Systemic Inflammatory Response Syndrome (SIRS) Criteria
- Temperature < 36C or > 38C
- Pulse > 90 beats per minute
- Respirations > 20/min or PCO2 < 32
- WBC < 4,000 or > 12,000 or 10% bands
- Subset of Cytokine Storm and Related to Sepsis
Types of Shock
- Hypovolemic
- Depleted Volume
- Cardiogenic
- Pump Failure
- Obstructive
- Indirect Pump Failure
- Distributive
- Lost Vascular Tone
- Neurogenic
- Anaphylactic
- Septic
Sepsis Assessment
- Systemic Infectious Process
- Fever
- Hypotension
- Change in LOC
- Increased WBC
- Shift to the Left
- Tachycardia
- Tachypnea
- Hyperglycemia
- Edema
Severe Sepsis and Septic Shock Assessment
- Microthrombi
- DIC
- Decreased Oxygen Saturation
- Decreased WBC
- Oliguria
- High Output Heart Failure
- Multiple Organ Failure
Types of Burns
- Superficial Thickness
- Sunburn
- Superficial Partial Thickness
- Blisters
- Blanching
- Deep Partial Thickness
- Little or Non-blanching
- Full Thickness
- Waxy White, Yellow or Black
- Decreased Pain
Rule of 9's for Burns
- Total Body Surface Area (TBSA)
- Head
- Chest
- Abdomen
- Upper Back
- Lower Back
- Posterior Leg (each)
- Anterior Leg (each)
- Each Arm
- Genitalia 1%
Burns Assessment
- Stage and Extent of Burn
- Dyspnea
- Singed Nasal Hairs
- Pain
- Initial Decrease Urinary Output
- Paralytic Ileus
- Signs of Inadequate Hydration
- Shock
- Hypothermia
- Hyperkalemia
Parkland Formula
- Burn victims
- 24 hours
- TBSA %
- x Weight (kg)
- x 4
- = Fluid Requirement (in first 24 hrs)
- 1/2 of fluid given in first 8 hours
Burns Interventions
- Ensure Airway Patency
- O2
- IV Fluid Replacement
- Dry Sterile Dressing
- Debridement
- Elevate Burned Limbs
- Analgesics
- Silver Sulfadiazine
- Escharotomy
Burns Considerations
- Maintain Body Temperature
- Increased Risk of Infection
- Venous Thromboembolism (VTE) Prophylaxis
- Curling's Ulcer
- Excision and Grafting
- Adequate Nutrition
- Contractures
Compartment Syndrome Assessment
- Trauma
- Increased Pressure
- Compressed Nerves and Blood Vessels
- 1 or more of 6 P's
- Ankle-Brachial Index (ABI)
- May take Days to develop
- Early Detection
- Ischemia
- Damage often Irreversible
Compartment Syndrome Interventions
- Frequent Neurovascular Assessments
- Evaluate Pain
- Do Not Elevate Extremity
- Remove or Loosen Restrictive Items
- Fasciotomy
- Amputation
- Infection
- Monitor Urine Output