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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
Q

What is the difference between meshed grafts and non-meshed grafts

A

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

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26
Q

What are autologous grafts?

A

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

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27
Q

What is a homograft?

A

a cadaver allograft sandwiched on

expensive & in short supply
rejection occurs in 7-14 days

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28
Q

Biobrane is a skin substitute, what is it?

A

synthetic nylon mesh fabric covered with a silicone rubber membrane

used as a temporary cover for partial thickness burns while grafts are prepared

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29
Q

BTM is a skin substitute, what is it?

A

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
Q

What are the signs and symtpoms of an inhalation injury?

A

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
Q

Where will you see damage in the respiratory tract?

A

upper: as a result of direct thermal damage
lower: as a result of chemical compounds contained in the inhaled smoke

32
Q

How do you confirm an inhalation injury?

A

bronchoscopy: airway oedema, inflammation, muscousal necrosis, soot in airways

33
Q

What are the clinical stages of inhalation injury?

A

actue pulmonary insufficiency (first 36 hours)
pulmonary oedema (6-72 hours)
bronchopneumonia (3-10 days)

34
Q

What does physiotherapy management of inhalation injuries look like?

A

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
Q

How would you differ treatments for ventilated patients?

A

more focus on positioning and manual hyperinflation/ventilator hyperinflation to move and remove secretion

tilt table activites and passive movements

36
Q

Where would you focus treatment on a patient that is not ventilated post inhalation injury?

A

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
Q

How long after a graft can we recommence manual techniques on patients with an inhalation injury?

A

3-5 days

longer for synthetic temporary grafts

38
Q

What are some long term respiratory complications after an inhalation injury?

A 
bronchiectasis
recurrent chest infections
pulmonary fibrosis
tracheal stenosis
persistent impairment of lung function 
lower exercise capacity
respiratory muscle weakness
39
Q

What are the 5 assessments that need to be done with a burns patient during a physical assessment?

A
  1. pain assessment
  2. respiratory assessment
  3. musculoskeletal assessment
  4. oedema assessment
  5. mobility assessment
40
Q

What are the 4 main things you are trying to achieve with treatment on patients with inhalation injuries?

A

increase air entry
improve secretion clearance
improve thoracic mobility
improve cardiovascular fitness

41
Q

Why do we need to manage oedema post burn injury?

A

oedema can prolong the healing of the wounds

42
Q

What is the aim of exercise post burn injury?

A 
decrease fear of movement
minimise contractures/maintenance of ROM
minimise effects of deconditioning 
minimise effects of hypermetabolism/muscle catabolism
minimise oedema
43
Q

When is it appropriate to start exercise with patients post burn injury?

A

day 1

on a graft area: 3-5 days

44
Q

Why should we do our first exercise session without dressings covering our patients burns?

A

to see where possible contracture is happening/may happen (blanching or banding)

45
Q

What exercise techniques might we use with our burns patients in their acute stage?

A

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
Q

What are some precautions to exercise in the acute phase of a burn injury?

A

exposed tendons
potential tendon damage due to location of burn (i.e. dorsum of hand, avoid combining joint movements)
escharotomies & fasciotomies

47
Q

Why is positiong of our patients during their acute phase post burn injury important?

A

it helps to maintain a passive stretch to avoid contracture

48
Q

What is contracture?

A

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
Q

What causes contracture?

A

scar tissue contracts due to the presence of myofibroblasts in the wound

peak numbers at 4-6 months post injury

50
Q

What are the 4 things we can do to prevent contracture?

A
  1. exercise
  2. mobility and ambulation
  3. splinting
  4. positioning
51
Q

What are our exercise goals for patients in the sub-actue/rehabilitaion phase post burn injury?

A
  1. maintain/ increase ROM and skin stretch
  2. increase strength
  3. improve cardiovascular endurance
  4. restore patient to their per morbid functionall level
52
Q

What is the most common contracture in the face?

A

microstomia: decreased mouth opening

53
Q

What is the most common contracture at the neck?

A

neck flexion with shoulder protraction and internal rotation

54
Q

What is the most common contracture at the elbow?

A

elbow flexion, may have loss of supination

55
Q

What is the most common contracture at the hip?

A

hip flexion

56
Q

What are some adjuncts to exercise we can use with sub-acute patients?

A

heat and paraffin wax
hydrotherapy
wii/interactive video games
virtual reality

57
Q

What is the point of using a pressure garment/compression therapy?

A

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
Q

What do contact media/silicones do during scar management?

A

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
Q

When is taping appropriate for scar management?

A

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
Q

Why do we use massage as a scar management technique?

A

decrease pain/itch
increase pliability of scar
decrease scar height/vascularity

begin 2-4 weeks after a skin graft

61
Q

What are some options for surgical scar management?

A

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
Q

What are some options for surgical scar management?

A

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
Q

What is a hypermetabolic response?

A

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
Q

What is heterotpoic ossification?

A

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
Q

What are the risk factors for heterotopic ossification?

A 
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
Q

What neurological complications may be seen post burn injury?

A

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
Q

When would amputation be required post burn injury?

A

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
Q

What kind of skin care is important for patients post burn injury?

A 
hydration (loss of sebaceous glands) 
sun protection (loss of melanocytes)
heat intolerance (due to loss of sweat glands)
67
Q

Why should patients wait 6-8 months to return to contact sports post burn injury?

A

scar tissue is only 80% as strong as normal skin at 12 months post injury

68
Q

How soon would we see wound closure in a superficial partial thickness burn?

A

~14 days

69
Q

How soon would we see wound closure for deep partial thickness burns?

A

> 14 days

70
Q

How soon would we see wound closure for deep full thickness burns?

A

> 3 weeks

PHTY2101 (10 decks)

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