Burn Injury and Rehab Flashcards
Characteristics of the Epidermis and Dermis:
EPIDERMIS
-provides protection
-consists of 5 layers
-avascular
-regenerated by keratinocytes
DERMIS
-papillary dermis: loosely distributed collagen and elastin
-reticular dermis: densely packed collagen; “Lattice work”
-fibroblasts
Contents of hypodermis/subcutaneous layer of the skin
-adipose and connective tissue
Layers of skin involved in 1st degree (superficial), 2nd degree (partial thickness), and 3rd degree burns (full thickness)
Superficial
-epidermis
Partial Thickness
-superficial partial (papillary dermis)
-deep partial (reticular dermis)
-epidermis and dermis involved
Full thickness
-epidermis, dermis, subcutaneous layer
Characteristics of a superficial thickness burn:
SURFACE: dry, no blisters, blanches with pressure
COLOR: red, bright pink
SENSATION: painful
HISTOLOGIC DEPTH: epidermis
HEALING: 3-7 days, may peel
NOT included in TBSA %
Characteristics of a superficial partial thickness burn:
SURFACE: blistered, weeping
COLOR: bright red
SENSATION: very painful
HISTOLOGIC DEPTH: epidermis, papillary dermis (exposes sensory nerves, sweat glands, hair follicles)
HEALING: 7-21 days, by re-epithelialization, minimal to no scarring, pigment change unlikely
Characteristics of a deep partial thickness burn:
SURFACE: pseudoeschar
COLOR: mottled white to pink, blanching indicated healing
–> will either heal on own or convert to full thickness burn
SENSATION: pain indicates healing, no pain indicates a deep burn
HISTOLOGIC DEPTH: epidermis, papillary and reticular dermis
HEALING:
-21-35 days
-may develop severe hypertrophic scarring (when too much collagen is deposited in the area of an injury, causing a raised scar.)
Full thickness burn
SURFACE:
-dry, leathery, charred
COLOR
-mixed white, waxy, pearly, khaki
SENSATION
-no pain, hair pulls out easily
HISTOLOGIC DEPTH
-epidermis, dermis, subcut tissue, beyond
HEALING
-skin grafting ** surgical intervention is required
Lund and Browder TBSA
- Most accurate method of determining Total Body Surface Area (TBSA)
- Necessary to calculate fluid resuscitation requirements
- Superficial burn NOT included in calculations **
- Inhalation injuries can add to TBSA depending on the degree of injury–> can have over 100%
Rule of 9s
- Body surface of an adult,
divided into 11 segments - Segments of 9% or multiples of
9%; 1% for perineum - Easy to remember
- Different table for children
- Palm of patient’s hand (including
fingers)= 1% of TBSA - Small areas may be estimated
in this manner
What are the 4 types of burns:
THERMAL - scald, flame, friction
ELECTRICAL
CHEMICAL
RADIATION
Scald burn type
-most common from hot liquids and grease
-common in children and elderly
-pattern:
–> downward with splash marks: accident
–> circumferential: abuse?
Flame burn type
-may involve inhalation injury in closed doors
-patterns vary
Electrical burns:
Tip of the iceberg: contact points may be small, internal damage may be more severse
-follows pattern of least resistance
bone>fat>tendon>skin>muscle>blood vessels>nerves
high voltage power lines are common cause
flash/flame/contact
Friction type burn
-road rash usually from MVA or bike accident
Chemical burns
-want to treat with mass dilution
–> continuous showering for a prolonged period after the injury
-attempts to chemically neuralize the burn can have adverse effects
-household cleaning agents can cause
-industrial: sodium hydroxide
What’s are types of radiation burns?
sunburn
radiation therapy
What is necrotizing fasciitis?
-bacterial infection
-progresses quick
–> red,warm,swollen area
–> fever
-need antibiotics and daily surgical debridement
-complications:
–> sepsis, shock, organ failure
–> life or limb
-severe scarring
-need to excise affected tissue immediately
Steven’s Johnson Syndrome
(SJS) vs TEN
-both usually result from allergic reaction to medication
SJS:
-higher mortality rate
< 10% TBSA
TENS:
-very painful
-less concerned about scarring
-effects the epidermis of the skin
> 30% TBSA
Frostbite:
-Hennepin score- quantifies injury and tissue loss of FB injury
-largely affects the homeless population
-tPA protocol, bone scan, rewarming
-heal vs amputation
Tissue plasminogen activator (tPA) is a protein that helps break down blood clots. I
Burns effect on renal system
HYPOVOLEMIC SHOCK:
–> most immediate life-threatening response to injury
–> marked fluid loss
–> fluid shift from intravascular space to extravascular (3rd) space : organs left dry
–> decrease BP decrease urine output
–> increase heart rate
-URINE OUTPUT CLOSELY MONITORED (bc decreased
-acute renal failure
Burns effect on Integumentary System
-similar temps cause different depths of injury to different parts of the body
ex: palm of hand versus eyelids
-change in temperature regulation-> acutely, burn victims are cold
–> after grafting, sweat through non-grafted areas
-infection is a risk
-pediatric and geriatric population have most delicate skin type
What is an escharotomy?
-when fluid accumulates in the extracellular space
-circumferential burn/eschar acts as a tourniquet (full thickness burn)
-can lead to ischemic extremities and compartment syndrome
-treat full-thickness circumferential burns, restore circulation, and allow for ventilation
Burns effects on respiratory system:
AIRWAY MANAGEMENT
-edema can invade airway
INHALATION INJURY
-enclosed space vs open area
-mechanical clearance of mucous
PRE-EXISTING CONDITONS
-COPD, emphysema, smoking
VENTILATOR ASSOCIATED PNEUMONIA
-extubate as soon as possible
Burns effects on the CV system:
TACHYCARDIA
-due to hypovolemia (initial injury)
-pain
-monitor during therapy
** know their typical baseline
BEDREST/DECONDITIONING
-associated with loss of plasma volume and LV atrophy
PRE-EXISTING CARDIAC CONDITIONS
–> these can contribute
Burns effects on GI system:
BOWEL MANAGEMENT
-opiates slow motility
-prevent bowel obsetruction
-rectal tube, stool softeners
–> keep wound clean and dry of any stool
NG TUBE (Dobhoff tube)
-pt with only 20% burn- diff to meet nutritional req with a regular diet
–> need to increase protein and calories for wound healing and body is in a hypermetabolic state > muscle catabolism
Types of Burn wound coverage:
Burn excision
Temporary:
-allograft
-xenograft
-skin substitutes
Definitive coverage
-autograft
Burn excision:
-burn eschar–> systemic inflammation
-leads to healthy, bleeding wound base
Allograft and Xenograft (temporary coverage)
-cadaver skin (allograft)
–> placed temporarily until the wound is ready for grafting
-xenograft (usually pig)
LARGE TBSA
-used for temp coverage
SMALL TBSA
-used to test readiness of wound bed for an autograft
Skin substitutes (synthetic or biologics) (temporary coverage)
-used to cover joints, bones, tendons, cartilage
-provides scaffolding for cellular invasion and capillary growth
** SCAFFOLDING
-often have to immobilize the joint if there is a skin substitute on it
Difference between split thickness skin graft and full thickness skin graft (autograft-definitive coverage)
STSG
-0.007-0.16 inches thick
-epidermis and portion of dermis
-heals in 10-14 days (where the skin graft came from)
-sheet graft, mesh graft
FTSG
-entire thickness of skin down to subcutaneous tissue
-heavy burden on the donor site
-used on eyelids, palmar aspect of hands/fingers
-reconstruction
-better cosmetic appearance?
Characteristics of donor site for autograft:
-partial thickness wound
-heals by re-epithelialization
-10-14 days
-re-harvest
Mesh graft (STSG) characteristics:
-graft has to go through machine to achieve “mesh” shape
-interstices allow for wound drainage
-can cover large area
-less durable than sheet grafts
-waffle like
Sheet graft (STSG) characteristics:
-unaltered graft
-more cosmetically appealing
-need large donor site
-watch for bleeding
-need to make small slits in graft to allow “breathing”
Cultured epidermal autograft
Patients with large TBSA- >30% TBSA
-skin biopsies taken at admission–> sent to lab to grow skin cells
–> very fragile
-surgeon places cassettes (with cells) over large meshed STSG
-skin cells fill in the gaps of the mesh
-period of immobilization (bed rest)
RECELL ASCS (autologous skin cell suspension)
-small donor site (size of postage stamp)
-donor skin placed into an enzymatic solution
–> 15-20 minutes surgeon scrapes epidermis from dermis
–> draws up solution and sprays onto a meshed STSG
ADVANTAGES:
-small donor
-faster healing
-deep partial thickness burns
-used on donor sites to promote faster healing for re-harvest
-less expensive and accessible than CEA
-quicker rehab and less bedrest
Role of PT on burn unit:
-can be in the OR to open up skin grafts to improve ROM
-outpatient therapy
-outpatient reconstruction
-wound care
-rounds
-family meetings
ICU–> step down–> floor level
What does circumferential involvement mean in burns?
In circumferential burns, defined by an involvement of more than two thirds of the extremities, this inelastic eschar acts like a tourniquet and causes a buildup of pressure in closed fascial spaces, resulting in burn induced compartment syndrome.
PT evaluation of burns (not included in standard MSK eval)
-position of involved extremities, head an neck
-edema due to possible hypovolemic shock
-mechanism of burn injury
-TBSA
-location of burn, circumferential involvement
-VITAL SIGNS: oftentimes this may be the only indicator of pain
Pt interventions specific to burns:
EDEMA:
-limb eval, positioning
-functional wrapping-use of conform and kerlix during wound care
-compression- ACE, isotoner gloves, tubigrip
-lymphedema bandaging for improved wound healing- short stretch bandaging and foam
** elevate extremities
POSITIONING:
-begins day 1
-maintain ROM of joints –> elongate
-skin and nerve protection
-vascular support
SPLINTING:
-autograft protection
–> immobilize graft until POD5
-maintain ROM
–> promote AROM and functional use when doffed
-joint protection
–> immobilize an exposed joint with splint
CASTING
-serial casting- remediate contractures
-total contact casts- redistribute ground forces during ambulation
ROM/STRETCHING:
- details on next flashcard
SCAR MANAGEMENT
-scar massage combined with stretching; identify hypertrophic scars and banding
-compression: start with off the shelf, then custom compression garments
–> wear up to 23 hours/day
-CO2 laser therapy- outpatient (soften up skin prior to contracture release)
-Z-plasty: scar release
EXERCISE
ROM/STRETCHING intervention for patients with burns:
AROM
-encouraged prior to grafting for edema reduction
-POD5 after autografting if good graft take
-gain as much of this before strengthening
-may start 24 hours after allografting
PROM
-prior to grafting, know available range given edema
-gentle PROM 5-7 days after autografting
-may start 24 hours after allografting
-be mindful of end-feels, skin blanching, speed/duration of passive stretch
–> during wound care/OR
AAROM
EXERCISE interventions post-burn
-begin day 1
-prevent contractures, maintain ROM/function
-important to appreciate current medical status and where the patient is in healing
-MONITOR VITALS
-stretch > strengthen within given ROM > splint to maintain ROM
-know PMH
** keep in mind all injuries –> exposed joint/tendon, fresh grafts, ortho issues
-larger TBSA %–> high risk of deconditioning (1 day in ICU for 1% TBSA)
