Burns

Definition A burn is a type of injury to the skin caused by heat, electricity, chemicals, light, radiation or friction. Most burns only affect the skin (epidermal tissue and dermis). Rarely deeper tissues, such as muscle, bone, and blood vessels can also be injured. Managing burns is important because they are common, painful and can result in disfiguring and disabling scarring. Burns can be complicated by shock, infection, multiple organ dysfunction syndrome, electrolyte imbalance and respiratory distress. Large burns can be fatal, but modern treatments, developed in the last 60 years, have significantly improved the prognosis of such burns, especially in children and young adults.

Causes 1. Dry heat o This is the most common type of burn and includes burns cause by hot objects such as exhaust or cigarettes or lighters.

Wet heat/ Scalding Scalding is caused by hot liquids (water or oil) or gases (steam), most commonly occurring from exposure to high temperature tap water in baths or showers or spilled hot drinks. A so called immersion burn is created when an extremity is held under the surface of hot water, and is a common form of burn seen in child abuse. A blister is a "bubble" in the skin filled with serous fluid as part of the body's reaction to the heat and nerve damage. The blister "roof" is dead. Steam is a common gas that causes scalds. The injury is usually regional and usually does not cause death. More damage can be caused if hot liquids enter an orifice. However, deaths have occurred in more unusual circumstances, such as when people have accidentally broken a steam pipe. The demographics that are of the highest risk to suffering from scalding are young children, with their delicate skin, and the elderly over 65 years of age. 2. Friction o When two objects rub together very quickly friction generates heat, causing another kind of dry burn.

3. Chemical burns

o Most chemicals that cause severe chemical burns are strong acids or
bases.]Chemical burns can be caused by caustic chemical compounds such as sodium hydroxide or silver nitrate, and acids such as sulfuric acid. Hydrofluoric acid can cause damage down to the bone and its burns are sometimes not immediately evident. 1

4. Electrical burns

o Electrical burns are caused by either an exogenous electric shock

or an uncontrolled short circuit. (A burn from a hot, electrified heating element is not considered an electrical burn.) Common occurrences of electrical burns include workplace injuries, or being defibrillated or cardioverted without a conductive gel. Lightning is also a rare cause of electrical burns. Since normal physiology involves a vast number of applications of electrical forces, ranging from neuromuscular signaling to coordination of wound healing, biological systems are very vulnerable to application of supraphysiologic electric fields. Some electrocutions produce no external burns at all, as very little current is required to cause fibrillation of the heart muscle. Therefore, even when the injury does not involve any visible tissue damage, electrical shock survivors may experience significant internal injury. The internal injuries sustained may be disproportionate to the size of the burns seen (if any), and the extent of the damage is not always obvious. Such injuries may lead to cardiac arrhythmias, cardiac arrest, and unexpected falls with resultant fractures.

5. Radiation burns

o Radiation burns are caused by protracted exposure to UV light (as

from the sun), tanning booths, radiation therapy (as patients who are undergoing cancer therapy), sunlamps, radioactive fallout, and X-rays. By far the most common burn associated with radiation is sun exposure, specifically two wavelengths of light UVA, and UVB, the latter being more dangerous. Tanning booths also emit these wavelengths and may cause similar damage to the skin such as irritation, redness, swelling, and inflammation. More severe cases of sun burn result in what is known as sun poisoning. Microwave burns are caused by the thermal effects of microwave radiation.

Effects/ Local or Systemic Responses to burn I. Cardiovascular Response

Hypovolemia is the immediate consequence of fluid loss resulting in decreased perfusion and oxygen delivery.

 Cardiac output decreases before any significant change in blood volume is evident. As fluid loss continues and vascular volume decreases, cardiac output continues to fall and blood pressure drops. This is the onset of burn shock. In response, the sympathetic nervous system releases catecholamines, resulting in an increase in peripheral resistance (vasoconstriction) and an increase in pulse rate. Peripheral vasoconstriction further decreases cardiac output. Myocardial contractility may be suppressed inflammatory cytokine necrosis factor. by the release of

II.

Burn Edema o Edema is defined as the presence of excessive fluid in the tissue spaces.

Patients with more severe burns develop massive systemic edema. Edema is usually maximal after 24 hours. It begins to resolve 1 to 2 days post-burn and usually is completely resolved in 7 to 10 days post-injury. Edema in burn wounds can be reduced by avoiding excessive fluid during the early post-burn period. Unnecessary over-resuscitation will increase edema formation in both burn tissue and non-burn tissue.

As edema increases in circumferential burns, pressure on small blood vessels and nerves in the distal extremities causes an obstruction of blood flow and consequent ischemia. This complication is known as compartment syndrome. The physician may need to perform an escharotomy, a surgical incision into the eschar (devitalized tissue resulting from a burn), to relieve the constricting effect of the burned tissue

III.

Effects on Fluids, Electrolytes, and Blood Volume Circulating blood volume decreases dramatically during burn shock. In addition, evaporative fluid loss through the burn wound may reach 3 to 5 L or more over a 24-hour period until the burn surfaces are covered.

Usually hyponatremia (sodium depletion) is present. Immediately after burn injury, hyperkalemia (excessive potassium) results from massive cell destruction. Hypokalemia (potassium depletion) may occur later with fluid shifts and inadequate potassium replacement. At the time of burn injury, some red blood cells may be destroyed and others damaged, resulting in anemia. The hematocrit may be elevated due to plasma loss. Abnormalities in coagulation, including a decrease in platelets (thrombocytopenia) and prolonged clotting and prothrombin times, also occur with burn injury. 3

IV.

Pulmonary Response Inhalation injury is the leading cause of death in fire victims. Inhalation injury has a significant impact on survivability of a burn patient. Deterioration in severely burned patients can occur without evidence of a smoke inhalation injury. Bronchoconstriction caused by release of histamine, serotonin, and thromboxane, a powerful vasoconstrictor, as well as chest constriction secondary to circumferential full-thickness chest burns causes deterioration. Even without pulmonary injury, hypoxia (oxygen starvation) may be present. More than half of all burn victims with pulmonary involvement do not initially demonstrate pulmonary signs and symptoms. Any patient with possible inhalation injury must be observed for at least 24 hours for respiratory complications. Airway obstruction may occur very rapidly or develop in hours. Decreased lung compliance, decreased arterial oxygen levels, and respiratory acidosis may occur gradually over the first 5 days after a burn.

Indicators of possible pulmonary damage include the following: o o o o o o History indicating that the burn occurred in an enclosed area Burns of the face or neck Singed nasal hair Hoarseness, voice change, dry cough, stridor, sooty sputum Bloody sputum Labored breathing or tachypnea (rapid breathing) and other signs of reduced oxygen levels (hypoxemia)

V.

o Erythema and blistering of the oral or pharyngeal mucosa Other Systemic Responses Destruction of red blood cells at the injury site results in free hemoglobin in the urine. The immunologic defenses of the body are greatly altered by burn injury. Serious burn injury diminishes resistance to infection. As a result, sepsis remains the leading cause of death in thermally injured patients. Loss of skin also results in an inability to regulate body temperature. Burn patients may therefore exhibit low body temperatures in the early hours after injury.

Two potential gastrointestinal complications may occur: paralytic ileus (absence of intestinal peristalsis) and Curlings ulcer.

Classifications 4

Burn injuries are described according to the depth of the injury and the extent of body surface area injured.

a) Burn Depth Burns are classified according to the depth of tissue destruction as superficial partial-thickness injuries, deep partial-thickness injuries, or full-thickness injuries. Burn depth determines whether epithelialization will occur. Determining burn depth can be difficult even for the experienced burn care provider. Superficial partial-thickness burn o the epidermis is destroyed or injured and a portion of the dermis may be injured. The damaged skin may be painful and appear red and dry, as in sunburn, or it may blister.

A deep partial-thickness burn o involves destruction of the epidermis and upper layers of the dermis and injury to deeper portions of the dermis. The wound is painful, appears red, and exudes fluid. Capillary refill follows tissue blanching. Hair follicles remain intact.

Deep partial-thickness burns o take longer to heal and are more likely to result in hypertrophic scars.

Full-thickness burn o involves total destruction of epidermis and dermis and, in some cases, underlying tissue as well. Wound color ranges widely from white to red, brown, or black. The burned area is painless because nerve fibers are destroyed. The wound appears leathery; hair follicles and sweat glands are destroyed (Fig. 57-1).

The following factors are considered in determining the depth of the burn: 5

 How the injury occurred Causative agent, such as flame or scalding liquid Temperature of the burning agent Duration of contact with the agent Thickness of the skin

A number of different classification systems exist. The traditional system divided burns in first-, second-, or third-degree. By degree Three degrees of burns First-degree burns are usually limited to redness (erythema), a white plaque and minor pain at the site of injury. These burns involve only the epidermis. Most sunburns can be included as first-degree burns. Second-degree burns manifest as erythema with superficial blistering of the skin, and can involve more or less pain depending on the level of nerve involvement. Second-degree burns involve the superficial (papillary) dermis and may also involve the deep (reticular) dermis layer. Deep dermal burns usually take more than three weeks to heal and should be seen by a surgeon familiar with burn care, as in some cases severe hypertrophic scarring can result. Burns that require more than three weeks to heal are often excised and skin grafted for best result. Third-degree burns occur when the epidermis is lost with damage to the subcutaneous tissue. Burn victims will exhibit charring and extreme damage of the epidermis, and sometimes hard eschar will be present. Third-degree burns result in scarring and victims will also exhibit the loss of hair shafts and keratin. These burns may require grafting. These burns are not painful, as all the nerves have been damaged by the burn and are not sending pain signals; however, all third-degree burns are surrounded by first and second-degree burns. b) Extent of Body Surface Area Injured Various methods are used to estimate the TBSA affected by burns among them are the rule of nines, the Lund and Browder method, and the palm method.

RULE OF NINES The rule of nines is a quick way to calculate the extent of burns. The system assigns percentages in multiples of nine to major body surfaces.

FIGURE 57-2 The rule of nines: Estimated percentage of total body surface area (TBSA) in the adult is arrived at by sectioning the body surface into areas with a numerical value 6

related to nine. (Note: The anterior and posterior head total 9% of TBSA.) In burn victims, the total estimated percentage of TBSA injured is used to calculate the patients fluid replacement needs. LUND AND BROWDER METHOD A more precise method of estimating the extent of a burn which recognizes that the percentage of TBSA of various anatomic parts, especially the head and legs, and changes with growth is by dividing the body into very small areas and providing an estimate of the proportion of TBSA accounted for by such body parts, one can obtain a reliable estimate of the TBSA burned. The initial evaluation is made on the patients arrival at the hospital and is revised on the second and third post-burn days because the demarcation usually is not clear until then. PALM METHOD In patients with scattered burns, a method to estimate the percentage of burn is the palm method. The size of the patients palm is approximately 1% of TBSA.

Prevention Dont play with fire. Avoid octopus connection. Be cautious in handling hot objects and chemicals. Use appropriate protective devices when handling hot objects. Keep flammable objects from childrens reach. Hold the rubber part of the wire in plugging or unplugging the socket. Avoid prolonged exposure to sunlight and UV rays. Use sunblocks and SPF creams and powders to protect your skin. Store chemicals in appropriate containers.

Escape and rescue (On-the-Scene Care) The first priority of on-the-scene care for a burn victim is to prevent injury to the rescuer. If needed, fire and emergency medical services should be requested at the first opportunity. AIRWAY, BREATHING, CIRCULATION o Although the local effects of a burn are the most evident, the systemic effects pose a greater threat to life. Therefore, it is important to remember the ABCs of all trauma care during the early postburn period: Airway Breathing 7

Circulation; cervical spine immobilization for patients with highvoltage electrical injuries and if indicated for other injuries; cardiac monitoring for patients with all electrical injuries for at least 24 hours after cessation of dysrhythmia Some practitioners include DEF in the trauma assessment: disability, exposure, and fluid resuscitation.

The circulatory system must also be assessed quickly. o Apical pulse and blood pressure are monitored frequently. Tachycardia (abnormally rapid heart rate) and slight hypotension are expected soon after the burn.

The neurologic status is assessed quickly in the patient with extensive burns. Often the burn patient is awake and alert initially, and vital information can be obtained at that time. A secondary head-to-toe survey of the patient is carried out to identify other potentially life-threatening injuries. Preventing shock in a burn patient is imperative.

NURSING ALERT No food or fluid is given by mouth and the patient is placed in a position that will prevent aspiration of vomitus because nausea and vomiting typically occur due to paralytic ileus resulting from the stress of injury. Usually, rescue workers will cool the wound, establish an airway, supply oxygen, and insert at least one large-bore intravenous line.

Emergency Procedures at the Burn Scene Extinguish the flames. When clothes catch fire, the flames can be extinguished if the victim falls to the floor or ground and rolls (drop and roll); anything available to smother the flames, such as a blanket, rug, or coat, may be used. Standing still forces the victim to breathe flames and smoke, and running fans the flames. If the burn source is electrical, the electrical source must be disconnected. Cool the burn. After the flames are extinguished, the burned area and adherent clothing are soaked with cool water, briefly, to cool the wound and halt the burning process. Once a burn has been sustained, the application of cool water is the best first-aid measure. Soaking the burn area intermittently in cool water or applying cool towels gives immediate and striking relief from pain and limits local tissue edema and damage. However, never apply ice directly to the burn, never wrap burn victims in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in patients with large burns. Remove restrictive objects. If possible, remove clothing immediately. Adherent clothing may be left in place once cooled. Other clothing and all jewelry should be removed to allow for assessment and to prevent constriction secondary to rapidly developing edema. 8

 Cover the wound. The burn should be covered as quickly as possible to minimize bacterial contamination and decrease pain by preventing air from coming into contact with the injured surface. Sterile dressings are best, but any clean, dry cloth can be used as an emergency dressing. Ointments and salves should not be used. Other than the dressing, no medication or material should be applied to the burn wound. Irrigate chemical burns. Chemical burns resulting from contact with a corrosive material are irrigated immediately. Most chemical laboratories have a high-pressure shower for such emergencies. If such an injury occurs at home, brush off the chemical agent, remove clothes immediately, and rinse all areas of the body that have come in contact with the chemical. Rinsing can occur in the shower or any other source of continuous running water. If a chemical gets in or near the eyes, the eyes should be flushed with cool, clean water immediately. Outcomes for the patient with chemical burns are significantly improved by rapid, sustained flushing of the injury at the scene.

Emergency Medical Management The patient is transported to the nearest emergency department. The hospital and physician are alerted that the patientis en route to the emergency department so that life-saving measures can be initiated immediately by a trained team. Initial priorities in the emergency department remain airway, breathing, and circulation. For mild pulmonary injury, inspired air is humidified and the patient is encouraged to cough so that secretions can be removed by suctioning. For more severe situations, it is necessary to remove secretions by bronchial suctioning and to administer bronchodilators and mucolytic agents. If edema of the airway develops, endotracheal intubation may be necessary. Continuous positive airway pressure and mechanical ventilation may also be required to achieve adequate oxygenation. After adequate respiratory status and circulatory status have been established, the patient is assessed for cervical spinal injuries or head injury if the patient was involved in an explosion, a fall, a jump, or an electrical injury. Once the patients condition is stable, attention is directed to the burn wound itself. All clothing and jewelry are removed. For chemical burns, flushing of the exposed areas is continued. The patient is checked for contact lenses. These are removed immediately if chemicals have contacted the eyes or if facial burns have occurred. It is important to validate an account of the burn scenario provided by the patient, witnesses at the scene, and paramedics. Information needs to include time of the burn injury, source of the burn, place where the burn occurred, how the burn was treated at the scene, and any history of falling with the injury.

 A history of preexisting diseases, allergies, and medications and the use of drugs, alcohol, and tobacco is obtained at this point to plan care. The physician evaluates the patients general condition, assesses the burn, determines the priorities of care, and directs the individualized plan of treatment, which is divided into systemic management and local care of the burned area. Nonsterile gloves, caps, and gowns are worn by personnel while assessing the exposed burned areas. Clean technique is maintained while assessing burn wounds. Assessment of both the TBSA burned and the depth of the burn is completed after soot and debris have been gently cleansed from the burn wound. Careful attention is paid to keeping the burn patient warm during wound assessment and cleansing. Assessment is repeated frequently throughout burn wound care. Photographs may be taken of the burn areas initially and periodically throughout treatment; in this way, the initial injury and burn wound can be documented. Such documentation is invaluable for insurance and legal claims. Clean sheets are placed under and over the patient to protect the area from contamination, maintain body temperature, and reduce pain caused by air currents passing over exposed nerve endings. An indwelling urinary catheter is inserted to permit more accurate monitoring of urine output and renal function for patients with moderate to severe burns. Baseline height, weight, arterial blood gases, hematocrit, electrolyte values, blood alcohol level, drug panel, urinalysis, and chest x-rays are obtained. If the patient is elderly or has an electrical burn, a baseline electrocardiogram is obtained. Because burns are contaminated wounds, tetanus prophylaxis is administered if the patients immunization status is not current or is unknown. Although the major focus of care during the emergent phase is physical stabilization, the nurse must also attend to the patients and familys psychological needs. Burn injury is a crisis, causing variable emotional responses. The patients and familys coping abilities and available supports are assessed. Circumstances surrounding the burn injury should be considered when providing care. Individualized psychosocial support must be given to the patient and family. Because the emergent burn patient is usually anxious and in pain, those in attendance should provide reassurance and support, explanations of procedures, and adequate pain relief. Because poor tissue perfusion accompanies burn injuries only intravenous pain medication (usually morphine) is given, titrated for the patient. If the patient wishes to see a spiritual advisor, one is notified.

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MANAGEMENT OF FLUID LOSS AND SHOCK Next to handling respiratory difficulties, the most urgent need is preventing irreversible shock by replacing lost fluids and electrolytes. Intravenous lines and an indwelling catheter must be in place before implementing fluid resuscitation. Baseline weight and laboratory test results are obtained as well. These parameters must be monitored closely in the immediate post-burn (resuscitation) period. Controversy continues regarding the definition of adequate resuscitation and the optimal fluid type for resuscitation. Refinement of resuscitation techniques remains an active area of burn research.

Fluid Replacement Therapy. The total volume and rate of intravenous fluid replacement are gauged by the patients response. The adequacy of fluid resuscitation is determined by following urine output totals, an index of renal perfusion. Output totals of 30 to 50 mL/hour have been used as goals. Other indicators of adequate fluid replacement are a systolic blood pressure exceeding 100 mm Hg and/or a pulse rate less than 110/minute.

NURSING ALERT Clinical parameters are far more important in resuscitation than any formula. Indeed, the patients individual response is the key to assessing the adequacy of fluid resuscitation. Additional gauges of fluid requirements and response to fluid resuscitation include hematocrit and hemoglobin and serum sodium levels. If the hematocrit and the hemoglobin levels decrease or if the urinary output exceeds 50 mL/hour, the rate of intravenous fluid administration may be decreased. The goal is to maintain serum sodium levels in the normal range during fluid replacement. Appropriate resuscitation endpoints for burn patients remain controversial.

Fluid Requirements.

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 The projected fluid requirements for the first 24 hours are calculated by the clinician based on the extent of the burn injury. Some combination of fluid categories may be used: colloids (whole blood, plasma, and plasma expanders) and crystalloids/electrolytes (physiologic sodium chloride or lactated Ringers solution). Adequate fluid resuscitation results in slightly decreased blood volume levels during the first 24 post-burn hours and restores plasma levels to normal by the end of 48 hours.

Chemical burns of the eye Treatment in chemical burns: 1. If you feel that you can safely approach the victim then do so carefully. 2. If necessary, wear protective clothing to protect yourself from contamination. 3. Ventilate the room if possible because many chemicals affect breathing. 4. When cooling the burn with water, ensure that the contaminated water drains away from both the victim and yourself. It may be necessary to flood the injured part for longer to ensure that the chemical is totally washed away. This may take more than 20 minutes. 5. Call emergency hotline. Make sure you have mentioned that it is a chemical burn so that additional help can be sent for if necessary and so that any antidotes can be sent with the ambulance. 6. If possible, remove contaminated clothes from the victim because these may keep burning, but only do this if you can do it without contaminating yourself or causing the victim more harm. 7. Cover the burn with a clean, non-fluffy material as appropriate and tie loosely in place if necessary. 8. Treat the shock and reassure the victim until emergency help arrives on the scene. Treatment in chemical burns in the eye: 1. Protect yourself, the victim, and bystanders from further contamination. 2. Hold the affected eye under cold running water for at least 10 minutes to flush out the chemical, allowing the injured person to blink periodically. You may need to hold the eyelid open. Make sure that the water flow is gentle. Do not allow contaminated water to fall across the good eye and so contaminate that eye also. 3. Ask the injured person to hold a non-fluffy sterile or clean pad across the eye, ting it in place if hospital treatment may be delayed. 4. Take or send the person to hospital with details of the chemical if possible.

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Poisoning
Toxicology - study of the harmful effect of various substances on the body. Poison - comes from the Latin word - potare - meaning to drink. A poison is any substance that, when ingested, inhaled, absorbed, applied to the skin, or produced within the body in relatively small amounts, injures the body by its chemical action. Emergency treatment is initiated with the following goals:

To remove or inactivate the poison before it is absorbed To provide supportive care in maintaining vital organ systems To administer a specific antidote to neutralize a specific poison To implement treatment that hastens the elimination of the absorbed poison I. TYPES OF POISON: 1. Ingested Poisons are poisons that are swallowed. They may be accidental or intentional. They can produce: Immediate effects poison is caustic to the body tissues (i.e., strong acid/alkali).

e.g. Alkaline products - toilet bowl cleaners, bleach, nonphosphate detergents, and button batteries (batteries used to power watches, calculators, or cameras). Acid products toilet bowl cleaners, pool cleaners, metal cleaners, rust removers, battery acid. Delayed effects poison must be bloodstream before they become harmful. e.g. a. Foods carrying poisoning. bacteria that cause food absorbed into the

Suspect food poisoning if: 1. The victim ate food that "didn't taste right" or that may have been old, improperly prepared, contaminated, left at room temperature for a long time, or processed with an excessive amount of chemicals. 2. Several people who ate together become ill. b. Prescription drugs taken accidental overdose. c. Alcohol in excess 13 as deliberate or

d. Plants eaten deliberately effect, or by accident

when

seeking

an

2. Inhaled Poisons: Carbon Monoxide Poisoning carbon monoxide poisoning may occur as a result of industrial or household incidents or attempted suicide. It is implicated in more deaths than any other toxin except alcohol. CO exerts its toxic effect by binding to circulating hemoglobin and thereby reducing the oxygen-carrying capacity of the blood. Hemoglobin absorbs carbon monoxide 200 times more readily than it absorbs oxygen. Carbon monoxidebound hemoglobin, called carboxyhemoglobin, does not transport oxygen.

3. Contact Poisons skin contamination poisoning/chemical burns are challenging because of the large number of offending agents with diverse actions and metabolic effects. The severity of a chemical burn is determined by: the mechanism of action, penetrating strength and concentration, and the amount and duration of exposure of the skin to the chemical. 4. Injected Poisons poisons that enters the body through a bite, sting, or syringe. e.g. a. Prescription drugs taken as a deliberate or accidental overdose b. Illegal drugs c. Insect bite or stings Odd breath odors Nausea & vomiting Abdominal pain Diarrhea

II. SIGNS AND SYMPTOMS: 1. Ingested Poison Altered mental status History of ingesting poisons Burns around the mouth

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2. Inhaled Poison History of inhaling poisons Breathing difficulty Chest pain Cough, hoarseness, burning sensation in the throat Cyanosis (bluish discoloration of skin and mucous membranes) Dizziness, headache Seizures, unresponsivene ss (advanced stages)

Stingers may be present. Pain Swelling Possible allergic reaction

ii. Spider bite Signs and Symptoms Nite mark Swelling Pain Nausea and vomiting Difficulty breathing or swallowing. iii. Marine Organisms Signs and Symptoms Possible marks. Pain Swelling Possible allergic reaction.

3. Contact Poison

History of exposures Liquid or powder on the skin Burns Itching, irritation Redness, rashes, blisters

iv. Snake bite Signs and Symptoms Bite mark Pain

4. Injected Poison
i. Bee sting Signs and Symptoms Comparative Characteristics of Snake CHARACTERISTIC Movement Head Body Skin Pupil VENOMOUS Cortina, side locomotion winding Semi-angular Rectangular Rough Vertical

NON-VENOMOUS Semicortina curvature Oblongated Circular Smooth Round

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Ways/ manner of attack Bite marks v. Dog bite

Nonconstrictor With fang marks

Constrictor Horeshoe shape

Signs and Symptoms Bite mark Bleeding

III. ANTIDOTE Antidotes prevent the poison from working or reverse the effects of the poison. The antidotes for some particular toxins are manufactured by injecting the toxin into an animal in small doses and extracting the resulting antibodies from the host animals' blood. This results in an antivenom that can be used to counteract poison produced by certain species of snakes, spiders, and other venomous animals. A number of venoms lack a viable antivenom, and a bite or sting from an animal producing such a toxin often results in death. Some animal venoms, especially those produced by arthropods (e.g. certain spiders, scorpions, bees, etc.) are only potentially lethal when they provoke allergic reactions and induce anaphylactic shock; as such, there is no "antidote" for these venoms because it is not a form of poisoning and anaphylactic shock can be treated (e.g., by the use of epinephrine).

Atropine is an antidote for certain nerve gases and insecticides. N-acetylcysteine (Mucomyst) is used to neutralize acetaminophen (Tylenol) overdoses. Acetaminophen, in normal doses, is one of the safest medications known, but after a massive overdose, the liver is damaged, and hepatitis and liver failure develop. Mucomyst works as an antidote by bolstering the body's natural detoxification abilities when they are overwhelmed. It may also be possible to reverse the harmful effect of a drug even if no antidote exists. o If a person with diabetes takes too much insulin, a dangerously low blood sugar (hypoglycemia) will cause weakness, unconsciousness, and eventually death. Sugar given by mouth or IV is an effective treatment until the insulin wears off.
o

When the poison is a heavy metal, such as lead, special medicines (chelators) bind the poison in the bloodstream and cause it to be eliminated in the urine. Another "binder" is sodium polystyrene sulfonate (Kayexalate), which can absorb potassium and other electrolytes from the bloodstream.

Once the poison has moved past the stomach, other methods are needed.
1. Activated charcoal acts as a "super" absorber of many poisons. Once

the poison is stuck to the charcoal in the intestine, the poison cannot get absorbed into the bloodstream. Activated charcoal has no taste, but the gritty texture sometimes causes the person to vomit. To be effective, activated charcoal needs to be given as soon as possible after the poisoning. It does not work with alcohol, caustics, lithium (Lithobid), or petroleum products. 16

2. Whole bowel irrigation requires drinking a large quantity of a fluid

called Golytely. This flushes the entire gastrointestinal tract before the poison gets absorbed. Some other toxins have no known antidote. For example, the poison aconitine, a highly poisonous alkaloid derived from various aconite species has no antidote, and as a result is often fatal if it enters the human body in sufficient quantities.

IV. FIRST AID CARE/EMERGENCY

KEY FIRST AID PRINCIPLES FOR DEALING WITH POISONS

1. Protect yourself and bystanders from the source of the poison by making the scene safe and wearing protective clothing if necessary. 2. Monitor and maintain the victims airway and breathing and be prepared to resuscitate if necessary. 3. Seek appropriate medical help or call the Poison Control Hotline to deal with dangerous substances. 4. Monitor the victims level of consciousness and be prepared to turn into recovery position if necessary. 5. Support the victim if he vomits and place in the recovery position until medical help arrives. 6. Treat any burns caused by corrosive poisons by flooding the affected area with running water. 7. Try to identify the source of the poison because this will help determine appropriate medical treatment.

FIRST AID CARE

1. Ingested poisoning

Chemicals a. Monitor and maintain the airway and breathing. Be prepared to resuscitate if necessary. b. Monitor consciousness. If the person becomes unconscious, put into the recovery position. c. Call 911 or the Poison control Hotline for advice on how to proceed. d. Treat any burns, wearing protective clothing if necessary. e. Support the person if he vomits and place in the recovery position if necessary. f. Reassure the person while you are waiting for emergency assistance to arrive. g. Identify the poison if possible because this will help medical staff determine what treatment is appropriate. Food a. Monitor and maintain the airway and breathing. If there are breathing difficulties call 911. 17

b. Help the person into a comfortable position. c. Call for medical advice on treatment and care. d. Give plenty of fluids to drink, particularly if the person has vomiting and diarrhea. e. Support the person if he/she vomits, providing a bowl and towel as necessary. Remember: Do not underestimate food poisoning, particularly in the very young or in the elderly.
2. Inhaled poison

Where possible, remove the victim from the chemical. If this is not possible, ensure that the area is well-ventilated (open doors and windows). If in doubt, do not stay in the room yourself. Many chemicals have no odor or obvious effect and you may not be aware that you are being poisoned. a. Monitor and maintain the victims airway and breathing and be prepared to resuscitate if necessary. b. If the victim becomes unconscious, place in recovery position. c. If the victim is conscious help into the most comfortable position. If there are breathing problems, this position is most likely to be sitting up. d. Call 911 and provide as much information as you can.

2. Injected poison
Bee Sting 1. 2. 3. 4. 5. Remove stinger. Wash wound. Cover the wound. Apply a cold pack. Watch for signals of allergic reaction Marine Organisms 1. If jellyfish- soak area in vinegar 2. If sting ray- soak in nonscalding hot water until pain goes away. 3. Clean and bandage the wound. 4. Call emergency number, if necessary. Snake bite 1. Wash wound. 2. Keep bitten part still, and lower than the heart. 3. Call local emergency number.

Spider Bite 1. Wash wound. 2. Apply a cold pack. 3. Get medical care to receive antivenin. 4. Get local emergency number, if necessary.

Dog bite 1. If bleeding is minor- wash wound. 2. Control bleeding. 3. Apply antibiotic ointment.

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4. Cover the wound. 5. Get medical attention if wound bleeds severely or if you suspect animal has rabies. 6. Call local emergency number or contact animal control personnel. 4. Contact poison

1. if available. 2. 3.

Do not contaminate yourself. Wear protective clothing Wash away the chemical with water, taking care to flush the contaminated water away from both yourself and the victim.

Monitor and maintain the victims airway and breathing and be prepared to resuscitate if necessary. 4. Call 911 and reassure the victim until help arrives.

REFERENCES: Books Smeltzer, S.C & Bare (2008). Brunner & Suddarths Textbook of Medical Surgical Nursing 11th Edition, Vol. 2, Philadelphia: Lippincott Williams & Wilkins. Nettina, S (2001). The Lippincott Manual of Nursing Practice 7th Edition, Vol. 2, Philadelphia: Lippincott Williams & Wilkins. Websites http://www.emedicinehealth.com/poisoning/page9_em.htm http://en.wikipedia.org/wiki/Burn http://www.medicinenet.com/burns/article.htm http://www.rcyofuplb.org/index.php/Basic-First-Aid/First-Aid-for-Poisoning.html

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