Shock and Burns

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Shock and Burns

• By Diana Blum MSN
• MCC
• NURS 2140

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Shock

• Life threatening
• Inadequate tissue perfusion that can lead to cell
  death
• Unpredictable
• Definition condition in which tissue perfusion
  is inadequate to deliver oxygen and nutrients to
  support vital organs and cellular function.

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Causes

• Death is not a classified as shock but as
  multiple organ dysfunction.

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Circulatory Homeostasis
Tissue perfusion is driven by blood pressure

• BP CO X PVR

CO Cardiac Output PVR Peripheral Vascular
resistance
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Cardiac Output

• CO SV X HR
• This means that
• BP SV X HR X PVR
• Blood Pressure Stroke Volume X Heart Rate X
  Peripheral Vascular Resistance

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Stroke Volume

• Volume of Blood pumped by the heart during 1
  cycle

What affects Stroke volume?
Rhythm Problems
Blood Volume
Heart Muscle Damage
MechanicalObstruction
Mechanical Obstruction
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What makes up blood volume
Plasma
RBCs
Platelets
WBCs
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Necessary blood flow components

• Adequate cardiac pump
• Effective circulatory system
• Sufficient blood volume
• If one component compromised cell starvation and
  death can occur. This in turn will cause organ
  death, and end of life of pt.

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Heart Rate

• Heart rate increases as a compensatory response
  to Shock
• Rarely you get
• High Output failure
• Heart rate too fast to allow adequate refilling
  of heart between beats

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What Alters PVR?

• Circulation cytokines Inflammatory mediators
  (e.g. Histamine)
• Endotoxins
• Drugs (e.g. Nitrates)

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Nurses must

• Be critical thinkers
• Be able to act fast
• Be able to anticipate orders
• Execute orders in a timely yet quickly manner

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Normal cell function

• Metabolism of energy within cell
• Nutrients broken down and stored as ATP
• ATP is used for muscle contraction, active
  transport, conduction of electrical impulses

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Patho of Shock

• Cells lack blood supply
• Normal function ceases
• Cell swells and membrane becomes permeable
• Electrolytes leak out of cell
• Mitochondria become damaged
• Death of cell occurs

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Stages

• Compensatory
• Progressive
• Irreversible

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Compensatory

• BP WNL
• Body shunts blood from organs in fight or flight
  response to the brain and heart
• s/s cool, clammy, hypoactive bowel sounds, HR
  greater than 100, RR greater than 20, decreased
  urine output, confusion, respiratory alkalosis,
  Na is elevated, BGM is elevated
• If treated here, prognosis good
• Tx find cause and fix, IVF, monitor vs, monitor
  LOC, monitor I/O, promote safety

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Pathophysiological Response

• Flight or fight response
• Increased Catecholamine release
• Activation of Renin-Angiotensin system
• Increase glucocorticoid and mineralcorticoid
  release
• Activation of Sympathetic nervous system

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• In stress situations
• catecholamines, cortisol, glucagons, etc are
  released
• Causes hyperglycemia
• Causes insulin resistance
• Promotes gluconeogenesis from proteins and fats
• All this leads to organ failure in the end

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Progressive

• s/s Hypotension lt90/40, interstitial edema,
  rapid/shallow respirations, crackles, desats,
  pulmonary edema, dysrhythmias, ischemia,
  tachycardic, chest pain, agitation, confusion,
  low U.O. , lethargic, jaundice, bloody diarrhea,
  metabolic acidosis, mottled, petechiae
• Leads to ards
• MI is possible
• DIC may occur
• Overworked heart causes ischemia and myocardial
  depression leading to heart failure
• Prognosis worsens
• DX BNP, CMP, CBC, ABG
• TX mechanical vent, enteral support, Insulin,
  careful assessments, ICU, Neuro checks, balloon
  pump, meds, dialysis, infection prevention,
  family support

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Irreversible

• Organ damage severe
• Death imminent
• s/s low BP, necrosis to liver and kidneys,
  respiratory system fails even on vent,
  unresponsive
• Dx based on failure to respond to tx
• Tx palliative care, experimental tx, monitor pt,
  provide comfort, pastoral care

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Treatment of Shock

• IVF and or blood products
• Blood if related to this
• LR or NS
• Intial amount 2-3 liters for an adult with
  unknown cause
• Monitor client closely
• Beta and alpha adrenergic receptors
• NIPRIDE, levaphed, vasopressin
• Pain management
• Sympathomimetics
• Dopamine, dobutamine, adrenalin, milrinone,
  amrinone
• Nutritional support
• Parenteral or enteral

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• http//www.youtube.com/watch?v9a7N9AU1GiQfeature
  related

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5 types

• Hypovolemic
• Cardiogenic
• Septic
• Neurogenic
• Anaphylactic

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hypovolemic
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Hypovolemic Shock Caused by Body Fluid Loss Hypovolemic Shock Caused by Body Fluid Loss
Site of Fluid Loss Mechanism of Loss
Skin Thermal or chemical burn, sweating from excessive heat exposure
GI tract Vomiting or diarrhea
Kidneys Diabetes mellitus or insipidus, adrenal insufficiency, salt-losing nephritis, the polyuric phase after acute tubular damage, and use of potent diuretics
Intravascular fluid lost to the extravascular space Increased capillary permeability secondary to inflammation or traumatic injury (eg, crush), anoxia, cardiac arrest, sepsis, bowel ischemia, acute pancreatitis
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Causes

• External fluid loss
• Trauma
• Surgery
• Vomiting
• Diarrhea
• Diuresis
• Diabetes insipidus

• Internal fluid shift
• Burns
• Hemorrhage
• Ascites
• Peritonitis
• Dehydration

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Treatment

• Treat underlying cause
• Replace fluid and/or blood
• Place in modified tredelenburg (legs elevated)
• Meds depending on cause
• Blood
• Oxygen

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cardiogenic
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• Impaired oxygen
• 2 types coronary and non coronary
• Coronary LV damage, MIgreatest risk
• Non-coronary Stress on myocardium (heart
  disease, acidosis, etc.)
• Manifestations angina, dysrythmia
• Dx cardiac enzymes, ekgs,
• Tx correct underlying cause, O2, pain control,
  IVF, balloon pump, ICU, CABG, nitro, dobutamine,
  dopamine, levophed, antiarrythmics, vent

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Mechanisms of Cardiogenic and Obstructive Shock Mechanisms of Cardiogenic and Obstructive Shock Mechanisms of Cardiogenic and Obstructive Shock
Type Mechanism Cause
Obstructive Mechanical interference with ventricular filling Tension pneumothorax, cava compression, cardiac tamponade, atrial tumor or clot
  Interference with ventricular emptying Pulmonary embolism
Cardiogenic Impaired myocardial contractility Myocardial ischemia or MI, myocarditis, drugs
  Abnormalities of cardiac rhythm Tachycardia, bradycardia
  Cardiac structural disorder Acute mitral or aortic regurgitation, ruptured interventricular septum, prosthetic valve malfunction
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Circulatory shock?aka Distributive

• Occurs with abnormally placed blood volume
• 3 types
• Septic
• Neurogenic
• anaphylactic

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septic
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Management

• Antibiotics
• rhAPC
• Aggressive nutritional support
• Aseptic technique for procedures
• Monitor IV lines, indwelling lines, and wounds
• Monitor LOC
• Monitor vskeep temp in check
• IVF
• Vasoactive agents like other shocks

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neurogenic
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• Vasodilatation occurs
• Results of balance loss b/w sympathetic and
  parasympathetic stimulation
• Sympathetic vascular smooth muscles constrict
• Parasympathetic causes smooth muscle to relax or
  dilate
• In neurogenic shock, the lean is to
  parasympathetic

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anaphylactic
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• Occurs rapidly
• Life threatening
• Caused by severe allergic reaction
• Tx remove agent, antihistamine, epinephrine,
  nebulizers, CPR, intubate, IVF, assess allergies,
  educate about meds and treatment if exposure

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Treatment of Shock

• ABC

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Multisystem organ dysfunction

• Complication of SIRS/Sepsis/tissue injury
• Unknown trigger
• Begins in lungs usually, then liver, GI, and
  kidneys
• s/s respiratory failure, hyperglycemia,
  hyperlacticacidemia, polyuria, infection,
  jaundice,
• Tx intubation, ICU, dialysis

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burns
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Causes

• Thermal electricity
• chemicals
• scalds
• Radiation
• inhaled

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• http//www.youtube.com/watch?vGj4GgioI5CMfeature
  related

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Superficial partial thickness

• Epidermis destroyed
• Parts of dermis injured
• s/s pain, appears red/dry
• Example sunburn

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Deep partial thickness

• Destruction of epidermis and upper dermis
• Injury to deeper portions of dermis
• s/s painful wound that appears red and exudes
  fluidcap refill follows tissue blanching
• Hair follicles are intact
• May result in scars

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Full thickness

• Destroyed epidermis
• Destroyed dermis
• Appears white, red, brown, or black
• No pain
• Wound appears leathery
• Hair follicles and sweat glands destroyed

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Classifying Burns

• How did injury occur
• Causative agent?scald or chemical
• Temp of burn agent
• Duration of contact
• Thickness of skin

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Rules of nine
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Lund Browdner Formula
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Parkland Formula

• Parkland Burn Formula 4 cc. per kg. body weight
  per deep burn during the first 24
  hours        1.  To calculate multiply 4 X kg.
  X burn total fluid requirement        2. 
  Give half of this amount during the first 8 hours
  from the time of injury        3.  In most
  cases, this will work out to 2 large bore IVs
  wide open until hospital arrival            a.
  Monitor and record the exact amounts given, and
  provide hospital personnel with this
  information        4.  Lactated Ringers is the
  preferred fluid, if available

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Electrical Burns

• Worst to get
• Will cause lifelong neurovascular problems
• High voltage (gt1000 volts) cause bone and tissue
  destruction
• Leads to amputations and death
• There is usually an entrance and exit wound
• Travels from least resistance to ground
• Clothes catch fire

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Compli cations

• HypoVolemia
• Decreased cardiac output
• Hypotension
• Edema
• Obstruction of blood flow
• Hyponatremia
• Hyperkalemia
• Inhalation injury
• Sepsis
• Ileus

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• REMEMBER
• CAB

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• http//www.youtube.com/watch?vBB8kTdbzzpofeature
  related

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TX

• Current immediately contracts muscles
• Dysrhythmias and spinal injuries occur
• EKG Monitoring
• Spinal collar
• IVF? LR
• Monitor urine output? Prone to RF
• Frequent Neuro Checks
• ET tube
• ICU or Burn Center

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Stages Of Burn Care

• Emergent
• Acute
• Rehab

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Emergent Care

• From onset of injury to end of fluid
  resuscitation
• Remove from harm/extinguish flames on victim
• Establish airway
• Cool wound with cool water
• O2
• Large bore IV
• Immobilize cervical spine

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At hospital

• Airway
• O2
• Chest x-rays
• CMP,CBC, Blood alcohol, ABG
• Clean sheets under and over pt
• Tetanus
• Photos taken
• Catheter placement
• Xfer to burn center

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Acute

• From the beginning of diuresis to wound closure
• Remove restrictive objects
• Irrigate chemical burns/Cover wound
• Nutritional support
• Prevent complications

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• Priority is airway, pain control, wound care, and
  maintaining balance
• Bronchial lavage may need to be done
• May be placed on vasoactive meds, diuretics, and
  fluid restriction
• ICU with Art line

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Infection prevention

• Asepsis
• Antibx as ordered
• Wound cleaning
• Baths are painful
• Topical antibacterials
• Loose dressings
• Debridment

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Grafts

• Autograft
• Homograft
• Biograft and synthetic dressings

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Care of graft site

• Occlusive dressing initially
• First dressing change 2-5 days after surgery
• Monitor drainage
• Position carefully
• Exercise 5-7 days after surgery

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Care of donor site

• Pain management
• Moist gauze at surgery
• Vaseline gauze
• Heals in 7-14 days

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Nutritional support

• Control stress and pain
• Protein requirements 1.5-4.0g per kg
• Include lipids
• Carbs good
• 5000 calories/day
• Or
• Enteral feeding

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Scars

• Hypertrophic cause contractures on joints
• Ace wraps are helpful to promote circulation
• rehab

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keloids

• Mass of scar tissue
• Mostly in dark skin individuals

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• Monitor healing process
• Monitor contractures

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Rehab

• Prevent scars and contractures
• PT,OT, Speech
• Reconstructive Surgery
• Counseling

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Research

• Nutrition
• Artificial skins

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SHOCK

• Clinical Scenarios

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• 1) A 26 year old man with a comminuted closed
  fracture of the femur shaft undergoes
  intramedullary nail fixation. Two days post
  operatively, he develops a pyrexia, shortness of
  breath and tachycardia.
• Discuss the emergency management?

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• 2) A 72 year old man develops sudden back pain
  and is brought to the emergency department with a
  swollen ,tense abdomen. He is tachycardic ,with a
  low volume pulse and low BP.
• Discuss the emergency management?

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• 3) A 72 year old man with an underlying prostate
  carcinoma sustains a femoral shaft fracture .He
  undergoes intramedullary nail fixation. At post
  operative day 7 he develops a shortness of breath
  ,hypotension and a tachycardia
• Discuss the emergency management?

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Questions