33

Background

Brad is 32 year old male. He was cooking methamphetamine in his kitchen when the substance caught on fire at 2300. The entire house was engulfed in flames when the fire department arrived on scene. The neighbor called 911 when he smelt smoke. Brad was found unconscious by the firefighters and was pulled out. He was stabilized on scene and was rushed to West Hills ED via ambulance. While enroute, the paramedics started an 18 gauge IV in the right C and had Brad on 100% O2 non-rebreather. Paramedics alerted ED of an estimated ETA of 5 minutes. Upon arrival at the ED, Brad was found to have stage 3 burn wounds on his anterior and posterior torso and entire left arm with stage 2 burns on his anterior neck. Brad was at risk for smoke inhalation and a compromised airway, so RT intubated him and fluid resuscitation was initiated.

En Route to Emergency Department

Paramedics alerted the emergency department of incoming arrival at 2350 and gave an estimated time of arrival of 10 minutes. Vital signs were as follows: blood pressure of 92/58, heart rate of 112, oxygen saturation of 91% respiratory rate of 22, and a temperature of 97.4°F. During transportation an 18 gauge IV was started in right AC and 1 liter of Lactated Ringers (LR) was administered. A non-rebrether O2 applied on 100% and 15 L to achieve a saturation of 93%. HIs reported weight in the ED was 75 kg, and a body surface area of 2.0 m2.

Emergency Department Assessment Findings

Per the advanced trauma assessment, using the ABCDE format, the following was noted at 0000:

• Airway- Brad’s airway is compromised and RT placed an endotracheal tube
• Breathing- Crackles were heard bilateral upon auscultation
• Circulation- Thready pulses in all four extremities
• Disability- Brad was unable to move left arm and upper body. His neck was beings stabilized until cervical injury was ruled out
• Examine – associated injuries and maintain warm environment- Nurse increased ED room temperature to 90°F

Further Assessment of Brad Revealed the following findings and interventions:

• Rule of Nines: 27% of Brad’s body was burnt (anterior and posterior torso, entire left arm, and anterior neck)
• Fluid Resuscitation: administration of LR
• Pain Medication – 1 mg IV dilaudid for pain
• Initial Labs – Pending (drew CBC, chem panel, lactic, toxicology screen [also got a urinalysis])
• Ruled out cervical spine injury
• Additional nursing Interventions that occurred in the ED were the placement of a second IV – a 20 gauge in right foot, a second liter of LR was hung, and a foley catheter was inserted

Burn ICU

Brad was transferred to the Burn Intensive Care Unit (BICU) at 0030, where fluid resuscitation was continued. At this time Brad had already received 2 bags of LR. The formula used to determine the total fluid is as follows:

(1,500 mL/m2) + [(25 + % TBSA burned) x (m2 x 24)] = total maintenance fluid (mL) to be given over 24 hours. (1,500 mL/2.0) + [(25 + 27% TBSA) x (2.0 x 24) = (750) + [52 x 48] +750 +  2,496 = 3,246 mL to be given over 24 hours for fluid resuscitation at a rate of 270.5 mL/hr.

Urine output is the gold standard for monitoring fluid resuscitation. An adult male should have an output of 0.5-1.0 mL/kg/hr. Brad is 75 kg; this would equate to 0.5-1.0 mL/75/hr = 37.5-75 mL/hr of urine output. Urine output during first hour in the BICU was 20 mL/hr. HR was 130 bpm, BP 96/60, and labs related to fluid resuscitation status are: elevated lactate of 3 mmol/L, and K of 5.5. These signs and symptoms indicated the need for increased fluid resuscitation. After increasing the hourly rate of the Lactated Ringer’s infusion, urine output during 3rd and 4th hour increased to 60 mL/hr, HR lowered to 90 bpm, an BP stabilized to 124/86. Further care in the BICU included burn dressings for coverage until surgical interventions, hourly vital signs, and continuous pain management via a morphine drip. Inhalation injury was ruled out after a bronchoscopy was performed. Signs of respiratory distress (increased RR, tachycardia, wheezing/hoarseness, increased work of breathing) were continuously monitored. An NG tube was placed to suction to prevent aspiration.

Operating Room

Due to the severity of Brad’s burns, he was taken on the OR at 0500 for a debridement of and allograft placement on the stage 3 burns of his torso and arm. Brad returned to the OR multiple times during his admission for additional phases of allograft placement. Eventually he was a candidate for autograft placement. Skin from both inner thighs was used for grafting on his torso and left arm.

Burn Unit

Brad was admitted to the burn unit at 0700 post surgery, and remained a patient on the burn unit for 4 weeks. Goals of his stay included monitoring vital signs, preventing infection, pain management, wound care, adequate nutrition, physical therapy, and psychosocial support.

Discharge Plans / Case Management

Brad is a candidate for various types of case management referral due to his drug addiction, recent housing loss, burn PTSD, body image issues, follow-up wound care therapy, and need for pressure garments. Maslow’s Hierarchy of Needs addresses multiple needs that Brad has presented: physiological, esteem, and self-actualization needs. Before discharge, the nurse will make sure Brad is aware of the medications he will be taken, how often and what times. The nurse will also explain the importance of a well-balanced diet and maintaining physical activity to avoid joint stiffness and muscle loss. The nurse will also show how to perform proper wound care and make sure Brad is able to perform the tasks on his own. The nurse will collaborate with case management to make sure Brad has compression garments in order to treat scars. Lastly, the nurse will assure that Brad has his follow-up appointments arranged.

Three Open-Ended Questions

1.During the initial fluid resuscitation for Brad’s burn, lactated ringers was the fluid of choice to be infused. Why would the nurse choose lactated ringers a the preferred fluid of administration?

2. A nurse is assessing a burn patient that came to the burn ICU. What total body surface area needs to be burnt in order to administer fluid resuscitation?

3. Brad experienced a variety of complex complications after his burn injury. He suffered physiological issues with the burns and psychological referrals Brad would need?

Reference

Perin, K.O. & Macleod, C.E. (2018). Understanding the Essentials of Critical care nursing. Boston: Pearson

Answer Key

Question 1: Lactated Ringer’s solution is the fluid of choice for burn resuscitation because it is slightly hypotonic, treating both intravascular volume losses and extracellular sodium losses.

Question 2: 20 % total body surface area.

Question 3: Psychosocial, occupational therapy, physical therapy, housing assistance, drug rehabilitation.