Burn Management Flashcards
Burns are a ______ problem, not just an integumentary issue
systemic
Burns are asses by ___________, not by staging or Wagner scale
thickness
Hydrotherapy is commonly used in the management of _______________
large body surface area burns
Any burn over ________% TBSA requires specialized care
9
Burn wounds are high risk for ____________ development when they span a joint
contracture
Burns are at a greater risk of developing __________________ scarring than other wound varieties
Hypertrophic or keloid
Aggressive ____________ interventions are required for optimal management of this patient population
ROM/positioning/splinting
_____________ garments are standard of care
compression
The epidermis is thin, __________ and _________
superficial and avascular
The roles of the epidermis
protection, waterproofing, and regeneration
Primary cell of the epidermis
keratinocyte
Keratinocyte
produces keratin which is the primary structural protein of the skin
What are the 5 layers of the epidermis from superficial to deep
Stratum corneum, stratum lucidum, stratum granulosum, stratum spinosum, and stratum basale
The basement membrane zone is the interface of the ___________ and ___________
epidermis and dermis
What is the key component of the basement membrane zone?
rete pegs
What do the rete pegs in the basement membrane do?
prevent shear
What is the primary cell of the dermis?
fibroblast
What are the roles of the dermis?
Tensile strength and nutrition to the epidermis
What does the dermis contain?
Collagen and elastin, blood vessels, lymphatics, nerves, and it encloses the epidermal appendages
What do fibroblasts produce?
Collagen
The dermis is located _________ to the epidermis and basement membrane
deep
What are the two layers of the Dermis?
Papillary and reticular
Papillary layer of the dermis is _______, has _________ collagen, and has ____________
superficial, loosely organized, vascular eminences
The Reticular layer of the dermis is _______, has ___________ collagen, and merges with the _______________
deep, thick/densely organized, hypodermis
The dermis contains _________ nerve receptors
sensory
The ____________ of a burn will determine sensory functions likely to be impaired
depth
Free nerve endings are located where and do what?
epidermis and dermis; pain and itch
Merkel’s disks are located where and do what?
stratum spinosum; touch
Meissner’s corpuscle are located where and do what?
Papillary dermis; touch
Ruffini’s corpuscle are located where and do what?
papillary dermis; warm/hot
Krause’s end bulb are located where and do what?
papillary dermis; cold
Pacinian corpuscle are located where and do what?
reticular dermis; pressure and vibration
What is a burn
energy from the heat source is transferred to the body and heat absorption causes cell death
Severity of a burn depends on what?
contact time, temperature, duration, and type
How many burn injuries are there a year in the US?
1.4 - 2 million
Who is at highest risk for a burn?
children under 3 and adults over 70
Most burns are ____________ (75% ______, 13% ____________, 5% __________ = 85-95% heat)
Thermal; flame, hot liquid, contact
About _____% of burns are due to electricity
3
About ________% of burns are chemical
1-2
Chemical burns can be caused by ________________
contact, ingestion, or inhalation of strong acids/alkalis
1% or less for each type of burn comes from ___________, _________, and _______________
hot gases, friction, and radiation
Not all burns are form a hot source, you can also have a ___________ injury
cold
Cold injuries are due to either __________ or ____________
overexposure to cold air/water or core body temp decreases
Hypothermia and frostbite are both cold injuries due to _____________________
overexposure to cold air/water
When a cold injury occurs due to core body temp decreases, ____________ occurs and tissue forms _____________, and __________ and _________ can occur
peripheral vasoconstriction; ice crystals; necrosis and gangrene
The ____________ is used to triage/approximate severity/extent of a burn, but is inaccurate in pediatric pts
rule of 9s
What is more commonly used than the rule of 9s in pediatric burns?
Lund and Browder
Lund and Browder is based on age associated changes in ___________: representation of body parts changes based on growth and development with infant head = _______% TBSA, and adult head = ________% TBSA, and it subdivides body structures farther than the rule of 9s
TBSA; 19; 7
burn depths
Superficial, partial thickness (superficial or deep), and full thickness (subdermal)
superficial burns are red/pink irritated _____________, painful, tender, no _________, min/no _________, and heal spontaneously with no __________ (sunburn)
epidermis, blisters, edema, scarring
First degree burns
superficial burns
Superficial partial thickness burns are bright pink or red, have an inflamed _______, are located in the __________ or __________, they have intact ________, moist surfaces, __________ are ____________ (exposed nerve endings), sensitive to temp and touch, have moderate ________, spontaneous healing, and minimal scarring/discoloration
dermis, epidermis and papillary dermis, blisters, weeping, painful, edema,
severe sunburn, scalds, brief contact thermal and dilute chemicals are examples of what kinds of burns?
superficial partial thickness
Superficial second degree burns
superficial partial thickness
Deep partial thickness burns are red/waxy white, have blanching with slow _____________, is located in the __________, ________, or __________, have broken blisters, a ___________ surface, are sensitive to ____________ but not light touch (_________________ damaged), have significant edema (damaged dermal vessels), Slow _____________, extensive ______________, and hair follicles and sweat glands are __________
capillary refill; epidermis, papillary dermis, and reticular dermis; wet; pressure; merkel’s discs/meissner’s corpuscles; healing; scarring; intact
Deep partial thickness burns are due to ____________________
contact with hot liquids, chemical burns, and flash burns
Deep second degree burns
deep partial thickness
Full thickness burns are what colors?
white, charred, tan, black, or red
Full thickness burns are non-blanching, have poor ____________, are located in the ___________, _____________, and ___________ tissue.
circulation; epidermis, dermis, subcutaneous
third degree burns
full thickness burns
Full thickness burns can be due to _____________
immersion scald, exposure to chemicals or electrical current, or prolonged flame/steam
If a full thickness burn has a ____________, ___________, or __________ skin appearance or the area is _____________ than it requires skin grafting or will have extensive scarring
leathery, rigid, dry; depressed
Subdermal full thickness burns have a ________ appearance, visible ___________ tissue, and have _____________ and _________ damage
charred, subcutaneous, muscle, neurologic
Fourth degree burns
subdermal full thickness burns
Subdermal full thickness burns can be caused by ___________________
electrical, prolonged thermal contact or exposure to strong chemicals
Subdermal full thickness burns cause tissue defects, require _____________, and cause ______________
skin grafting; extensive scarring
What are the 3 zones of burn injury?
zone of coagulation, zone of stasis, and zone of hyperemia
Zone of coagulation
central most area or most significant/prolonged contact with offending agent; greatest risk for developing a full thickness injury, and/or tissue necrosis
Zone of stasis
partial thickness injury with compromised blood flow; with proper wound and medical management, this area of tissue may be preserved or may be lost depending on severity and appropriateness of management
Zone of hyperemia
vasodilation and increased cellular activity; cells from this area, help to support zone of stasis
Superficial and superficial partial thickness burns heal by ___________ in how long?
re-epithelialization; in 5-10 days
Deep partial thickness burns: surface heals by __________ and depth heals by ____________ in ____________
re-epithelialization; scar formation; 2-3 weeks
Full thickness wounds: if small _________ or __________, but usually require ____________
contract or scar; skin grafting
3 common burn related surgical interventions
skin grafts, escharotomy, and fasciotomy
autograft
removed from the donor site and placed on the same individual
What are two types of autografts?
Split-thickness skin grafts (STSG) and Full-thickness skin grafts (FTSG)
Split-thickness skin grafts (STSG)
epidermis and portion of dermis harvested
2 types of Split-thickness skin grafts (STSG)
Meshed and sheet
Meshed Split-thickness skin grafts (STSG)
processed to increase surface area that can be covered
Sheet Split-thickness skin grafts (STSG)
more cosmetic, covers less surface area
Full-thickness skin grafts (FTSG)
Epidermis and all of the dermis harvested, very durable
For a Full-thickness skin grafts (FTSG), the donor site itself must be __________ or _____________
grafted or closed by primary intention
Most skin grafts we hope to be permanent are ____________
autografts
A temporary graft is usually rejected in __________
2-3 weeks
Types of temporary grafts
allograft (homograft), xenograft (heterograft), and dermal substitutes
Allograft (homograft)
from another person
Xenograft (heterograft)
from another species
Skin grafts are held in place by what 3 things
surface tension, staples, and sutures
Vascularity is estabilished in about _________: requires the graft to ___________ in the wound bed and it lacks _________________ initially requiring _____________ wrapping in dependent position
48 hours; remain immobile; vasomotor tone; light compression
Most skin grafts are adhered in _____________
5 days
Donor site heals via _____________
epithelialization
What are 3 common causes of graft failure?
excessive edema or bacteria, mobility of graft, and inadequate excision to healthy tissue prior to application
Early ambulation results in _____________ graft take than delaying ambulation
better
Escharotomy
incision through Eschar into subcutaneous tissue, releases superficial tissue to decompress underlying tissue, and improves circulation
Fasciotomy
incision through fascia, improves circulation, and decompresses underlying tissue
Integumentary system issues related to burn injury
scarring, altered thermoregulation, sensory changes, and UV sensitivity
What are the two types of scarring?
keloid and hypertrophic
Scarring can lead to _______________
contracture, deformity, and impaired cosmesis
Respiratory system pathology related to burns
Inhalation injury, edema in lungs, and circumferential thoracic and abdominal burns
Inhalation injury is the primary cause of death and can be due to _____________
pulmonary edema, ARDS (acute respiratory distress syndrome), and carbon monoxide
cardiovascular system pathology related to burn injury
Burn shock
Burn shock: Increased _____________ leakage and causes _______ (large amount in 8-36 hours and resolves in 7-21 days), reduced _____ : decreased intravascular volume causes dec ____ and ________ as much as ______% for 1st ________ days
extravascular/interstitial fluid, edema; CO; SV and MAP; 50; 2-4
Burn shock causes decreased intravascular fluid volume, which causes increased __________, which leads to increased _____________ and therefore an increased risk of ____________
hematocrit, blood viscosity, VTE
Large amounts of ___________ are given early in the burn process to combat burn shock
IV fluids
Musculoskeletal system pathology related to burns
Rhabdomyolysis/Muscle break down (atrophy/weakness) and heterotopic ossification
Heterotopic ossification: Associated with burns < _____% TBSA, highest risk locations: _______________ which contribute to _________; have point specific pain and a possible bony end fee
20; elbow, shoulder, and hip; contracture
Immune system pathology related to burns: high risk of ________________ which is the most common complication of a burn: they cause loss of ___________ function, there’s endogenous/exogenous bacteria, and they’ll have an altered __________ response
sepsis and infection; barrier; immune
Renal impairments due to burn
excessive myoglobin (muscle destruction) impairs renal function, and decreased perfusion (hypovolemia) reduces GFR (glomerular filtration rate) which causes acute renal failure
Neurologic system pathology related to burn: polyneuropathy - due to _________ and associated with >__________% TBSA and local neuropathy - regional and electrical burns with common locations being: _______________
Neurotoxicity; 20; brachial plexus, ulnar, peroneal, and median nerves
Other pathologies related to burns are ophthalmic and auditory losses as well as psychosocial: acute - ______ or ________; or chronic - _____________, __________, or _________
delirium, anxiety; depression, PTSD (in 45% of survivors at 1 year), and sleep disturbance
Severe pain is an obstacle to rehab, position of comfort is the position of ____________, so we want to pre-medicate prior to PT intervention, and they’re going to need extensive PT __________
contracture; education
Burn wound care has the same general principles as other wounds: cleanse, _______ dressings to remove - don’t try to _________, ___________ wound environment, appropriate dressing, and need a more frequent use of ________________ with this population
cut; unwind; moist; topical antimicrobials
Burn wound care: _____________ for large BSA wounds - cleanse/dressing removal; uses a __________ or __________: temp _________ deg for adults, _____ deg pediatric, and < ______ min submersion
submersion; hubbard tank or whirlpool; 95-100; 90; 30
Debridement
removal of devitalized tissue
PT can perform what kinds of debridement?
Autolytic, mechanical, enzymatic, and selective/sharp
Need to be careful when using topical antimicrobial agents as they may be ____________
cytotoxic
Topical antimicrobial agents
Silver Sulfadiazine: gram + and –, Mafenide acetate (sulfamylon): typical wound flora, Silver nitrate: broad spectrum bacteriostatic (also stops focal bleeding), and Bacitracin/polysporin: gram +
Silver Sulfadiazine: gram + and – is used for which common infecting agents?
Pseudomonas aeruginosa (gram - rod) and Staphylococcus aureus (gram + cocci)
Mafenide acetate (sulfamylon): typical wound flora is used for which common infecting agents?
Pseudomonas aeruginosa (gram - rod)
Bacitracin/polysporin: gram + is used for which common infecting agents?
Staphylococcus aureus (gram + cocci)
Common infecting agents
Pseudomonas aeruginosa (gram - rod), Staphylococcus aureus (gram + cocci), Proteus mirabilis (gram - rod), and Escheria coli (gram - rod)
Scar tissue has less _________________ and more ________________ than normal skin
hyaluronic acid; chondroitin 4 sulfate
Scar tissue is less _____________, the collagen is ________________, maximal tissue length is __________, contributes to scar banding and contracture risk, and needs ____________ application several times a day
elastic; less organized; reduced; moisturizer
Skin and scars S/P burn require stretching and positioning through ______________, stressing relaxation and static splinting, and tissue creep which is ___________________ that requires a low load prolonged stretch (LLPS) and a minimum of 3 minutes at end range per motion involved and allows for ____________ and tissue expanders
soft tissue mobilization and transverse fiction massage; progressive elongation over time in response to prolonged force; dynamic splinting
GOAL OF BURN REHAB
PREVENT/TREAT BURN SCAR, CONTRACTURE, AND RELATED DEFORMITY
What should be documented when assessing a wound?
Extent and distribution, Location, Depth, Tissue quality, drainage, % viable vs necrotic tissue, odor, appearance, measurement
Burn rehab positioning/splinting
Maintain tissue at end ROM/state of elongation, in position opposite the location of the burn wound
Burn rehab manual stretching: low load _____ second hold repeated ______ times per motion with at least 3 minutes of end range time, may incorporate contract relax/hold relax and PNF patterns of movement, and need pt education on _______________ (caregiver training is super important!)
30-60; 3-5; self-stretching
If the neck is burned, what is the likely contracture?
flexion
If the anterior axilla is burned, what is the likely contracture?
Adduction
If the posterior axilla is burned, what is the likely contracture?
Extension
If the antecubital space is burned, what is the likely contracture?
elbow flexion
If the Forearm is burned, what is the likely contracture?
Pronation
If the wrist is burned, what is the likely contracture?
Flexion
If the dorsal hand is burned, what is the likely contracture?
MCP hyperextension, IP flexion, thumb add
If the palmar hand is burned, what is the likely contracture?
Finger flexion, thumb flexion/adduction
If the hip is burned, what is the likely contracture?
Flexion, add, ext, rotation
If the knee is burned, what is the likely contracture?
flexion
If the ankle is burned, what is the likely contracture?
plantar flexion
Preventative positioning
direction opposite of likely contracture
Splinting is used to ________________
prevent or correct contracture and protect joint and tendons
Static splinting
No moving parts, positioning only immobilize; and is modified once increased motion is obtained
Dynamic splinting
LLPS, has moving parts, applies constant force
Airplane position
shoulders abducted 90-120
Elbow conformer
keep elbow extended
Wrist cock up splint
keep wrist extended
hand splint
keep MPs flexed, IPs extended, and digits abducted
Hip slint
keep hips abducted and extended
Knee conformer
keep knee extended
Ankle splint
keep foot dorsiflexed
Goals of exercise for burn rehab
reduce edema, prevent contractures, recondition, increase strength and mobility, promote independence
ROM exercise is best performed when and why?
during dressing changes; no restriction from bulky dressings
AROM should be performed when
immediately after burn but wait 1 week after skin grafting
AAROM promotes ________ and ___________
scar tissue elongation and self-management
PROM promotes ______________ and consists of ____________
scar tissue elongation; LLPS
For conditioning, as long as we are not threatening a new skin graft, all modes of exercise are appropriate, and we want to put emphasis on _________________
strengthening muscle groups opposite of likely scar formation
What does pressure application to scars during the remodeling process do?
Reduces hypertrophy of scar, Realigns collagen, Decreases interstitial edema in hypertrophic scars reducing their severity, Reduces chondroitin A sulfate and increases hyaluronic acid concentration, and Reduces mast cell’s release of histamine reducing edema
Wounds with <____ days healing time-not likely to require pressure garment
14
Wounds requiring _______ days for closure should receive pressure Garment
14-21
Wounds requiring more than _____ days to heal require pressure Garment; at least _______ mmHg required, but possibly as high as ________ mmHg
21; 5-15; 25
Elastic band (ace wraps): _______ mmHg and need _____________
10-15; frequent rewrapping
tubular support bandages (tubigrip): ________ mmHg
10-20
Custom pressure garments: ________mmHg
25
Compression/pressure garments should be worn for __________ hours a day within _______ days of initial injury
23; 60
pressure garments duration of use: _______________; remodeling continues for up to __________ months, but what is an issue with this
12-24 months; 24; compliance
what’s the problem with pull on compression garments?
it results in increased shear forces
What massage techniques are sometimes used for burns?
effleurage, petrissage, transverse friction, iastm
What thermal modalities are sometimes used for burns (not acutely) and why?
ultrasound, diathermy, and moist heat; used to improve tissue extensibility prior to stretching
