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PHTY2101 > Burn Management > Flashcards

Burn Management Flashcards

1
Q

Is the epidermis or dermis superficial?

A

epidermis

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2
Q

What is the purpose of the epidermis?

A

protection, adherence to the dermis via rete pegs, UV protection (melanin produce pigments)

avascular

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3
Q

What is the purpose of the dermis?

A

provides mechanical strength for the skin

made up of 2 layers- papillary layer, reticular layer

vascular and innervated

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4
Q

What are epidermal appendages?

A

hair follicles, sweat glands, sebaceous glands

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5
Q

What is the hypodermis?

A

subcutaneous fat & fascia

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6
Q

Where is skin thinnest?

A

eyelids

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7
Q

Where is skin thickest?

A

palms, soles of feet, back

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8
Q

What is the Fitzpatrick skin type scale?

A

a numerical classification for skin colour

Type 1-6 (light to dark)

type 1, 5 and 6 at high risk of scarring

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9
Q

What are some implications of skin loss due to burn injuries?

A 
impaired temperature control
increased sensitivity
sun burn
vitamin D deficiency 
infection
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10
Q

How are burn classified?

A

by the type, depth and size/area of burn

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11
Q

How does a superficial burn present?

A

epidermis is destroyed
appears red and blistered
rapid capillary return (dermis intact)
wounds close spontaneously 7-10 days

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12
Q

How does a superficial partial thickness burn present?

A 
epidermis and some dermis destroyed
rapid capillary return 
red and blistered appearance 
sensation intact
wound closure spontaneously in 14 days
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13
Q

How does a deep partial-thickness burn present?

A 
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
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14
Q

How does a deep full-thickness burn present?

A 
epidermis dermis and underlying structures destroyed
dry leathery appearance
no capillary return 
no sensation 
takes >3 weeks to heal with graft
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15
Q

What are the 3 stages of wound healing?

A 
inflammatory phase (1-5 days)
cell proliferation phase (3-5 days - 3 weeks)
remodelling phase (3 weeks- 12-18 months)
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16
Q

What occurs during the cell proliferation phase of wound healing?

A

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

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17
Q

What occurs during the remodeling phase of wound healing?

A

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

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18
Q

What are some characteristics of a hypertrophic scar?

A

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)

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19
Q

Who is more likely to scar post-burn injury?

A

females
adults, elderly
those who do not comply with/access early treatment
dark skin (type 5 & 6)

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20
Q

What is appropriate first aid with burns?

A

stop the burning
copious water irrigation (20 minutes)
avoid dirt & dirty water

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21
Q

What is an escharotomy?

A

in the case of a circumferential burns

an incision through dead tissue to relieve pressure and improve tissue perfusion in muscle compartment

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22
Q

How is conservative burn wound management approached?

A

silver-based dressings (provides antibacterial effect & promotes healing)

silvazine/flamazine cream changed daily

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23
Q

What is an autograft?

A

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

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24
Q

What is the difference between split-thickness and full-thickness grafts?

A

split= epidermis & varying amounts of dermis

full= epidermis & dermis

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25
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
26
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
27
What is a homograft?
a cadaver allograft sandwiched on expensive & in short supply rejection occurs in 7-14 days
28
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
29
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
30
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
31
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
32
How do you confirm an inhalation injury?
bronchoscopy: airway oedema, inflammation, muscousal necrosis, soot in airways
33
What are the clinical stages of inhalation injury?
actue pulmonary insufficiency (first 36 hours) pulmonary oedema (6-72 hours) bronchopneumonia (3-10 days)
34
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
35
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
36
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
37
How long after a graft can we recommence manual techniques on patients with an inhalation injury?
3-5 days longer for synthetic temporary grafts
38
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 ```
39
What are the 5 assessments that need to be done with a burns patient during a physical assessment?
1. pain assessment 2. respiratory assessment 3. musculoskeletal assessment 4. oedema assessment 5. mobility assessment
40
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
41
Why do we need to manage oedema post burn injury?
oedema can prolong the healing of the wounds
42
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 ```
43
When is it appropriate to start exercise with patients post burn injury?
day 1 on a graft area: 3-5 days
44
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)
45
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
46
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
47
Why is positiong of our patients during their acute phase post burn injury important?
it helps to maintain a passive stretch to avoid contracture
48
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
49
What causes contracture?
scar tissue contracts due to the presence of myofibroblasts in the wound peak numbers at 4-6 months post injury
50
What are the 4 things we can do to prevent contracture?
1. exercise 2. mobility and ambulation 3. splinting 4. positioning
51
What are our exercise goals for patients in the sub-actue/rehabilitaion phase post burn injury?
1. maintain/ increase ROM and skin stretch 2. increase strength 3. improve cardiovascular endurance 4. restore patient to their per morbid functionall level
52
What is the most common contracture in the face?
microstomia: decreased mouth opening
53
What is the most common contracture at the neck?
neck flexion with shoulder protraction and internal rotation
54
What is the most common contracture at the elbow?
elbow flexion, may have loss of supination
55
What is the most common contracture at the hip?
hip flexion
56
What are some adjuncts to exercise we can use with sub-acute patients?
heat and paraffin wax hydrotherapy wii/interactive video games virtual reality
57
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 ```
58
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
59
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
60
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
61
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
61
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
62
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
63
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
64
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 ```
65
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
66
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
67
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) ```
67
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
68
How soon would we see wound closure in a superficial partial thickness burn?
~14 days
69
How soon would we see wound closure for deep partial thickness burns?
>14 days
70
How soon would we see wound closure for deep full thickness burns?
>3 weeks

PHTY2101 (10 decks)

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