Burns-
Assessment of such as age and the depth of the burn , bsa, inhalation injury , injury of other special surfaces such as the face the perineum , hands or feet or genital areas as well as medical hx.
Burns are classified as : superficial partial thickness --- deep partial thickness--- full thickness injuries, it is important to remember that these are similar to but not the same as first second and third degree burns.
Fourth degree burn if used is classified as a full thickness burn that destroys also tendons and muscle usually from high voltage injury or prolonged flame contact.
Superficial partial thickness- the epidermis is destroyed or injured and portion of the dermis may be injured to
Deep partial thickness – the epidermis is destroyed and the upper layers of the dermis with possible involvement of the deep layers, cap refill and tissue blanching, hair follicle still in tact
Full thickness- destroys everything up to and including the underlying tissue of bone and muscle, color ranges from pale white to red and charred brown and black. No sensation due to destruction of the nerve. Wound is leathery no hair or sweat glands. Wound must be grafted to heal
BSA:
Rule of nines: head is 9, arms are 9, chest is 18 anterior and 18 posterior , belly is 18 anterior and posterior, legs are 18 and genitals are 1.
Lund/bowder method is more accurate it determines BSA based on proportion of the area to the whole body and is more precise. Usually is given estimate then revised after 72 hours once the burn is more readily assessed.
Palmer method: used in pre-hospital, goes off of the pts palm size and states that the palm size not the digit area is 1 % of the BSA.

TBSA- total body surface area if the bsa is less that 20 % then the body will probably produce local response. If the burn is greater than 20% than it may be local or produce a systematic response.
After the burn the pts body fluid shifts from intravascular to interstitial , this reduces the vascular volume and decrease the cardiac output and also decrease the b/p and pt goes in to burn shock. Once the body starts to compensate for this it makes it worse by increasing the vasoconstriction. Pt needs rapid fluid resusatation. The fluid shift peaks at about 6-8 hours post burn but is complete about 24-36 hours post burn.
Pt may become hyponatremic and hypokalemic after the burn from the destruction of the cells and the fluid shift.
Pulmonary complications arise from burns caused from inhalation. Catagorized as upper airway injurt and below the glottis injury. The treatment for inhaliation injuries is intubation with 100% o2 and this will make a 4 hour carboxyhemoglobin issue and resolve it in 45 mins. s/s of inhalation injury include: injury in an enclosed space, burns of the face or neck, singed nasal hair , hoarseness of voice high pitched stridor or dry cough, sooty or bloody sputum, labored or rapid breathing, blistering of the oral mucosa. s/s of lower airway injury : ABGS carboxyhemoglobin levels and direct observation of the airway by a fiber optic bronchiscope
Renal complications: myoglobin from the broken down muscle and hemoglobin from injury to the red blood cells become free in the kidneys and then can become lodged in the renal tubes resulting in the acute tubular necrosis and renal failure.
Immune complications arise from the fact that the skin is the largest barrier from infection. Burn pt is at an increased risk for infection and sepsis.
Burn pt is also at an increased risk for hypothermia
Pt is also at risk for GI issues such as paralytic ileus , curlings ulcer. Pt is also at risk for abdominal compartment syndrome and pt is also at risk for infection from the permability from the GI tract allowing the bacteria to move out and infect other organs.
Phases of burn care:
Emergent: on scene pt needs rapid management of ABC’s including c-spine and ekg stabilize c spine if needed. Pt needs to be monitored for inhalation injury and if any sign or respiratory distress they need tubed. Pt needs 100% o2 pt also needs to be npo. Fluid resuscitation and prevention of burn shock as well as detection treatment of contaminants. Encourage pt to cough and to get out secretions , if pt needs to be intubated and suctioned , pt may also need bronchodiliators and mucolytics to increase production of secretions. Once pt is stabilized you can worry about the wound or burn itself. Assess pt family for coping and pt for support system. Assess how burn happened , how long it happened , what it was that burned them. Assess for co morbid in their hx. If more than 20-25% TBSA pt needs ng tube and suction for GI decompression.
Pts with more than 10% of full thickness burns of any age, a burn in a special are like hands face joints or genitalia, chemical , electrical or inhalation burns, pt with co morbid hx or trauma should be reffered to a burn center.
Fluid replacement therapy :
Pt fluid therapy is measured by output that should be .5-1 ml/kg/hr. The formula used for fluid resuscitation is 2-4 ml/ kg/ % of tbsa , give half in first 8 hours of burn and the second half in the next 16 hours. Watch output and monitor electrolytes remember that hypokalemia and hyponatremia is common but keep serum levels in line

Acute / intermediate phase: focus still stays on airway and also of circulation must beware of vascular fluid shifts and that it may move back into the vascular system and cause fluid volume overload. Must also beware of pt on vent get VAP ventilation acquired pneumonia pt may need broncholavage. This phase also focuses on infection control , burn/ wound care, pain management and nutritional support.
Burn goals are to restore pre burn function or best possible function prevent infection and burn shock.
Burn grafting :
Autografts- are from the person own body from an unburned site
Biological grafting(homografts/ heterografts) the homografts come from a live person or a recently deceased person and the hetergrafts are from animals such as pigs
Biosynthetic dressings- are synthetic layers of nylon and silastic collagen derivative membrane
All grafts are meant to keep out infection and promote healing of the person.
Must take care of the donor site in autographs , they are still a partial thickness wound and need care. Put moist dressing on the site to maintain pressure and stop oozing , after wards a med like epi or thrombin can be applied to the site and covered with , gauze, biosynthetic matrix or biobrane. Site will usually heal in 7-14 days.
Make sure you control pain in burn pt, background pain, breakthrough pain and procedural pain. Can also try non pharm way to control pain such as relaxation tec, guided imagery , distraction ,hypnosis ext.
Burn pt needs nutritional support they are in a hypermetabolic state. That can last for up to 1 year after burn. Pt will have increased catabolic hormones like cortisol and catechols and decreased anabolic hormones like hgh and test.
Nurse management in burn in the intermediant phase: restore fluid balance, prevent infection, adequate nutrition , promote skin integrity, relieve pain and discomfort, promote mobility, coping stratagies, support family and pt, monitor for complication.
Nurse intervention in rehab phase: assessment , diagnosis of activity intolerance related to pain and limited joint mobility, disturbed body image, defeicent knowledge. Interventions: promote activity tolereance, improve self image, monitor for complitcations , promote home and community based care.

Triage : catorgize pt upon medical urgency, widely used sytem of Emergent, Urgent, and Non Urgent and some times a fourth level of fast track
Emergent – needs care right not cannot wait
Urgent – must be seen with in 1 hour
Non urgent- needs addressed in 24 hours
Other system of triage is a five level system: resuscitation, emergent, urgent, non urgent, and minor
Resuscitation and emergent need life saving measures now
Urgent needs 2 or more rescources to provide their care
Non urgent needs only 1 resource
Minor can be delt with in a clinic and need no resource
Things you need for triage:
What where and when did this happen?
When did the symptoms start?
Any LOC?
How did they get here ?
What kind of health do they have ?
Medical hx?
Meds?
Allergies?
Smoke or drink or drugs?
Fears and are they safe at home?
Last oral intake of food and water?
Last period?
Are they under a DRs care?
Last tetnus?

Heat stroke most common from environmental exposure of temp of 102.5 or higher, such as in heat waves or high humidity. This is different from heat exhaustion in which person temp maybe up to 104 marked by weakness hypotension and increase heart rate and thirst
Treatment is actively trying to cool them as fast as possible, best if done within 1 hour. Monitor and watch for hypothermia with tx and for rebound hyperthermia that can return in 3-4 hours
Frostbite most common in hands feet nose and ears measured from 1-4 degrees.
Tx. Usually from immersion in water of 98-104 degree or in whirlpool bath for 30-40 mins at time, done until return of circulation. Do not massage, do not handle the extremity. Provide for pain relief and provide elevation to prevent swelling. Cover hands with gauze to prevent maceration, do not rupture hemmoragic blebs, debriement of non hemmoragic blebs to decrease the inflammatory mediators that are found in the fluid. Stay aseptic tech from risk for infection, provide pain and nsaids, and tetnus booster. After circulation is achieved provide hourly range of motion exercise. Dr may do eschar or fasciotomy to tx compartment syndrome.
Snake bites most are from pit vipers 19 venoms snakes in US: management
Was the snake venomous? If it is dead take with you
When and where the bite occurred and the circumstances.
Sequence of events such as bite , pain , edema, swelling,
Severity of the effect
Vitals
Circumference of the are bitten compared to its non bitten side
Lab data.
Corticosteroids are contraindicated in the first 6-8 hours following a bite because it may surpress the body and hinder the antivenin
Give antivenin with in 4 hours is best , assess for allergies to horse serum, there are two kinds of antivenin Antivenin polyvalent ACP and the crotalidae polyvalent immunie fav antivenin FABAV
Dose depends on the pt size and medical state, the amount of toxin and the progression of symtoms. Kids may need more than adults from smaller body size to amount injected from snake
Look at circumrence q15 during treatment and give benedrly and tagament for anit histamine if you can put antivenin in 500-1000 bag and infuse slow increase after 10 mins and then infuse rest over the next 4-6 hours after symptoms decrease assess circumference q30-60 and assess for compartment syndrome.

Anthrax Is the most likely weaponized biologic agent , bacillus anthracis is naturally occurring gram positive rod spore that lives in the soil. It is liberated with exposed to air and is only infectious when in the spore form.
It replicates bacteria that release a toxin that cause hemorrhage, edema, and necrosis, it incubates over 1-6 days. Three ways to become infected: skin contact, inhalation, and ingestion. Skin lesion is most common gives a painless edema and pruritus then forms papule that falls off in 1-2weeks. Ingestion causes fever nausea and abdominal pain vomiting bloody diarrhea and can cause sepsis. Inhalation is the worst flu symptoms, tx usually is sought in secondary stage of infection when acute respiratory problems occur. Can incubate for up to 60 days most people have relief for first stage then go into secondary stage and progress rapidly and can progress to meningittius and brain hemorrhage. Tx is anti biotics early such as pcn and other like doxy or cipro