feel the burn case study quizlet

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Feel the Burn

Biochemical Testing and the Integumentary System

By Holly A. Basta, Sheela Vemu

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This PowerPoint-driven case study follows a young woman who acquires a third-degree burn and receives a skin graft. As the graft becomes inflamed and infected, students interpret results from diagnostic tests (gram stain, MSA plates, etc.) to diagnose a Staphylococcus infection. The patient is prescribed antibiotics, but the inflammation worsens; she develops an abscess, and acquires bacteremia. Students then interpret tests for antibiotic resistance (latex agglutination and disc diffusion tests) and diagnose the patient with a methicillin resistant Staphylococcus aureus (MRSA) infection. Students discuss in groups the appropriate treatment of MRSA infections and the mechanisms behind such treatments. The case is designed to integrate a broad range of anatomy topics (integumentary system, immunity, etc.) with microbiology themes (antibiotic resistance, culturing, etc.) and data interpretation. It is appropriate for use in undergraduate courses in medicine, anatomy and physiology, immunology, and microbiology.

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• Describe the structure and function of features of the epidermis, dermis and hypodermis.
• Describe the classification of burns and the types of skin grafts.
• Outline the process of tissue repair involved in normal healing of a superficial wound.
• Apply knowledge of bacteria and prokaryotic cells to real-world decisions on antibiotic usage.
• Analyze data and make appropriate conclusions.

Skin; burn; MRSA; healing; microbiology; inflammation; graft; integumentary; immunology; antibiotic resistance;

Subject Headings

EDUCATIONAL LEVEL

Undergraduate lower division, Undergraduate upper division, Professional (degree program), Clinical education

TOPICAL AREAS

TYPE/METHODS

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Materials & Media

Supplemental materials.

The following files are used with this case study.

• Diagnostic Laboratory 1
• Diagnostic Laboratory 2
• MRSA Information Sheet
• All files as one document

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Burn Injury Case Study (60 min)

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Mr. Travis is a 32 year old male who presents to the ED after sustaining severe 2nd and 3rd degree burns in a house fire.  The below diagram estimates his wounds. He weighs 85 kg and is 5’11”.

Using the Rule of Nines, estimate the Total Body Surface Area Burned (TBSA %).

• Half of the head/neck – 4.5%
• Top half of front torso – 9%
• Top half of back – 9%
• Full top half of right arm – 4.5%
• Full top half of left leg – 9%
• Half of front abdomen – 4.5%
• Half of lower back – 4.5%
• TOTAL – 45%

Calculate the total fluid volume required for resuscitation in the first 24 hours using the Parkland Burn Formula.

• 4 x 45% x 85 kg = 15,300 mL in 24 hours
• Give ½ in the first 8 hours = Start fluids at 956 mL/hr

What is the TOP nursing priority for Mr. Travis?

• Fluid resuscitation to prevent hypovolemic shock
• Mr. Travis’s vitals are: BP 90/48, HR 108, Temp 97.2, Pain 10/10.

You note circumferential burns around the Right Upper Arm and soot around the mouth with singed nose hairs, plus some facial swelling.

What are your main concerns for complication(s)?

• Airway due to possible/likely inhalation burns and airway swelling
• Compartment syndrome due to circumferential burns around right arm

Physiologically, explain the alterations in Mr. Travis’s vital signs.

• He is likely hypovolemic due to the loss of fluids from the burns, hence the low BP and high HR
• He is hypothermic because of his inability to regulate temperature due to skin loss

How will you know if fluid resuscitation is effective?

• Fluid resuscitation should be titrated to urine output of at least 0.5 mL/kg/hr or 30-50 mL/hr
• If excess urine output, slow fluids
• If not enough, speed up fluids
• Mr. Travis is intubated for airway protection and taken to the OR for surgical debridement of his burns. He is then transferred to the Burn ICU

What are priorities for daily care of Mr. Travis?

• Infection prevention and meticulous wound care – sterile dressing changes
• Pain control – PCA if able
• Manage ventilator and respiratory needs until able to be extubated
• Maintain temperature and hemodynamics

Mr. Travis will need skin grafts. How will you explain autologous skin grafts to Mr. Travis and his family?

• Autologous skin grafts are performed by taking a slice of healthy tissue from somewhere else on the patient’s body, for example, his right thigh that isn’t burned, and then running it through a meshing device.
• This allows it to be stretched over the wound and secured in place, then the skin will grow in around the graft.

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This nursing case study course is designed to help nursing students build critical thinking.  Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process.  To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy  to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs.  If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding.  In the end, that is what nursing case studies are all about – growing in your clinical judgement.

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Evaluation and Management of the Burn Patient: A Case Study and Review

Advances in the management of burn patients have contributed to significant improvements in morbidity and mortality over the last century. The physiologic insult from this injury pattern, however, still requires extensive surgical intervention, resuscitation and multidisciplinary care. This paper will review the standard of care of these patients in the context of a recent case study from our institution.

Introduction

In spite of a decreasing frequency of burn-related injuries in the 21 st century due to improved manufacturing production of commercial goods, thermal injury in the United States is still a major injury pattern. Over 200,000 patients in the United States alone were burned between 2005 and 2016, resulting in over 6000 deaths. 1 Mankind has been dealing with thermal injuries for thousands of years, yet “modern” burn care has evolved exponentially over the last 50–60 years. Advances in resuscitation, operative care and grafting techniques, infection prevention and treatment, and mitigation of hypermetabolism have all improved survival and recovery. In spite of these advances, however, questions and controversies regarding best practices are still prevalent, and numerous burn centers and laboratories across the United States continue to research various aspects of burn care, from the resuscitative phase to the reconstructive and recovery phase.

These advances in burn care have improved burn survival from a near 100% mortality seen with a burn size of 30% in the early 1900s, 2 to survival estimates over 50% in young, healthy patients with burn sizes up to 95%. 3 Nonetheless, the acute phase of resuscitation still generates significant controversy and is not a standardized process. One can query the resuscitation protocols of various burn units throughout the country and find many variations, from the usage of crystalloid-only formulae to adding colloid at various time points in the acute period, to the usage of “rescue therapies” and what they constitute and when to use them. While this review will not go into great detail of the variations, we will describe our initial burn evaluation, subsequent resuscitation, and overall management plan in caring for a seriously thermally-injured patient.

Case Presentation

A 58-year-old female patient was activated as a Level 1 trauma alert after being involved in a house explosion with resultant fire. She was awake and alert with no loss of consciousness at the scene but sustained significant thermal injuries per EMS report. She was intubated pre-hospital for “airway protection” out of concern for inhalation injury with facial burns. Initial evaluation revealed an older woman, orally intubated with bilateral breath sounds, mildly tachycardic in the 100s, moderately hypertensive in the 160s/90s, with readily apparent full-thickness burns to the face, neck, anterior torso, bilateral arms, and bilateral legs ( Photos 1 and 2 ). Secondary survey and imaging revealed no further injuries. At this juncture, it’s important to remember and remind the non-burn or trauma center practitioner that a thermally-injured patient is still a “trauma” patient. While a large, third degree burn certainly elicits a significant morbid response in many observers, spending significant time managing the burn wounds while neglecting potential internal hemorrhage will invariably lead to a delay in treatment and worse outcomes.

Patient Initial Burns

The patient was immediately taken to our specialized Burn Operating Room once other injuries were ruled out and both non- and -excisional debridement of her burn wounds occurred, with resultant wound dressing application. Her upper body burns were debrided and dressed with antimicrobial dressings. She then resuscitated for the next 48 hours, ultimately receiving approximately 3.3 mL/kg/%TBSA in the first 24 hours post-injury based on a TBSA of 63%, primarily full-thickness (third degree). Resuscitation continued over the first 48 hours, and the patient underwent serial excisional debridement and wound preparation procedures over the next few weeks. Given the size of her burns, we opted to utilize cultured epidermal autografts for assistance with skin/wound coverage. It is important to note that during the entirety of our patient’s two-month hospitalization she received attentive multidisciplinary care including efforts from nutrition services, therapy services, social work, as well as the nursing and physician teams. After continued local wound and graft care the patient was discharged on HD61 to a rehabilitation facility, where she stayed for approximately three weeks until discharge home, where she now lives independently and is continuing to improve.

Evaluating overall burn size can, likewise, be difficult to the untrained. While we expect that many in the medical field have heard of “the rule of 9s”, establishing the rule in practice is trickier. Many studies have evaluated overall accuracy of pre-burn center size estimates from both EMS and referring hospitals, many of which are incorrect. What is perhaps more troubling is that the inaccuracies run in both direction, i.e. overestimating burn size is as frequent as underestimating. The American Burn Association (ABA) has a list of Burn Center Referral Criteria as well as a helpful guide to the “Rule of 9s for public usage on their main website, reprinted in this summary ( Figure 1 ).

ABA Burn Referral Criteria

Historically, “burn surgery” consisted of reconstruction and scar release if the patient survived. Lieutenant Colonel C.P. Artz, in 1955, discussed “exposing” the burn wounds to air until eschar forms, “[i]n full-thickness burns there is dehydration of the pearly white or charred dead skin, and it is converted into a protective eschar....This eschar serves as a temporary physiological cover until liquefaction occurs beneath it in 14 to 21 days.” 4 It wasn’t until the 1970s that a Yugoslavian surgeon, Zora Janzekovic, described her experience tangentially excising deep partial- and full-thickness burn wounds in over 1,600 patients that “burn surgery” truly developed into a surgical subspecialty. 5 Most modern burn units excise deep-partial and full-thickness burn wounds “early,” typically 24–72 hours post-injury. In our experience, “early” means at or near admission, as burned tissue is a nidus of the inflammatory cascade that potentially leads to the “burn shock” phenomenon. 6

Fluid resuscitation of the thermally injured patient is, in many ways, the most important early aspect of burn care, and likely contributes most to overall improvement in burn survival. The need for fluid resuscitation was first recognized in modern times in the 1920s. A physiologist at Yale Hospital, Dr. Frank Underhill, while caring for 20 burn-injured patients, discovered upon evaluation of burn-blister fluid a composition quite similar to plasma. He correctly theorized that “burn shock,” or the hemodynamic instability that occurs after a major burn injury, was a hypovolemic state and that an intravascular volume-based treatment was necessary. 7 In 1942 the “Cocoanut Grove” nightclub, a popular, Pacific-Island themed club in Boston, Ma., caught fire. Drs. O. Cope and F. D. Moore cared for a majority of the patients between Boston City and Massachusetts General Hospitals, and in so doing helped codify the relationship between patient size and overall burn size as they related to fluid resuscitation. This resuscitation work was further advanced by C. Baxter and T. Shires at Parkland Hospital in Dallas, Texas, in the 1960s and 70s, ultimately leading to the Parkland™ formula, or 4mL/kg/%TBSA of Lactated Ringers solution, which is the most common burn resuscitation formula used in the United States. 8

Large body-surface area burns are typically very difficult to close in an expedited manner, primarily due to lack of donor site autograft to use. To combat this issue numerous tissue substitutes have been developed over the last several decades. C. P. Artz, described earlier, relates using “postmortem homografts,” “removed from the body of a deceased person under aseptic conditions soon after death…”. 4 In modern times, “postmortem homografts” are now standardly called allografts and are typically utilized in a cryopreserved rather than fresh fashion. These are nearly always temporary dressings meant for wound coverage and desiccation prevention. Concerns of disease transmission, skin supply, and expense make the use of allografts somewhat problematic. Bioengineered “skin substitutes” have been utilized in large body surface area burns for decades. The first, and perhaps most widely used is a bilaminar product called Integra.™ Developed in the 1980s, it combines bovine collagen and shark cartilage-derived chondroitin-6-sulfate, and allows for vascularization and formation of a neodermis when placed on full-thickness burns. The outer layer is a Silastic silicone-based material that acts like an epidermis and allows for protection of the fragile underlying collagenous material. Once the collagen is engrafted in a few weeks, it allows for placement of an ultra-thin split-thickness skin graft. Similar materials have been developed for use in burn care, including another bovine collagen product called Primatrix™ as well as a Hyaluronic acid derivative called Hyalomatrix.™ In very large burns with extremely limited donor sites, cultured “skin” has been utilized with great success at wound closure. Called Epicel,™ confluent sheets are grown into epidermis within two to three weeks from a sample of patients’ full-thickness skin sample by a company in Cambridge, Massachusetts. These sheets can then be implanted on a prepared wound and are FDA-approved for compassionate use in large burns. The end-result is a closed but imperfect wound as the thin epidermal layer offers little resistance to blistering or shearing. The expense associated with its usage is also considerable. An offshoot of “cultured” skin is a product commonly called “spray-on skin” in social media and by the public. ReCell™ is a real-time non-cultured skin graft alternative that is presently being evaluated by the FDA. By obtaining a small full-thickness skin sample, a clinician prepares a suspension containing basal keratinocytes using a proprietary kit in real-time that may be “sprayed” on an excised and prepared wound bed in an approximate 80:1 expansion, which is truly donor-site sparing. 9 Thus, on HD2 a 6 × 2 cm full-thickness skin sample from our patient was sent for growth of epidermal sheets which were implanted without complication approximately one month after injury.

Burn care is a true “team effort,” and, in fact, was likely the first “team-centered” surgical subspecialty developed after more than 500 people were killed and 3,000 injured in the “Texas City Disaster” in 1947, still considered to be America’s “worst industrial accident.” 10 The injured were cared for by Dr. T. Blocker and the University of Texas Hospital in Galveston, and during their convalescence were cared for by a team comprising nurses, physicians, therapists, nutritionists, and social workers to maximize outcomes. The team recognized the need for early nutrition, early mobilization, and aggressive wound care. These concepts are still followed today.

Care of the patient with a large body-surface area burn is complex, lengthy, and fraught with potential complications. These complications can be anticipated and minimized in burn centers accustomed to the complexities of major burn care; ultimately yielding improved survival and functional outcomes. The patient in this article, in spite of an anticipated initial mortality approaching 70% on admission, survived to discharge with only a few treatable complications, and is currently home, driving, and otherwise living independently. Her burn scars are being managed with outpatient scar exercises such as moisturization, massage, and compression. This positive outcome is the norm in burn centers, and an excellent example of why patients with major burn injuries should be cared for in these specialized centers. Any patient with a significant burn, even if not delineated on the ABA referral list, warrants discussion with a burn-trained surgical team.

Jeffrey S. Litt, DO, FACS, is Assistant Professor of Surgery, Burn Director, Division of Acute Care Surgery, Department of Surgery, University of Missouri School of Medicine, Columbia, Missouri.

Contact: ude.iruossim.htlaeh@sjttil

J. Litt received Acelity/KCI Speaker Honoraria.

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Burn Case Study

A kitchen grease fire ignites causing 2nd and 3rd degree burns in patient Anna Sites. 40,000 hospitalizations occur each year in the United States from burn related injuries (American Burn Association, 2013). In this case, we’ll explore the assessment, pathophysiology, and treatment of a major burn and subsequent shock.

Module 1: Burn

Anna Sites was cooking a meal for her boyfriend. She was frying bacon to add...

Burn - Page 1

Firefighters and paramedics arrived quickly on the scene. Emergency responders...

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The patient was started on an IV drip of 3-5 mg/10 minutes of morphine for pain...

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Lab tests were ordered including a CBC, chemistry panel, urinalysis, and carboxyhemoglobin...

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Seven days following Anna's admission to the burn unit...

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