Inhalation Injuries

There are four types of inhalation injury that most occurred: Smoke inhalation injury, carbon monoxide poisoning, smoke poisoning, and direct thermal heat injury.

Smoke Inhalation Injury
Smoke inhalation injury is occurred when the person is trapped in an enclosed, hot, smoke filled space. Patient with smoke inhalation might be have facial burns, erythema, swelling of oropharynx and nasopharynx, flaring nostrils, hoarse voice, stridor, wheezing, dyspnea, sooty (carbonaceous sputum), cough and tachycardia.


Carbon Monoxide Poisoning
Carbone monoxide is a colorless, practically odorless, and poisonous gas formed by the incomplete combustion of carbon; its toxic action is due to its strong affinity for hemoglobin, myoglobin, and the cytochromes, reducing oxygen transport and blocking oxygen utilization.
Oxygen molecules are displaced and carbon monoxide reversibly binds to hemoglobin to form carboxyhemoglobin that tissue will be hypoxia.

The signs and symptom of carbon monoxide poisoning are depended on the level of carbon monoxide in blood. It will be from impaired visual activity, headache, nausea, vomiting, dizziness, syncope, tachypnea, tachycardia, until coma or death.

Smoke Poisoning
Smoke poisoning is injury result when the victim inhales by-products of combustion. The localized inflammatory reaction occurs that causing a decrease in bronchial ciliary action and decrease in surfactant. The victim will have mucosal edema and wheezing.

Direct Thermal Heat Injury
Direct thermal heat injury can occur to the lower or upper airways by the inhalation of steam or explosive gases. Mucosal edema can lead to upper airway obstruction especially during the first 24 hours.

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Burn Injury Management

There are four phases of Burn Injury Management: Emergent phase, resuscitative phase, acute phase, and rehabilitative phase.

Emergent Phase

• It includes pre-hospital care and emergency room care and begins at the time of injury till the restoration of capillary permeability.
• Usually 48-72 hours following burn injury.
• The management is to prevent hypovolemic shock and preserve vital organ functioning.

Resuscitative Phase

• The resuscitative phase begins with the initiation of fluids until capillary integrity returns to normal level.
• Administration of fluid is based on the body weight and extent of injury, and the formulas are calculated from the time of injury and not from the time of arrival at the hospital.
• Management of this phase is to prevent shock by maintaining adequate circulating blood volume.

Acute Phase

• This phase begins when the victim is hemodynamically stable, capillary permeability is restored, and diuresis has begun and continues until wound closure is achieved.
• Usually 48-72 after the time of injury.
• Management of this phase focus on infection control, wound care, wound closure, nutritional support, pain management, and physical therapy.

Rehabilitation Phase

• This is final phase of burn management.
• It focuses that the patient can gain independence and achieve maximal function.

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Burn Injuries (Part 3)

Rule of Nines

This method is used in calculating body surface area involved in burns. Here are Rule of Nines (Adult):

• Head and nect: 9%
• Anterior trunk: 18%
• Posterior trunk: 18 %
• Arm (9% each): 18%
• Legs (9% each): 18%
• Perineum: 1%

We can estimate the body surface area on an adult that has been burned by using multiples of 9.
For example, if both legs (18% x 2 = 36%), anterior trunk (18%) and both of arm (18%) were burned, this would involve 72% of the body.

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Burn Injuries (part 2)

Types of Burn Injuries

There are four major types of burns: thermal burns, chemical burns, electrical burns, and radiation burns.

Thermal Burns
Thermal burns are caused by exposure to flames, hot liquids, steam or any hot objects.

Chemical Burns
Chemical Burns are caused by contact with strong acids, alkalis, or organic compounds.

Electrical Burns
Electrical burns are caused by an exogenous electric shock that passes through the body. Muscle and tissue damage will be occurred particularly in high-voltage electrical injuries. The voltage, type of current, contact site, and duration of contact are important to identify the quick action. Just to be remembered that alternating current is more dangerous than direct current because it associated with cardiopulmonary arrest, ventricular fibrillation, titanic muscle contraction and bone fracture.


Radiation Burns
Radiation burns are caused by exposure to ultraviolet light (sun exposure), x-rays, or a radioactive source. Sun exposure is the most common burn, specifically two wavelength of light UVA and UVB that may more dangerous.

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Burn Injuries (part 1)

A burn injury is a type of injury that may be caused by heat, cold, electricity, chemicals, light, radiation, or friction.

Burn Size:

1. Small burns: Localized burn to the injury area.
2. Large burns: Consist of 25% or more of the total body surface area, and the response is systemic means all of the major systems of the body is affected.

Burn Classification by Depth:

1. Superficial-thickness Burn
It is similar to first-degree burn. There is mild to severe erythema but no blisters. Burn is painfull, and is ceased by cooling. It heals in 3 -7 days.


2. Partial-thickness Superficial Burn
It is similar to second-degree burn. Large blisters cover an extensive area and edema is present. Mottled red base and broken epidermis with a wet, shiny, and weeping surface. Burn is painful and sensitive to cold air. Superficial partial thickness burn heals in 2-3 weeks while the deep partial thickness heals in 3-6 weeks. If the healing process is prolonged, the grafts may be used.

3. Full-thickness Burn
It is similar to third-degree burn. A deep red, black, white, yellow or brown area are present with edema. Burn causes tissue disruption with fat exposed and spontaneous healing will not occur. There is little or no pain of burn area. It requires removal of eschar and split or full thickness skin grafting. The healing will be weeks to months.

4. Deep Full-thickness Burn
It is similar to fourth-degree burn. It involves injury to the muscle and bone. The injured area appears black, no edema, no pain and no blisters. The eschar is hard and inelastic, and healing take weeks to months. Graft are required.

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Decubitus Ulcer

Decubitus ulcer is an impairment of skin integrity when staying in one position for too long without shifting weight. It is also called as bedsore or pressure ulcer. This case often happens when using wheelchair and bedridden. The common places for decubitus ulcer are over bony prominences such as the elbow, heels, hips, ankles, shoulders, back, and the back of the head.

The constant pressure against the skin can reduce the blood supply to that area and will affect tissue dies. It will start as reddened skin and will progressively worse to form a blister, open sore, and a crater. The important thing is to prevent of skin breakdown, particularly in caring or the bedridden or immobile patient.

There are factors that increase the risk for decubitus ulcer:

• elderly
• inability to move parts of body
• malnourishment
• bedridden or wheelchair patient
• chronic condition (diabetes or vascular disease)
• urinary or bowel incontinence
• fragile skin, and
• mental disability.

Stage of Decubitus Ulcers:

STAGE 1
Ulcer is a reddened area that returns to normal skin color after 15 to 20 minutes of pressure relief. The skin still intact and the red area does not blanch with external pressure.

STAGE 2
The top layer of skin is missing. The ulcer is shallow with a pink to red base and white or yellow eschar may be present.

STAGE 3
The ulcer extends into the dermis and subcutaneous tissues, white, gray or yellow eschar is present. Purulent drainage is common.

STAGE 4
The ulcer extends into muscle and bone, four smelling with brown or black eschar, and purulent drainage is common.

Care for Decubitus Ulcer:

• Prevent the position that promote pressure.
• Assess the nutritional status.
• Adequate nutritional intake to promote tissue integrity.
• Remove any pressure on the skin.
• Turn and preposition the bedridden patient every two hours or more if necessary.
• Active and passive exercises every 8 hours.
• Keep the skin clean and dry.
• Use moisture barrier if needed as prescribed.
• Use an alternating air pressure mattress or sheep skin padding.
• Wound dressing and medications as prescribed.

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Acne Vulgaris

Acne Vulgaris is a skin condition characterized by whiteheads, blackheads, and inflamed red pimples. And there are types of lesions include comedones, pustules, papules, and nodules. It requires active treatment for control until it resolves.

The exact cause is unknown but may include:

• Androgenic influence on sebaceous glands,
• Increased sebum production,
• Proliferation of propionibacterium acnes,
• Oil cosmetics and hair products,
• Drugs such as steroids, testosterone, estrogen, and phenytoin,
• Sweating and high level of humidity.
• The exacerbation of acne vulgaris is coincided with the menstrual cycle from hormonal activity.

Acne vulgaris is commonly appeared on the face and shoulders, trunk, arms, legs, and buttocks, and mostly in teenagers.

Cares for person with acne vulgaris are:

1. Topical or oral antibiotic as doctor prescribed.
2. Isotretinoin (Accutane) to inhibit sebum production and reduce sebaceous gland size.
3. Tell the client about the adverse effects of isotretinoin that include cheilitis (lip inflammation), skin dryness, triglycerides elevation, and eye discomfort.
4. Avoid taking vitamin A during treatment with isotretinoin
5. Appropriate skin cleansing methods (not scrubbing the face, using only the agreed on topical agents)
6. Not to squeeze, pick or prick at lesions.
7. Use cosmetics that are water-based and avoid contact with excessive oil-base products.

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Frostbite

Frostbite is local tissue destruction resulting from prolonged exposure to extreme cold. In mild cases, frostbite will result in superficial, reversible freezing followed by erythema and slight pain. In severe cases it can be numbness, paresthesia, painless and result in blistering, persistent edema and gangrene. Fingers, toes, nose and ears are the areas often affected.

Medical or nursing intervention of frostbite will include:

• Handle the tissue gently.
• Rewarm the affected area rapidly with a warm water bath (90o to 107o F) in 15 to 20 minutes or until the skin flushes.
• Avoid massage.
• Do not debride blisters.
• Apply bulky dressing as prescribed to provide protection.

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Impetigo

Impetigo is a contagious superficial pyoderma, caused by Staphylococcus aureus and/or group A streptococci, that begins with a superficial flaccid vesicle that ruptures and forms a thick yellowish crust, most commonly occurring in children.

The most common sites of infection are the face, around the mouth, the hands, the neck, and the extremities. The lesions begin as vesicles or pustules surrounded by edema and redness and progresses to an exudative and crusting stage. And after crusting, the initially serous vesicular fluid becomes cloudy and ruptures. It makes a honey-colored crust covering an ulcerated base.

Persons with impetigo will have specific signs:

1. Pruritus
2. Lesions
3. Burning
4. Lymph node involvement

How to care person with impetigo?

Here are the guidelines:

• Use standard precautions and implement agency specific isolation procedures in relation with impetigo.
• Let lesions to dry by air exposure.
• Daily bathing with antibacterial soap such as pHisoHex.
• Warm compresses to lesions 2 or 3 times per day to remove crusts and healing.
• Oral antibiotic for impetigo as prescribed.
• Use emollients to prevent skin cracking.
• Frequent hand washing when caring person with impetigo, to prevent the spread of infection.
• Use separate towels, linens, and dishes.
• All linens and clothing should be washed separately with detergent in hot water.

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