Burn Management Flashcards
Is the epidermis or dermis superficial?
epidermis
What is the purpose of the epidermis?
protection, adherence to the dermis via rete pegs, UV protection (melanin produce pigments)
avascular
What is the purpose of the dermis?
provides mechanical strength for the skin
made up of 2 layers- papillary layer, reticular layer
vascular and innervated
What are epidermal appendages?
hair follicles, sweat glands, sebaceous glands
What is the hypodermis?
subcutaneous fat & fascia
Where is skin thinnest?
eyelids
Where is skin thickest?
palms, soles of feet, back
What is the Fitzpatrick skin type scale?
a numerical classification for skin colour
Type 1-6 (light to dark)
type 1, 5 and 6 at high risk of scarring
What are some implications of skin loss due to burn injuries?
impaired temperature control increased sensitivity sun burn vitamin D deficiency infection
How are burn classified?
by the type, depth and size/area of burn
How does a superficial burn present?
epidermis is destroyed
appears red and blistered
rapid capillary return (dermis intact)
wounds close spontaneously 7-10 days
How does a superficial partial thickness burn present?
epidermis and some dermis destroyed rapid capillary return red and blistered appearance sensation intact wound closure spontaneously in 14 days
How does a deep partial-thickness burn present?
epidermis and deeper dermis destroyed delayed capillary return decreased sensation (some nerve endings damaged) creamy moist white appearance wound takes >14 days to heal potentially need a skin graft to heal
How does a deep full-thickness burn present?
epidermis dermis and underlying structures destroyed dry leathery appearance no capillary return no sensation takes >3 weeks to heal with graft
What are the 3 stages of wound healing?
inflammatory phase (1-5 days) cell proliferation phase (3-5 days - 3 weeks) remodelling phase (3 weeks- 12-18 months)
What occurs during the cell proliferation phase of wound healing?
fibroblasts begin synthesising collagen & ground substance (provides tensile strength)
fibroblasts differentiate into myofibroblasts
myofibroblasts cause wound contraction (pull wound edges together)
at the end of this phase the collagen within the dermis is disorientated, lack of rete pegs and the wound is prone to abrasion and minor trauma
What occurs during the remodeling phase of wound healing?
collagen forms cross-links (increase tensile strength of scar tissue)
tensile strength continues to increase up to 12 months post-injury
ground substance is more dense and bony like
continual collagen synthesis with orientation becoming parallel with mechanical stress
myofibroblasts peak in number 4-5 months post-injury
scars are adaptable to rehab during this phase
What are some characteristics of a hypertrophic scar?
common when healing time exceeds 3 weeks
reduced skin stretch (constant contracture of myofibroblasts)
scar adheres to underlying structures
reduced skin strength (reduced collagen cross-linking)
Who is more likely to scar post-burn injury?
females
adults, elderly
those who do not comply with/access early treatment
dark skin (type 5 & 6)
What is appropriate first aid with burns?
stop the burning
copious water irrigation (20 minutes)
avoid dirt & dirty water
What is an escharotomy?
in the case of a circumferential burns
an incision through dead tissue to relieve pressure and improve tissue perfusion in muscle compartment
How is conservative burn wound management approached?
silver-based dressings (provides antibacterial effect & promotes healing)
silvazine/flamazine cream changed daily
What is an autograft?
a graft is taken from patient and placed over burn injury
most common graft used for superficial partial-thickness wounds
takes within 48 hours and is vascularised on day 5-6
can be meshed, non-meshed, split-thickness or full-thickness
What is the difference between split-thickness and full-thickness grafts?
split= epidermis & varying amounts of dermis
full= epidermis & dermis
What is the difference between meshed grafts and non-meshed grafts
meshed: graft put through meshing device, better early take of graft, cosmetically worse as mesh pattern sticks around
non-meshed: used for cosmetically important areas (face & hands), longer to take
What are autologous grafts?
grafts created from patients’ epidermal cells (takes 2-3 weeks for cells to be cultured)
allows large sites to be covered without donor sites and nil rejection as it is patients own skin
skin remains fragile
What is a homograft?
a cadaver allograft sandwiched on
expensive & in short supply
rejection occurs in 7-14 days
Biobrane is a skin substitute, what is it?
synthetic nylon mesh fabric covered with a silicone rubber membrane
used as a temporary cover for partial thickness burns while grafts are prepared
BTM is a skin substitute, what is it?
biodegradable temporizing matrix
2 layer system: dermal replacement made of synthetic sponge, epidermal replacement made of silicone
stays in place for 4-5 weeks while granulation occurs
What are the signs and symtpoms of an inhalation injury?
facial/oral burns
burn injury occured within an enclosed space (i.e. within a house)
lowered conciousness at the time of the fire (i.e. drug, alcohol use or pre-existing conditions)
soot in nose or mouth
hoarse voice
respiratory distress
high levels of carboxyhaemoglobin, decreased O2
Where will you see damage in the respiratory tract?
upper: as a result of direct thermal damage
lower: as a result of chemical compounds contained in the inhaled smoke
How do you confirm an inhalation injury?
bronchoscopy: airway oedema, inflammation, muscousal necrosis, soot in airways
What are the clinical stages of inhalation injury?
actue pulmonary insufficiency (first 36 hours)
pulmonary oedema (6-72 hours)
bronchopneumonia (3-10 days)
What does physiotherapy management of inhalation injuries look like?
respiratory assessment (of both injury & other resp. complications)
techniques to:
- increase air entry
- improve secretion clearance
- improve thoracic mobility
- improve cardiovascular endurance and exercise tolarence
How would you differ treatments for ventilated patients?
more focus on positioning and manual hyperinflation/ventilator hyperinflation to move and remove secretion
tilt table activites and passive movements
Where would you focus treatment on a patient that is not ventilated post inhalation injury?
increasing their ventilation & removal of secretions using incentive spirometry & positive pressure devices
improving mobility esp through the thoracic region
manual techniques of vibration and percussion
cardiovascular exercises
How long after a graft can we recommence manual techniques on patients with an inhalation injury?
3-5 days
longer for synthetic temporary grafts
What are some long term respiratory complications after an inhalation injury?
bronchiectasis recurrent chest infections pulmonary fibrosis tracheal stenosis persistent impairment of lung function lower exercise capacity respiratory muscle weakness
What are the 5 assessments that need to be done with a burns patient during a physical assessment?
- pain assessment
- respiratory assessment
- musculoskeletal assessment
- oedema assessment
- mobility assessment
What are the 4 main things you are trying to achieve with treatment on patients with inhalation injuries?
increase air entry
improve secretion clearance
improve thoracic mobility
improve cardiovascular fitness
Why do we need to manage oedema post burn injury?
oedema can prolong the healing of the wounds
What is the aim of exercise post burn injury?
decrease fear of movement minimise contractures/maintenance of ROM minimise effects of deconditioning minimise effects of hypermetabolism/muscle catabolism minimise oedema
When is it appropriate to start exercise with patients post burn injury?
day 1
on a graft area: 3-5 days
Why should we do our first exercise session without dressings covering our patients burns?
to see where possible contracture is happening/may happen (blanching or banding)
What exercise techniques might we use with our burns patients in their acute stage?
active/active assissted repeated movements until full ROM is achieved
progress to resisted exercise as able
slow sustained stretching with end of range holds (to allow for creep in tissues)
hold relax/contract relax
encourage functional use of affected areas (i.e. holding utensils)
education
What are some precautions to exercise in the acute phase of a burn injury?
exposed tendons
potential tendon damage due to location of burn (i.e. dorsum of hand, avoid combining joint movements)
escharotomies & fasciotomies
Why is positiong of our patients during their acute phase post burn injury important?
it helps to maintain a passive stretch to avoid contracture
What is contracture?
the inability to perform full ROM of a joint or body part
may be transient or persistent
33% of patients with burns requiring autografting will experience contracture
What causes contracture?
scar tissue contracts due to the presence of myofibroblasts in the wound
peak numbers at 4-6 months post injury
What are the 4 things we can do to prevent contracture?
- exercise
- mobility and ambulation
- splinting
- positioning
What are our exercise goals for patients in the sub-actue/rehabilitaion phase post burn injury?
- maintain/ increase ROM and skin stretch
- increase strength
- improve cardiovascular endurance
- restore patient to their per morbid functionall level
What is the most common contracture in the face?
microstomia: decreased mouth opening
What is the most common contracture at the neck?
neck flexion with shoulder protraction and internal rotation
What is the most common contracture at the elbow?
elbow flexion, may have loss of supination
What is the most common contracture at the hip?
hip flexion
What are some adjuncts to exercise we can use with sub-acute patients?
heat and paraffin wax
hydrotherapy
wii/interactive video games
virtual reality
What is the point of using a pressure garment/compression therapy?
to maintain a constant presure applied to a body area through the use of a tight-fitting garment
works to: reduction of local blood flow to scar reduction in fibroblast activity reduced collagen deposition reduces itching, pain and blood rush sensation
What do contact media/silicones do during scar management?
reduces scar maturation time and improve cosmetic appearance through direct contact with the scar
works by:
increased temperature
increased scar hydration
accelerated tissue remodelling
can come in sheets, gel or moulds
When is taping appropriate for scar management?
for prevention of friction on high use areas i.e. the thumb and finger webspaces
downsides: allergies to tape and safe removal of tape
Why do we use massage as a scar management technique?
decrease pain/itch
increase pliability of scar
decrease scar height/vascularity
begin 2-4 weeks after a skin graft
What are some options for surgical scar management?
corticosteriod injections (inhibits fibroblast growth, causes collaged degradation)
dermabrasion
revision surgery
reconstruction surgery
laser (pulsed dye laser or ablative fractional CO2 laser) works similar to microneedling where small wounds are made in the epidermis and trigger collagen renewal
What are some options for surgical scar management?
corticosteriod injections (inhibits fibroblast growth, causes collaged degradation)
dermabrasion
revision surgery
reconstruction surgery
laser (pulsed dye laser or ablative fractional CO2 laser) works similar to microneedling where small wounds are made in the epidermis and trigger collagen renewal
What is a hypermetabolic response?
when burns occur >20% of the body, catabolism of lean muscle mass and decreased muscle strength occurs
metabolic rates can increase 150-200% and can continue for 9 to 12 months post injury
What is heterotpoic ossification?
a complication of burns resulting in bone formation in connectve tissue where it shouldn’t be
often seen in the postero-medial elbow
decreases ROM, deep joint pain, warmth in joint, swelling
What are the risk factors for heterotopic ossification?
burns >30% of the body delay of skin coverage (i.e. wound infection, sepsis graft loss) lots of surgery prolonged immobilisation prolonged ICU stay persistent oedema patient agitation/restlessness limited shoulder ROM circumferential full thickness burns
What neurological complications may be seen post burn injury?
localised neuropathy: 15-37% incidence, commonly in the peroneal, ulnar, radial nerves and brachial plexus
critical illness polyneuropathy (ICU weakness syndrome: 15-30% incidence, generalised weakness in muscles
When would amputation be required post burn injury?
if the limb if non viable or as a life saving measure
i.e. in those with vascular diseases, chemical injuries where more than the skin is damaged, shrapnel injust or severe fracture affecting the circulatory bed of the limb
What kind of skin care is important for patients post burn injury?
hydration (loss of sebaceous glands) sun protection (loss of melanocytes) heat intolerance (due to loss of sweat glands)
Why should patients wait 6-8 months to return to contact sports post burn injury?
scar tissue is only 80% as strong as normal skin at 12 months post injury
How soon would we see wound closure in a superficial partial thickness burn?
~14 days
How soon would we see wound closure for deep partial thickness burns?
> 14 days
How soon would we see wound closure for deep full thickness burns?
> 3 weeks
