression against people and animals/Deceitfulness/Destrcution of property/Serious violations of rules