burn PT Flashcards
1
Q
epidermis
A
- provides protection
- consists of 5 layers
- avascular in nature
- regenerated by keratinocytes
2
Q
dermis
A
- sweat glands, nerve endings, hair follicles
- 2 layers
- papillary dermis: loosely distributed collagen and elastin
- reticular dermis: densely packed collage “lattice work”
- fibroblasts
3
Q
subcutaneous layer
A
adipose and connective tissue
4
Q
burn depth classification
A
- superficial (first degree): epidermis
- partial thickness (second degree): subcategories - superficial partial [papillary] or deep partial [reticular], epidermis, dermis
- full thickness (third degree): epidermis, dermis, subcutaneous layer
5
Q
superficial thickness
A
- really bad sunburn
- surface appearance: dry, no blisters, blanches with pressure
- color: red, bright pink
- sensation: painful
- histologic depth: epidermis only
- heals on its on: 3-7 days, may peel
- not included in TBSA %
6
Q
superficial partial thickness
papillary
A
- surface appearance: blistered, weeping
- color: bright red
- sensation: very painful
- histologic depth: epidermis, papillary dermis
- healing: 7-21 days by re-epithelization, minimal to no scarring, pigment change unlikely
7
Q
deep partial thickness
A
- surface appearance: psudoeschar - white
- color: mottled white to pink, blanching indicates healing
- sensation: pain indicates healing, no pain indicates deep burn
- histologic depth: epidermis, papillary and reticular dermis
- healing: 21-35 days, may develop severe hypertrophic scarring
- seesaw: know within a few days, will either heal on its own or convert to full thickness – due to risk factors, age burn size
8
Q
full thickness burns
A
- surface appearance: dry, leathery, charred
- color: mixed white, waxy, pearly, khaki
- sensation: no pain, hair pulls out easily – past reticular dermis, past sensation
- histologic depth: epidermis, dermis to subcutaneous tissue, beyond
- healing: skin grafting
9
Q
lund and browder
A
- most accurate method of determining total body surface area (TBSA)
- necessary to calculate fluid resuscitation requirements: liquid/edema shunted outward, so inside dry
- superficial burn NOT included in calculations - only partial and full thickness burns
- inhalation injuries can add to TBSA depending on degree on injury: 85% + 20% inhalation burn = 105%
10
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
11
Q
types of burns
A
- thermal: scald, flame, friction
- electrical
- chemical
- radiation
12
Q
scald burn
A
- most common from hot liquids and grease: deeper burns because retains heat longer
- common in children and elderly
- patterns: downward with splash marks is accident, circumferential abuse
13
Q
flame burn
A
- may involve inhalation injury in closed doors (vs outside at campfire and fell in)
- patterns vary
14
Q
friction burn
A
- road rash usually from motorcycle, motor vehicle accidents, or bikes
15
Q
electrical burns
A
- “tip of the iceberg” – contact points may be small, internal damage may be more severe
- follows a pattern of least resistance: bone > fat > tendon > skin > muscle > blood vessels > nerve
- job related/power lines: high voltage (1000+ V)
- flash/flame/contact
16
Q
chemical burns
A
- treat by massive dilution – get chemical off – continuous showering for a prolonged period after the injury
- attempts to chemically neutralize the burn can have an adverse affect
- household cleaning agents
- industrial - sodium hydroxide
17
Q
radiation burn
A
- sunburn
- radiation therapy
18
Q
necrotizing fasciitis
A
- bacterial infection: usually group A streptococcus (flesh eating bacteria)
- point of entry: cut, needle, bug bite
- progresses quickly: red, warm, swollen area, severe pain, fever
- antibiotics and daily surgical debridement necessary - deep excision
- complications: sepsis, shock, organ failure, life or limb
19
Q
SJS and TEN
A
- SJS = < 10% TBSA
- TEN = > 30%
- allergic reaction to meds: chemo, antibiotics
- affects mucosal areas: lips, eyes, genitals, gut
- stop meds: patient heals on their own or skin starts to slough
- less worried about scarring and loss of function: become medically sick – heart and lungs
- oral/IV pain meds usually, maybe topical lidocaine
20
Q
frostbite
A
- dif scoring sheet
- Hennepin score - quantifies injury and tissue loss of FB injury
- largely affects homeless population
- t-PA protocol, bone scan, rewarming
- heal vs amputation - if not managed
- timing very important: tiny vessels getting little clots, t-PA busts clots and restore perfusion
21
Q
renal system in burns
A
- hypovolemic shock
- most immediate life-threatening response to injury
- marked fluid loss - from organs (acute kidney failure)
- fluid shift from intravascular space to extravascular (3rd) space: decreased blood pressure, increase heart rate, decreased urine output
- urine output closely monitored - acute renal failure
22
Q
integumentary system with burn
A
- similar temperatures cause different depths of injury to different body parts: palm of hand/soles of feet, volar forearm/eyelids/ears
- temperature regulation: patients always cold acutely, hot subacturely - don’t sweat from grafted skin
- infection: not if but when for large burns
- dressing choises: dry vs wet wounds
- special consideration to pediatric and geriatric population: difficult to graft thin skin
- escharotomy: fluid accumulates in extracellular space, circumferential burn/eschar acts as tournigquet - fluid shunted out has no where to go, prevent ischemic extremities, compartment syndrome - fluid weeps out
23
Q
respiratory system with burns
A
- airway management: edema formation does not spare airway
- inhalation injury: enclosed space vs open area, mechanical clearance of mucous with bronchoscopy
- pre-existing conditions: COPD, emphysema, smoking
- ventilator associated pneumonia (VAP): with large burns and multiple trips to OR, extubate as soon as possible
24
Q
cardiovascular system with burns
A
- tachycardia: 140s RHR normal with age, hypovolemia (initial injury), pain (HR increased with pain), monitor during therapy session
- bedrest/deconditioning: associated with loss of plasma volume (PV) and left-ventricular (LV) atrophy
- pre-existing cardiac conditions
25
Q
gastrointestinal system and burns
A
- bowel management: opiates slow GI motility, prevent bowel obstruction, rectal tube, stool softener
- nasogastric (NG) tube placement: NG tube feeds, patient with only 20% TBSA burn - difficult to meet nutritional requirements with a regular diet
- increased protein and caloric needs: wound healing, body in hypermetabolic state -> muscle catabolism for protein
26
Q
burn wound coverage
A
- burn excision: surgical
- temporary coverage: allograft, xenograft, skin substitutes
- definitive coverage: autograft
27
Q
burn excision
of any nonviable tissue
A
- burn eschar causes system inflammation (and infection)
- creates healthy, bleeding wound base
28
Q
allograft and xenograft
temporary coverage
A
- allgraft (cadaver skin) and xenograft (usually pig)
- large TBSA: temporary coverage
- small TBSA: test readiness of wound bed for autograft
29
Q
skin substitutes
temporary coverage
A
- integra
- silicone outer layer with bovine collagen matrix
- used over joints, bones, tendons, and cartilage
- provides scaffolding for cellular invasion and capillary growth
30
Q
definitive coverage - autograft
types
A
- split thickness skin graft (STSG) – 99%
- full thickness skin graft (FTSG) – less common
31
Q
split thickness skin graft (STSG)
autograft
A
- dermatome, 0.007-0.16 inches thick
- heal in 10-14 days
- sheet graft, mesh graft
99%
32
Q
full thickness skin graft (FTSG)
autograft
A
- entire thickness of skin down to subcutaneous tissue
- problem areas
- eyelids, palmar aspect of hand/fingers
- reconstruction/cosmetic
33
Q
mesh graft
split thickness skin graft - autograft
A
- graft run through a “mesher”
- insterstices allow for wound drainage
- expanded over a large area of skin
- less durable than sheet graft - more fragile than sheet grafts but still tough
- waffle-like appearance
34
Q
sheet graft
split thickness skin graft - autograft
A
- graft is unaltered
- more cosmetically appealing
- requires large donor site
- watch for “bleeders”
35
Q
donor site
A
- partial thickness wound
- heals by re-epithelialization
- 10-14 days
- reharvest
36
Q
cultured epidermal autograft (CEA)
autograft
A
- patients with large TBSA % (>30%)
- skin biopsies taken upon admission and sent to lab in Boston to grow skin cells
- extremely fragile: 2-8 cell layers thick
- surgeon places “cassettes” over a larger meshed (6:1) STSG – $7500/cassette
- skin cells fill in the gaps of the mash
- period of immobilization (~2 weeks)
37
Q
RECELL ASCS (autologous skin cell suspension)
A
- small donor site (size of a postage stamp)
- donor skin placed into an enzymatic solution
- after 15-20 minutes the surgeon scrapes the epidermis from the dermis
- surgeon draws up solution and sprays onto a meshed STSG
- advantages/uses: small donor, used in combination with STSG for faster healing, used on deep partial thickness burns, used on donor sites to promote faster healing in order to re-harvest, less expensive and more readily available than CEAs, quicker time to rehabilitative interventions and less bedrest
38
Q
where do PTs fit in on a burn unit
A
- throughout continuum of care
- ICU > step-down > floor level of care
- wound care
- interdisciplinary rounds
- family meetings
- in OR
- outpatient
39
Q
PT burn evaluation
A
- patient history: PMH, PSH, comorbidities, MOI - inhalation injury, trauma, mental health, drug/alcohol abuse
- PLOF: family dynamics, social history
- edema
- ROM
- burn assessment: size/depth estimate, Lund and Browder (TBSA), blanching vs non-blanching, pain, sensation, location/circumferential involvement (joint involvement)
- vital signs: resting and with burn assessment, PROM, oftentimes only indicator of pain (wound care and PT are generally most painful parts)
- position of invovled extremities, head, neck
- strength and functional mobility, if able
40
Q
edema management
PT interventions specific to burns
A
- limb elevation, positioning
- functional wrapping: use of conform and kerlix during wound care
- compression: ACE, isotoner gloves, tubigrip, tensoflex
- lymphedema bandaging for improve wound healing - short stretch bandaging and foam better when patient is up and moving – high work P, low resting P
- (ACE is opposite)
41
Q
positioning
PT interventions specific to burns
A
- begins day 1
- maintain ROM of joints
- position of comfort - position of contracture
- skin and nerve protection: off-load bony prominences, avoid pressure on or overstretching of nerves
- vascular support - elevation
42
Q
splinting
PT interventions specific to burns
A
- types: off the shelf, custom, non-conventional
- autograft protection: immobilize grafts that cross joints (5 days), at all times until POD5 for autografts
- maintain ROM: prevent contractures and deformities, don when at rest and at night, promote AROM and functional use when doffed
- joint protection: exposed joint - immobilize with splint
43
Q
casting
PT interventions specific to burns
A
- serial casting: remediate skin/joint contractures
- total contact casts: immobilize joint and redistribute ground forces during ambulation, allows for weightbearing during healing
44
Q
ROM/stretching
PT interventions specific to burns
A
- AROM
- encouraged prior to grafting for edema reduction
- POD5 after autografting - if good graft take, may start AROM (patient controlled)
- gain as much as A/PROM before strengthening
- may start 24 hours after allografting
- PROM
- may do prior to grafting, keeping in mind available ROM given edema
- may start gentle PROM 5-7 days after autografting
- may start 24 hours after allografting
- be mindful of end-feels, skin blanching, speed/duration of passive stretching
- during wound care/OR
- AAROM
- AROM with PT assisting with overpressure
45
Q
scar management
PT interventions specific to burns
A
- scar massage: identify hypertrophic scars and banding, combine with stretching
- compression: initiate with off the shelf options, if tolerating and compliant, then custom compression garments, silicone - moisture retaining, foam inserts for added compression
- CO2 laser therapy: outpatient
- Z- plasty: to elongate skin
46
Q
exercise
PT interventions specific to burns
A
- necessary but painful: being day 1
- prevent contractures, maintain ROM/function
- important to appreciate current medical status and where the patient is in their healing course
- monitor vital signs
- stretch > strengthen within given ROM > splint to maintain (stretch then strengthen)
- be aware of the patient’s medical history
- know your patient’s injuries: exposed joint/tendon, fresh grafts, orthopedic issues
- large TBSA% = high risk of deconditioning (per 1% TBSA expect 1 day in ICU)
- initially therapist led: HEP, home stretching program
