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PHTY2101 EOS > B3 L41/42: Management of Burn Injuries > Flashcards

B3 L41/42: Management of Burn Injuries Flashcards

1
Q

What is the function of the epidermis?

A

Superficial protective layer

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2
Q

Are there blood vessels in the epidermis?

A

No

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3
Q

What are the 3 things in the epidermis? How do they relate to the function of the epidermis?

A
  • Keratin which toughens and waterproofs
    • Melanin (melanocytes) for UV protection
    • Rete pegs (undulation) for attachment/adherence to dermis
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4
Q

How many layers are in the dermis?

A

2

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5
Q

What are the 2 layers of the dermis?

A

Papillary layer

Reticular layer

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6
Q

What is found in the dermis?

A

Collagenous network of blood and lymph vessels, nerves, elastin fibres and collage

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7
Q

What is the function of the dermis?

A

Provides mechanical strength of the skin

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8
Q

What are 3 epidermal appendages? What are they all surround by? What is the function of the epidermal appendages?

A

• Hair follicles, sweat glands, sebaceous glands
• All are surrounded by epidermal cells & a rich network of capillaries
Centre for regeneration of the epidermis

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9
Q

If _______ intact, then epidermis will heal. If no _______, then healing by secondary intention.

A

hair follicles; hair follicles

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10
Q

The ______ of dermis and epidermis varies throughout the body. Where is the thinnest and thickest skin found?

A

thickness

* Thinnest skin – eyelids (0.05mm epidermis and 0.3mm dermis)
* Thickest skin – palms and soles (1.5mm epideris) and back (3mm dermis)
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11
Q

What does the Fitzpatrick Skin Type Scale measure? What does it indicate? Which skin types have the worst healing ability?

A

measures skin’s tolerance to sunlight and tendency to tan or burn.
• Indicates the ability to heal burns. Also depends on genetics.
• Type I & VI have the worst healing ability.

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12
Q

What are 2 features of type I skin?

A

• Pale white; blond or red hair; blue eyes; freckles;

Always burns, never tans

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13
Q

What are 2 features of type II skin?

A

• White; fair; blond or red hair; blue, green, or hazel eyes;
Usually burns, tans minimally

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14
Q

What are 2 features of type III skin?

A

• Cream white; fair with any hair or eye colour; quite common;
Sometimes mild burn, tans uniformly

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15
Q

What are 2 features of type IV skin?

A

• Moderate brown; typical Mediterranean olive skin tone;

Rarely burns, always tans well

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16
Q

What are 2 features of type V skin?

A
  • Dark brown; Middle Eastern skin types;

* Very rarely burns, tans very easily

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17
Q

What are 2 features of type VI skin?

A
  • Deeply pigmented dark brown to black;

* Never burns, tans very easily

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18
Q

What are 2 features of glabrous skin? Give examples of body parts with this skin?

A

• Thick epidermis
• No hair
e.g. Palms, soles, lips, genitals

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19
Q

What are 2 features of hairy skin? Give examples of body parts with this skin?

A

• Thin epidermis

Yes hair follicles

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20
Q

What are the 5 functions of skin?

A

Interprets sensory input and protects from environment

Prevents excessive water loss

Regulates temperature control
• Allows heat dissipation via conduction, convection and radiation (via papillary plexus)
• Regulation of Sweat glands to control temperature

Provides defence against infection

Maintains moist environment for internal organs

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21
Q

What are 5 implications for the body from skin loss?

A

Impaired skin sensation - hypersensitivity

Increased evaporation of water from skin

  • Increased energy requirements
  • metabolic disturbances
  • Implications for fluid balance
  • Impaired temperature control

Access point for infection

Loss of moist environment for muscles, tendons and nerves - damage, ruptures.

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22
Q

What are the 4 types of burns?

A

Flame
Scald
Chemical
Electrical

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23
Q

Which type of burn is most common in adults?

A

Flame

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24
Q

Which type of burn is most common in children and the elderly?

A

Scald

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25
Q

Which type of burn is most common in the workplace?

A

Flame
Chemical
Electrical

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26
Q

What is the complication with an electrical/chemical burn?

A

damage to deeper structures (e.g. muscles, nerves)

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27
Q

What are the 4 depths of burns?

A

Superficial burn

Superficial partial thickness burn

Deep partial thickness burn

Full thickness burn

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28
Q

What area(s) is destroyed in a superficial burn?

A

Epidermis

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29
Q

What area(s) is destroyed in a superficial partial thickness burn? (2)

A

Epidermis + superficial dermis

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30
Q

What area(s) is destroyed in a deep partial thickness burn? (2)

A

Epidermis + deep dermis

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31
Q

What area(s) is destroyed in a full thickness burn? (3)

A
  • Epidermis + dermis + underlying structures
  • Subcutaneous fat, nerves, tendons, bones
  • Bone burn - esp fingers & toes - amputation
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32
Q

What is the appearance of a superficial burn?

A

Red and blistered

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33
Q

What is the appearance of a superficial partial thickness burn?

A

Red to pink, blistered. Brown is epidermis peeling off. Hair follicles alive.

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34
Q

What is the appearance of a deep partial thickness burn?

A

• Creamy moist white appearance
• Pseudomembrane (fluid film) may be present, oedematous
More scarring

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35
Q

What is the appearance of a full thickness burn?

A
  • White, tan, black, bright red
  • Redness around wound = infection = cellulitis
  • Dry leathery appearance.
  • No hair follicles.
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36
Q

What is the sensation like in a superficial burn?

A

Sensation intact, hypersensitive.

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37
Q

What is the sensation like in a superficial partial thickness burn?

A

Sensation intact, hypersensitive and painful.

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38
Q

What is the sensation like in a deep partial thickness burn?

A

• Sensation intact but maybe decreased
• sensation to light touch in some areas (some nerve
endings damaged)

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39
Q

What is the sensation like in a full thickness burn?

A

No light touch sensation because no nerves.

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40
Q

What is the sensation like in a superficial burn?

A

Rapid capillary return/blanching, because no capillaries in epidermis - no damage to circulation.

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41
Q

What is the sensation like in a superficial partial thickness burn?

A

Rapid capillary return/blanching

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42
Q

What is the sensation like in a deep partial thickness burn?

A

Delayed capillary return/blanching (5-6 seconds)

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43
Q

What is the sensation like in a full thickness burn? What does this cause?

A
  • No capillary return/blanching

* Full thickness burn circumferentially around the limb will constrict blood flow around limb - compartment syndrome.

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44
Q

Is there wound closure in a superficial burn?

A

Wound closure spontaneously in 7-10-14 days

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45
Q

Is there wound closure in a superficial partial thickness burn?

A

Wound closure spontaneously in 14 days

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46
Q

Is there wound closure in a deep partial thickness burn?

A

From wound edge and epidermal appendages in >14 days

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47
Q

Is there wound closure in a full thickness burn?

A

Takes >3 weeks for closure (healing by secondary intention)

Need grafting

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48
Q

How can the size of the burn be measured?

A

Total body surface area affected (% TBSA)

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49
Q

Why is the total body surface area affected (% TBSA) important?

A

essential for accurate calculation of fluid replacement - prevent renal failures especially in bigger burn

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50
Q

What are 2 benefit of the Lund & Browder chart?

A

Fast (done in the ambulance)

Prioritise skin grafting & rehab by depth of burn

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51
Q

How is a burn measured by the Lund & Browder chart?

A

Rule of nines gives a quick estimate of % burn

52
Q

What are 10 criteria for assessing whether burns require treatment in a specialised burns unit?

A

• Burns >10% TBSA
• Burns of special areas - face, hands, feet, genitalia, perineum, and major joints
• Full-thickness burns >5% TBSA
• Electrical burns
• Chemical burns
• Burns with an associated inhalation injury
• Circumferential burns of the limbs or chest
• Burns in the very young or very old
• Burns in people with pre-existing medical disorders that could complicate management, prolong recovery, or increase mortality
Burns with associated trauma.

53
Q

What is the time period of the inflammatory phase?

A

(1-5 days)

54
Q

What is the time period of the proliferation phase?

A

3-5days - 3 weeks

55
Q

What is the time period of the remodelling phase?

A

3 weeks - 12-18 months - 2 years

56
Q

What are the 3 features of the inflammatory phase?

A

• Vasodilation and increased permeability of
• blood vessels
• Oedema
Coagulation - promotes migration of macrophages.

57
Q

What are the 4 features of the proliferation phase?

A
  • Macrophages release chemotactic agents which attracts fibroblasts
  • Fibroblasts produce collagen
  • Fibroblasts differentiate into myofibroblasts
    • Myofibroblasts first appear day 3-5, peak in number at 4-5/12 post burn.
    • Myofibroblasts are contractile and pull edges of wound together - scar contracture especially around joints.
  • Wound closed with scar.
    • Dermis of disorganised collagen. Thick red hypertrophic scars.
    • Epidermis lacks connection with dermis.
    • Prone to abrasion and micro trauma.
58
Q

What are the 3 features of the remodelling phase?

A

• Collagen forms crosslinks to strengthen the scar.

Collagen organised, more parallel. Exercise helps to line up collagen

59
Q

What are 12 features of a hypertrophic scar?

A

• Excessive collagen deposition by fibroblasts into whorl-like haphazard collagen bundles
• Reduced amount of highly cross linked collagen (reduced skin strength)
• Develops within 1-3 months post-injury, progresses for 3-6 months, gradual regression over time
• Increased blood supply in scar (highly vascular/red)
• Build-up of granulation tissue (thick and raised)
• 2-3x rate of normal skin fibroblasts
• No significant difference in collagen degradation
• Minimal regeneration of elastin fibres
• Changes in ground substance (“bony like”)
• Significantly reduced skin stretch
• Constant contraction through myofibroblast activity
Adhesion to underlying structures

60
Q

What are 11 risk factors for scarring? Explain why?

A

• Race: Dark skinned = more scarring. Asian and African skin types = less scarring.
• Genetic predisposition: Keloid > hypertrophic scar.
• Site of scar: Head, hands, neck and axilla, across joints
• Depth of wound: Deeper the wound takes longer to heal
• Prolonged inflammation and increased granulation
• Skin grafting: Reduced scar vs wounds > 21 days to heal
• Type of grafting: SSG > full thickness grafts
• TBSA, no. of surgical procedures and anatomical location – increase contracture risk
• Age: Children and adolescents > adults.
○ Children already collagen because growing + additional scar collagen. Scar has to stretch with growth, but it doesn’t stretch well - high risk of contracture.
• Female gender
Compliance or access to early treatment: Non-compliance = high risk of scar.

61
Q

What are 8 contributing factors to contractures?

A

• Depth of Wound
• Time to wound healing
• Large % burn wound
○ Muscle catabolism due to hypermetabolic state
○ Multiple areas to address at once
• Duration of joint immobilisation
• Deconditioning and loss of muscle strength to oppose skin contracture
• Muscle weakness e.g. associated neuropathy
• Other soft tissue or bony pathology: e.g. Heterotopic ossification, underlying fractures and need for longer immobilisation
• Decreased access to or compliance with therapy

62
Q

What are 3 first aid steps (most important) after a burn?

A

• Stop the burning
○ Stop drop roll / Wrap in blanket / water irrigation
○ Remove heat source
• Copious water irrigation
○ 20 mins cold running water, then cling wrap the wound
○ Avoid dirt/dirty water if possible
Avoid hypothermia: Wrap blanket around patient because skin burn = lose temperature

63
Q

What are 9 medical management steps after a burn?

A

• Assessment of size and depth of burn
• Fluid resuscitation if TBSA >15%
• Management of airway +/- inhalation injury: Burns around face & neck.
• Escharatomy prevents compartment syndrome.
• Prevention and management of infection: Tetanus injection
• Nutritional support
○ Early enteral feeding reduced morbidity (<24 hours) - shorter ICU stay and reduced wound infections.
○ >15% TBSA burn should have supplemental feeding via oral route
○ High protein diet helps healing.
• Wound management: Conservative vs skin grafting
○ Early debridement and grafting blunts SIRS response and reduces risk of infection (< 48 hours)
○ Priority areas – line sites, trachea site
• Pain management
○ Long acting (MS contin), short acting for procedures (morphine), ketamine
○ Gabapentin – burning pain. Use from the start.
○ Others – entonox (happy gas), anti-anxiety medications
DVT and ulcer prophylaxis

64
Q

What is a escharotomy?

A

Incision through eshar to relieve pressure and improve tissue perfusion in muscle compartment

65
Q

When and where is an escharotomy done?

A
  • Usually done when circumferential full thickness burns

* Limbs, chest, abdominal (rarely neck/digits)

66
Q

What are 5 assessments for an escharotomy?

A 
○ Pain/paraesthesia/loss of function
		○ Cap refill/pulse oximeter < 90% O2
		○ Peripheral pulse/doppler pulses
		○ Compartments feel tight (compartment pressures >25mmHg)
Increased ventilatory pressures
67
Q

When are abdominal and chest escharotomies required?

A

May be necessary to improve ventilation

68
Q

Escharotomies can extend to ________ if pressures not corrected – more common in _________injury

A

fasciotomy; electrical

69
Q

What is the Conservative Wound Management?

A

Silver based dressings

70
Q

What are the 2 benefits of the Silver based dressings?

A
  • Provides antibacterial effects

* Promotes wound healing

71
Q

What are the 2 types of Silver based dressings? How are they different?

A
  • Acticoat and Mepilex Ag can stay intact for 3-7 days (outpatient dressing, waterproof)
    • Silvazine / Flamazine cream 24 hours effect, changed daily
72
Q

What are 5 surgical treatments for a burn (Early excision and wound closure)?

A 
• Autograft
	• Cultured autologous keratinocytes
	• Homograft – Cadaver allograft
	• Skin Substitutes
		○ Integra
		○ Biobrane
Flaps
73
Q

How is an autograft post burn done?

A
  • Burn wound bed is debrided to viable tissue
    • Donor skin taken usually from anterolateral thigh- absolute thickness is variable (8/1000 - 24/1000 inch)
    • Skin graft secured (usually with staples but also use glue or sutures)
    • Surrounding joints immobilised with splints for 3 days to allow take of the graft
74
Q

What are 3 features of a Full thickness graft?

A
  • Thick donor site of all layers of skin - uncommon
  • Take graft from somewhere that closes easily (e.g. webspace of hand)
  • Needs a split thickness graft to cover the defect left at donor site
75
Q

What are 2 features of a split thickness graft?

A

• Epidermis + superficial dermis
• Burn wound heals quickly
Donor site heals 2/52

76
Q

What are 4 features of a meshed graft?

A
  • Mesh stretches skin graft 4x size - greater coverage, need less skin graft.
  • Better earlier take of graft
  • Mesh allows exudate to be evacuated from under graft
  • Cosmetically always left with a mesh pattern
77
Q

What are 4 features of a non-meshed graft?

A
  • Cannot spread skin - need more skin grafts.
  • More fragile, purple in earlier stages as no mesh to allow escape of exudate from under graft
  • Nurses may need to prick graft and roll exudate or haematoma out from under graft to improve graft take
  • Better aesthetically as no mesh pattern – usually used for face or hands
78
Q

What are 3 factors in graft take/

A

• Appearance: Pink skin, securely adhered and blanches with pressure
• Adherence: Fibrin is responsible in first 48 hours
• Revascularisation
○ First 48 hours - plasmic imbibition
○ 48-72 hours: Anastomoses of vessels in graft and wound bed. Growth of new endothelial buds.
○ Day 3 start exercise
Complete at day 5-6

79
Q

What is the process of Cultured Autologous Keratinocytes?

A
  • Biopsy of epidermal cells taken behind ears
    • Cells cultured in lab to form skin sheets (2-3 weeks) or cell suspension (5 days)
    • Indication: TBSA >50%, then not enough autografts.
80
Q

What are 2 advantages of Cultured Autologous Keratinocytes?

A
  • Cover large %TBSA burns without need for donor sites

* Nil rejection, heal quickly (patient’s own skin)

81
Q

What are 2 disadvantages of Cultured Autologous Keratinocytes?

A
  • Skin remains fragile - lack of dermal attachments

* Inflammation can cause blistering and sloughing off of cells

82
Q

What is an indication to use Cultured Autologous Keratinocytes?

A

TBSA >50%, then not enough autografts

83
Q

What are 4 factors to consider for a homograft (Cadaver Allograft)?

A

• Temporary cover - used as biological bandaid.
○ Over debrided wound bed
○ Sandwich graft: Deep autograft + mesh + superficial homograft. Homograft will slough off later. Autograft will adhere.
• Rejection occurs in 7-14 days
• Risk of transmitting viruses/infection
• Expensive, short supply, needs cryopreservation

84
Q

What is integra?

A

• 2 layer artificial skin substitute
○ Dermal replacement layer provides scaffold for patient’s own dermis to grow into
○ Epidermal substitute - silicone layer
• Artificial dermis is allowed to vascularise (14-21 days), then silicone layer is removed and replaced with a thin epidermal autograft

85
Q

What are 6 advantages of intergra?

A

• Early wound closure without donor sites
• Large TBSA covered in one operation
• Less hypertrophic scarring
• Thinner donor sites needed for coverage - less donor site pain, faster healing, frequent reharvesting
• No rejection
Grows with children

86
Q

What are 2 disadvantages of intergra?

A

• Poor resistance of dermis to infection
• Less drainage of exudate through solid sheet of silastic
Need for a second operation in smaller burns

87
Q

What are 5 features of biobrane?

A

• Synthetic nylon mesh fabric covered with silicone rubber membrane
• Semi-permeable to water
• Protective barrier to micro-organisms
• Temporary cover for partial thickness burns
May still require grafting after removal of biobrane

88
Q

What are 6 features of flaps (plastic surgery)?

A

• Performed when a simple skin graft is not enough to cover a wound
• Used to cover exposed bone, tendon or other structures.
• Flaps are classified as either
○ Skin flaps (skin and subcutaneous tissue with or without underlying fascia)
○ Muscle flaps (flap created from muscle with or without attached overlying skin).
• Difference between a flap and a graft
○ Flap usually transferred with its own blood supply
○ Skin graft blood supply has to come from the underlying wound bed
• Free flap vs Pedicle flap vs Rotational flap
• More prolonged immobilisation – 10 days

89
Q

What are 3 reasons for an increased risk of respiratory complications after burn injuries?

A 
• Bed rest
		○ Reduced FRC
		○ Increased risk of pneumonia
	• Multiple anaesthetics
	• Inhalation injury: Lower respiratory tract damage due to chemical compounds in smoke
		○ Damage to mucosal lining
		○ Mucosal oedema
		○ De-epithelialisation
		○ Pseudomembrane formation - airway plugging and compromised alveolar ventilation
		○ Deactivation of surfactant
90
Q

What are 12 signs and symptoms of Inhalation Injury?

A

• Burn injury occurred in enclosed space
• Lowered consciousness at time of fire
○ Alcohol use
○ Drug use
○ Pre-existing condition eg HI, CP
• Facial / oral burns
• Singed nasal hairs
• Soot in mouth or nose
• Hoarse voice
• Respiratory distress: #RR, # accessory muscle use, SOB
• Bronchospasm/stridor
• Carbonaceous / sooty sputum
• Auscultation - wheezes initially and then fine crackles
• ABGs - high levels of carboxyhaemoglobin, decreased PaO2
• Chest X-ray - patchy atelectasis and pulmonary oedema

91
Q

How can an inhalation injury be diagnosed? What are 5 clinical presentations?

A 
Bronchoscopy
	• Airway oedema
	• Airway inflammation
	• Mucosal necrosis
	• Pseudomembranous plugs
Soot or char in the airways
92
Q

What are 3 symptoms of an acute pulmonary insufficiency

(first 36 hours post injury) of an inhalation injury?

A

• Hypoxia / atelectasis / CO poisoning
• Fire consumes available oxygen
• CO disturbs O2 carrying capacity
• Atelectasis compounded by laryngeal spasm and coughing
• Bronchospasm - due to acids / aldehydes
Laryngeal and upper airway oedema compromise airway

93
Q

What are 3 symptoms of a pulmonary oedema

(6-72 hours post injury - peaks at 12 hours) of an inhalation injury?

A

• Massive inflammatory reaction - increased vascular permeability - oedema
Presence of pulmonary oedema and deactivation of surfactant leads to decreased lung compliance

94
Q

What are 3 symptoms of a bronchopneumonia

(3-10 days post injury) of an inhalation injury?

A
  • De-epithelialisation of mucosa
  • Pseudomembrane forms on airway wall
  • Separation of pseudomembrane
    • Obstruct airway
    • Prevention of normal mucous clearance
    • Pooling of secretions
    • Distal atelectasis and bronchopneumonia
95
Q

What are 8 Medical Management of Inhalation Injury?

A
  • Oxygen
    • Intubation and ventilation
    • PEEP (positive end expiratory pressure) / CPAP / BiPAP (bilevel positive airway pressure)
    • Escharotomies to chest wall
    • Bronchodilators
    • Humidification
    • Nebulised heparin/mucomist break down secretion.
    • Regular chest physiotherapy 3-4 times/day, overnight service.
96
Q

What are 5 Physiotherapy Respiratory Techniques

for ventilated Patients after a burns injury?

A
  • Manual hyperinflation
    • Percussion and Vibrations with towel on skin + analgesia
    • Suctioning
    • Positioning
    • Passive/Active limb movements assisted demand ventilation
97
Q

What are 5 Physiotherapy Respiratory Techniques

for non-ventilated Patients after a burns injury?

A
  • Active mobilisation staged basal expansion ex with insp holds
    • Incentive spirometry
    • Demand ventilation and mobility
    • Positive pressure devices – NIV - BiPAP, PEP masks, flutter. Non-invasive ventilation. High pressure so they can cough.
    • Percussion, vibration, postural drainage
98
Q

What are 4 Physiotherapy Respiratory Techniques after a burns injury?

A

• Prior to grafting: Can perform percussion / vibrations over burns to anterior chest
• Post grafting: Recommencement of manual techniques depends on grafting technique
○ Post-op day 5 - percussion & vibrations
○ If risk of death, then percussion at post-op day 2, but no vibrations because it shears off the graft from chest wall.
• Inhalation injury
○ Ensure humidification
○ Nebulised heparin
○ Positive pressure techniques are helpful to assist with secretion removal
• Once well enough, then gym CVS fitness.

99
Q

What are 3 Oedema Management techniques after a burns injury?

A

• Bandaging – distal to proximal
• Positioning in elevation
Active exercise to activate muscle pum

100
Q

What are 3 steps to Finger bandaging (2.5cm bandage) after a burns injury?

A

• anchor at the wrist (no pressure)
• cross up and back on DORSUM, not palmer
spiral 50% overlap down fingers

101
Q

What are 7 steps to hand bandaging (5-6cm bandage) after a burns injury?

A 
• Spread the fingers
• 1st – around MCP’s
• 2nd – 50% overlap to thumb web
• 3rd – around base of thumb
• 4th – through thumb web
• 5th + - spiral 50% overlap from base of thumb
anchor between fingers
102
Q

What are 4 steps for Initial ROM and Mobility after a burns injury?

A

• Start day 0
• Assess level of consciousness (LOC) / cognitive state
• Precautions to movement
○ Other injuries e.g. Fractures, tendon repairs
○ Escharotomies / Fasciotomies
○ Exposed Tendons
• Monitor vital signs
○ Remember high baseline resting HR – this is not a contraindication to early mobility
○ Monitor changes

103
Q

What are 5 aims of exercise after a burns injury?

A

• Minimise Contractures / Maintenance of ROM
○ Exercises / Movement in opposite direction to potential contracture
○ Elongation and stretching of skin and underlying structures to minimise risk of contracture
○ Allow collagen to lay down in lines of movement and tension - oriented in a more parallel fashion with scar maturation
• Overcome effects of deconditioning / bed rest
• Minimise effects of hypermetabolism/ muscle catabolism
• Minimise oedema
• Decrease fear of movement
○ Adequate pain relief for exercise session

104
Q

What are the sessions like (after a burns injury)?

A

• 1st ROM session whilst dressings down
○ Skin blanching vs skin banding
○ Explain exercises do not cause harm. they can see oedema decreasing - positive feedback. therapist can assess status of burn too.
• 2nd session with dressing on.
• Multiple times a day, once with dressing on, once with dressing off.
• Assess depth of burn and potential contracture

105
Q

What 6 importants techniques after a burns injury?

A

• Active / active assisted repeated movements until achieve full ROM day 1
○ Improve muscle strength and endurance to oppose ongoing contracture force
• Passive ROM if patient sedated
• Slow sustained stretch with EOR holds – 1 minute minimum (tissue elongation)
○ Allows gradual creep in tissues
• Hold relax / contract relax
• Encourage functional use of affected areas - encourage adherence
• Education

106
Q

What are 5 early mobility techniques after a burn injury?

A

• Mobilise from Day 1 post burn injury if able
• Mobilisation with full WB
○ Improve ambulation, balance, co-ordination and proprioception
○ Restore patient to their premorbid functional level
• Minimise effects of deconditioning
• Minimise effects of catabolism from hypermetabolic response to burns
• Use appropriate compression (e.g. Coban)
○ External support when skin cannot support
○ Decrease blood rush pain, so they can mobilise more easily
○ 50% overlap and 50% stretch
○ Don’t stop at mid-calf – tourniquet effect
○ Don’t leave gaps where swelling can accumulate
○ Monitor capillary refill, sensation

107
Q

What are 4 Precautions to Exercise - Acute Phase (after a burns injury)?

A

• Exposed Tendons
○ Avoid activities that will produce high tension in tendons eg combined movements across 2 joints
• Care to protect for potential tendon damage
○ E.g. Full thickness burns to dorsum of hand
○ Avoid combined movements eg fist and fist with Wr F
○ Isolated movements can be done eg MCP Flex with PIP/DIP Ext and MCP Ext with PIP/DIP Flex (no full fist + wrist flext)
• Take care with Full weight bearing Mobilisation if
○ IV line in foot – need to secure line
○ Escharotomies down legs – need adequate compression
○ Exposed achilles tendon – don’t want combined DF with knee E. Isolated ankle movement with knee flexed. NWB/PWB to offload Achilles tendon
○ Full thickness burn to soles of feet – need adequate protection and footwear
○ Cellulitis – wait until IV antibiotics have commenced and Drs happy
Slow ROM exercises to avoid overstretching and tissue bleeding

108
Q

What are the 3

ROM Post-grafting techniques?

A
  • Consider surgical technique/Graft take time frames
    • Protocols
    • See with dressings down for initial ROM if possible
109
Q

What are 5 Physiotherapy Management techniques in Grafting period?

A

• Maintain Full ROM prior to skin grafting
• Immobilise (3-5 days) joints above and below grafts immediately following skin graft – protocols to follow
○ Then debulk in bath, reveal the wound - start mobilisation
○ Can have review surgeries, or more grafts
• Maintain ROM at all other areas
• Recommence ROM – usually commence with full view of grafted tissue
• Progress back to full ROM

110
Q

What are 2 Physiotherapy Management in Subacute/Rehabilitation Phase?

A

• Usually outpatient with dressings

Up to 2 years post injury

111
Q

What are 5 aims in the Physiotherapy Management in Subacute/Rehabilitation Phase?

A 
• increase ROM
	• increase strength
	• improve CVS endurance
	• scar management
return to function
112
Q

What are the 9 Exercise Progression in the subacute/rehabilitation phase?

A
  • Regular / multiple exercise sessions per day – 3-6/12 hourly exercises.
    • Consider movement patterns / watch for compensatory movements (cheating activities) / correct and isolate appropriate movement
    • After day 5-7 Combined stretches to ensure full excursion of the skin as soon as possible
    • After 2-4/52 Add scar massage to EOR stretch to assist in improving skin pliability
    • Early strengthening programs using resistance eg light weights
    • Add endurance programs as soon as possible
    • Encourage functional use of affected areas – incidental exercise
    • Incorporate patients hobbies / interests into exercise program e.g. golf – trunk rotation / grip activities
    • Work in conjunction with positioning, splinting program
113
Q

What are 5 features of Hypermetabolism?

A

• Most patients with large %TBSA have spent either a long time in ICU or on bed rest and are debilitated
• Burns > 20% TBSA - hypermetabolic response
○ Metabolic rates ↑ 150-200%
○ Increased energy and protein requirements
○ Significant wasting of skeletal muscles
○ Loss of up to 15% of lean body mass
○ Can continue for 9 to 12 months post injury or longer
• Need early mobility, resisted and aerobic exercise to
○ Minimise deconditioning
○ Minimise effects of catabolism from hypermetabolic response to burns
• CV exercise program is important to build up fitness levels in preparation for return to work
• Early gym programs – resisted and aerobic exercise improve patient outcomes
○ Decreased contracture release surgery
○ Increased Strength, ROM, endurance
Imp roved Quality of Life

114
Q

What are 6 signs of a Signs of Hypertrophic Scar?

A

• Colour and Vascularity (purple ➢ red ➢ pink)
• Height: Thickened texture of scar
○ Bumpy & irregular scar texture
• Pliability: Hard, non supple or pliable feel
○ ↓ ROM & function
• Sensation: Altered sensation, hypersensitivity, itch, pain
• Associated Oedema
Scar Maturation – 18 months to 2 years

115
Q

What are some Acute Anti-deformity Positions (Rest in positions with skin stretch)?

A

Image

116
Q

ADD CONTRACTURES

A

ADD

117
Q

What are the 6 features of pressure garments?

A 
• Worn 23 hours per day
	• Continued for 18 months - 2 years. 
		○ Could be hot - need compliance
	• 2 sets: Interim to customised garments.
	• Pressure = 25mmHg
	• Replaced every 3-6 months to maintain adequate pressure
	• Multiple colours
Silicon under pressure garments
118
Q

What are 2 psychosocial aspects for scar management?

A

• Depression, body image concerns
Cosmetic camouflage products: Microskin-simulated second skin which is formulated individually to colour correct for patient’s skin. Is sprayed on, is waterproof and lasts several days.

119
Q

What are the 4 rationales for scar massage?

A

• Remodels/softens collagen bundles and adhesions
• Scar desensitisation including where itch is present
• Increased joint / skin mobility
Reduction in oedema

120
Q

What are the 5 indications for scar massage?

A

• Skin well healed – ≥2 weeks post skin graft
• Scarring with underlying adhesions or blocking lymphatic flow
• Scar nodules/bands
• Performed with non-perfumed moisturising cream
Enough pressure for scar blanching

121
Q

What are the 4 contraindications for scar massage?

A

• Scar inflammation
• Fragile scar
• Newly healed skin
Check before and after massage for blistering

122
Q

What are the 6 outcomes for scar massage?

A 
• Decrease in pain 
• Decrease in itch
• Decrease in scar height
• Decreased scar vascularity
• Increased scar pliability
Improved levels of depression
123
Q

What are 5 important general information about the skin post burn?

A

• Skin care: Keep skin well moisturised
• Water based moisturiser – no perfumes
○ Oatmeal based moisturiser may help with decreased itch (e.g. dermaveen products)
• Sun protection: Skin will now always be more susceptible to sun burn – need SPF30+ sunscreen and long sleeves even over pressure garments (garments do not provide full sun protection).
• Swimming
○ Majority of wounds healed
○ Sun protection
○ Garment vs no garment
• Contact sports
○ The burnt skin is still only 80% as strong as normal skin at 12 months post injury
Contact sports need to be avoided for first 6-8 months but all other activities can be continued (e.g. running, gym program etc)

124
Q

Heterotopic Ossification ADD

A

ADD

125
Q

How does burns affect the other parts of the body? (not just skin)

A

ADD

126
Q

What are the 3 main things for physiotherapy in a burns unit/

A

• Ongoing respiratory management
○ Positive pressure techniques
○ Long term effects of inhalation injury
○ Referral to respiratory physician
• Ongoing contracture management
○ Effective pain relief – liaise with chronic pain team
○ Stretch programs – long stretch times at EOR
○ Work with occupational therapist
○ Problems with compliance with therapy – liaise with social work and psychology
• Improve muscle strength/CVS endurance/mobility
○ Strengthening opposite to potential contracture
○ Early gym programs – resisted and aerobic exercise
○ Gait re-education
○ Hydrotherapy once majority wounds healed

127
Q

What are the 3 main things for physiotherapy for Long Term Rehabilitation/Outpatients after a burns injury?

A

• Ongoing issues of skin contracture/hypertrophic scar
○ Long term exercise program (minimum of 6-12 months)
○ Pressure garments (18 months – 2 years)
○ Referral to OPD Physiotherapy and Occupational Therapy
• Psychology and Social Work Follow Up
○ Referral to and liaison with local psychology services
○ Updates to GP
• Burn OPD Clinic Follow Up
• Return to work / School / Re-integration

PHTY2101 EOS (22 decks)

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