Transcript
Felicia Hudson Case Study 2 9/10/14 Chief Complaint: 8-year-old girl admitted for severe second- and third-degree burns following her rescue from a burning house. History: Angela Creighton, an 8-year-old white female, was transported by ambulance to the emergency room after being rescued from her burning house. She was asleep at night when a spark from the family fireplace started a fire, leaving her trapped in her bedroom. By the time the fire rescue squad arrived, she had suffered severe burns and excessive smoke inhalation. In the emergency room, Angela was unconscious. She had second-degree burns over 5% of her body and third-degree burns over 15% of her body -- both covering her thoracic and abdominal regions and her right elbow. Her vital signs were quite unstable: blood pressure = 55 / 35; heart rate = 210 beats / min.; and respiratory rate = 40 breaths / min. She was quickly deteriorating from circulatory failure. Two IVs were inserted and fluids were administered through each. Her vital signs stabilized and she was transported to the pediatric intensive care unit (ICU). Angela regained consciousness the following morning, surprisingly complaining of only minor pain over her trunk. Following debridement of her burns and application of a broad-spectrum, topical antibiotic, a plastic epidermal graft was applied over the burned areas. Despite treatment with a broad-spectrum antibiotic, she developed a systemic staphylococcal infection, necessitating a switch to a different antibiotic. Angela began a long, slow recovery. Her position in bed had to be changed every 2 hours to prevent the formation of decubitus ulcers (i.e. bedsores). She lost 9 pounds over the next 3 weeks, despite nasogastric tube feeding of 5000 calories ("Kcals") per day. After 9 weeks, sheets of cultured epidermal cells were grafted to her regenerating dermal layer. By the 15th week of her hospitalization, her epidermal graft was complete, and she was back on solid foods, her antibiotics were discontinued, and she was discharged from the hospital with a rehabilitation plan for both physical and occupational therapy at home, as well as twice-weekly visits by a nurse. Top of Form Questions: Briefly describe the three major layers that make up healthy skin. Epidermis: the outer layer of cells covering an organism. It provides a waterproof barrier and creates our skin tone. Dermis: beneath the epidermis, it contains tough connective tissue, hair follicles and sweat glands. Hypodermis: Deep subcutaneous tissue made of fat and connective tissue. Briefly describe the extent of damage seen in first-degree burns, second-degree burns, and third-degree burns. First-degree burn: only the surface of the epidermis is affected. Example: sunburn. Second-degree burn: the entire epidermis and perhaps some of the dermis are damaged. Accessory structures such as hair follicles and glands are generally not affected, but blistering, pain and swelling occur. Third-degree burn: the epidermis and dermis are destroyed with damage extending into the hypodermis. Why was this girl relatively pain-free when she woke up? Because the majority of her burns were third-degree burns. These burns are less painful because sensory nerves are destroyed. Why was it important to immediately administer intravenous fluids to this girl? In full-thickness/third-degree burns, the rate of fluid loss through the skin may reach five times the normal level. What is a "broad-spectrum" antibiotic, and why did she need it? Is healthy skin normally colonized by bacteria? A “broad-spectrum” antibiotic refers to an antibiotic that acts against a wide range of disease-causing bacteria. Burn wounds are commonly infected with fungal pathogens, so a broad-spectrum antibiotic is more appropriate than narrow-spectrum. Yes, bacteria such as flora normally colonize on the skin. Skin flora are usually non-pathogenic. One of the benefits flora offers is preventing transient pathogenic organisms from colonizing the skin surface. Why was skin-grafting necessary in this patient? (Why not just let the skin heal on its own?) Third-degree burns cannot repair themselves because granulation tissue cannot form and epithelial cells are unable to cover the injury. Describe the series of events that occur in skin which is healing with the help of a skin-graft. A full thickness graft involves the epidermis and both layers of the dermis. A skin graft is made with a patient’s own undamaged skin called an autograft. During the revascularization phase of skin graft healing, the skin graft cells begin to connect with the host cells. Bonding is further encouraged with the help of collagen and fibrin. Regeneration begins after a skin graft is attached and continues throughout the entire healing process. During regeneration, sweat glands, sebaceous glands and hair begin to grow. Why are bedridden patients at risk for developing decubitus ulcers? Where on the body do such ulcers most commonly occur? Bedsores are localized injuries to the skin and/or underlying tissue that usually occur over a bony prominence as a result of pressure, or pressure in combination with shear and/or friction. As bedridden patients are constantly in one position, it restricts blood flow and puts pressure in certain areas, creating the sores. For individuals who are bedridden, the sores are most likely to form on or around the heels, the hip-bone, and the lower back or tailbone. Pressure ulcers may also develop in a variety of other areas, including the spine, ankles, knees shoulders, and head, depending upon the position of the patient. Why did the patient lose so much weight despite being on a very high-calorie diet? This occurs largely because burn injuries increase the metabolism, with severe burns causing a significant boost. This means the body breaks down food and other nutrients quicker, leading to weight loss. What long-term problems may the patient have as a result of extensive scar tissue formation over her trunk and her right elbow? The newly formed skin will be thinner and less protective than the original skin. There may be a decreased sensation of hot/cold, sharp/dull, and light touch. Bottom of Form
