Download 2. Lectures prof. BI Dmitriev from Odessa State Medical University.

MINISTRY OF PUBLIC HEALTH OF UKRAINE
BUKOVINIAN STATE MEDICAL UNIVERSITY
APPROVED
on the cathedral meeting of the
Department of patient care and higher nurse education
"______"___________________200___.
minute № ____
Head of department
Associate professor
Plesh I.A.
METHODICAL GUIDELINES
for 3 – year students of the medical faculty
rd
MODULE 2
THE MAIN DUTIES AND PROFESSIONAL SKILLS OF NURSE
AT THE SURGICAL DEPARTMENT
SEMANTIC MODULE 2
TRAUMATISM AND DAMAGE.
DESMURGY.
Topic:
Burns and frostbites
Subject: Nursing practice
3rd-year students of Medical faculty
Speciality: "General medicine" – 7.110101
7.110104 – "Pediatrics"
Duration - 2 hours
Methodical guidelines composed by:
Professor R.I. Sydorchuk
Assoc. professor O.Y. Khomko
Assistant R.P. Knut
Chernivtsi – 2008
AIM: To determine the basic clinical, laboratory attributes of disease; to acquire
algorithm and principles of diagnostics, treatment of burns and frostbites.
PROFESSIONAL MOTIVATION: Damage with temperature remains an
important problem of modern surgery. Burns take the third place in general
structure of traumatism. Hard damages are accompanied with high lethality and
percent. The treatment of these patients require a lot of efforts and money.
Frostbites are the results of influence of low temperature on tissues. Predominantly
suffer the asocial elements. Deep frostbites sometimes can cause the death of the
patient due to adding of pneumonia and meningitis. The damage with electricity
can threaten the human life, electric burns occur due to electric trauma.
BASIC LEVEL:
Burns and Frostbites
Bums are caused by the action of heat (flame, sun, hot liquid, contact with
hot metal, etc.), caustics, alkalis and certain drugs (silver nitrate, iodine tincture) on
the body.
Characteristics of First-, Second-, and Third-Degree Burns
First' degree - exposure to sunlight or minor flash, red color, surface dry or
small-to moderate-sized blisters, sensation-painful, healing - 3 -6 days.
Second degree-limited exposure to hot liquid, flash, flame, or chemical
agent. Colour pink or mottled red, surface- bullae or moist, weeping surface,
painful (deep second - degree burns may be anaesthetic to pinprick with intact
pressure sensation, healing 10-21 days-superficial second degree, more then 21
days-deep second degree.
Third degree - prolonged exposure to flame, hot object, or chemical agent.
Contact with high-voltage electricity. The colour is pearly white, charred,
translucent, or parchment-like. Deeply tanned-strong acid burns. Dark red-in
young children. Surface dry, with thrombosis of superficial vessels. Focal tissue
loss - high-voltage electrical injury. Sensation is absent. Requires grafting.
Other variant classification degrees of burns. Four degrees of burns are
distinguished.
The first degree, the weakest burn, is characterised by an inflammatory
process accompanied by local dilation of the blood vessels and slight serous
impregnation of the tissues. The skin develops a redness and swelling and becomes
painful. After 2 - 3 days of treatment everything returns to normal and only a dark
spot (pigmentation) on the burned part remains.
In second degree burns the inflammatory process produces a serous
exudation which comes to the foreground and fosters formation of blisters with a
serous or jelly-like content on the surface of the reddened and swollen skin. When
a blister bursts, it reveals a bright-red, painful, easily vulnerable epithelial layer of
the skin tending toward infection. If the burn is not infected, the content of the
blisters is resorbed or they burst and dry up within 4 - 5 days. The epidermis is
restored from the edges, as well as from the depth. For some time afterwards the
skin is pink, delicate and quite vulnerable, but subsequently it resumes its normal
appearance and properties. No cicatrices are formed.
Second degree burns are often aggravated by infection. In some cases
healing is retarded, the content of the blisters assumes a purulent appearance, the
blisters burst, granulations appear on the bare surface of the epidermis and after
healing a whitish or dark superficial cicatrix may remain.
In third degree bums, a crust is formed on the burned surface because of
coagulation of proteins and destruction of tissues. The destruction of tissues may
cause circulatory disorders and obctrution of the blood vessels of the skin. In such
burns the superficial layers of the skin usually peel off and hang in tatters. Healing
trites a long time. After disengagement of the necrotic parts granulations begin to
form on the new wound. Granulation takes from several weeks to several months
(in extensive burns). In cases of infection ichorous or purulent complications,
general exhaustion, etc. are possible.
After disengagement of the necrotic tissues epithelisation begins from the
edges of the wound and not infrequently forms large cicatrices which contract the
surrounding tissues, sometimes making it partly or completely impossible to use
the burned pail, especially if the cicatrices are located in the region of the joints
(Fig. 156) and on the neck. Vast burns may not heal completely, in which cases
skin has to be transplanted to cover up such granulating surfaces.
A fourth degree burn - charring of the tissues under the direct effect of flame
or eiectric current - is also distinguished.
If the injuries from a burn are very extensive or penetrate deep into the
tissues, they are dangerous to life. Burns involving one-third of the body surface,
whatever their degree, are usually followed by grave disorders which not
infrequently lead to death. Burns of half the surface of the body are almost always
fatal. Burns are particularly dangerous for children, since they may end fatally
even if they are not so extensive.
General changes in the body may develop immediately after the burn has
been sustained, owing to stimulation of the nerve endings and reaction of the
nervous system (shock) and subsequently (affection of the internal organs - blood,
kidneys, central nervous system) as a result of absorption of the toxic products of
decomposition from the burned tissues.
Noninfectious toxicosis appeal's within 12-72 hours. Excitement or clouded
consciousness and then complete loss of consciousness, vomiting, convulsive
muscle twitching, pyrexia, rapid pulse, cyanosis, icterus and oliguria are
characteristic of non-infectious toxicosis.
Infectious toxicosis develops in cases of infection of the burned surface and
is accompanied by pyrexia with considerable fluctuations (higher temperature in
the evening), and changes in the blood (leukocytosis and increasing anemia). The
patient's condition is aggravated by complications (erysipeals, pneumonia, etc.).
Treatment. First-aid to the burned at the place of accident consists in
prevention ofshock; the victim is administered morphine, kept warm and given hot
drinks. The burned part is covered with a sterile sheet or an aseptic bandage. The
patient is covered up warmly and is rapidly and carefully delivered to a medical
institution (in short time - to the closest casualty-clearing station), where he is
administered antitetanic serum.
Patients with first degree burns and those with no marked intoxication and
only small burned areas, as well as those with second and third degree burns
(except burns of the eyes, perineum, genital organs and feet) are subject to
ambulatory treatment. All the other burns are treated in hospitals.
If large numbers of burned patients are admitted to a medical institution,
they must be assorted according to the urgency and sequence in which they are to
he administered aid.
The victims to be administered urgent aid are those who are in a state of
shock or have considerable burned areas and may develop shock.
Firstaid in bums is aimed at terminating as swiftly as possible the action of
heat and al protecting the site of the burn from infection and trauma. The injured
must be brought out of the heat zone and his burning clothing must be extinguished
either with water or a stream of foam from a fire extinguisher. If such measures are
impossible, the injured must be wrapped in a blanket, overcoat, rug, etc. The
clothing soaked in kerosene, benzine or napalm must be extinguished only by this
method.
Extinction with sand or earth is contraindicated because it infects the burn.
With his clothing on fire the patient must lie down rather than move about.
After extinction of the flame, water must be poured on the smouldering parts of the
clothing and the latter must be removed. Drops of napalm must not be spread or
removed with an unprotected hand. The burning part must be completely immersed
in water or compressed with the clothing.
Recurrent combustion of napalm which contains phosphorus is prevented by
moist bandages soaked in a 5 % blue vitriol solution. The clothing covered with
napalm or saturated in hot liquid must be quickly removed without injuring the
burned parts. The clothing adhering to the surface of the burn must not be torn off
but rather cut away without touching the surface of the burn.
Administration of pantopon is desirable before removal of the clothing and
application of the first dressing. It is desirable soon (during the first minutes after
the burn has been sustained). To immerse the burned part in cold water or pour
water from the top over it for several minutes, or treat it with alcohol (toilet water
alcoholic liquor). In burns caused by caustics the affected surface should be
washed with large amounts of water. In burns produced by quicklime no water
must be used; in these cases the burned surface of the body must be covered with
an oil. In burns made by acids, alkaline solutions (soda, calcium or soapy water)
are used or the affected part is powdered with chaik, magnesium or tooth powder.
In burns caused by alkalis weak acid solutions (acetic, citric, etc.) are used. The
victims of burns experience unendurable suffering and, to alleviate the pain in first
degree burns moist dressings containing a potassium permanganate solution, lead
water or other solutions are applied to the burned surface.
In the emergency room, a large - caliber intravenous cannula should be
placed and fluid infusion begun using a balanced salt solution. As far as possible, a
history should be obtained, with emphasis on determining the circumstances of the
injury, the presence of pre-existing disease, and medications taken prior to injury.
Fluid needs are then estimated based on extent of burn and body weight, and
the fluid infusion is adjusted accordingly with accurate recording of the volume
and type of all administered fluids. The ventilatory status should again be assessed
in terms of the need for endotracheal intubation, the need for oxygen
administration, and the need for mechanical ventilatory assistans. A urethral
catheter should be placed in all patiens requiring intravenous fluid therapy and the
hourly urinary output measured and recorded. ECG monitoring is continued for at
least 48 hours in all patients with high-voltage electrical injury, and if such patients
manifest cardiac irregularity, the monitoring should be continued for 48 hours
beyond the last episode of arrhythmia.
The burned areas should be cleansed gently using a surgical soap or
detergent, following which loose nonviable skin should be debrided. Bullae that
are less than 2 cm in diameter can be left intact, but larger bullae cvMwuowty
vuptuve, are easily u\ tec ted, &&< $ should be excised. The 'palm' rule is based on
that ihe area of the patient's palm makes approximately 1% of his total skin area.
The essence of "nines" rule lies in the fact that the total skin area is divided into
parts divisible by 9. Thorax and abdomen make 18 % of the total skin area, lower
extre-mities - in 18 %, upper extremities - in 9 %, head and neck - 9 %, perineum 1 %.
Average quantity of total area of human body is taken as 16.000 cm2.
During this disease distinguish periods of burn shock, acute bum toxaemia,
burn septicotoxaemia and convalescence.
Burn shock. It develops due to the irritation of a great number of nerve
elements of a vast area of lesion and more complicated the shock takes its course.
In burns with more than 50 % of body surface, shock is observed in all the victims
and is the main cause of death. In burn shock a prolonged erectile phase is
observed. For the development and course of shock, besides the flow of very
powerful neuroreflex impulses i'rom the burn area into the central nervous system,
a large loss of plasma (particularly marked in vast burns of the 2nd degree), and
also toxemia with the products of tissue disintegration are of a great importance.
Toxaemia. It begins from the first hours after the burn, gradually increases
and after the way out of shock determines the condition of a victim in future. In the
development of toxaemia an absorption of products of tissue and toxins
disintegration from the burn area plays its part. In its development hypochloremia,
hypoproteinemia, disturbances of metabolism are of importance.
Infection. In the development of infection on the burnt surface appear septic
effects (septic phase of the disease), body temperature increases, chills appear,
leucocytosis and neutrophilia increase, anaemia develops, etc.
Metabolism disturbances are characterised by dehydration, acidosis,
hypochloraemia, disturbance of oxidizing processes.
Marked disturbances are observed in the blood composition: haemoglobin
level increases, a number of erythrocytes averages to 7 – l0xl012/L and leucocytes 30 - 35xl09/L.
Local changes of tissues in burns develop as follows: under the influence of
traumatising agent hyperaemia develops. It leads to the inflammatory exudation of
tissues development of oedema. Some tissues die due to the proper effect of high
temperature and due to the disturbance of blood circulation. Squeezing with an
inflammatory exudation and effect of tissue disintegration produced on nerve
formations are accompanied by clearly marked painful syndrome. In burns of the
1st degree blood circulation disturbances and inflammatory exudation soon
disappear, oedema decreases, pains disappear and the process eliminates. If burns
of the 2nd degree are not infected exudation absorbs, the surface of the burn is
covered by epithelium and in 14 -16 days recovery is observed. In infected burns
of the 2nd degree granulations are formed. They are gradually covered by
epithelium.
In burns of the 3rd degree all the thickness of the skin, and sometimes
deeper lying tissues become necrosed. These burns are healed by the second
intention. At first a rejection of dead tissues takes place and then follows filling of
defect by granulations with formation of vast cicatrix, which often limit
movements (cicatricial contractures) and are easily traumatised, resulting in the
formation of ulcers.
Treatment of burns may be divided into 4 groups:
a) closed;
b) open;
c) mixed;
d) operative.
Choice of method of treatment is determined by the heaviness of burn, time
passed from the moment of trauma, character of primary treatment and
surroundings in which treatment will be carried out. •
The open method is used for extensive burns in children, burns on the face,
perineum and buttocks of adults, and in cases of infection.
The patient is placed on sterile linens, the region of the burn is left opened
and a grid covered with a sterile sheet and a blanket on top of the sheet is placed
over the bed (Fig-1). If there is no grid, the sheet may be placed on strips of
bandage stretched over the bed. Electric bulbs are fastened to grid under the sheet
to keep the patient warm. The toilet of the wound is made, every day.
Fig.1. Open treatment of burn
Surgical treatment is administered at different periods in the course of third
and fourth degree burns: this consists in primary dermatoplasty during the first day
after excision of limited parts of the burn and delayed early dermatoplasty between
the 7th and 24th day, involving excision of necrotic layers and replacement of the
defect with skin flaps taken from healthy parts of the body. In cases of very
extensive burns the skin for transplantation is taken from volunteer donors or from
corpses. Lastly, weeks and even months after the burn has been sustained, large
granulating surfaces, is well as cicatrices, may be subjected to surgical treatment
(delayed late dermatoplasty).
Frostbite (congelation) results from prolonged action of extreme cold,
although it is sometimes produced even at a temperature of about 0° or somewhat
higher. The changes in the tissues during frostbite are due mainly to thrombosis of
the vessels and subsequent disturbance in blood circulation.
The skin is pale, cold and sometimes hard (congealed), and its sensitivity is
diminished.
In first degree frostbite the vessels sharply contract (spasm), the skin
becomes pale and insensitive, and after warming bluish-red, painful and
oedemalous. First degree frostbite lasts only a few days, but sensitivity to cold and
sometimes a bluish colouration of the skin persists.
In second degree frostbite blisters with a serous or turbid content appear on
the footgear are factors predisposing to frost bite.
The degree of frostbite is established only during development of reactive
phenomena, sometimes within several days after the effect of the cold. During the
first, latent period of frostbite, in all its degrees, affected part, the skin around it
becoming bluish-red. ,In this case blood circulation is impaired and the exuding
fluid raises the epidermis in the form of blisters.
In third degree frostbite the affected tissues become hard to touch and, when
carelessly handled, fragile. After warming-up, the blood circulation is deeply
disturbed and nutrition of the tissues is affected by occlusion of blood vessels.
Disturbances in tissue nutrition are sometimes discovered only within a few days,
whereas in the beginning the frostbitten part presents the same appearance as in
second degree frostbite (it is blue-brown and covered with blisters and crusts) and
the soft tissues necrotise. Healthy and vigorous people can withstand cold longer
than weak, emaciated and anaemic people. The tips of the fingers and toes, cheeks
and tip of the nose are the parts most frequently affected. Four degrees of frostbite
are distinguished.
In fourth degree frostbite all soft tissues and bones necrotise, and gangrene,
often moist, develops; demarcation and healing proceed slowly. Frostbite is not
infrequently accompanied by tetanus.
In frostbite of the lower extremity it is first necessary to remove the
footgear, which has to be done carefully to avoid injury to the extremity. If the
footgear has congealed, it is best to cut it open.
Firstaid in frostbite consists primarily in restoration of the blood circulation.
Massaging the frostbitten part with the hand wearing a sterile glove is
recommended. The massage must be delicate and may be administered more
vigorously only after signs of restoration of the blood circulation have appeared.
No rubbing down with snow or massaging with dirty hands are allowed.
It is best to rub down the skin at first with a piece of cotton soaked in alcohol
and then with a piece of dry cotton. It is recommended to warm up the frostbitten
extremities in a bath the temperature of which is raised from 18°C to 37°C over a
period of 20 - 30 minutes. The extremity should simultaneously be washed with
soap and water to be cleaned from contamination.
If the patient applies for aid already during the stage of reactive phenomena,
firstaid will consist in treatment of the skin in the region of frostbite with alcohol
and application of a sterile gauze and cotton dressing.
The patient must be kept warm, protected against repeated exposure to cold
and given a prophylactic injection of antitetanic serum.
To protect the patient against infection in second, third and fourth degree
frostbite, dry aseptic warming bandages are applied, the blisters are lanced and the
disengaged epidermis is removed; during all these proceedures the rules of asepsis
must be strictly observed. In third and fourth degree frostbite the blisters are
removed and the tissues affected with gangrene are painted with iodine tincture.
To improve the blood cirulation, a novocain block is produced. To dry the
tissues in the region of necrosis, the affected parts are subjected to irradiation by a
sun lamp and ultra-high frequency current, and are kept in the open air (dry air
baths). To alleviate pain, narcotics and dry air baths are employed; to improve the
blood circulation, the affected extremities are raised (suspended), in fourth degree
frostbite the necrotic tissues on the limbs are dissected (necrotomy) or excised
(necroectomy). As soon as the line of demarcation is established and the blood
circulation in the surrounding tissues has improved, the frostbitten organ is
amputated. In these cases the wound resulting from amputation not infrequently
heals slowly because of sluggish granulation.
Electric Shock. Extensive utilisation of electricity in industry and agriculture
raises the important question of preventing and treating electric shock. Passing
through the body, high voltage electric currents cause local and general injuries. It
is impossible precisely to set the dangerous limit of current tension because it
varies with many factors, for example, the humidity of the body. At any rate, a
current above 100 V. is dangerous and above 500V. almost always fatal.
Firstaid in electric shock and in injury by lightning must srart by
disassociating the subject from the source of current or putting the victim to the
ground, must vary with the condition. In cases of cardiac and respiratory arrest,
measures to revieve the patient must be taken during the very first minutes.
The first thing to do in such cases is to administer artificial respiration.
According to literature, there were cases in which a clinical picture of death caused
by electric shock seemed to be established and yet the patients were returned to
life.
The most efficient and widespread method of artificial respiration must not
be used. If the ribs are injured, only pulling of the tongue should be resorted to.
Artificial respiration must be administered continuously and for a
long period of time. It is most appropriately administered with the aid of a
special apparatus resembling bellows developed by V. Negovsky; this apparatus
blows air into the lungs.
Simultaneously with administering artificial respiration it is necessary to
keep the victim warm, rub him down (preferably with pieces of cloth) and give him
to smell ammonia water.
In addition to artificial respiration during apparent death, it is necessary to
administer cardiac massage. To do this, the person administering aid places a hand
on the region of the victim's heart with fingers pointed towards the head. With
palm of the hand he effects 20 -30 vigorous pushes against the part of the chest
located under his hand.
Under hospital conditions the fibrillation of the heart muscle may be
discontinued and the heart restored to normal activity by a single discharge of
electric current from a special device (defibrillator condenser), with a simultaneous
imra-arterial blood transfusion.
It is also necessary immediately to protect the site of the burn against
infection; as in the other eases of burn, it is necessary to apply an aseptic-dressing
with alcohol, a 4 % potassium permangnale solution, rivanol, streptocid emulsion,
etc.
The general measures include administration of glucose and large amounts
of fluid, inspiration of oxygen, etc. Treatment of bums produced by electric shock
is usually the same as it is in other burns.
In electric shock patients require close watching and thorough care owing to
the possibility of sudden death and considerable spread of necrosis in the region of
affection.
STUDENTS’ INDEPENDENT STUDY PROGRAM
I.
Objectives for Students’ Independent Studies
You should prepare for the practical class using the existing textbooks and
lectures. Special attention should be paid to the following:
1. To learn an ethiology, a pathogenesis and kinds of burns
2. A clinical picture, first aid and principles of treatment of burns.
3. An ethiology, a pathogenesis of frostbites.
II.
Tests and Assignments for Self – assessment
Multiple Choices.
Choose the correct answer/statement:
1. The square of the adult's hand is …% of body surface:
A. 1-1,1
B. 0,4-0,6
C. 2-2,1
D. 3-3,1
E. 4-4,1
2. For the local symptoms of the I degree burn is characteristic everything
accept:
A. Hyperesthesia;
B. Hyperthermia;
C. Pain;
D. Hyperaemia;
E. Edema;
3. For the local symptoms of the II degree burn is characteristic everything
accept:
A. Hyperesthesia;
B. Hyperthermia;
C. Pain;
D. Hyperaemia;
E. Edema;
4. Burns' disease occur in adults due to superficial burns with the square more
than:
A. 25-30%;
B. 5%;
C. 10%;
D. 15%;
E. 20%;
5. Burns' disease occur in adults due to superficial burns with the square more
than:
A. 10%;
B. 3%;
C. 5%;
D. 15%;
E. 25%;
Real-life situations to be solved:
6. A 2 years old child 60 minutes ago poured out on herself a pan of boiling
water. Pale, screaming, trembling, acrocianosis, one-time vomiting.
Hyperemia on the anterior body surface and upper extremities with the
scraps of epidermis.
Your diagnosis and tactics?
7. To the reception was transported an injured person from the place of fire.
The consciousness is shadowed, face and hands smoked, the hair in the nose
is burnt. The breath is superficial, periodical cough, phlegm with additives
of soot
Your diagnosis and tactics?
III.
Answers to the Self-Assessment:
1. A;
2. A;
3. A;
4. A;
5. A;
6. Burns' shock. It's necessary to inject the pain-relief preparations, heat the
patient, apply the aseptic bandage with Novocaine, transport to specialized
medical institution.
7. Burns with a flame of face and hands. Burns of the air ways. Patient
requires hospitalization to the intensive care unit.
IV.
References:
Essential reading:
1. Gostishchev V.K. General surgery /The manual. – M.: GEOTAR-MED,
2003. – 220p.
2. Lectures prof. B.I. Dmitriev from Odessa State Medical University.
3. Surgery: Text-book for English medium medical students / S.I.
Shevchenko, O.A. Tonkoglas, I.M. Lodyana, R.S. Shevchenko. –
Kharkiv: KSMU, 2001. – 344p.
4. Kushnir R. Ya. General surgery /Lectures.- Ternopil, Ukrmedknyha,
2005.- 308 p.
5. Butyrsky A. General surgery /The manual.- Simpheropol: publishers
CGMU, 2004.- 478 p.
Further reading:
1. Oxford handbook of clinical surgery / Edited by G.R. Mc Latchie, D.J.
Leaper, 2002.- 930 p.
2. Clinical Nursing Skills and Techniques: basic, intermediate and
advanced. The C.V. Mosby Company, 1986.- 1296 p.
Students’ Practical Activities:
V.
 Work 1. To make the individual circuit of diagnostic search, to analyse
results of objective research. To determine a role and a place of laboratory
and instrumental diagnostics in formation of the diagnosis.

Work 2. To plan and prove the plan of individual treatment;
 Work 3. To carry out interpreting the clinical, laboratory and instrumental
data of the supervised patient. To prove his clinical diagnosis and
treatment.
VI.
Seminar Discussion Of Theoretical Questions And Practical Work:
VII. The initial level of knowledge and skills is checked by the decision of
situational problems (tasks) from each theme, answers to tests such as
"Step", constructive questions etc.
Students must know:
 Definition of term "burns";
 Main ethiologic factors of burns appearance;
 Classification of thermal burns;
 Methods of determination of square and depth of thermal damage;
 Appropriateness of burns' disease flow;
 Clinical signs of burns' shock;
 Clinical signs of acute burns' toxemia;
 Clinical signs of burns' septicotoxemia;
 General principles of burns' disease treatment;
 Methods of local treatment of burns;
 Ethiologic factors of frostbites' appearance;
 Classifications of frostbites;
 Clinical pictures of frostbites and prereactive and reactive period;
 General principles of frostbites' treatment;
 Peculiarities of the electricity's influence on the organism;
 Clinical signs of electricity trauma;
 First aid in electricity damage.
Students should be able to:
 To determine the square of burns;
 To determine the depth of burns;
 To determine the hardness of the thermal damage;
 To determine the signs of burns' shock;
 To prescribe the rational infusion and transfusion therapy to a patient with
the burns' shock;
 To choose the optimal method of local treatment of burns;
 To provide a first aid to patient with the frostbite;
 To chose the tactics of treatment dependently from the period of disease;
 To provide a first in electricity damage.