Superficial thickness First-degree Full thickness Third- or fourth-degree Partial thickness — deep Second-degree Partial thickness — superficial Second- degree Epidermis involvement Dermis and underlying tissue Deep (reticular) dermis Superficial (papillary Erythema minor pain, lack of blisters Hard, leather-like eschar, purple fluid, no sensation (insensate) Whiter appearance, with decreased pain. Difficult to distinguish from full thickness Blisters, clear fluid, and pain Nomenclatu re Traditional nomenclatur e Depth Clinical findings BURN
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Superficial thickness
First-degree
Full thicknessThird- or fourth-
degree
Partial thickness —
deepSecond-degree
Partial thickness — superficial
Second-degree
Epidermis involvement
Dermis and underlying
tissue
Deep (reticular) dermis
Superficial (papillary
Erythema minor pain, lack of blisters
Hard, leather-like eschar, purple fluid, no sensation
(insensate)
Whiter appearance, with decreased pain. Difficult to
distinguish from full thickness
Blisters, clear fluid, and pain
Nomenclature
Traditional nomenclature
Depth Clinical findings
BURN
Require only symptomatic treatment.
Usually heals in 7 days.
No blister formation.
Skin is red, painful, and tender.
Involves only the Epidermal layer of the skin.
Leaves no scars.
I= 1st DEGREE BURN
The deeper layer of the dermis, hair follicles, sweat glands and sebaceous glands are spared
II= 2nd DEGREE BURN1- SUPERFICIAL – PARTIAL THICNESS The burn extends to the dermis
The epidermis and superficial (papillary layer) dermis are injured
Blistering of the skin
Exposed dermis is red, moist at blister base
Very painful to touch
Good perfusion of dermis with intact capillary refill
Heal in 14 – 21 days
Scaring usually minimal
II= 2nd DEGREE BURN2- DEEP – PARTIAL THICKNESS
Extends into the deep reticular layer of the dermis
There is damage in the hair follicles, sweat glands, & sebaceous glands
Caused by steam, hot liquids, flameSkin may be blisteredThe burned areas don’t blanchNo capillary fillingAbsent pain sensationHealing takes 3 W – 2 monthsScaring is commonSurgical debridement & skin grafting may be necessary to obtain maximum function
III= 3rd DEGREE BURN
Involves the entire skin thickness
All epidermal and dermal layers are destroyed
Caused by flame, hot oil, steam and contact e’ hot object
Skin is charred, pale, painless, leathery
Injuries will not heal spontaneously
Surgical repair and grafting are necessary
Injuries will leave significant scaring
9%
Front18%
Back18%
9%9%
18%18%
ESTIMATION OF BURN %(ADULT)
RULE OF 9 & ESTIMATION OF BURN SIZE
CLASSIFICATIONS OF BURN ACCORDING TO SEVERITY
1= MINOR
Partial thickness burn less 15% of BSA in the 10 – 50 – year old age group
Partial thickness burn less than 10% BSA in children under 10 and adults more than 50
Full thickness burn of less than 2% BSA in any one with out associated injuries
These burn imply out patient treatment
2 =MODERATE
CLASSIFICATIONS OF BURN ACCORDING TO SEVERITY / cont
Partial thickness burn of 15 – 25 % BSA in 10 – 50 year – old age group
Partial thickness burn of 10 – 20 % BSA in children under 10 or adults over 50
Full thickness burn of less than 10% in any one
Partial thickness burn of the hands, face, feet, perineum, or circumferential burn of an extremity are excluded
3 =MAJOR
CLASSIFICATIONS OF BURN ACCORDING TO SEVERITY / cont
Partial thickness burn greater than 25% BSA in the 10 – 50 – year – old age groupPartial thickness burn greater than 20% BSA in children younger than 10 and adults over 50Full thickness burn greater than 10% BSA in any oneBurn involving face, feet, hands and perineumBurn complicated by inhalation burnBurn crossing major jointsCircumferential burns of an extremityElectrical burnsBurn complicated by # or other traumaBurns in infants & elderly
FLUID REPLACEMENT
PARKLAND FORMULA
use crystalloids
ADULTS
RL 4ml X patient Wt ( kg ) X % BSA over initial 24 h
½over the 1st 8 hrs from the time of burn
½over the subsequent 16 hrs
FLUID REPLACEMENT
PARKLAND FORMULA
use crystalloids CHILDREN
they have an increased body surface area – to - wt ratio, so they have greater fluids requirement
RL 3 ml X patient Wt ( kg ) X % BSA over initial 24 hrs plus maintenance fluid
½over the 1st 8 hrs from the time of burn
other ½ over the subsequent 16 hrs
Maintenance
Based upon the child’s wt
100 ml/kg for the 1st 10 kg
then 50 ml/kg up to 20 kg
then 2o ml/kg for any wt above 20kg
DIGOXIN TOXICITY• S/S• Acute & chronic• DX• FAB
HYPERKALEMIA • Is life threatening Hyperkalemia present ?• ECG changes• high risk ( RF,On dialysis, medication)• Serum K > 5.5mEq/l
IV 0.9%Nacl
YDOC > Alkalinizing agents > Sodium bicarbonateIncrease pH, which results in a temporary K shift from the ECS to ICS• Adult: 1 mEq/kg slow IV push not to exceed 50-100 mEq• Children: 1-2 mEq/kg IV over 5-10 min; repeat in 10 min prn
Stabilize the myocardium > IV Calcium gluconate • Adult: 10 mL of 10% sol IV over 10 min (under ECG monitor)•Children: 100 mg/kg (1 mL/kg) of 10% sol IV over 10 min; not to exceed 10 mL
Shift K into the cells
DW & InsulineAd: 5-10 U simple insuline and 25-50 g D (50-100 ml 50% DW)children: 0.5g Dw 25% and 0.1u/kg IV slowly
Albuterol (Ventolin) NEB
Adult: 5 mg mixed with 3 mL NS high-flow Nebulizer q20min Children: 2.5 mg/dose with 3 mL isotonic saline nebulized
Enhance elimination of K
N
N or HighLow
Pt volume status Kayexalate: 25-50 g mixed with 100 mL of 20% sorbitol PO/PR
Is urine output present?
N
NO
RESPONSE
Y
Attempt loop diuretics(lasix 40-100mg)
Hemodialysis
Simple febrile seizures are: Temperature greater than 38 C Age – 6 months to 6 years isolated Generalized tonic – clonic seizures lasting less than 15 minutes do not recur within 24 hours or within the
same febrile illness No CNS infection or inflammation No systemic metabolic abnormality No history previous afebrile seizure
HYPOGLYCEMIA
1- Serum glucose level < 50 mg/dl.2- Symptoms consistent with the diagnosis.3- History of DM4- Patient with altered mental status
Yes
Is patient responsive ? No
• 1g/kg/IV 50% D/W• IV infusion of 10% D/w• 200 mg hydrocort when (adrenal crisis, no response to treatment)
IV line Present ?
• Glucagon: 1gm IM,SC• NG tube >> sweet Drink
Y
N
• Asess and monitor patient Response• Check RBS q 15 min
• continue to monitor• Search for causes• Ensure patient safety
• Establish IV access• 1g/kg/IV 50% D/W• Continuous infusion of 10% D/w• Glucagon: 1gm IM,SC
Recheck RBS in 15 min
• 20 – 30 gms of oral carbohydrate• Assess response
Is patient NPO
Yes
Yes
NO
Is patientResponsive
Retreat with 1gm/kg
CarbohydratePO, IV
• Monitor Pt• If eating, feed meal within 30 min• Evaluate etiology• Educate Pt how to prevent future episode
Is RBS greaterThe 70 mg/dl
Yes
Recheck RBS in 30 min
Is RBS greater than
60 mg/dl
No
Is patient NPO
• Retreate with 20-30gm carbohydrate• continue monitoring Pt
No
Yes
NO
YEs
No
S/S OF HYPOGLYCEMIA
NEUROGLYCOPENICSYMPTOMS
HYPEREPINEPHRINEMICsymptoms
-Alternation in LOC -Lethargy, confusion
- Agitation- Unresponsiveness
- Seizures- Focal neurological deficits
- Coma
-Anxiety, nervousness -Irritability
-Nausea, vomiting -Palpitation, tremor
- Sweating ,- Change in pupils size
-Salivation -Bradycardia
Due toHypoglycemia
Due torelease of adrenaline
HYPOTHERMIA
IT IS DEFINEDAS A CORE TEPERATURE LESS THAN 35C ( 95F )
- Sinus bradycardia - AF or Flutter - Nodal rhythm - AV block - PVC,s - VF - Asystole
ECG CHANGES IN HYPOTHERMIA
J wave: it is a positive reflection at the junction of the QRS and S – T segment.
CORE TEPERATURE LESS THAN 35C ( 95F )Primary: Secondary
Resulting from a medical illnessSee D/D
Radiation, Conduction, Convection& Evaporation
Mechanisms of heat loss
Due to environmental exposure, with no underlying medical condition
REWARMING TECHNIQUES
1. Passive warming:Removal from cold environmentUse of insulating blankets
GENERAL & SUPPORTIVECARE
2. Active external warmingRadiant heat, Warmed blanketWarm water immersion, heated objects
3. Active core re – warming= warm NS (42*C) throughNG tube, folly’s catheter, peritonial catheter. Rectal tube= Warm IV fluids
ABC Assessment, RR, pulse oxymetry, effort
V/S: core temperature, HR, BP
adequateYes
No
O2
INTUBATIONLMA, ETT
CORE TEMP < 35*C
Warm IV fluids, ECG monitoring, soft handling
TREATMENT OF THE CAUSE (See D/D)
Treatment of dysrhythmiasaccordingly
YES
Paracetamol poisoning1. toxic dose
2. Paracetamol level
3. Activated charcoal
4. Lavage
5. NAC IV dose
Time of ingestion
< 2 hours > 8 hours 2 – 8 hours
Activated charcoal
< 150 mgs/kg >150mgs/kg < 150 mgs/kg >150mgs/kg
NAC
Treat possible , probable and high risk group with NAC.
Paracetamol level at presentation
Paracetamol level at 4 hours
PROTOCOLS FOR NAC ADMINISTRATION(Do not Delay NAC treatment while waiting for paracetamol level)
• ORAL:72 h treatment= Loading dose: 140 mg/kg, Subsequent Doses: 70mg/kg q 4h for 17 doses.• IV: 20 h treatment= Loading dose:150 mg/kg over 15 min, Subsequent Doses: 50 mg/kg over 4h followed by 100mg/kg over 16h
Paracetamol Poisoning
Patient assessment in ACLS
And care priority
ABC: when patient either responsive of not with intact circulation
CAB: when patient not responsive with no pulse
Antidotes for Toxins in Emergency Overdose Patients
Antidote Toxin Dose and comments Naloxone Opiates Naloxone2 mg; less to avoid narcotic withdrawal,
more if inadequate response; same dose in children
Bicarbonate
Tricyclics 44–88 mEq in adults; 1–2 mEq/kg in children; IV push, not by slow infusion
Flumazenil Benzodiazepines 0.2 mg, then 0.3 mg, then 0.5 mg, up to 5 mg; not to be used if patient has signs of TCA toxicity; not
approved for use in children but probably safe Calcium Calcium channel
blockers1 g calcium chloride IV in adults, 20–30 mg/kg/dose in children, over a few minutes with continuous monitoring
Glucagon b-blockers, calcium channel
Blockers
5–10 mg in adults, then infusion of same dose per hour
Physostigmine Anticholinergics 1–2 mg IV adults, 0.5 mg in children over 2 min for anticholinergic delirium, seizures, or dysrhythmias
Atropine Organophosphates, carbamates
Test dose 1–2 mg IV in adults, 0.03 mg/kg in children. Titrate to drying of pulmonary secretions
N-acetylcysteine
Acetaminophen 140 mg/kg, then 70 mg/kg q4h; IV form still investigational
Antidotes for Toxins in Emergency Overdose Patients
Antidote Toxin Dose and comments Ethanol Methanol, ethylene
glycolLoading dose 10 ml/kg of 10%; maintenance dose
0.15 ml/kg/hr of 10%; double rate during dialysis Fomepizole Methanol, ethylene
glycol15 mg/kg every 12 hr
Pyridoxine. Isoniazid 5 g in adults, 1 g in children, if ingested dose unknown. Antidote may cause neuropathy
Simple wound care (dressings, recheck) Crutches, splints, slings
Toxidromes (a toxic “fingerprint)
Refers to the collection of signs and symptoms.
It include grouped, physiologically based abnormalities of vital signs General appearance Skin, eyes, mucous membranes Lungs, heart, abdomen Neurologic examination
Helpful in establishing a diagnosis when the exposure is not well defined.
Certain clinical findings may narrow the etiologic possibilities
Common Toxic Syndromes (Toxidromes) Anticholinergic Common
signs
Delirium with mumbling speech, tachycardia, dry flushed skin, dilated pupils, myoclonus, slightly elevated temperature, urinary retention, decreased bowel sounds. Seizures and dysrhythmias may occur in
tachycardia (or bradycardia with pure a-agonist), hypertension, hyperpyrexia, diaphoresis, Delusions, paranoia, piloerection, mydriasis,
hyperreflexia. Seizures, hypotension, and dysrhythmias. Common causes
Cocaine, amphetamine, methamphetamine and its derivatives, ephedrine, pseudoephedrine. In caffeine and theophylline overdoses, similar findings, except for the organic psychiatric signs, result from
catecholamine release.
Common Toxic Syndromes (Toxidromes) Opioid/sedative/ethanol Common
signs
Coma, respiratory depression, miosis, hypotension, bradycardia, hypothermia, pulmonary edema, decreased bowel sounds, hyporeflexia, needle marks. Seizures may occur after overdoses of some narcotics