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med con iii > Burn Injury and Rehab > Flashcards

Burn Injury and Rehab Flashcards

1
Q

Characteristics of the Epidermis and Dermis:

A

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

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2
Q

Contents of hypodermis/subcutaneous layer of the skin

A

-adipose and connective tissue

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3
Q

Layers of skin involved in 1st degree (superficial), 2nd degree (partial thickness), and 3rd degree burns (full thickness)

A

Superficial
-epidermis

Partial Thickness
-superficial partial (papillary dermis)
-deep partial (reticular dermis)
-epidermis and dermis involved

Full thickness
-epidermis, dermis, subcutaneous layer

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4
Q

Characteristics of a superficial thickness burn:

A

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 %

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5
Q

Characteristics of a superficial partial thickness burn:

A

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

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6
Q

Characteristics of a deep partial thickness burn:

A

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.)

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7
Q

Full thickness burn

A

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

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8
Q

Lund and Browder TBSA

A
  • 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%
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9
Q

Rule of 9s

A
  • 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
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10
Q

What are the 4 types of burns:

A

THERMAL - scald, flame, friction

ELECTRICAL

CHEMICAL

RADIATION

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10
Q

Scald burn type

A

-most common from hot liquids and grease
-common in children and elderly
-pattern:
–> downward with splash marks: accident
–> circumferential: abuse?

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10
Q

Flame burn type

A

-may involve inhalation injury in closed doors

-patterns vary

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11
Q

Electrical burns:

A

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

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11
Q

Friction type burn

A

-road rash usually from MVA or bike accident

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11
Q

Chemical burns

A

-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

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11
Q

What’s are types of radiation burns?

A

sunburn

radiation therapy

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12
Q

What is necrotizing fasciitis?

A

-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

12
Q

Steven’s Johnson Syndrome
(SJS) vs TEN

A

-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

12
Q

Frostbite:

A

-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

12
Q

Burns effect on renal system

A

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

13
Q

Burns effect on Integumentary System

A

-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

14
Q

What is an escharotomy?

A

-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

15
Q

Burns effects on respiratory system:

A

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

16
Q

Burns effects on the CV system:

A

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

17
Q

Burns effects on GI system:

A

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

18
Q

Types of Burn wound coverage:

A

Burn excision

Temporary:
-allograft
-xenograft
-skin substitutes

Definitive coverage
-autograft

19
Q

Burn excision:

A

-burn eschar–> systemic inflammation

-leads to healthy, bleeding wound base

20
Q

Allograft and Xenograft (temporary coverage)

A

-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

21
Q

Skin substitutes (synthetic or biologics) (temporary coverage)

A

-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

22
Q

Difference between split thickness skin graft and full thickness skin graft (autograft-definitive coverage)

A

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?

23
Q

Characteristics of donor site for autograft:

A

-partial thickness wound
-heals by re-epithelialization
-10-14 days
-re-harvest

24
Q

Mesh graft (STSG) characteristics:

A

-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

25
Q

Sheet graft (STSG) characteristics:

A

-unaltered graft
-more cosmetically appealing
-need large donor site
-watch for bleeding

-need to make small slits in graft to allow “breathing”

26
Q

Cultured epidermal autograft

A

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)

27
Q

RECELL ASCS (autologous skin cell suspension)

A

-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

28
Q

Role of PT on burn unit:

A

-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

29
Q

What does circumferential involvement mean in burns?

A

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.

30
Q

PT evaluation of burns (not included in standard MSK eval)

A

-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

31
Q

Pt interventions specific to burns:

A

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

32
Q

ROM/STRETCHING intervention for patients with burns:

A

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

33
Q

EXERCISE interventions post-burn

A

-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)

34
Q
A

med con iii (14 decks)

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