Burns Flashcards
Burns
An injury of the tissues of the body caused by heat, cold, chemicals, electricity, friciton or radiation
M>F
Most deaths associated with fires are d/t inhalation injuries
Function of Skin
(8)
- Protection against infections - barries of infectious agents into the body
- Protection against UV rays
- Protection against fluid loss
- Temperature regulation (trhough excretion of sweat & electrolytes)
- Sensation (pain, itch, touch, temperature, pressure, vibration) - mediate sensations found in the eipdermis & dermis
- Secretion of oils to lubricate skin
- Vitamin D synthesis
- Cosmetic appearance
Two distinct layers of the skin
Characteristics (4+4)
Epidermis (Superficial Sensation)
- Outermost layer exposed to the environment (no such thing as “pain” receptors > intepreted & processed in the brain> brain will intrepret it - needs to pay attn or not)
- Avascular
- Free nerve endings - AFFERENT - take sensory input from the skin - brain && nocicpetors - detect threat - something the body needs to pay attn too
- Composed of 5 layers
Dermis
- Deepest layer
- 20-30x thicker than epidermis
- Contains blood vessles, lymphatics, nerve endings, collagen & elastin fibers
- Encloses the epidermal appendages which include sweat glands, sebaceous (oil) glanes, & hair follicles which are a source of epidemeral cells (required for wound healing)
Classification of Burns
(2)
Depth of Injury:
1. Superficial (1st degree)
2. Superfiical Partial Thickness (2nd degree)
3. Deep Partial Thickness (2nd degree)
4. Full Thickness (3rd degree)
5. Subdermal (4th)
Total Body Surface:
- Rule of Nines
- Modified Lund-Browder Chart
Depth of Injury - Degree:
Superficial
Characteristics, Depth of injury, Rate of Healing
Think SUNBURN
Characteristics:
- Pink or red (erythema)
- No blisters
- Dry
- Minimal edema
- skin barrier to infection intact
- Mild pain
Depth of Injury:
- Damage to epidermis only
Rate of Healing
- 2-3 days
- Desquamation = skin peels or flakes off
- No scarring
Depth of Injury - Degree:
Superficial Partical Thickness (2nd)
Characteristics, Depth of injury, Rate of Healing
Think: Scald Burn
Characteristics:
- Bright pink or red (mottled)
- Intact blister
- Dry surface
- Moist weeping when blister is removed
- Moderate edema
- Quick capillary refill
- VERY painful
Damage to vascularature, lympatics, sensory receptors (nociceptors)
** Nerve endings are damaged but NOT destroyed
- Sensitive to changes in temperature, air, exposure, & light touch
Depth of Injury:
- Damage to epidermis & into papillary dermis
Rate of Healing:
- 4-10 days
- Minimal Scarring (colour changes remain)
Depth of Injury - Degree:
Deep Partial Thickness (2nd)
Characteristics, Depth of injury, Rate of Healing
Think: Immersion scald, cooking oil burn, flame burn
Characteristics:
- Red or waxy white
- Broken blister (No other burn w/ broken blisters)
- Wet surface - leaked plasma from the blister
- Marked edema
- Sluggish capillary refilll
- Sensitive to pressure
- Insensitive to light touch or light pinprick (receptors have been destroyed)
Depth of Injury:
- Damage to epidermis & into the reticular dermis
Rate of Healing:
- 3-5 weeks if the healing process does not het affected ie. infection
- Scar formation (hypertropic or keloid)
May require skin grafting - cosmetic purposes rather than functional
Depth of Injury - Degree:
Full Thickness (3rd)
Characteristics, Depth of injury, Rate of Healing
Thick: Flame burn, chemical burn
Characteristics:
- White, charred, back, or red
- Eschar formation - scab of necrotic tissue
- “Parchment-like”
- Rigid, dry, &/r leathery
- No lanching with pressure (vascular system is disrupted)
- Marked edema
- Painless - nerve endings are damaged
- Severe infection risk - portal of entry
Depth of Injury:
- Damage to epidermis, dermis, and partially into subcutaneous tissue
Subcutaneous = means fair follicles are destroyed
Rate of Healing:
- 3-5 weeks
- Scar formation (hypertropic or keloid)
- May require skin grafting - more required for functional rather than just comestic functions
Depth of Injury - Degree:
Subcutaneous (4th)
Characteristics, Depth of injury, Rate of Healing
Think: High voltage electrical burn
Characteristics:
- Charred
- Subcutaneous tissue visible (may see mm or bone)
- Muscle damage
- Neurological involvement
- Large exit wound (ground) & smaller entry wound
Follows the path of least resistance - nerve path - heat can damage surrounding tissue along the path
- Always considered severe regardless of surface area of damage
Depth of Injury
- Damage to epidermis, dermis, and into subcutaneous tissue, muscle, bone, and large nerves
Rate of Healing:
- Extensive healing time
- Requires extensive Sx, debridemnet, and grafting
- May require amputation
Total Body Surface
Estimates the total body thats affected - does NOT count for the severity of the burns
Need to take both DEPTH & surface area into account
Rules of Nines
Modified Lunds-Browder Chart
Rules of Nines:
Adult & Children
Percentages
Adult:
Head & neck - 9%
Anterior Trunk - 18%
Posterior Trunk - 18%
Right Arm - 9%
Left Arm - 9%
Pubic Area - 1%
Right Leg - 18%
Left Leg - 18%
**Head & Neck - 18% - children have larger heads in comparison to their bodies
Anterior Trunk - 18%
Posterior Trunk - 18%
Right Arm - 9%
Left Arm - 9%
** Pubic Area - 0%
** Right Leg - 14%
** Left Leg - 14%
Slightly smaller - difference of 9 points compared to the adult
What is the leading cause of death & mortality in burns?
Infection
- Can spread from burn wound to other tissues
- Can convert a deep-partial thickness burn into a deeper wound
Complications: Metabolic
Increase metabolic activity following burns (INC burn = INC rate of metabolism):
- DEC energy stores - using proteins as the metabolite to create energy
- Weight loss - fluid loss & mm atrophy (catabolic effect happening to the protein)
- Muscle atrophy - caused by immobilization & d/t defficiency in energy
- INC evaporative heat loss - impaired skin barrier - lead to INC metabolic rate
Do NOT tolerate heat cold well
Complications: Pulmonary
S/S of inhalation & associated complications
Inhalation injury d/t smoke inhalation or inhalation of hot gases
Most common cause of mortality in burn injury
Signs of inhalation:
1. Facial burns
2. Signed eyebrows & nasal hairs
3. Harsh cough
4. Hoarseness in voice
5. Carbonaceous sputum
6. Abnormal breath sounds (wheezing or stridor)
7. Respiratory distress
8. Hypoxenia - d/t excess carbon dioxide (breathed in more CO2 = higher affinity w/ hemoglobin = O2 capacity is decreased)
Associated complications:
1. Carbon monoxide posioning
2. Tracheal damage
3. Upper airway obstruction - wheezing (constricting eschar - Sx to debride it)
4. Pulmonary edema
5. Pneumonia
Complications: Cardiovascular
Increase capillary permeability leading to:
- Fluid loss (intravascular -> interstitium) - evaporate from interstitium = DEC fluid d/t INC fluid loss
- DEC cardiac output (at risk for hypovolemic shock)
DEC fluid volume inside the vascular structures (Frank-Sterling Law) = DEC CO = HR x SV - so DEC SV b/c less fluid to be pumped out = DEC blood carrying O2 to the tissue = hypoxia
Capilarry permeability returns to normal after 24 hours
Fluid replacement therapy helps manage intravascular fluid loss
Complication: Heterotopic Ossification
Higher incidence in patients with larger TBSA burns
Ususally occurs in areas with full thickness burns
Most common areas:
- elbows
- hips
- shoulders
S/S include:
- DEC ROM
- Point-specific pain
Complication: Neuropathy
Peripheral Neuropathy:
Local: compression of a specific peripheral nerve
Causes:
- Compression from tight bandages
- Poorly fitted splints
- Prolonged or inappropraite positioning
Common sites:
- Brachial plexus
- Ulnar nerver
- Common peroneal nerve
Polyneuropathy: the simultaneous malfunction of many peripheral nerves throughout the body
- higher incidence in patients with larger TBSA burns
- etiology unknown
Complication: Amputation
Reason & most common cause
Common in subdermal burns (4th) d/t lack of viable blood vessels
Most common cause is electrical burns
Complication: Pathological Scars
Types & INC risk
- Hypertropic Scar
- Excessive scar formation that raises above the level of the adjacent skin
- Raised, red, and rigid (3R’s)
** Does not typcially interfere w/ mvmt - Keloid Scar
- A type of hypertropic scar that extends beyond the boundary of the original wound
- More common in people with dark pigmentation
** Collagen synthesis is greater than the breakdown - Scar contracture (scar bands) - can lead to mm contractures formation
- Skin is so tight -> person does not move -> mm contractures
Increased risk:
- Deep partial thickness burns that heal spontaneously
- Full-thickness burns with incomplete coverage by skin graft (at margins of skin graft)
Wound Care
(4) Key Aspects
Inspect the wound
- Appearance, depth, size, exudate, and odor
Clean wound
- Antiseptic solutions
Debridement of wound
- Removal of necrotic or infected tissues to improve the healing potential of the remaining healthy tissue
- Sharp debridement: the use of scalpel or surgicial scissors & forcepts to debride wound
Prevent infection
- Tropical &/or systemic antibiotics are applied or reapplied
- Burn dressings may provide physical portection against infections, hold topical antibiotics on wound, and reduce fluid loss from wound
Skin Grafts
Types & subtypes
Permanent Grafts:
Autograft: From patient’s own skin (taken from unburned area)
- Common donor sites: thighs or back
- Sheet graft: A skin graft which is applied w/o alteration
- Better cosmetic appearance (face, neck, and hands) - smoother - Mesh graft: A skin graft processed through a device that makes tiny incisions to allow the skin graft to expand
- Used when there is limited donor skin
- Greater surface area but poorer cosmetic appearance (“scaley”)
Temporary Grafts:
1. Allograft (Homo): From the same species (usually from a cadaver)
2. Xenograft (Heter): From another species (usually a pig - closed to human skin)
Escharotomies
Performed when eschar is restricting circulation
Correction of Scar Contracture
When & Inc Risk
Performed when scar has become contracted limiting function & ROM
INC RISK:
- Deep partial thickness
- Full thickness
Positioning & Splinting
Goals & Considerations
Goals:
1. Minimize edema
2. Prevent contractures
3. Perserve function
IF you can prevent contractures - you will perserve function
- Certain burn areas have associated positions of contracture
(Positions pt will put themselves in b/c it shortens the tissue - DEC tensile stress thats on that area) - Positions in an elongated state or in functional position (not mutally exclusive)
- Consider risk of pressure ulcers when choosing positions
Positioning: Anterior Neck
Position of contracture, Suggest position, & Methods
Position of contracture:
- Flexion
Suggested Positioning:
- Neutral or extension
Method:
- Double mattress (provides a gap for the head to fall back into)
- Cervical collar
Positioning: Axilla (Shoulder)
Position of contracture, Suggest position, & Methods
Position of contracture:
- Adduction
- IR
Suggested Positioning:
- Abduction
- Flexion
- ER
(opposite action of the pecs)
Method:
- Airplane splint
- Arm trough
- Foam wedges
Positioning: Anterior Elbow
Position of contracture, Suggest position, & Methods
Position of contracture:
- Flexion
- Pronation
Suggested Positioning:
- Extension (Not full extension - can lead o a joint contracture
- Supination
Method:
- Splint
- Arm trough
Positioning: Wrist & Hand
Position of contracture, Suggest position, & Methods
Position of contracture:
- Wrist flexion
- Thumb adduction
- Intrinsic minus position (CLAW hand) = Fingers 2-5 - All MCP are in extension, DIP/PIP in flexion
Suggested positioning:
- Wrist extension (15-20 degrees)
- Intrinsic plus position (Hamburger hands) = MCP in flexion, PIP/DIP in extnesion
- Thumb abduction
Functional position
Methods:
- Wrap fingers separately to maintain webspaces
- Place pillow over wedge with hand elevated to control edema
Positioning: Hip & Groin
Position of contracture, Suggest position, & Methods
Position of contracture:
- Flexion
- Adduction
Suggest positioning:
- Extension
- Abduction
- Neutral rotation
Method:
- Wedges
Positioning: Knee
Position of contracture, Suggest position, & Methods
Position of contracture:
- flexion
Suggested positioning:
- Extension - slight flexion to prevent extensor contraction
Method:
- Posterior knee splint
Positioning: Ankle
Position of contracture, Suggest position, & Methods
Position of contracture:
- Plantar flexion
Suggested positioning:
- Neutral
Method:
- AFO w/ cutout at Achilles tendon
